The document outlines various clinical quality performance indicators and goals for a healthcare organization. It provides data on metrics related to prenatal care access, low birth weights, weight assessment for children, adult weight screening, tobacco cessation, cancer screenings, immunizations, chronic disease management, and behavioral health. Charts show the organization's performance compared to national benchmarks and goals over time.

1. Clinical Quality Performance Indicators
Summary

2. Prenatal Care
Access to Prenatal Care
Goal: 90% of pregnant women will enter prenatal care in the
1st trimester of pregnancy
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (90%) 2016 National
(74%)
2015 (71%) 2016 (93%) 2017 (100%) Q1 2018 (100%)
Prenatal Health

3. Low Birth Weights
Goal: 0% of children will be born at low-birth weights
(<2500g)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (0%) 2016 National
(8%)
2015 (0%) 2016 (50%) 2017 (0%) Q1 2018 (0%)
Low-Birth Weights

4. Weight Assessment and Counseling for Children and Adolescents (ages 3 to 17 years)
Goal: 80% of children, ages 3 to 17, with a recorded BMI percentile will have
documentation of counseling for nutrition and physical activity during the
measurement year that is appropriate for the BMI.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (80%) 2016 National
(63%)
2015 (73%) 2016 (81%) 2017 (64%) Q1 2018 (76%)
Weight Assessment and Counseling in Children
Preventative Health Maintenance

5. Adult Weight Screening and Follow-Up Care
Goal: 88% of patients 18 and older will have a BMI recorded during the most
recent visit or within six months of the most recent visit and will have a
follow-up plan documented when the BMI is outside of normal parameters.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (88%) 2016 National
(62%)
2015 (90%) 2016 (83%) 2017 (70%) Q1 2018 (86%)
Adult Weight Screening and Follow-Up Care

6. Tobacco Use Screening and Cessation Intervention
Goal: 90% of patients 18 years and older who were screened for tobacco use
one or more times within the past 24 months will receive cessation
counseling intervention if identified as a tobacco user.
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Goal (90%) 2016 National
(85%)
2015 (83%) 2016 (89%) 2017 (89%) Q1 2018 (89%)
Tobacco Use and Cessation Intervention

7. Colorectal Cancer Screening
Goal: 42% of adults 50-75 years of age will have appropriate screening for
colorectal cancer.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (42%) 2016 National
(40%)
2015 (31%) 2016 (27%) 2017 (41%) Q1 2018 (71%)
Colorectal Cancer Screening

8. Cervical Cancer Screening
Goal: 70% of women 23-64 years of age will receive one or more pap tests to
screen for cervical cancer. Women age 23-64 who had a cervical cancer
(cytology) every 3 years & women age 30-64 years of age who had cervical
cytology/ human papillomavirus co-testing every 5 years.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (70%) 2016 National
(54%)
2015 (64%) 2016 (51%) 2017 (67%) Q1 2018 (63%)
Cervical Cancer Screening

9. Childhood Immunizations
Goal: 60% of children two years of age who had appropriate immunizations.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (60%) 2016 National
(43%)
2015 (81%) 2016 (45%) 2017 (47%) Q1 2018 (42%)
Childhood Immunizations

10. Oral Health Sealants
Goal: 70% of children 6 to 9 years, at moderate to high risk of caries will receive
dental sealants.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (70%) 2016 National
(49%)
2015 (42%) 2016 (81%) 2017 (54%) Q1 2018 (63%)
Oral Health Sealants

11. Depression Screening and Follow-Up
Goal: 75% of patients 12 years and older screened for clinical depression and
found positive on screening for depression will have a follow-up plan
documented on the date of the positive screen.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (75%) 2016 National
(60%)
2015 (39%) 2016 (56%) 2017 (63%) Q1 2018 (77%)
Depression Screening and Follow-Up

12. Asthma Treatment
Goal: 84% of patients with having persistent asthma were prescribed the
appropriate medications.
Chronic Disease Management
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Goal (84%) 2016 National
(87%)
2015 (48%) 2016 (76%) 2017 (93%) Q1 2018 (71%)
Asthma Treatment

