Table: public_hospital_redesign_and_incentives_in_medi_cal_pri_a93ac809 , metric_name like all*

A  B  C  D  E  F  G  H  I  J  K  L  M  N  O  P  Q  R  S  T  U  V  W  X  Y  Z  *

dph_dmph	hospital	metric_number	metric_name	numerator	numerator_annotation_code	denominator	denominator_annotation_code	achievement_value	achievement_rate	achievement_rate_annotation_code	baseline_rate	baseline_rate_annotaion_code	target_rate	allocation
DPH	Alameda Health System	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	2370	0	19932	0	0	0.1189	0	0.1185	0	0.1203	455760.095
DPH	Alameda Health System	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	15009	0	19932	0	1	0.753	0	0.7315	0	0.7342	455760.095
DPH	Alameda Health System	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1535	0	4575	0	0	0.3355	0	0.3107	0	0	911520.19
DPH	Alameda Health System	1.1.5.f	Screening for Clinical Depression and follow-up	13505	0	15958	0	1	0.8463	0	0.7992	0	0	911520.19
DPH	Alameda Health System	1.1.6.t	Tobacco Assessment and Counseling	14216	0	14377	0	1	0.9888	0	0.9944	0	0	911520.19
DPH	Alameda Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	418	0	638	0	1	0.6552	0	0.313	0	0.3245	303840.0633
DPH	Alameda Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	97	0	638	0	1	0.152	0	0.0305	0	0.0349	303840.0633
DPH	Alameda Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	175	0	638	0	1	0.2743	0	0.0915	0	0.0937	303840.0633
DPH	Alameda Health System	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	15009	0	19932	0	1	0.753	0	0.7315	0	0.7342	455760.095
DPH	Alameda Health System	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	2370	0	19932	0	0	0.1189	0	0.1185	0	0.1203	455760.095
DPH	Alameda Health System	1.2.10	REAL and/or SO/GI disparity reduction	477	0	1198	0	0	0.3982	0	0.3622	0	0	911520.19
DPH	Alameda Health System	1.2.11	REAL data completeness	17285	0	25486	0	1	0.6782	0	0.9998	0	0	911520.19
DPH	Alameda Health System	1.2.12.f	Screening for Clinical Depression and follow-up	13505	0	15958	0	1	0.8463	0	0.7992	0	0	911520.18
DPH	Alameda Health System	1.2.13	SO/GI data completeness	15798	0	18320	0	1	0.8623	0	0.9214	0	0	911520.18
DPH	Alameda Health System	1.2.14.t	Tobacco Assessment and Counseling	14216	0	14377	0	1	0.9888	0	0.9944	0	0	911520.18
DPH	Alameda Health System	1.2.2	CG-CAHPS: Provider Rating	2127	0	2811	0	1	0.7567	0	0.7305	0	0	911520.19
DPH	Alameda Health System	1.2.3.c	Colorectal Cancer Screening	5744	0	9357	0	0	0.6139	0	0.6709	0	0	911520.19
DPH	Alameda Health System	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1535	0	4575	0	0	0.3355	0	0.3107	0	0	911520.19
DPH	Alameda Health System	1.2.5.b	Controlling Blood Pressure	4264	0	6741	0	0	0.6325	0	0.7903	0	0	911520.19
DPH	Alameda Health System	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	576	0	619	0	1	0.9305	0	0.9279	0	0	911520.19
DPH	Alameda Health System	1.2.8	Prevention Quality Overall Composite #90	374	0	42242	0	0	0.0089	0	0.0087	0	0	911520.19
DPH	Alameda Health System	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	10425	0	11258	0	1	0.926	0	0.9723	0	0	911520.18
DPH	Alameda Health System	1.3.2	DHCS All-Cause Readmissions	139	0	762	0	0	0.1824	0	0.149	0	0	911520.18
DPH	Alameda Health System	1.3.3	Influenza Immunization	3586	0	4316	0	1	0.8309	0	0.7783	0	0	911520.18
DPH	Alameda Health System	1.3.5	Request for Specialty Care Expertise Turnaround Time	21297	0	24747	0	0	0.8606	0	0.9962	0	0	911520.18
DPH	Alameda Health System	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	1069	0	25089	0	0	0.0426	0	0.0471	0	0	911520.18
