Quality Improvement

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

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 2018 perfect score of 100 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 

Patient Experience:

Patient Assistance Program for Medications

At Church Health, we know cost can be a barrier for our patients to keep compliant with their medications. To advocate for our patients, Church Health helps our uninsured patients attain the most cost-effective medication options through pathways navigated by our Patient Assistance Program (PAP).

The PAP team attended our own Church Health Quality Improvement Curriculum this spring, which provided them with the know-how to make process improvements within their area. Through cycles of improvement and pure will, they have dramatically reduced their patient wait list and increased their productivity, thereby improving the experience of care for our patients and their ability to be healthy.


Within the six weeks of the QI course, the PAP team:
...reduced the 30 page, 150 patient ordered referral list down to just 8 patients.
...decreased pending refills from 737 to 193.
...increased the monthly number of first-time patient approvals by 300%.
The PAP team reports:
Better time management
Stronger team morale
Less phone calls
Fewer patient complaints and more thank you's

Clinic Visit Data

Patient Care:

Physical Therapy

Each patient seen in Church Health’s Physical Rehabilitation clinic is given an evaluation at their first visit that uses defined measurements to assess a patient’s case complexity. External benchmarking shows that the typical PT panel is 54% comprised of cases with medium or high complexity.

In our Physical Rehabilitation clinic in FY19, 74% of patient cases were of medium or high complexity. Our physical therapists feel that this is likely due to the influence of external barriers their patients face in receiving care. Issues such as lack of transportation, inability to get off work, access to affordable care and other health co-morbidities can cause them to delay seeking care.

The Physical Rehab group has worked hard to adjust their schedules to better accommodate with the needs of their patients and lessen some of these access issues, which has led to increased productivity:

Westberg Institute

Effectiveness of Faith-Based Community Nurse (FCN) Program in Baptist Memorial Hospital – Desoto
A research collaboration between Church Health and the University of Memphis

The Westberg Institute for Faith Community Nursing has engaged in a randomized controlled research study to measure the impact of faith community nurse (FCN) engagement in hospital readmission. The study compared FCN patient care post-hospital stay to that of the normal post-hospital care program at Baptist Memorial Health Care Hospital in Desoto.

In a sample of ~170 patients, statistical analysis showed patients assigned to FCN transitional care had a mean projected length of 33 days until their next inpatient care stay, compared to 22 days for patients in the typical post-care programming. This finding held statistically significant difference, reflecting the FCN post-hospital care as an effective model of care delivery.

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