LAKE ST. PROVIDER 6

I. 330 HEALTH CARE PLAN

LIFECYCLE / GOAL / 1ST QRTR / 2ND QRTR / 3RD QRTR / 4TH QRTR / 06-07
AVG / 07-08
CUM. AVG / VARIANCE
FROM GOAL
PRENATAL
Prenatal patient completed depression screening (PHQ) / 90%
Prenatal patient completed HIV test during pregnancy. / 95%

NOTE: Data highlighted in red signifies results below goal

Starred (*) items indicate a sample size of three or less

Numbers highlighted in blue indicate set goals for fiscal year

Underlined “ND” indicates indicators that are not consistently documented, unable to measure accurately

LIFECYCLE / GOAL / 1ST
QRTR / 2ND QRTR / 3RD QRTR / 4TH QRTR / 06-07
AVG / 07-08
CUM. AVG / VARIANCE
FROM GOAL
PEDIATRIC
Received DPT3 by 15 mos of age
IPV3 by 15 mos of age
HIB3 by 15 mos of age
Hep B3 by 15 mos of age
Varicella by 15 mos of age / 90%
90%
90%
90%
90%
Received DPT4 by 36 mos of age
IPV3 by 36 mos of age
HIB3 by 36 mos of age
Hep B3 by 36 mos of age
MMR1 by 36 mos of age
Varicella by 36 mos of age / 95%
95%
95%
95%
95%
95%
First immunization visit completed by 3 mos of age / 90%
Breastfeeding status was assessed/breastfeeding education / 95%
If child <6 years of age, was screened for elevated lead levels / 95%

NOTE: Data highlighted in red signifies results below goal

Starred (*) items indicate relatively small sample size

Numbers highlighted in blue indicate set goals for fiscal year

Underlined “ND” indicates indicators that are not consistently documented, unable to measure accurately

LIFECYCLE / GOAL / 1ST
QRTR / 2ND QRTR / 3RD QRTR / 4TH QRTR / 06-07
AVG / 07-08
CUM. AVG / VARIANCE
FROM GOAL
ADOLESCENT
Behavioral-psychosocial risk assessment form is completed / 95%
Adolescents found to be at risk were fully evaluated / 90%
Comprehensive longitudinal family planning counseling was provided to adolescents (contraception, safe sex…) demonstrated by documentation of screening. /
90%

NOTE: Data highlighted in red signifies results below goal

Starred (*) items indicate a sample size of three or less

Numbers highlighted in blue indicate set goals for fiscal year

Underlined “ND” indicates indicators that are not consistently documented, unable to measure accurately

LIFECYCLE / GOAL / 1ST
QRTR / 2ND QRTR / 3RD QRTR / 4TH QRTR / 06-07
AVG / 07-08
CUM. AVG / VARIANCE
FROM GOAL
ADULT
Smoking status is documented / 99%
Patient is a smoker / <18%
Smoking cessation counseling is documented in medical record / 90%
Patient has been screened for cholesterol in past 5 years (starting at age 20) / 80%
If female, patient has had a pap test within the past 3 years / 90%
If patient is > 50, patient was referred/recommended to have colon cancer screening in past 5-10 years / baseline
If patient is > 50, patient has had yearly fecal occult blood test, sigmoidoscopy in past 5-10 years, colonoscopy in past 10 years / 50%
If patient is female and > 40, patient was referred to have mammogram in past 2 years / baseline
If patient is female and > 40, patient has had mammogram in past 2 years / 70%

NOTE: Data highlighted in red signifies results below goal

Starred (*) items indicate a sample size of three or less

Numbers highlighted in blue indicate set goals for fiscal year

Underlined “ND” indicates indicators that are not consistently documented, unable to measure accurately

