Form #4 Form #4 Primary Care Practice Profile (PCPP)

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

P

Public reporting burden for this collection of information is estimated to average 30 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

rimary Care Practice Profile

Primary Care Practice Profile – Modified

A. Purpose: Why does your practice exist?

Site Name:

Site Contact:

Date:

Practice Manager:

MD Lead:

Nurse Lead:

B. Know Your Patients: Take a close look into your practice, create a “high-level” picture of the PATIENT POPULATION that you serve. Who are they? What resources do they use? How do the patients view the care they receive?

Est. Age Distribution of Patients:

%

List Your Top 10 Diagnoses/Conditions

Top Referrals (e.g. GI Cardiology)

Birth-10 years

1.

6.

11-18 years

2.

7.

19-45 years

3.

8.

46-64 years

4.

9.

65-79 years

5.

10.

80 + years

Patients who are frequent users of your practice and their reasons for seeking frequent interactions and visits

Other Clinical microsystems you interact with regularly as you provide care for patients (e.g. OR, VNA)

Pt Population Census: Do these numbers change by season? (Y/N)

#

Y/N

% Females

Est. # (unique) pts. In Practice

Patients seen in a day

Patients seen in last week

Disease Specific Health Outcomes, pg 24

New patients in last month

Disenrolling patients in last month

Diabetes HgA1c =

Encounters per provider per year

Hypertension B/P =

Out of Practice Visits

LDL <100 =

Condition Sensitive Hospital Rate

Emergency Room Visit Rate

C. Know Your Professionals: Use the following template to create a comprehensive picture of your practice. Who does what and when? Is the right person doing the right activity? Are roles being optimized? Are all roles who contribute to the patient experience listed? What hours are you open for business? How many and what is the duration of your appointment types? How many exam rooms do you currently have? What is the morale of your staff?

Current Staff

FTEs

Comment/ Function

3rd Next Available

Cycle Time

Days of Operation

Hours

Enter names below totals Use separate sheet if needed

PE

Follow-up

Range

Monday

Tuesday

MD Total

Wednesday

Thursday

Friday

Saturday

NP/PAs Total

Sunday

Do you offer the following? Check all that apply.

Group Visit

RNs Total

E-mail

Web site

RN Clinics

LPNs Total

Phone Follow-up

Phone Care Management

Disease Registries

LNA/MAs Total

Protocols/Guidelines

Appoint. Type

Duration

Comment:

Secretaries Total

Others:

Do you use Float Pool?

____

Yes

____

No

Do you use On-Call?

____

Yes

____

No

E. Know Your Patterns: What patterns are present but not acknowledged in your microsystem? What is the leadership and social pattern? How often does the microsystem meet to discuss patient care? Are patients and families involved? What are your results and outcomes?

Does every member of the practice meet regularly as a team?

Do the members of the practice regularly review and discuss safety and reliability issues?

What have you successfully changed?

What are you most proud of?

How frequently?

What is your financial picture?

0

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005