Achieving TCPi Milestones with VCSQI

Practice has met its targets and has sustained improvements in practice-identified metrics for at least one year.

Practice has reduced unnecessary tests, as defined by the practice.

Practice has reduced unnecessary hospitalizations.

Practice can demonstrate that it encourages patients and families to collaborate in goal setting, decision making, and self-management.

Practice has a formal approach to obtaining patient and family feedback and incorporating this into the QI system, as well as the strategic and operational decisions made by the practice.

Practice sets clear expectations for each team member’s functions and responsibilities to optimize efficiency, outcomes, and accountability.

Practice has a reliable process in place for identifying risk level of each patient and providing care appropriate to the level of risk. Risk identification may be done within the specialty practice or may be obtained from the patient's primary care provider. Practice ensures that patients assessed to be at highest risk receive care management support or have a care plan in place that the practice is following.

Practice facilitates referrals to appropriate community resources, including community organizations and agencies as well as direct care providers.

Practice works with the primary care practices in its medical neighborhood to develop criteria for referrals for episodic care, co-management, and transfer of care/ return to primary care, processes for care transition, including communication with patients and family.

Practice identifies the primary care provider or care team of each patient seen and (where there is a primary care provider) communicates to the team about each visit/ encounter.

Practice uses evidence -based protocols or care maps where appropriate to improve patient care and safety.

Practice has a system in place for patient to access their care team 24/7.

Practice has developed a vision and plan for transformation that includes specific clinical outcomes and utilization aims that are aligned with national TCPI aims and that are shared broadly within the practice.

Practice uses an organized approach (e.g. use of PDSAs, Model for Improvement, Lean, FMEA, Six Sigma) to identify and act on improvement opportunities.

Practice builds QI capability in the practice and empowers staff to innovate and improve.

Practice regularly produces and shares reports on performance at both the organization and provider/care team level, including progress over time and how performance compares to goals. Practice has a system in place to assure follow up action where appropriate.

Practice uses technology to offer scheduling and communication options that improve patient access by including alternative visit types and electronic communication approaches.

Practice uses sound business practices, including budget management and return on investment calculations.

Practice has effective strategies in place to cultivate joy in work and can document results.

Practice shares financial data in a transparent manner within the practice and has developed the business capabilities to use business practices and tools to analyze and document the value the organization brings to various types of alternative payment models.

Practice considers itself ready for migrating into an alternative based payment arrangement.