To determine the appropriate action for the provider based on the Ongoing Professional Practice Evaluation (OPPE) profile shown, we first assess how many measures meet the thresholds set by the organization and categorize the provider's performance according to the provided criteria:
Timely Medical Record Documentation: Current performance is 95%, which meets the threshold of 90%.
Readmission Rate: Current performance is 13%, which does not meet the threshold of 10%.
Surgical Site Infection Rate: Current performance is 9%, which does not meet the threshold of 5%.
Use of Pre-procedure Timeouts: Current performance is 100%, which meets the threshold of 100%.
Patient Experience Score (Top Box): Current performance is 94%, which meets the threshold of 80%.
Clinical Pathway Adherence: Current performance is 81%, which meets the threshold of 70%.
Out of these six measures, four measures meet or exceed the threshold:
Timely Medical Record Documentation
Use of Pre-procedure Timeouts
Patient Experience Score (Top Box)
Clinical Pathway Adherence
This constitutes meeting the threshold in approximately 67% of the measures (4 out of 6).
According to the OPPE criteria:
Fully Meets: >80% of measures at threshold
Meets: 65% to 80% of measures at threshold
Partially Meets: 40% to 64% of measures threshold
Does Not Meet: <40% of measures at threshold
Given that 67% of measures meet the thresholds, the provider's performance falls within the "Meets" category.

The Centers for Medicare and Medicaid Services (CMS) oversee the development of electronic clinical quality measures (eCQMs). CMS isresponsible for ensuring that eCQMs are aligned with federal reporting requirements and quality improvement initiatives. eCQMs are used to assess the quality of care provided to patients, leveraging electronic health record (EHR) data to facilitate accurate and efficient measurement.
DNV GL Healthcare (B): This organization provides accreditation and certification but does not develop eCQMs.
Occupational Safety and Health Association (OSHA) (C): OSHA is concerned with workplace safety, not clinical quality measures.
The Joint Commission (TJC) (D): The Joint Commission accredits healthcare organizations and sets quality standards, but CMS specifically oversees eCQM development.
References
NAHQ Body of Knowledge: Quality Measurement and Reporting in Healthcare NAHQ CPHQ Exam Preparation Materials: Development and Use of eCQMs
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Detailed Explanation:
The Control phase of DMAIC focuses on sustaining improvements and ongoing evaluation to ensure changes are maintained.
Option D: Control
This phase involves monitoring and evaluating outcomes to confirm that improvements continue over time.
References:
DMAIC methodology, as discussed in CPHQ resources, emphasizes the Control phase for sustaining quality improvements.

The three broad aimspursued by the National Quality Strategy (NQS), as recognized by the Agency for Healthcare Research and Quality (AHRQ), are better care, healthy people/healthy communities, and affordable care. These aims reflect a comprehensive approach to improving healthcare by focusing on enhancing the overall quality of care, improving the health of populations, and reducing the cost of care to ensure it is affordable for all.
Reduce medical waste, use Lean, and achieve equity and better access to care (A): These are important goals, but they do not summarize the NQS's broad aims.
Reduce complications, reduce readmissions, and improve health outcomes (B): These are specific targets within the broader framework but not the three broad aims.
Triple aim, reduce utilization, and affordable care (D): The triple aim concept is related, but it is not identical to the three broad aims of the NQS.
References
NAHQ Body of Knowledge: National Quality Strategy and Healthcare Improvement NAHQ CPHQ Exam Preparation Materials: Understanding National Quality Initiatives
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