Quality Improvement the YNHS Way

Who do we report to?

Our Patients Our Board PCMH

Meaningful Use UDS

I have to report what to who?

PCMH

Meaningful Use

UDS

Each piece, or entity, can link together to make a cohesive whole

YNHS QI ScheduleAspect of Care Rationale Quality Indicator Benchmark

EPSDTEarly and Periodic Screening, Diagnosis and treatment

HEDIS®HCAHigh RiskHigh VolumePopulation specific

6 or more well child visits in the first 15 months of life.

Mammography HEDIS®HCAClinical measuresHigh RiskHigh volumePopulation specific

Percent of women age 40 through 69, who have received a mammogram during the previous 2 years

2010 HEDIS® Report Medicaid Average – 52.4%

Quality Committee• Structure

– Previously the committee consisted of the entire management team (20+ people)

– Changed 1 year ago to include the CEO, COO, Medical Directors, Dental Director, Nursing Director and QI Director

• Responsibilities– The CEO and COO have the 30,000 foot view of the “entities” and

what is needed to support our efforts (reporting capabilities, Collaboratives, etc.)

– Medical Directors, Dental Director and Nursing Director have the knowledge of workflow, EHR/EDR functionality, provider and support staff buy in

– QI Director generates the reports (Deep Domain, SSRS, EPM/EHR), summarizes and presents the findings, monitors the standards and requirements