13. Coronary Artery Disease and Lipid Lowering Therapy
Goal: 80% of patients 18 years and older with a diagnosis of Coronary Artery
Disease (CAD) will be prescribed a lipid lowering therapy.
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Goal (80%) 2016 National
(79%)
2015 (75%) 2016 (78%) 2017 (91%) Q1 2018 (92%)
CAD and Lipid-Lowering Therapy

14. Ischemic Vascular Disease and Use of Aspirin or Another Antithrombotic
Goal: 80% of patients 18 years and older with Ischemic Vascular Disease (IVD)
will have documentation of use of aspirin or another antithrombotic during
the measurement year.
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Goal (80%) 2016 National
(78%)
2015 (73%) 2016 (78%) 2017 (83%) Q1 2018 (67%)
IVD and Treatment

15. Blood Pressure Control
Goal: 72% of patients 18-85 years of age will have blood pressure adequately
controlled (<140/90).
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Goal (72%) 2016 National
(62%)
2015 (67%) 2016 (67%) 2017 (67%) Q1 2018 (71%)
Blood Pressure Control

16. Diabetes Control
Goal: 22 % or less of diabetic patients will have a Hemoglobin A1C > 9.0%.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (22%) 2016 National
(32%)
2015 (24%) 2016 (25%) 2017 (26%) Q1 2018 (22%)
Diabetes Control

17. HIV Linkage into Care
Goal: 100% percent of patients diagnosed with HIV will be linked into care
within 90 days of diagnosis.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (100%) 2016 National
(83%0
2015 (100%) 2016 (100%) 2017 (100%) Q1 2018
(100%)
HIV Linkage to Care

18. HIV Testing
Goal: 25% of patients 16 to 64 years of age seen in the last 12 months will be
screen at least once in their lifetime for HIV.
Other Performance Indicators Chosen by CFHC, Inc.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (20%) 2015 (13%) 2016 (38%) 2017 (49%) Q1 2018 (38%)
HIV Testing

19. HIV and Dental Care
Goal: 25% of HIV patients will have a documented dental exam with a dentist
in the measurement year.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (25%) 2016 (19%) 2017 (26%) Q1 2018 (9%)
HIV and Dental Care

20. Migrant Seasonal Farmers Workers and Green Tobacco Sickness/Pesticide
Counseling
Goal: 55% of Migrant Season Farmworkers will receive education on green
tobacco sickness/pesticides.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (55%) 2015 (79%) 2016 (51%) 2017 (66%) Q1 2018 (72%)
MSFW and GTS/Pesticide Counseling

21. Breast Cancer Screening
Goal: 65% of women ages 40-64 years old will be screened for breast cancer
at least every two years.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (65%) 2015 (76%) 2016 (74%) 2017 (58%) Q1 2018 (61%)
Breast Cancer Screening

22. Hepatitis C Screening
Goal: 30% of adults born between the years 1945-1965 will be screened for
Hepatitis C.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (30%) 2016 (17%) 2017 (58%) Q1 2018 (54%)
Hepatitis C Screening

23. Diabetes and Foot Exams
Goal: 65% of diabetic patients will receive a foot exam annually.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (65%) 2015 (63%) 2016 (31%) 2017 (32%) Q1 2018 (34%)
Diabetes and Foot Exams

24. Diabetes and Retinal Eye Exams
Goal: 35% of diabetics will have a retinal eye exam.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (35%) 2015 (11%) 2016 (13%) 2017 (18%) Q1 2018 (20%)
Diabetes and Retinal Eye Exams

25. Depression and Use of the PHQ9 Tool to Monitor Treatment
Goal: 85% of the patients diagnosed with depression will have a PHQ9
completed and on file to monitor treatment outcomes.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goal (85%) 2015 (79%) 2016 (84%) 2017 (70%) Q1 2018 (72%)
Depression and PHQ9