Quality and performance Improvement Projects 2014-2015 6D &E
6D 1and 2 and 6E2Pneumococcal Vaccine: we will review and tabulate our pneumococcal vaccine rates
for the last 6 months of 2014. Starting January 2015 we will set up in rules manager a flagging system to
flag all patients above the age of 65 who have not had a pneumococcal vaccine and we will actively
target these patients and counsel them to get the pneumococcal vaccine.
Vaccination rates 7/1/2014 to 12/31/2014 – 87%
Target set for 1/1/2015 to 6/30/2015 – 90%
Rate for 1/1/2015 to 4/30/2015 – 92%
6D 1 and 2 and 6E2Influenza Vaccine: We will review and tabulate our influenza rate for the 2013-2014
flu season. For the 2014-2015 flu season, we will educate all staff members on the importance of
influenza vaccination and all staff members will work on educating patients on taking the influenza
vaccine at every opportunity they can get.
Vaccination Rate 2013-2014 season – 1073/2099 = 51.1%
Target for 2014-2015 season – 60%
Vaccination rate 2014-2015 season – 1381/2261 = 61.1%
6D 1 and 2 and 6E2Breast Cancer Screening: We will review our mammography rates for the last 6
months of 2014. Starting January 2015 we will use rules manager to flag all patients between 50 and 75
years of age who have not had a mammogram in the last 24 months and will counsel these patients on
getting a mammogram
Mammography rate 7/1/2014 to 12/31/2014 – 68%
Target for 1/1/2015 to 6/30/2015 – 75%
Mammography rate 1/1/2015 to 4/30/2015 – 80%
6D 3 and 4 and 6E3Emergency Department Follow up: we will identify patients who have been to the
ED and the percentage of these patients that were contacted by our office within 48 hours to find out
how they were doing and schedule a follow up. We will set a target and we will proactively keep a list of
all patients that go to the ED and will make phone calls to these patients to help with transition of care
and follow up.
ED follow up 2 week period 4/2/2015 to 4/16/2015 – 3/15 = 20%
Target 50%
ED follow up for 2 week period 4/17/2015 to 5/1/2015 – 12/15 = 80%
6D 5 and 6 and 6E4Access to Care: we will look at our quarter 3 Press Gainey survey results pertaining
to our access to care. We will set a target to improve this score for quarter 4. We will make sure all
messages are answered in a timely manner and all patients are offered an appointment on the same
day. We will then look at our Press Gainey scores for quarter 4 to see for improvement.
Standard Access to care quarter 3 2014 – 96.6 percentile
Target for Quarter 4 – 98 percentile
Standard Access to Care quarter 4 2014 – 98.2 percentile
6D 7Disparity in BP control: We reviewed our disparities and noticed a disparity in BP control for our
elderly population above the age of 80. We calculated a disparity for the month of January 2015. We put
a process in place to document living situation for our patients above the age of 80 and set up a system
where they would call in their BP readings so we could make adjustments if needed. We rechecked the
disparity for the month of March.
BP control January 2015 for all patients 362/474 = 76.4%, for patients >80 is 50/71 = 70.4%
Disparity is 6%
Goal for March is to reduce disparity by 2% to 4%
BP control March 2015 for all patients 391/495 = 79%, for patients >80 is 56/74 = 75.7%
Disparity is 3.3% ( Reduction of 2.7%)