QI Documentation for Performance Improvement CME Please review this form before completing it. All questions marked with an * are mandatory. Incomplete forms will be returned for completion before credit will be recorded. Thank you! Last Name*: First Name*: Primary Degree*:

MD/DO PA NP RN/BSN/MSN PharmD/RPh PhD/PsyD/MSW/LCSW RD Other, please specify:

Kaiser Permanente Provider Number*: Region*: Facility*: Date you are starting this activity*: mm/dd/yyyy

Department*: Administration (medical group) Administration (health plan) Allergy Anesthesiology Cardiology Call Center Chemical Dependency Dermatology Emergency Medicine/Urgent Care Endocrinology Family Medicine Gastroenterology General Surgery/Vascular Surgery Hospitalist Infectious Disease Institute for Healthcare Research Internal Medicine IM/SNF/Palliative Care/Home Health Mental Health Neonatology Nephrology

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Neurology Neurosurgery OB/GYN/Pelvic Surgery/Urodynamics Occupational Medicine Oncology/Hematology Ophthalmology/Retinal Surgery Orthopedics Otolaryngology Pathology Pediatrics Perinatology Physical Medicine Plastic Surgery Preventive Medicine Pulmonology Radiation Oncology Radiology Reproductive Endocrinology Rheumatology Urology Other, please specify

QI Documentation for Performance Improvement CME

Other individuals working on this project with you, who are ACTIVELY INVOLVED in analyzing data, working with targeted patients, and making practice improvements: Name (last, first) Degree KP Provider number (CO only)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

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QI Documentation for Performance Improvement CME Project name:

Goal (Objective) of your Performance Improvement Project (What specifically are you trying to improve?)*

Why did you choose this as a topic?*

Describe your project in detail:*

Skills supported by this activity (check all that apply): X Analyze practice/clinical experience to make improvements X Assimilating/applying evidence to patients & population Select at least 1 response.

Applying clinical guidelines in practice Appropriate documentation Clinician-patient communication Communicating with other members of the health care team Cost effectiveness Culturally responsive care Interdisciplinary care / referrals Patient education Patient safety Patient satisfaction Patient self-care Population management Preventive Care Quality of care Shared decision making Team-based care Other, please specify:

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QI Documentation for Performance Improvement CME Evidence-based source(s) of Information & Measures on which your Performance Improvement project is based (provide specific sources for each item used):* Enter at least 1 response.

Sources of data on your patients used in Improvement Project (check all that apply):* Select at least 1 response.

KP Guidelines are accessible thru the KP Clinical Library Kaiser Permanente National Guideline (specify): KP Colorado Guideline (specify):. Other KP regional Guideline: Region: Region: United States Preventive Services Taskforce http://www.ahrq.gov/clinic/uspstfix.htm Recommendation (indicate specific recommendation): National Guideline Clearinghouse http://www.guideline.gov/ Guideline (indicate specific recommendation): Other practice guideline (specify guideline and source): Meta-analysis/systematic review (include specific article citation): Benchmark/best practice data (describe source): Best practice identified in the literature (include article citation): Other (describe):

Appointment data (access, utilization by appointment, etc.) Art of Medicine/Patient satisfaction/complaints data Chart review or audit – number of charts audited (10 minimum required before and after the intervention): Diagnostic imaging utilization report HealthConnect data (from Clarity reports) HealthTrac patient panel report Laboratory utilization report Peer review data Pharmacy utilization report Referral data Other (Please specify):

Sources of Comparison (Benchmark) Data Used in Improvement Project (check all that apply):*

team/facility department Art of Medicine/Patient satisfaction/complaints data Diagnostic imaging Utilization report HealthTrac/POINT/other registry patient panel report Laboratory utilization Report Pharmacy utilization Report Referral data

Study from the Literature, if used as a benchmark (include citation here):

Other (describe here, if used):

