Practice Facilitation Handbook

Module 9 Appendix

A. Performance Metric Calculator for Diabetes

Diabetes HEDIS Measure Outcomes

HEDIS Measure Audit Results Practice Goal National or Local Benchmark
HbA1c screening rate = [Total(A)/30 (total # of charts audited)] x 100 =      
HbA1c less than 7.0 = [Total(B)/Total(A)] x 100 =      
Blood pressure documented = [Total(C)/30 (total # of charts audited)] x 100 =      
Blood pressure less than 130/80 = [Total(D)/Total(C)] x 100 =      
LDL-C screening rate = [Total(E)/30 (total # of charts audited)] x 100 =      
LDL-C less than 100 mg/dL = [Total(F)/Total(E)] x 100 =      
Eye Exams = [Total(G)/30 (total # of charts audited)] x 100 =      
Foot Exams = [Total(H)/30 (total # of charts audited)] x 100 =      

B. WeServeEveryone Clinic Case Example

WeServeEveryone is a federally qualified health center (FQHC) in Long Beach, California. It served 35,000 patients and provided approximately 80,000 patient visits last year. Average cycle time for a visit at all three of its practice sites is 75 minutes. The organization wants to improve patient experience and is interested in reducing patient cycle time as one way to do this.

Approximately 50 percent of the patients who receive care from the clinic are Latino and about 20 percent are monolingual Spanish. About 3 percent of the patients speak Nahuatl. Thirty percent of patients receiving care from the clinic are Asian and Pacific Islanders, and the remaining 20 percent are Caucasian. Forty-five percent of patients are children, 50 percent of patients are adults, and 5 percent are geriatric. Fifty percent of patients are uninsured, and 98 percent are at or below 200 percent of poverty; 70 percent are at or below 100 percent of poverty. Twenty percent of patients are diagnosed with diabetes, 15 percent with hypertension, and 3 percent with asthma.

The chief medical officer (CMO) of WeServeEveryone was serving as a quality improvement (QI) committee of one for the clinic until recently when she attended a session at a conference about QI methods for FQHCs. After returning, she engaged your organization to assist her in forming a QI committee, updating the clinic’s QI plan, and identifying some first improvement aims.

Because so many of their patients have diabetes, the CMO and the QI team decided to focus their initial QI work on improving their diabetes care. They are interested in seeing how they are performing on HEDIS* quality indicators for diabetes and comparing themselves to benchmarks from the local community clinic association and those contained in the National Healthcare Quality Report.

The clinic recently hired a care coordinator to help with the care of chronic disease patients. It also recently implemented an electronic health record. One of the clinicians recently realized that entries for foot exams had been mapped incorrectly and were not being captured as part of the comprehensive diabetes care record. This is the only data field that appears problematic at this point.

Dr. Sand thinks the clinic is doing “fine” with diabetes care and does not think it is necessary to look at the data. On the other hand, the CMO, Dr. Likes, is very interested in seeing what the data look like not only for diabetes but also for hypertension and asthma.

* HEDIS stands for Healthcare Effectiveness Data and Information Set.

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Page last reviewed May 2013
Internet Citation: Module 9 Appendix. Content last updated May 2013. Agency for Healthcare Research and Quality, Rockville, MD.