Preventive Care & Screening

MANDATORY

5 criteria

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.

REFERENCES

1. [6] Research estimates that delivering all recommended preventive services for a standard patient panel would require approximately 14.1 hours per day on top of acute and chronic disease care, with surveyed primary care providers reporting they prioritize only one to three preventive services per visit due to time constraints.

Delivering every recommended preventive service to a full patient panel would take more hours in a day than exist, and research shows clinicians under real time pressure default to prioritizing only one to three preventive services per visit — a systematic tracking process is what prevents this real constraint from quietly becoming ad hoc, memory-dependent neglect of services a specific patient is actually due for.

1 Tracking exists for common services like blood pressure but not for less frequently considered ones like lung cancer screening.

Every genuinely indicated service deserves the same systematic tracking, not only the most familiar ones.

2 The system flags due services but doesn't account for a patient's specific risk factors beyond basic demographics.

Genuine individualization requires more than age and sex alone for many preventive services.

3 Tracking is reviewed for scheduled visits but not consulted during same-day or urgent encounters.

A preventive care opportunity during any visit type is a genuine opportunity worth capturing.

Week 1 Review current preventive care identification practice for reliance on memory versus systematic tracking.

Week 2 Build or strengthen a systematic tracking process reflecting individual patient risk factors.

Week 3 Integrate tracking consultation into standard visit workflow, including same-day visits.

Ongoing Audit tracking accuracy and actual use across visit types.

Ask to see the actual tracking system for a specific patient and compare against their real risk profile.

A real, specific example reveals genuine individualization, not a generic checklist.

Ask a clinician how they identify due preventive services during a same-day, non-preventive visit.

This reveals whether tracking genuinely extends beyond scheduled preventive visits.

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.

REFERENCES

1. [7] Established evidence-graded preventive service recommendation systems identify high-priority services as those with high or moderate net benefit for eligible patients, recognized in various forms across many countries' preventive care guidance.

A patient who doesn't know a specific service exists, or doesn't think to ask, shouldn't be less likely to receive genuinely beneficial, evidence-graded preventive care than a patient who happens to be more informed or assertive — proactive offering is what makes preventive care actually equitable, not dependent on the patient's own health literacy or confidence to ask.

1 Offering happens for well-known services like vaccination but less consistently for less familiar screenings.

Every grade A or B service deserves the same proactive practice, not only the most commonly discussed ones.

2 Proactive offering happens during dedicated preventive visits but not during other visit types.

Any visit is a genuine opportunity to proactively offer a due service.

3 Offering is generally consistent but staff report being less thorough during high-volume periods.

Genuine equity in preventive care delivery shouldn't depend on how busy the practice happens to be.

Week 1 Review current preventive care delivery for reliance on patient-initiated requests.

Week 2 Establish a standard proactive offering practice across all visit types.

Week 3 Train staff on consistent offering regardless of patient assertiveness or literacy.

Ongoing Track completion rates to confirm proactive offering is genuinely improving uptake.

Observe an actual visit where a patient doesn't raise preventive care themselves.

This tests whether proactive offering genuinely happens, not just when the patient prompts it.

Ask about offering practice specifically during a high-volume period.

This is where proactive practice is most likely to lapse under real pressure.

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Requires improvement plan.

REFERENCES

1. [8] National data from multiple countries document a persistent gap between long-established, high-priority screening recommendations and actual completion rates, demonstrating that completion rates require active measurement rather than assumed adequacy.

Real-world completion rates for even well-established, widely recommended screenings can be genuinely lower than assumed, and a practice that doesn't measure its own actual performance has no way of knowing whether real gaps exist in its population, or of directing genuine improvement effort where it's actually needed.

1 Completion is measured for one or two screenings but not systematically across all key services.

Every key preventive screening benefits from the same genuine measurement discipline.

2 A shortfall is identified but the response addresses only the immediate finding, not the underlying reason for the gap.

Genuine improvement requires understanding why a gap exists, not just noting that it does.

3 Measurement happens but doesn't specifically account for patients who haven't visited the practice recently.

Disengaged patients are often exactly where the real screening gaps exist.

Week 1 Review current screening completion measurement for real, panel-wide coverage.

Week 2 Establish systematic completion rate calculation for key preventive screenings.

Week 3 Build a genuine response process for identified shortfalls, addressing underlying causes.

Ongoing Review completion rates regularly and track improvement over time.

Ask for the practice's actual, current completion rate for a specific screening, not a general impression.

A specific, real number reveals genuine measurement, not an assumption.

Ask what the practice did the last time a completion rate was found to be genuinely low.

A real example reveals whether measurement leads to real action.

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.

REFERENCES

1. [9] Established evidence-graded preventive service guidance recommends annual lung cancer screening for eligible patients based on sufficient evidence of net benefit, while specifically requiring a thorough process of informed and shared decision-making prior to screening given the genuine tradeoffs between benefits and harms involved.

Not every recommended preventive service carries the same balance of benefit and harm, and treating a service with genuine tradeoffs as an automatic default — rather than a decision the patient makes with real understanding of both sides — risks patients undergoing screening without accurately understanding what they're actually agreeing to.

1 Shared decision-making happens for the most well-known high-tradeoff screening but not consistently for others carrying similar genuine tradeoffs.

Every screening with genuine tradeoffs deserves the same substantive conversation, not only the most familiar example.

2 The conversation covers benefits thoroughly but harms are mentioned only briefly.

Genuine shared decision-making requires honest, balanced weight given to both sides.

3 Documentation shows the conversation occurred but doesn't capture what the patient actually understood.

Documentation of occurrence isn't the same as evidence of genuine understanding.

Week 1 Review current practice for genuine shared decision-making versus automatic default screening.

Week 2 Build a structured shared decision-making conversation covering honest benefit and harm information.

Week 3 Establish documentation capturing genuine patient understanding, not just conversation occurrence.

Ongoing Spot-check patient understanding after shared decision-making conversations.

Ask a patient who underwent a high-tradeoff screening what they remember being told about potential harms.

This tests genuine understanding, not just that a conversation occurred.

Compare how thoroughly harms are discussed relative to benefits in actual documentation.

This reveals whether the conversation is genuinely balanced or benefit-weighted.

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.

REFERENCES

1. [10] Systematic immunization tracking against current recommended schedules, with active identification and closure of gaps, is established practice in primary care preventive medicine, distinct from reliance on unprompted patient request or assumed currency.

An immunization gap that goes unnoticed provides no protection at all, and unlike many preventive services, immunization gaps compound risk not just for the individual patient but for the wider community — active tracking and closure is what actually catches a gap in time to matter.

1 Tracking happens reliably for childhood immunizations but less consistently for adult boosters and updates.

Adult immunization schedules carry genuine, real importance too, not only childhood series.

2 Gaps are identified but follow-through to actually close them isn't consistently tracked to completion.

An identified gap that isn't closed provides no more protection than one never noticed.

3 Status is checked during well-visits but not during acute or urgent encounters.

Any visit is a genuine opportunity to catch and address an overdue gap.

Week 1 Review current immunization tracking practice across all age groups and visit types.

Week 2 Establish active tracking extending to adult immunizations, not only childhood series.

Week 3 Build a gap closure process tracked through to actual completion.

Ongoing Audit gap identification and closure rates periodically.

Ask whether immunization status is checked during an acute or urgent visit specifically.

This is where verification most commonly lapses relative to dedicated well-visits.

Ask for a real example of an identified gap and how it was actually closed.

A real example reveals whether gap closure is genuine practice, not just identification.