No. A measure looking to increase the number of patients who complete the satisfaction survey would not meet the requirement. Practice should look at improving an area identified using the patient experience data collected in QI 04.
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5.29.2018 QI 11 May practices focus on improving the number of patient experience survey responses it receives back from patients?
5.29.2018 QI 04B May practices use the “comments” section in the patient experience survey to meet this requirement?
5.29.2018 QI 02B Are preventive care measures considered utilization measures?
No. Although effective preventive care can reduce future health care costs, preventive care measures address quality of care and are not utilization measures. Utilization measures address direct health care savings, in accordance with evidence-based guidelines.
This applies to the following Programs and Years:
PCMH 20175.29.2018 QI 12 How do practices assess the effectiveness of improvement actions?
Assessing effectiveness of improvement actions includes remeasurement to compare results over time and evaluation of what is driving change. Results may be quantitative (numerical data that demonstrate performance and can be compared to benchmarks) or qualitative (conceptual data that describe why performance is high or low), but practices must look at the goals set, actions taken to improve and previous or baseline results.
This applies to the following Programs and Years:
PCMH 20175.29.2018 QI 06 Does the CAHPS PCMH Survey meet both QI 04 and QI 06?
The CAHPS PCMH Survey meets the requirement for QI 06 but only partially meets QI 04. The CAHPS PCMH Survey only meets the quantitative data requirement (QI 04A) for this criterion.
Note: No modifications to the survey questions or length may be made.
This applies to the following Programs and Years:
PCMH 20175.29.2018 QI 04A Are practices required to use the CAHPS PCMH survey to meet this requirement?
No. Practices may use any patient experience survey that includes questions related to three of the four categories specified in the standards (access; communication; coordination; whole-person care, self-management support and comprehensiveness).
This applies to the following Programs and Years:
PCMH 20175.29.2018 QI 05 How can practices stratify data for vulnerable populations?
Practices select a vulnerable population for measurement using fields that are available in their practice system. Practices may use categories such as race, age, ethnicity, language needs, education, income, type of insurance, disability or health status to identify specific populations that may experience disparities in care.
This applies to the following Programs and Years:
PCMH 20175.29.2018 CC 08 Are practices required to only refer to specialists with whom they have agreements, or is the requirement that an agreement be in place? Give an example of an agreement.
Practices are not restricted to referring patients only to practices with whom they have established agreements. NCQA reviews at least one example of a formal or informal agreement with a subset of specialists, but does not expect practices to have agreements with all specialists to whom they refer patients. The goal is that expectations are outlined in the agreement, in addition to expectations of timeliness/content of response from specialists.
This applies to the following Programs and Years:
PCMH 20175.29.2018 CC 08 What is an example of an informal agreement?
An informal agreement could be a few sentences in a referral form, e-mail or other method of communication containing expectations for the specialist, including, but not limited to, the time frame for reporting to the primary care physician and specifying lab or test results that should be included in the report. This information is essential to clarify the relationship between the primary care provider and specialist.
This applies to the following Programs and Years:
PCMH 20175.29.2018 CC 04C May practices use a “tickler file” for this item within CC 04?
No. The tracking system needs to include a record of both the order and receipt of results. A tickler system includes a copy of the order and is removed when results are received; it does not meet the requirement of the CC 04C because it does not maintain a record of receiving results.
This applies to the following Programs and Years:
PCMH 20175.29.2018 CC 06 & CC 07 May a practice use credentialing information to meet CC 06 and CC 07?
No. Credentialing—although important to a clinician’s ability to practice—is not a specific indicator of performance or quality information. Practices must use performance data to evaluate the quality of specialists or consultants to whom they send patients. Performance data can be qualitative or quantitative and may be gathered from external reporting sources (e.g., PCSP recognition, CMS public reporting) or may be internal based on criteria defined by the practice (e.g., evaluating a specialist’s timeliness in returning referral reports, evaluating whether patients had a positive experience).
This applies to the following Programs and Years:
PCMH 20175.29.2018 CC 14 Are practices required to show they can identify all patients who have been admitted to the hospital and treated in the ED?
No. Practices are not required to identify all patients admitted to the hospital or ED, but they must have a process for identifying patients admitted to facilities used most often by their population. In addition to a documented process, practices must also submit a log or report demonstrating that patients were identified.
