ABMS Portfolio ProgramNew QI Activity form

ABMS Portfolio Program

New QI Activity form

QI Activity Title*

QI Activity Start Date*

QI Activity Anticipated End Date*

Note: If the QI Activity is 'continuous' or 'ongoing', the end date should be listed as 1/1/2099.

QI Activity Leader name*

QI Activity Leader email*

QI Activity Leader phone number*

Phone

Select up to five relevant topics for this QI Activity*

Select

Indicate the other topic area*

Select one or more medical specialties addressed as part of this QI Activity*

Select

Funding for this QI Activity meets Portfolio Program Requirements.*

Select

Provide a one-sentence AIM statement for this QI Activity below*

Example AIM statement:

We will [improve, increase, decrease] the [number, amount, percent] of [the process/outcome] from [baseline measure] to [goal measure] by [date].

Complete a section below for each measure used in the QI Activity, if known. If there aren't enough sections, you can upload a document with additional information at the bottom of this form.

Note: A patient outcome is not required though HIGHLY desirable.

Measure 1

Target Population

Include all inclusionary and exclusionary criteria

Measure Title

Measure Type

Outcome, Process, Balancing

Measure Source

HEDIS, PCPI, Medicare 5*, internal, USPSTF, etc.

Numerator

Denominator

Baseline Rate

Individual, clinic, practice, organization

Target Rate

Individual, clinic, practice, organization

Benchmark and Source (as available)

This can be from the literature

Measure 2

Target Population

Include all inclusionary and exclusionary criteria

Measure Title

Measure Type

Outcome, Process, Balancing

Measure Source

HEDIS, PCPI, Medicare 5*, internal, USPSTF, etc.

Numerator

Denominator

Baseline Rate

Individual, clinic, practice, organization

Target Rate

Individual, clinic, practice, organization

Benchmark and Source (as available)

This can be from the literature

Describe the types of interventions and tools that are being, were, or will be used by participants in the QI Activity and describe how each will impact individual practice and patient care.

Note:

We recognize that interventions may be added, removed and/or modified to meet the needs of the individual practice as QI work progresses.
You must complete, at a minimum, the impact on patient care and individual practice at this point. If you do not know interventions/tools at this point, indicate “Unknown at this time”.

Intervention/Tool Type and Description #1*

E.G.; We have a checklist that prints from our EMR for adult PCP visits; we had HTN added for every visit for every pt. 18+

How will this impact individual practice?*

E.G.; Will lengthen individual visit time for every patient who screens high

How will this impact patient care?*

E.G.; This change ensures that every patient 18 and older who is seen at least annually is screened for hypertension regardless of the type of visit

Intervention/Tool Type and Description # 2

E.G.; We have a checklist that prints from our EMR for adult PCP visits; we had HTN added for every visit for every pt. 18+

How will this impact individual practice?

E.G.; Will lengthen individual visit time for every patient who screens high

How will this impact patient care?

E.G.; This change ensures that every patient 18 and older who is seen at least annually is screened for hypertension regardless of the type of visit

Physicians/PAs will engage in this QI work in the following way(s) (select all that apply)*

Select

Individual participants in this QI Activity will complete the following.*

Identify and/or review data related to the gap(s).
Identify or acknowledge appropriate intervention(s) designed to improve the gap(s), OR participate in the planning and selection of intervention(s) designed to improve the gap(s).
Implement intervention(s) for a timeframe appropriate to addressing the gap(s), OR monitor and manage implementation of intervention(s) for a timeframe appropriate to addressing the gap(s).
Review data related to the gap(s).
Reflect on outcomes to determine whether the intervention(s) resulted in improvement. If no improvement occurs after an intervention, diplomates must reflect on why no improvement occurred.
Attest to meeting the above requirements and obtain the attesting signature of the project leader or person in a position of authority.

Select

By submitting this QI Activity, you are agreeing to share project level information (Aim Statement, Measures, and Interventions) with other Portfolio Sponsors.*

No outcomes data will be shared without express permission from you.

Select

Please upload any additional documentation you would like to include.

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