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Clinical Quality Performance Indicators
Summary
Prenatal Care
Access to Prenatal Care
Goal: 90% of pregnant women will enter prenatal care in the
1st trimester of pregnancy
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (90%) 2017 National
(74%)
2015 (71%) 2016 (93%) 2017 (100%) Q1 2018
(100%)
Q2 2018
(100%)
Q3 2018 (50%)
Prenatal Health
Low Birth Weights
Goal: 0% of children will be born at low-birth weights
(<2500g)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (0%) 2017
National
(8%)
2015 (0%) 2016 (50%) 2017 (0%) Q1 2018
(0%)
Q2 2018
(0%)
Q3 2018
(0%)
Low-Birth Weights
Weight Assessment and Counseling for Children and Adolescents (ages 3 to 17 years)
Goal: 80% of children, ages 3 to 17, with a recorded BMI percentile will have
documentation of counseling for nutrition and physical activity during the
measurement year that is appropriate for the BMI.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (80%) 2017 National
(66%)
2015 (73%) 2016 (81%) 2017 (64%) Q1 2018
(76%)
Q2 2018
(80%)
Q3 2018
(87.14%)
Weight Assessment and Counseling in Children
Preventative Health Maintenance
Adult Weight Screening and Follow-Up Care
Goal: 88% of patients 18 and older will have a BMI recorded during the most
recent visit or within six months of the most recent visit and will have a
follow-up plan documented when the BMI is outside of normal parameters.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (88%) 2017
National
(64%)
2015 (90%) 2016 (83%) 2017 (70%) Q1 2018
(86%)
Q2 2018
(87%)
Q3 2018
(21.42%)
Adult Weight Screening and Follow-Up Care
Tobacco Use Screening and Cessation Intervention
Goal: 90% of patients 18 years and older who were screened for tobacco use
one or more times within the past 24 months will receive cessation
counseling intervention if identified as a tobacco user.
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Goal (90%) 2017
National
(88%)
2015 (83%) 2016 (89%) 2017 (89%) Q1 2018
(89%)
Q2 2018
(80%)
Q3 2018
(86.07%)
Tobacco Use and Cessation Intervention
Colorectal Cancer Screening
Goal: 42% of adults 50-75 years of age will have appropriate screening for
colorectal cancer.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (42%) 2017
National
(42%)
2015 (31%) 2016 (27%) 2017 (41%) Q1 2018
(71%)
Q2 2018
(77%)
Q3 2018
(68.57%)
Colorectal Cancer Screening
Cervical Cancer Screening
Goal: 70% of women 23-64 years of age will receive one or more pap tests to
screen for cervical cancer. Women age 23-64 who had a cervical cancer
(cytology) every 3 years & women age 30-64 years of age who had cervical
cytology/ human papillomavirus co-testing every 5 years.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (70%) 2017
National
(56%)
2015 (64%) 2016 (51%) 2017 (67%) Q1 2018
(63%)
Q2 2018
(63%)
Q3 2018
(45.71%)
Cervical Cancer Screening
Childhood Immunizations
Goal: 60% of children two years of age who had appropriate immunizations.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (60%) 2017
National
(40%)
2015 (81%) 2016 (45%) 2017 (47%) Q1 2018
(42%)
Q2 2018
(42%)
Q3 2018
(54.28%)
Childhood Immunizations
Oral Health Sealants
Goal: 70% of children 6 to 9 years, at moderate to high risk of caries will receive
dental sealants.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (70%) 2017 National
(66%)
2015 (42%) 2016 (81%) 2017 (54%) Q1 2018
(63%)
Q2 2018
(86%)
Q3 2018
(50%)
Oral Health Sealants
Depression Screening and Follow-Up
Goal: 75% of patients 12 years and older screened for clinical depression and
found positive on screening for depression will have a follow-up plan
documented on the date of the positive screen.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (75%) 2017
National
(66%)
2015 (39%) 2016 (56%) 2017 (63%) Q1 2018
(77%)
Q2 2018
(86%)
Q3 2018
(77.14%)
Depression Screening and Follow-Up
Asthma Treatment
Goal: 84% of patients with having persistent asthma were prescribed the
appropriate medications.
