1. Quality Improvement the YNHS Way

2. Who do we report to? Our Patients Our BoardPCMH Meaningful Use UDS

3. I have to report what to who?

4. PCMH Meaningful Use UDS Each piece, or entity, can link together to make a cohesive whole

5. YNHS QI Schedule Aspect of CareRationaleQuality IndicatorBenchmark EPSDT Early and Periodic Screening, Diagnosis and treatment HEDIS® HCA High Risk High Volume Population specific 6 or more well child visits in the first 15 months of life. MammographyHEDIS® HCA Clinical measures High Risk High volume Population specific Percent of women age 40 through 69, who have received a mammogram during the previous 2 years 2010 HEDIS® Report Medicaid Average – 52.4%

6. Quality Committee Structure – Previously the committee consisted of the entire management team (20+ people) – Changed 1 year ago to include the CEO, COO, Medical Directors, Dental Director, Nursing Director and QI Director Responsibilities – The CEO and COO have the 30,000 foot view of the “entities” and what is needed to support our efforts (reporting capabilities, Collaboratives, etc.) – Medical Directors, Dental Director and Nursing Director have the knowledge of workflow, EHR/EDR functionality, provider and support staff buy in – QI Director generates the reports (Deep Domain, SSRS, EPM/EHR), summarizes and presents the findings, monitors the standards and requirements