DPH	Alameda Health System	1.3.7	Tobacco Assessment and Counseling	5241	0	5298	0	1	0.9892	0	0.9972	0	0	911520.18
DPH	Alameda Health System	1.5.1.b	Controlling Blood Pressure	4264	0	6741	0	0	0.6325	0	0.7903	0	0	911520.18
DPH	Alameda Health System	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	576	0	619	0	1	0.9305	0	0.9279	0	0	911520.18
DPH	Alameda Health System	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	9254	0	10441	0	0	0.8863	0	0.9066	0	0	911520.18
DPH	Alameda Health System	1.5.4.t	Tobacco Assessment and Counseling	14216	0	14377	0	1	0.9888	0	0.9944	0	0	911520.18
DPH	Alameda Health System	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	0	0	0	0	None	984441.8
DPH	Alameda Health System	2.1.2	Exclusive Breast Milk Feeding (PC-05)	154	0	232	0	0	0.6638	0	0.7772	0	0	984441.8
DPH	Alameda Health System	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	945	0	1	None	1	None	1	0	984441.8
DPH	Alameda Health System	2.1.5	PC-02 Cesarean Section	64	0	331	0	1	0.1934	0	0.1503	0	0	984441.8
DPH	Alameda Health System	2.1.6	Prenatal and Postpartum Care: Prenatal Care	797	0	893	0	0	0.8925	0	0.9419	0	0.9075	492220.9
DPH	Alameda Health System	2.1.6	Prenatal and Postpartum Care: Postpartum Care	598	0	893	0	0	0.6697	0	0.739	0	0.7391	492220.9
DPH	Alameda Health System	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	30	0	104	0	1	0.2885	0	0.1566	0	0	984441.8
DPH	Alameda Health System	2.1.8	Unexpected Newborn Complications (UNC)	47	0	782	0	1	0.0601	0	0.0485	0	0	984441.8
DPH	Alameda Health System	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	Yes	0	3 Safety Drills?	0	n/a	0	0	0	0	None	328147.2667
DPH	Alameda Health System	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes	Yes	0	10 Debriefs?	0	n/a	0	0	0	0	None	328147.2667
DPH	Alameda Health System	2.1.9	OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16)	16	0	16	0	1	1	0	1	0	None	328147.2667
DPH	Alameda Health System	2.2.1	DHCS All-Cause Readmissions	143	0	818	0	0	0.1748	0	0.1435	0	0	984441.8
DPH	Alameda Health System	2.2.2	H-CAHPS: Care Transition Metrics (3)	4380	0	10000	0	0	0.438	0	0.458	0	0	984441.8
DPH	Alameda Health System	2.2.3	Medication Reconciliation – 30 days	1152	0	1167	0	1	0.9871	0	0.9241	0	0	984441.8
DPH	Alameda Health System	2.2.4	Reconciled Medication List Received by Discharged Patients	2237	0	2443	0	1	0.9157	0	0.7854	0	0	984441.8
DPH	Alameda Health System	2.2.5	Timely Transmission of Transition Record	1112	0	2142	0	0	0.5191	0	0.7262	0	0	984441.8
DPH	Alameda Health System	2.3.2	Medication Reconciliation – 30 days	1066	0	1079	0	1	0.988	0	0.9253	0	0	984441.8
DPH	Alameda Health System	2.3.4	Timely Transmission of Transition Record	1045	0	1900	0	0	0.55	0	0.7197	0	0	984441.8
DPH	Alameda Health System	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	2952	0	3473	0	1	0.85	0	0.8036	0	0.7587	492220.9
DPH	Alameda Health System	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	582	0	3473	0	1	0.1676	0	0.1439	0	0.1368	492220.9
DPH	Alameda Health System	2.6.2	Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen	51	0	85	0	0	0.6	0	0.7615	0	0	984441.8
DPH	Alameda Health System	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	85	0	85	0	1	1	0	0.9358	0	0	984441.8
DPH	Alameda Health System	2.6.4	Screening for Clinical Depression and follow-up	2524	0	2851	0	1	0.8853	0	0.8266	0	0	984441.8
DPH	Alameda Health System	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	3409	0	3489	0	1	0.9771	0	0.9856	0	0	984441.8
