Clinical Quality Measures

In Spring 2022, the introduction of HRSA’s Community Health Quality Recognition (CHQR) measures and a review of Healthy People 2030 (HP 2030) measures and targets prompted a review and update of Quality Measures for the HCCN. A subcommittee of the Connections Advisory Committee reviewed a matrix of various program measures along with CHQR and HP 2030 targets, then selected the following 11 measures for the HCCN to focus on in the future. In July, the Committee recommended, and the Community Care Board of Directors approved, these measures and targets for Health Center Connections.

2021 UDS  Targets
Measure Performance Gold Silver Rationale
Body Mass Index (BMI) Screening and Follow-Up Plan 73.5% 83.1% 78.3% Gold – CQHR
Silver – median of perf and gold
Breast Cancer Screening 48.0% 77.1% 62.6% Gold – HP 2030
Silver – median of perf and gold
Cervical Cancer Screening 57.3% 84.3% 70.8% Gold – HP 2030
Silver – median of perf and gold
Childhood Immunization Status 39.5% 48.4% 24.8% Gold – median of top half
Silver – median of bottom half
Before choosing, eliminated 6 PHCs with a denominator < 50.
Colorectal Cancer Screening 39.9% 74.4% 57.2% Gold – HP 2030
Silver – median of perf and gold
Controlling High Blood Pressure 60.2% 80% 60.8% Gold – CQHR/MH
Silver – CHQR/HP 2030
Dental Sealants 77.3% 85.6% 59.3% Gold – median of top 4
Silver – median of bottom 4
Before choosing, eliminated 7 PHCs with a denominator < 50.
Depression Remission at 12 Months 7.8% 18.2% 13% Gold – CQHR
Silver – median of perf and gold
Diabetes: HbA1c Poor Control (>9.0%) 32.5% 11.6% 22.1% Gold – CHQR/HP 2030
Silver – median of perf and gold
Screening for Depression and Follow-Up Plan 79.4% 90% 80.5% Gold – previous target
Silver – CHQR
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents 66.7% 77.4% 72.1% Gold – CQHR
Silver – median of perf and gold

In late 2018, participants in the Connections Quality Forum added the 4 italicized measures below to the list for future Forum sessions. At the same time, Bronze targets were dropped. From 2018 through July 2022, the HCCN Project Team provided T/TA toward improvement in these measures through the Quality Forum sessions, monthly check-ins, and other forms of assistance.

2019-July 2022 Measures of Focus Gold Target Silver Target
Body Mass Index (BMI) Screening and Follow-Up Plan
>=72% >=58%
Breast Cancer Screening >=55% >=48%
Cervical Cancer Screening >= 93% >= 65%
Childhood Immunization Status >= 80% >= 30%
Colorectal Cancer Screening >= 70.5% >= 50%
Controlling High Blood Pressure >= 75% >= 70%
Dental Sealants >=60% >=28.1%
Diabetes: HbA1c Poor Control (>9.0%) <= 16.1% <= 25%
Screening for Depression and Follow-Up Plan >= 90% >= 85%
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents >=92% >=80%

In late 2017, participants of the Connections Quality Forum identified 6 measures and targets to focus on during 2018 Forum sessions.

2018 Measures of Focus Gold Target Silver Target Bronze Target
Cervical Cancer Screening >= 93% >= 65% >=50%
Childhood Immunization Status >= 80% >= 30% >=20%
Colorectal Cancer Screening >= 70.5% >= 50% >=40%
Controlling High Blood Pressure >= 75% >= 70% >=61.2%
Diabetes: HbA1c Poor Control (>9.0%) <= 16.1% <= 25% <=40%
Screening for Depression and Follow-Up Plan >= 90% >= 85% >=80%