Resources and Tools for Self-Assessment

Specific tools and resources that can enable practices to assess their care delivery structures and processes are described as follows.

National Committee for Quality Assurance – 2017 Medical Home Components

The National Committee for Quality Assurance (NCQA) is the formal body that develops criteria for Patient Centered Medical Home (PCMH) Recognition.

There are six concepts that are important to achieving recognition:

  • Team-based care and practice organization
  • Knowing and managing your patients
  • Patient-centered access and continuity
  • Care management and support
  • Care coordination and care transitions
  • Performance measurement and quality improvement

Practices can download the specific criteria in these domains, work toward completing a self-assessment against these criteria, and enroll directly on the NCQA website.

Improving Primary Care

The MacColl Center for Healthcare Innovation has helped pioneer improvements and advances in primary care. The Center developed the Primary Care Team Guide, a website that provides advice and resources to help primary care teams transform to be more effective and improve patient care.

Improving Chronic Illness Care

The MacColl Center for Healthcare Innovation’s work includes practice level self-assessment in chronic care delivery. It also provides practice facilitation and coaching, resources for primary care teams and information about the Patient Centered Medical Home.

The MacColl Center’s self-assessment tool, the Assessment of Chronic Illness Care (ACIC), can be downloaded and self-scored. Find the resources at The Assessment of Chronic Illness Care (PDF, 149 KB).

The Patient Assessment of Care for Chronic Conditions (PACIC), a self-assessment geared to obtain patient feedback, can also be found on the site at PACIC Survey.

ACP Practice Advisor

The American College of Physicians has developed the ACP Practice Advisor (formally known as the Medical Home Builder) to help practices learn how to run optimally. There are multiple modules to assist in practice transformation, including:

  • Building the Foundation— enables self-assessment against key attributes and expectations of the Patient Centered Medical Home to prepare for formal certification as a PCMH or to simply allow practices to provide care in a more patient centered manner.
  • Specialty Practice Recognition— provides a self-assessment resource for practices attempting to build bridges between providers, clinics, hospitals and other care providers.
  • Improving Clinical Care— offers practices tools to deliver better care for specific populations (such as diabetes).
  • Managing Your Practice— provides tools to allow practices to deliver more efficient and effective care.
  • Maintenance of Certification (MOC)— enables health care professionals to obtain MOC credit for performing self-evaluation of a practice.

Resources are available at ACP Practice Advisor | Patient-Centered Medical Home.

Practices are advised to stay current on PCMH criteria and self-assessment scores.

Baldrige Criteria for Performance Excellence

The President of the United States gives the Baldrige Award to for-profit, education, health care and nonprofit organizations that apply and are judged to be outstanding in seven areas of performance excellence. It is important for health care leaders to understand the different components of the Baldrige Performance Excellence framework1 (even at a high level) to assure that they are familiar with critical elements required for excellent performance. These include:

  1. Leadership
  2. Strategic planning
  3. Customer focus
  4. Measurement and analysis
  5. Workforce (e.g., Do they learn and grow?)
  6. Operational processes (e.g., Are they efficient and do they eliminate waste?)
  7. Results (e.g., Do they show a strong financial return on investment?)

To learn more about the Baldrige award, the Health Care Criteria Category and Item Commentary (PDF, 639 KB) provides brief summaries of the health care criteria for performance excellence and provides examples and guidance. Lessons from the Baldrige winners in health care describes how three health care organizations won the Baldridge Award.

Bridges to Excellence

In order to recognize practices that provide excellent care, the NCQA helped develop the Bridges to Excellence Program (BTE), of which diabetes is one of several conditions that practices can apply for recognition. The BTE Diabetes Care Recognition Program allows practices to submit performance metrics online for blood pressure, LDL control, documented ophthalmologic exams, documented tobacco status and cessation advice, nephropathy assessment, podiatry exams and documented body mass indexes.

There are three levels of recognition:

Level 1: Clinicians-centric measurement of individual metrics
Level 2: Movement towards composite metrics as well as defect rates of poor control measures on a per patient basis
Level 3: Focus on a patient-centered view where clinicians must demonstrate that they are using advanced processes and delivering all the right care on a per patient basis

The Quality Payment Program

The Quality Payment Program (QPP) is the new clinician payment system under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The primary goal of the QPP is to reward clinicians for quality patient outcomes, rather than paying for the volume of services provided. Regardless of whether a clinician participates in the Merit-Based Incentive Payment System (MIPS) or an Advanced Alternative Payment Model (Advanced APM), clinicians will be assessed on the quality of care provided.

Other Self-Assessment Opportunities

Professional societies such as the American Board of Internal Medicine and the American Academy of Family Practice provide tools to perform practice assessments in the context of Maintenance of Certification.

The Indian Health Services developed a workbook (PDF, 852 KB) to provide a resource for assessment and evaluation of diabetes programs, and it also has useful information and tools to assist with assessment and goal setting.