Provider Insider

Quadruple Aim progress report

Fall 2017 | Issue No. 1

Measuring performance and setting targets

Here’s the exciting news: Coordinated Care’s Clinical Committee obtained approval from the board of directors to monitor a clearly defined set of key performance indicators (KPIs). These metrics are a means to quantify the performance of the clinical quality improvement efforts implemented by our network partners, agnostic of value-based arrangements (i.e., payer arrangements and government programs).


The Clinical Committee selected six (6) KPIs for 2018 and 2019, across two domains: Chronic Disease Management and Prevention. How were they selected? The Clinical Transformation Workgroup used these guiding principles to nominate, discuss and refine each of the KPIs mentioned below:

  • Do they positively influence patient outcomes?
  • Do they positively influence the Quadruple Aim (improvement in population health, patient experience, per capita cost and provider experience)?
  • Do they positively influence the quality performance among the Network’s value-based arrangement?


Diabetic patients a primary focus

Care for our diabetic patients was chosen as the Network’s main focus for 2018. Here’s why:

  1. A single focus allows Coordinated Care to explicitly assign resources for optimal outcomes.
  2. Allows the Network to evaluate the direct correlation between improvement efforts implemented and improved patient outcomes.
  3. Diabetes is a high-cost disease, both monetarily and physically.
  4. Diabetes is a chronic condition tracked by all our value-based arrangements (commercial and government payers).
  5. Since diabetes increases in prevalence among older populations—and our Medicare programs are a majority of the lives managed—addressing this chronic condition will positively affect a significant portion of the population.
  6. There is significant improvement to be captured in obtaining ophthalmology/optometry records.

CHRONIC DISEASE MANAGEMENT is for conditions where high-quality primary care intervention can potentially prevent the need for hospitalization, or where early intervention can prevent complications or more severe disease.

  • KPI 1. Diabetes Composite Metric—unique patients ages 18–75 years of age who have type 1 or type 2 diabetes diagnosis on their problem list, have had an A1c > 6.5 percent in the past 24 months, have had two (2) encounters with a diabetes diagnosis in the past 24 months, compared to patients who satisfy the criteria for the four (4) components of the diabetes composite:
    • HbA1c Control—the percentage of patients 18–75 years of age with diabetes who had A1c > 8 percent or no A1c value in the past 12 months.
    • Diabetes Blood Pressure Control—unique patients 18–75 years of age who have a diabetes diagnosis on their problem list who have had an encounter within the past 24 months AND whose most recent blood pressure is < 140/90 mmHg.
    • Diabetes Eye Exam—percentage of patients 18–75 years of age who have a diabetes diagnosis on their problem list who had an eye exam performed to screen for diabetic retinal disease.
    • Diabetic Nephropathy Prevention and Treatment—the percentage of patients 18–75 years of age who have a diabetes diagnosis who are on an ACE or ARB OR have completed a nephropathy screening within the past 12 months.
  • KPI 2. Hypertension—percentage of patients 18–85 years of age who had a diagnosis of hypertension and whose blood pressure was < 140/90 mmHg during the reporting period.

PREVENTION and diagnostic interventions detect or monitor health issues to maintain patient well-being or mitigate complications. Here are the four areas of focus:

  • KPI 3. Breast Cancer Screening—the percentage of patients ages 50–74 who have had a mammogram in the past two years.
  • KPI 4. Colorectal Cancer Screening—the percentage of patients ages 50–75 who have had the appropriate screening for colorectal cancer.
  • KPI 5. Pneumococcal Vaccine—the percentage of patients 65 years of age and older who have ever received or have documented historical administration in the administration in the immunization module of a 13-valent pneumococcal conjugate vaccine (PCV13, Prevnar13) OR a 23-valent pneumococcal polysaccharide vaccine (PPSV23, Pneumovax23).
  • KPI 6. Cervical Cancer Screening—the percentage of women ages 21–64 who have completed the appropriate cervical cancer screenings.

Sharing information is critical to success

Now that we have identified our KPIs, tracking and reporting is important. Beginning in 2018, regularly scheduled reports will be disseminated to the appropriate groups through a multitier approach to ensure awareness, engagement and action. Want to play a role in accelerating our Quadruple Aim vision? Get involved. Talk to your peers. Share our progress with your staff, and encourage new and innovative ideas.


Tier 1 Sample Report

Tier 2 Sample Report

Tier 3 Sample Report