Chronic Disease Management
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (84%) 2017 National
(87%)
2015 (48%) 2016 (76%) 2017 (93%) Q1 2018
(71%)
Q2 2018
(68%)
Q3 2018
(60%)
Asthma Treatment
Coronary Artery Disease and Lipid Lowering Therapy
Goal: 80% of patients 18 years and older with a diagnosis of Coronary Artery
Disease (CAD) will be prescribed a lipid lowering therapy.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (80%) 2017 National
(81%)
2015 (75%) 2016 (78%) 2017 (91%) Q1 2018
(92%)
Q2 2018
(74%)
Q3 2018
(87.80%)
CAD and Lipid-Lowering Therapy
Ischemic Vascular Disease and Use of Aspirin or Another Antithrombotic
Goal: 80% of patients 18 years and older with Ischemic Vascular Disease (IVD)
will have documentation of use of aspirin or another antithrombotic during
the measurement year.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (80%) 2017 National
(79%)
2015 (73%) 2016 (78%) 2017 (83%) Q1 2018
(67%)
Q2 2018
(89%)
Q3 2018
(88.88%)
IVD and Treatment
Blood Pressure Control
Goal: 72% of patients 18-85 years of age will have blood pressure adequately
controlled (<140/90).
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (72%) 2017
National
(63%)
2015 (67%) 2016 (67%) 2017 (67%) Q1 2018
(71%)
Q2 2018
(74%)
Q3 2018
(70.33%)
Blood Pressure Control
Diabetes Control
Goal: 22 % or less of diabetic patients will have a Hemoglobin A1C > 9.0%.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (22%) 2017
National
(33%)
2015 (24%) 2016 (25%) 2017 (26%) Q1 2018
(22%)
Q2 2018
(28%)
Q3 2018
(13.93%)
Diabetes Control
HIV Linkage into Care
Goal: 100% percent of patients diagnosed with HIV will be linked into care
within 90 days of diagnosis.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (100%) 2017
National
(85%)
2015 (100%) 2016 (100%) 2017 (100%) Q1 2018
(100%)
Q2 2018
(100%)
Q3 2018
(100%)
HIV Linkage to Care
HIV Testing
Goal: 25% of patients 16 to 64 years of age seen in the last 12 months will be
screen at least once in their lifetime for HIV.
Other Performance Indicators Chosen by CFHC, Inc.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (20%) 2015 (13%) 2016 (38%) 2017 (49%) Q1 2018 (38%)Q2 2018 (6%) Q3 2018
(51.76%)
HIV Testing
HIV and Dental Care
Goal: 25% of HIV patients will have a documented dental exam with a dentist
in the measurement year.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (25%) 2016 (19%) 2017 (26%) Q1 2018 (9%) Q2 2018 (6%) Q3 2018 (15.15%)
HIV and Dental Care
Migrant Seasonal Farmers Workers and Green Tobacco Sickness/Pesticide
Counseling
Goal: 55% of Migrant Season Farmworkers will receive education on green
tobacco sickness/pesticides.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (55%) 2015 (79%) 2016 (51%) 2017 (66%) Q1 2018
(72%)
Q2 2018
(84%)
Q3 2018
(65.71%)
MSFW and GTS/Pesticide Counseling
Breast Cancer Screening
Goal: 65% of women ages 40-64 years old will be screened for breast cancer
at least every two years.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal
(65%)
2015
(76%)
2016
(74%)
2017
(58%)
Q1 2018
(61%)
Q2 2018
(77%)
Q3 2018
(67.14%)
Breast Cancer Screening
Hepatitis C Screening
Goal: 30% of adults born between the years 1945-1965 will be screened for
Hepatitis C.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal
(30%)
2016 (17%) 2017 (58%) Q1 2018 (54%) Q2 2018 (53%) Q3 2018
(32.47%)
Hepatitis C Screening
Diabetes and Foot Exams
Goal: 65% of diabetic patients will receive a foot exam annually.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal
(65%)
2015
(63%)
2016
(31%)
2017
(32%)
Q1 2018
(34%)
Q2 2018
(51%)
Q3 2018
(42.47%)
Diabetes and Foot Exams
Diabetes and Retinal Eye Exams
Goal: 35% of diabetics will have a retinal eye exam.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal
(35%)
2015
(11%)
2016
(13%)
2017
(18%)
Q1 2018
(20%)
Q2 2018
(34%)
Q3 2018 (40%)
Diabetes and Retinal Eye Exams
Depression and Use of the PHQ9 Tool to Monitor Treatment
Goal: 85% of the patients diagnosed with depression will have a PHQ9
completed and on file to monitor treatment outcomes.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (85%) 2015
(79%)
2016
(84%)
2017
(70%)
Q1 2018
(72%)
Q2 2018
(57%)
Q3 2018
(79.31%)
Depression and PHQ9

