Vicki Lynn Cheshire

NPI1407923980

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: 50
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_PSPA_13 Participation in Joint Commission Evaluation Initiative
IA_EC_CC_8 Implementation of documentation improvements for practice/process improvements
IA_EC_PM_7 Use of QCDR for feedback reports that incorporate population health
IA_EC_PM_11 Regular Review Practices in Place on Targeted Patient Population Needs
IA_EC_PSPA_20 Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes
IA_EC_PSPA_19 Implementation of formal quality improvement methods, practice changes, or other practice improvement processes
IA_EC_PSPA_11 Participation in CAHPS or other supplemental questionnaire
IA_EC_PSPA_16 Use of decision support and standardized treatment protocols
IA_EC_PSPA_8 Use of Patient Safety Tools
IA_EC_PSPA_28 Completion of an Accredited Safety or Quality Improvement Program
IA_EC_PSPA_7 Use of QCDR data for ongoing practice assessment and improvements
MIPS_EC_424_overall Perioperative Temperature Management 100 124 REG
MIPS_EC_430_overall Prevention of Post-Operative Nausea and Vomiting (PONV) Combination Therapy 100 130 REG
QCDR_EC_AQI62_overall Obstructive Sleep Apnea: Patient Education 100 1132 QCDR