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radiology mammography quality coding
cancer care improvementcardiac surgery outcomescare coordinationcommunity acquired pneumonia
compliance with medical staff influenza vaccination policycongestive heart failure outcomes
controlling high blood pressurecoronary artery disease outcomes
depression screening for the chronically illeffective use of hospital resources
electronic health recordshospitalist program effective handoffsophthalmology: diabetic retinopathy
osteoporosis screeningpatient registry usagepatient safety office assessmentphysician office access
population health wellness initiativepostpartum carepotentially avoidable admissions
radiology mammography quality codingradiology turnaround timessepsis risk adjusted mortality index
smoking cessation education programstructured data capturesurgical care improvement
other additional initiatives

Objective: To reduce the misrepresentive assignment of Bi-Rad 3 coding by radiologists performing screening mammograms and to increase the number of Breast MRI procedures with the assignment of a BIRADS code value.   



Year over Year Performance Indicator

Breast Imaging-Reporting and Data System (Bi-Rad) 3 Code Utilization < 1%

Performance equal to or above 2010 APP result

Bi-Rad 3 Code Utilization < 1.5%

Performance equal to or above 2010 APP result

Breast MRI Procedure with Approved Bi-Rad Code 50%   Performance equal to or above 2010 APP result
Brease MRI Procedure with Approved Bi-Rad Code 25%

Performance equal to or above 2010 APP result


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