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Clinical quality performance indicators

  • 1. Clinical Quality Performance Indicators Summary
  • 2. Prenatal Care Access to Prenatal Care Goal: 90% of pregnant women will enter prenatal care in the 1st trimester of pregnancy 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Goal (90%) 2017 National (74%) 2015 (71%) 2016 (93%) 2017 (100%) Q1 2018 (100%) Q2 2018 (100%) Q3 2018 (50%) Prenatal Health
  • 3. Low Birth Weights Goal: 0% of children will be born at low-birth weights (<2500g) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Goal (0%) 2017 National (8%) 2015 (0%) 2016 (50%) 2017 (0%) Q1 2018 (0%) Q2 2018 (0%) Q3 2018 (0%) Low-Birth Weights
  • 4. Weight Assessment and Counseling for Children and Adolescents (ages 3 to 17 years) Goal: 80% of children, ages 3 to 17, with a recorded BMI percentile will have documentation of counseling for nutrition and physical activity during the measurement year that is appropriate for the BMI. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Goal (80%) 2017 National (66%) 2015 (73%) 2016 (81%) 2017 (64%) Q1 2018 (76%) Q2 2018 (80%) Q3 2018 (87.14%) Weight Assessment and Counseling in Children Preventative Health Maintenance
  • 5. Adult Weight Screening and Follow-Up Care Goal: 88% of patients 18 and older will have a BMI recorded during the most recent visit or within six months of the most recent visit and will have a follow-up plan documented when the BMI is outside of normal parameters. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Goal (88%) 2017 National (64%) 2015 (90%) 2016 (83%) 2017 (70%) Q1 2018 (86%) Q2 2018 (87%) Q3 2018 (21.42%) Adult Weight Screening and Follow-Up Care
  • 6. Tobacco Use Screening and Cessation Intervention Goal: 90% of patients 18 years and older who were screened for tobacco use one or more times within the past 24 months will receive cessation counseling intervention if identified as a tobacco user. 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% Goal (90%) 2017 National (88%) 2015 (83%) 2016 (89%) 2017 (89%) Q1 2018 (89%) Q2 2018 (80%) Q3 2018 (86.07%) Tobacco Use and Cessation Intervention
  • 7. Colorectal Cancer Screening Goal: 42% of adults 50-75 years of age will have appropriate screening for colorectal cancer. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Goal (42%) 2017 National (42%) 2015 (31%) 2016 (27%) 2017 (41%) Q1 2018 (71%) Q2 2018 (77%) Q3 2018 (68.57%) Colorectal Cancer Screening
  • 8. Cervical Cancer Screening Goal: 70% of women 23-64 years of age will receive one or more pap tests to screen for cervical cancer. Women age 23-64 who had a cervical cancer (cytology) every 3 years & women age 30-64 years of age who had cervical cytology/ human papillomavirus co-testing every 5 years. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Goal (70%) 2017 National (56%) 2015 (64%) 2016 (51%) 2017 (67%) Q1 2018 (63%) Q2 2018 (63%) Q3 2018 (45.71%) Cervical Cancer Screening
  • 9. Childhood Immunizations Goal: 60% of children two years of age who had appropriate immunizations. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Goal (60%) 2017 National (40%) 2015 (81%) 2016 (45%) 2017 (47%) Q1 2018 (42%) Q2 2018 (42%) Q3 2018 (54.28%) Childhood Immunizations
  • 10. Oral Health Sealants Goal: 70% of children 6 to 9 years, at moderate to high risk of caries will receive dental sealants. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Goal (70%) 2017 National (66%) 2015 (42%) 2016 (81%) 2017 (54%) Q1 2018 (63%) Q2 2018 (86%) Q3 2018 (50%) Oral Health Sealants
  • 11. Depression Screening and Follow-Up Goal: 75% of patients 12 years and older screened for clinical depression and found positive on screening for depression will have a follow-up plan documented on the date of the positive screen. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Goal (75%) 2017 National (66%) 2015 (39%) 2016 (56%) 2017 (63%) Q1 2018 (77%) Q2 2018 (86%) Q3 2018 (77.14%) Depression Screening and Follow-Up
  • 12. Asthma Treatment Goal: 84% of patients with having persistent asthma were prescribed the appropriate medications. Chronic Disease Management 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Goal (84%) 2017 National (87%) 2015 (48%) 2016 (76%) 2017 (93%) Q1 2018 (71%) Q2 2018 (68%) Q3 2018 (60%) Asthma Treatment