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KP Region

KP National

N/A

QI Documentation for Performance Improvement CME

Start date baseline analysis:*

mm/dd/yyyy

End date of baseline analysis:*

mm/dd/yyyy

Sample size (number of patients) involved in baseline analysis (must be at least 10): DO NOT INCLUDE ANY INFORMATION THAT IDENTIFIES SPECIFIC PATIENTS. For each metric, indicate at least one comparison metric from the previous section. You can enter more than one comparison metric for each measure, but only one is required. You must identify at least one metric for each project; you can have as many as 5. You will use the same metric(s) for your post-project analysis. METRIC 1 BASELINE DATA (list specific metrics, your actual data, either or both peer and literature benchmark data):* METRIC 2 BASELINE DATA (list specific metrics, your actual data, either or both peer and literature benchmark data): METRIC 3 BASELINE DATA (list specific metrics, your actual data, either or both peer and literature benchmark data): METRIC 4 BASELINE DATA (list specific metrics, your actual data, either or both peer and literature benchmark data): METRIC 5 BASELINE DATA (list specific metrics, your actual data, either or both peer and literature benchmark data):

and

and

and

and

and

Specific metric: Your data: Peer comparison data: Literature comparison data: Specific metric: Your data: Peer comparison data: Literature comparison data: Specific metric: Your data: Peer comparison data: Literature comparison data: Specific metric: Your data: Peer comparison data: Literature comparison data: Specific metric: Your data: Peer comparison data: Literature comparison data:

Copyright © 2005 CPMG Department of Education

QI Documentation for Performance Improvement CME In looking at your baseline data, what opportunities do you see to improve performance*? Consider these opportunities when designing your quality improvement intervention.

What barriers do you anticipate to improving performance*? Consider these barriers when designing your quality improvement intervention.

Copyright © 2005 CPMG Department of Education

QI Documentation for Performance Improvement CME Improvement project implementation start date:*

mm/dd/yyyy

Date when you started collecting post-project data:*

mm/dd/yyyy

Methods used in Performance Improvement/Practice Modification Project (check all that apply):*

After visit summary in HealthConnect Collaborative care/shared visits with another specialist Co-management with clinical pharmacist Co-management with nurse care manager Customized order set Customized prescription Decision support tool embedded in HealthConnect Discussion script with patients Documenting patient specific goals and plans in the problem list Dot phrase in HealthConnect Flow sheet in HealthConnect Group visits HealthTrac or other population registry Laminated card P-advice tab in HealthConnect Patient education handout Patient questionnaire Phone visits Postpone and/or forward function in HealthConnect Smart set in HealthConnect Tickler/reminder file Virtual/e-visits (using 'Your Health Record' to communicate with patients) Other, please specify

Copyright © 2005 CPMG Department of Education

QI Documentation for Performance Improvement CME Start date follow-up analysis:* End date of follow-up analysis:*

mm/dd/yyyy mm/dd/yyyy

The metrics entered below should BE THE SAME METRICS as measured in the baseline period. Do NOT include any information that identifies specific patients. Sample size (number of patients) involved in follow-up analysis (must be at least 10): METRIC 1 FOLLOW-UP DATA (list specific metrics, your actual data, and either or both peer and literature benchmark data):* METRIC 2 FOLLOW-UP DATA (list specific metrics, your actual data, and either or both peer and literature benchmark data):

Specific metric: Your data: Peer comparison data: Literature comparison data: Specific metric: Your data: Peer comparison data: Literature comparison data:

METRIC 3 FOLLOW-UP DATA (list specific metrics, your actual data, and either or both peer and literature benchmark data):

Specific metric: Your data: Peer comparison data: Literature comparison data:

METRIC 4 FOLLOW-UP DATA (list specific metrics, your actual data, and either or both peer and literature benchmark data):

Specific metric: Your data: Peer comparison data: Literature comparison data:

METRIC 5 FOLLOW-UP DATA (list specific metrics, your actual data, and either or both peer and literature benchmark data):

Specific metric: Your data: Peer comparison data: Literature comparison data:

Copyright © 2005 CPMG Department of Education

QI Documentation for Performance Improvement CME Things that went well during your Performance Improvement Activity:*

Any surprising learnings? If so, describe.

Next Steps:*

Completion date of this activity*

mm/dd/yyyy

Copyright © 2005 CPMG Department of Education

QI Documentation for Performance Improvement CME Please indicate your level of agreement with the following statements*:

Agree

Neither agree nor Disagree

Disagree

The tool helped me organize my QI project: The tool helped me document my QI project: The instructions for completing the tool were clear:

The most helpful part of this tool was*:

Suggestions for improving this tool:

Please save this document with a name such as “(Lastname)CMEQI(date)”. Keep a copy for your records. Return this form electronically by secure email to David Price, MD at [email protected]. 20 AMA category 1 CME credits ™ will be entered into your record. Thank you for your time!

Copyright © 2005 CPMG Department of Education