LIFECYCLE / GOAL / 1ST
QRTR / 2ND QRTR / 3RD QRTR / 4TH QRTR / 06-07
AVG / 07-08
CUM. AVG / VARIANCE
FROM GOAL
GERIATRIC
Chart contains a Geriatric Functional Assessment Form / 95%
If chart contains Functional Assessment Form, it is completed by provider / 80%
Chart contains a preventive health flowsheet / 90%
Patient has been immunized for pneumonia within the past 5 yrs / 50%
Patient has been immunized for influenza this year or most recent flu season / 50%
Patient has been screened for cholesterol in past 5 years (starting at age 20) / 80%
If patient is > 50, patient was referred/ recommended to have colon cancer screening in past 5-10 yrs / baseline
If patient is > 50, patient has had yearly fecal occult blood test, sigmoidoscopy in past 5-10 years, colonoscopy in past 10 yrs / 50%
If patient is female and > 40, patient was referred to have mammogram in past 2 years / baseline
If patient is female and >40, patient has had mammogram in past 2 years / 70%

NOTE: Data highlighted in red signifies results below goal

Starred (*) items indicate a sample size of three or less

Numbers highlighted in blue indicate set goals for fiscal year

LIFECYCLE / GOAL / 1ST
QRTR / 2ND QRTR / 3RD QRTR / 4TH QRTR / 06-07
AVG / 07-08
CUM. AVG / VARIANCE
FROM GOAL
ALL LIFECYCLES
If patient is new, there is a complete family history form / 90%
Patient has documented H&P by the 3rd visit / 90%
Patient’s allergies are documented on problem list / 95%
Patient problem list is updated / 90%
Patient medication list is updated / 90%
Patient received oral health screening and education from their provider / 90%
If an abnormal screen and for all children ages 1-12 years of age, patient was referred to dentist for comprehensive oral health treatment and screening / 90%

NOTE: Data highlighted in red signifies results below goal

Starred (*) items indicate a sample size of three or less

Numbers highlighted in blue indicate set goals for fiscal year

Underlined “ND” indicates indicators that are not consistently documented, unable to measure accurately

II.  DIABETIC COLLABORATIVE

KEY MEASURES / GOAL / 1ST QRTR / 2ND QRTR / 3RD QRTR / 4TH QRTR / 07-08
CUM. AVG / VARIANCE
FROM GOAL
Average HbA1c / < 7.0
Patients with 2 HbA1c’s in last year (at least 3 months apart) / >90%
Documentation of self-management goal setting / >70%
Cardiac Risk Reduction:
Patients 55 years of age and older with a current prescription for ACE inhibitors or ARB medication / >75%
Patients with BP <130/80 / >40%
Patients with dental exam in past year / >70%
Received influenza vaccine during most recent flu season / >90%

Note: All reported diabetic collaborative numbers are tabulated on a cumulative basis and reflect cumulative rather than quarterly findings.

III.  ASTHMA COLLABORATIVE

TOPIC / GOAL / 1ST QRTR / 2ND QRTR / 3RD QRTR / 4TH QRTR / 07-08
CUM. AVG / VARIANCE
FROM GOAL
Patients with current severity assessment / >90%
Patients appropriately treated with anti-inflammatory medication / >95%
Documentation of self-management goal setting / >70%
Average symptom free days in previous two weeks / >10 days
Received influenza vaccine during most recent flu season / >90%

Note: All reported asthma collaborative numbers are tabulated on a cumulative basis and reflect cumulative rather than quarterly findings.

IV. PRODUCTIVITY (OUTPATIENT ACTIVITY)

LAKE ST.

VOLUME / GOAL / 1ST QRTR / 2ND QRTR / 3RD QRTR / 4TH QRTR / 07-08
CUM. AVG / VARIANCE
FROM GOAL
LAKE ST.
OUTPATIENT ENCOUNTERS / 474
PERCENTAGE / 100%

INTERFAITH HOUSE

VOLUME / GOAL / 1ST QRTR / 2ND QRTR / 3RD QRTR / 4TH QRTR / 07-08
CUM. AVG / VARIANCE
FROM GOAL
INTERFAITH HOUSE
OUTPATIENT ENCOUNTERS / 30
PERCENTAGE / 100%

V.  INPATIENT UTILIZATION

N/A

VI. PATIENT SATISFACTION

MEASURE / GOAL / 1ST QRTR / 2ND QRTR / 3RD QRTR / 4TH QRTR / 07-08
CUM. AVG / VARIANCE
FROM GOAL
Patient satisfaction with provider / 4.25

Patient comments: