Quality Improvement

At Church Health, we strive to provide the best care, and we’re always exploring new ways to improve our services.

 Our Quality Commitment

Here at Church Health, quality means caring for the whole person. We do this by offering cost-effective services that are based on best practices and align with national standards. Caring at Church Health extends beyond the individual to include and engage the community – our patients, families, volunteers, neighbors, employees, donors and more. We foster a culture of excellence that prioritizes person-centered, trusted care.

 What are we doing to improve quality?

Quality Payment Program

The Center for Medicare and Medicaid Services (CMS) mandates participation for all clinical practices in the Quality Payment Program (QPP). As such, Church Health participates in the Merit-Based Incentive Payment System (MIPS). This program looks at four domains: Quality Clinical Outcomes, Promoting Interoperability, Clinic Improvement Activities and Cost as a means of assessing Church Health’s commitment to providing high quality care to each patient we see.

We are proud to boast our MIPS 2017 score of 84.89 out of 100 possible points. This score awarded a distinction of “Exceptional Care” given by our medical providers.

If you would like to learn more about the program, please follow the link to their website: www.qpp.cms.gov


Patient-Centered Medical Home

Church Health has been recognized as a Patient-Centered Medical Home by the National Committee for Quality Assurance, an independent nonprofit that works to improve quality of care through evidence-based standards, measures, programs and accreditation.

Patient-Centered Medical Home standards emphasize the use of systematic, patient-centered, coordinated care that supports access, communication and patient involvement. The designation applies to Church Health’s clinical and integrated behavioral health programs.

Talk to us. We’re listening.

If you have ideas on how we can improve quality, we encourage you to let us know by taking our Patient Survey or joining our Patient and Family Advisory Council (PFAC).

Current Quality Improvement Projects & Performance

We work hard to ensure that our services are delivered with the highest quality. Here are some of the quality improvement projects we’re currently working on:


Reducing phone wait times


Increasing diabetes and hypertension control rates among patients


Formalizing our referral processes to decrease patient wait time for specialty care

Phone Wait Improvement

Through continuous improvement and effort by our phone room team, we’ve seen great improvement in reducing our phone wait time. Just within the 2018 calendar year, Church Health has reduced our average phone wait time from around 5 minutes to under a minute!  We are so happy to see these results and are glad to have this improvement in patient experience. Please see the below graph for our results.

Diabetes Control Rate

Hemoglobin A1c is a test that indicates a patient’s average level of blood sugar over the past 2 -3 months. It is important for patients with diabetes to have an A1c of 9 or less. We look to see how well our providers are working with patient to keep their A1c at 9 or lower. The below graph shows how our Church Health providers are doing.

Hypertension Control Rate

Blood Pressure (BP) is a measurement of the force of blood against the walls of the arteries as your heart pumps blood through your body. Hypertension (HTN) describes high blood pressure. Blood pressure is read using two numbers: systolic BP (the top number) and diastolic BP (the bottom number). Hypertension is considered controlled if a patient’s systolic and diastolic blood pressure is 140/90 or less. The below graph shows how our Church Health providers are doing.

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