U.S. Department of Health and Human Services

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 – 2014 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 principles that are important to achieve recognition:
  • Access to care for patients
  • Team-based care, with all team members working at the highest potential
  • Care management support
  • Care coordination and care transition
  • Performance measurement
  • Continuous quality improvement

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

Improving Chronic Illness Care

The MacColl Center for Healthcare Innovation has helped pioneer improvements and advances in primary care. The Center’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. 

Tools You Can Use

View a video by a Baldrige Winner: https://youtu.be/JtZ7pblJ8pE

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

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, 852KB) 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.


1. The Baldrige Performance Excellence Framework. 2013. Available at http://www.sixdisciplines.com/services/thebaldrigeperformanceexcellenceframework

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