Claude Jefferson Case

Cullman Regional Medical Center NPI1295763894

Performance

Public Reporting for Performance Scores

More Details

Final MIPS Score

80.68 out of 100

Score Breakdown

Quality Category Score 72.92
PI Category Score 0

 

IA Category Score 40
Cost Category Score 0
Total Patients: 13
Source of Scores: group

Performance Details

Measure Code Measure Title Performance Rate Patient Count Star Value Five Star Benchmark Collection Type
IA_EC_AHE_6 Provide Education Opportunities for New Clinicians
IA_EC_BE_13 Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.
IA_EC_BE_22 Improved Practices that Engage Patients Pre-Visit
IA_EC_BE_6 Collection and follow-up on patient experience and satisfaction data on beneficiary engagement
IA_EC_CC_15 PSH Care Coordination
IA_EC_CC_8 Implementation of documentation improvements for practice/process improvements
IA_EC_PSPA_13 Participation in Joint Commission Evaluation Initiative
IA_EC_PM_11 Regular Review Practices in Place on Targeted Patient Population Needs
IA_EC_PM_7 Use of QCDR for feedback reports that incorporate population health
IA_EC_PSPA_19 Implementation of formal quality improvement methods, practice changes, or other practice improvement processes
IA_EC_PSPA_20 Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes
IA_EC_PSPA_16 Use of decision support and standardized treatment protocols
IA_EC_PSPA_11 Participation in CAHPS or other supplemental questionnaire
IA_EC_PSPA_28 Completion of an Accredited Safety or Quality Improvement Program
IA_EC_PSPA_8 Use of Patient Safety Tools
IA_EC_PSPA_7 Use of QCDR data for ongoing practice assessment and improvements
MIPS_EC_424_overall Perioperative Temperature Management 100 139 REG
QCDR_EC_AQI62_overall Obstructive Sleep Apnea: Patient Education 100 185 QCDR