  • 13. Coronary Artery Disease and Lipid Lowering Therapy Goal: 80% of patients 18 years and older with a diagnosis of Coronary Artery Disease (CAD) will be prescribed a lipid lowering therapy. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Goal (80%) 2017 National (81%) 2015 (75%) 2016 (78%) 2017 (91%) Q1 2018 (92%) Q2 2018 (74%) Q3 2018 (87.80%) CAD and Lipid-Lowering Therapy
  • 14. Ischemic Vascular Disease and Use of Aspirin or Another Antithrombotic Goal: 80% of patients 18 years and older with Ischemic Vascular Disease (IVD) will have documentation of use of aspirin or another antithrombotic during the measurement year. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Goal (80%) 2017 National (79%) 2015 (73%) 2016 (78%) 2017 (83%) Q1 2018 (67%) Q2 2018 (89%) Q3 2018 (88.88%) IVD and Treatment
  • 15. Blood Pressure Control Goal: 72% of patients 18-85 years of age will have blood pressure adequately controlled (<140/90). 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Goal (72%) 2017 National (63%) 2015 (67%) 2016 (67%) 2017 (67%) Q1 2018 (71%) Q2 2018 (74%) Q3 2018 (70.33%) Blood Pressure Control
  • 16. Diabetes Control Goal: 22 % or less of diabetic patients will have a Hemoglobin A1C > 9.0%. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Goal (22%) 2017 National (33%) 2015 (24%) 2016 (25%) 2017 (26%) Q1 2018 (22%) Q2 2018 (28%) Q3 2018 (13.93%) Diabetes Control
  • 17. HIV Linkage into Care Goal: 100% percent of patients diagnosed with HIV will be linked into care within 90 days of diagnosis. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Goal (100%) 2017 National (85%) 2015 (100%) 2016 (100%) 2017 (100%) Q1 2018 (100%) Q2 2018 (100%) Q3 2018 (100%) HIV Linkage to Care
  • 18. HIV Testing Goal: 25% of patients 16 to 64 years of age seen in the last 12 months will be screen at least once in their lifetime for HIV. Other Performance Indicators Chosen by CFHC, Inc. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Goal (20%) 2015 (13%) 2016 (38%) 2017 (49%) Q1 2018 (38%)Q2 2018 (6%) Q3 2018 (51.76%) HIV Testing
  • 19. HIV and Dental Care Goal: 25% of HIV patients will have a documented dental exam with a dentist in the measurement year. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Goal (25%) 2016 (19%) 2017 (26%) Q1 2018 (9%) Q2 2018 (6%) Q3 2018 (15.15%) HIV and Dental Care
  • 20. Migrant Seasonal Farmers Workers and Green Tobacco Sickness/Pesticide Counseling Goal: 55% of Migrant Season Farmworkers will receive education on green tobacco sickness/pesticides. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Goal (55%) 2015 (79%) 2016 (51%) 2017 (66%) Q1 2018 (72%) Q2 2018 (84%) Q3 2018 (65.71%) MSFW and GTS/Pesticide Counseling
  • 21. Breast Cancer Screening Goal: 65% of women ages 40-64 years old will be screened for breast cancer at least every two years. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Goal (65%) 2015 (76%) 2016 (74%) 2017 (58%) Q1 2018 (61%) Q2 2018 (77%) Q3 2018 (67.14%) Breast Cancer Screening
  • 22. Hepatitis C Screening Goal: 30% of adults born between the years 1945-1965 will be screened for Hepatitis C. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Goal (30%) 2016 (17%) 2017 (58%) Q1 2018 (54%) Q2 2018 (53%) Q3 2018 (32.47%) Hepatitis C Screening
  • 23. Diabetes and Foot Exams Goal: 65% of diabetic patients will receive a foot exam annually. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Goal (65%) 2015 (63%) 2016 (31%) 2017 (32%) Q1 2018 (34%) Q2 2018 (51%) Q3 2018 (42.47%) Diabetes and Foot Exams
  • 24. Diabetes and Retinal Eye Exams Goal: 35% of diabetics will have a retinal eye exam. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Goal (35%) 2015 (11%) 2016 (13%) 2017 (18%) Q1 2018 (20%) Q2 2018 (34%) Q3 2018 (40%) Diabetes and Retinal Eye Exams
  • 25. Depression and Use of the PHQ9 Tool to Monitor Treatment Goal: 85% of the patients diagnosed with depression will have a PHQ9 completed and on file to monitor treatment outcomes. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Goal (85%) 2015 (79%) 2016 (84%) 2017 (70%) Q1 2018 (72%) Q2 2018 (57%) Q3 2018 (79.31%) Depression and PHQ9