Step 2: Determine Your Goal

When you are setting out to improve patient care, you need to be able to measure what you are improving and have a clear understanding of what you want to achieve. Your goal will answer the question, “What are we trying to accomplish?” and creates a shared language to communicate about your project. Your goal should be specific, measurable, attainable, relevant, and time based. A good goal will help define the measure.

Here are some criteria to consider when evaluating your goal:

• Is it clear what is expected to happen and by when?
• Is the population defined?
• Are specific numeric goals clearly stated?

1. What is Your Desired Level of Improvement Over the Baseline?

Benchmarking for Quality Measures

Goal setting, or benchmarking, compares an organization’s performance with those of similar organizations, or nationally-recognized targets or goals. With the rise of public reporting and value-based payment models, it is important to set up your practice for success by using recognized benchmarks and targets. This helps avoid payment penalties and allows you to receive incentives tied to quality.

The targets below are for Adult Immunizations, from Healthy People 2020, a national health promotion and disease prevention initiative. Some of the measures listed are from the 2018 Physicians Quality Reporting System (PQRS), a reporting program that uses a combination of incentive payments and adjustments to promote reporting quality information by providers. The PQRS program ties quality outcomes to payments through the application of the Value-Based Payment Modifier, a Medicare value-based payment program.

Healthy People 2020 Immunization Targets:

• Influenza: Adults > 18 years – 70% (PQRS measure)
• Pneumococcal: Adults > 65 years – 90% (PQRS measure)
• Zoster: > 60 years – 30%

Alcohol Screening and Brief Intervention Targets:

USPSTF recommends screening for unhealthy alcohol use in primary care settings in adults 18 years or older, including pregnant women, and providing persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use.

Increase in percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user.

Ex. 10% increase in baseline percentage after 12 months or 3 rapid cycles