DPH	Alameda Health System	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	35	0	62	0	1	0.5645	0	0.6667	0	0	1230552.25
DPH	Alameda Health System	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	18249	0	123501	0	1	0.1478	0	0.2089	0	0	1230552.25
DPH	Alameda Health System	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	20	0	203	0	1	0.0985	0	0.2506	0	0	1230552.25
DPH	Alameda Health System	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR	6440	0	10000	0	1	0.644	0	0.865	0	0.8377	1230552.25
DMPH	Antelope Valley Hospital, Lancaster	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	0	0	0	0	None	608430
DMPH	Antelope Valley Hospital, Lancaster	2.1.2	Exclusive Breast Milk Feeding (PC-05)	161	0	283	0	1	0.5689	0	0.5294	0	0	608430
DMPH	Antelope Valley Hospital, Lancaster	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	1666	0	1	None	1	None	1	0	608430
DMPH	Antelope Valley Hospital, Lancaster	2.1.5	PC-02 Cesarean Section	128	0	487	0	0	0.2628	0	0.2882	0	0	608430
DMPH	Antelope Valley Hospital, Lancaster	2.1.6	Prenatal and Postpartum Care: Prenatal Care	45	0	311	0	0	0.1447	0	None	1	0.7689	304215
DMPH	Antelope Valley Hospital, Lancaster	2.1.6	Prenatal and Postpartum Care: Postpartum Care	196	0	311	0	0	0.6302	0	0.7155	0	0.7179	304215
DMPH	Antelope Valley Hospital, Lancaster	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	19	0	95	0	1	0.2	0	0.1806	0	0	608430
DMPH	Antelope Valley Hospital, Lancaster	2.1.8	Unexpected Newborn Complications (UNC)	21	0	1335	0	1	0.0157	0	0.016	0	0	608430
DMPH	Antelope Valley Hospital, Lancaster	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	Yes	0	3 Safety Drills?	0	n/a	0	0	0	0	None	202810
DMPH	Antelope Valley Hospital, Lancaster	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes	Yes	0	10 Debriefs?	0	n/a	0	0	0	0	None	202810
DMPH	Antelope Valley Hospital, Lancaster	2.1.9	OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16)	16	0	16	0	1	1	0	1	0	None	202810
DMPH	Antelope Valley Hospital, Lancaster	2.2.1	DHCS All-Cause Readmissions	363	0	4005	0	1	0.0906	0	0.0461	0	0	608430
DMPH	Antelope Valley Hospital, Lancaster	2.2.2	H-CAHPS: Care Transition Metrics (3)	2507	0	5297	0	0	0.4733	0	0.4347	0	0	608430
DMPH	Antelope Valley Hospital, Lancaster	2.2.3	Medication Reconciliation – 30 days	33	0	33	0	1	1	0	1	0	1	608430
DMPH	Antelope Valley Hospital, Lancaster	2.2.4	Reconciled Medication List Received by Discharged Patients	4102	0	4283	0	1	0.9577	0	0.8994	0	0	608430
DMPH	Antelope Valley Hospital, Lancaster	2.2.5	Timely Transmission of Transition Record	696	0	4544	0	0	0.1532	0	0.1499	0	0	608430
DMPH	Antelope Valley Hospital, Lancaster	2.3.2	Medication Reconciliation – 30 days	33	0	33	0	1	1	0	1	0	0	608430
DMPH	Antelope Valley Hospital, Lancaster	2.3.4	Timely Transmission of Transition Record	145	0	1122	0	0	0.1292	0	0.1499	0	0	608430
DMPH	Antelope Valley Hospital, Lancaster	2.7.1	Advance Care Plan	386	0	503	0	1	0.7674	0	0.1287	0	0	608430
DMPH	Antelope Valley Hospital, Lancaster	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	119	0	136	0	1	0.875	0	0.1642	0	0	608430
DMPH	Antelope Valley Hospital, Lancaster	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	33	0	33	0	1	1	0	1	0	0	608430
DMPH	Antelope Valley Hospital, Lancaster	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	17	0	73	0	1	0.2329	0	0.2031	0	0	608430
DMPH	Antelope Valley Hospital, Lancaster	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	12	0	64	0	0	0.1875	0	None	1	0	608430
DMPH	Antelope Valley Hospital, Lancaster	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	98	0	114	0	1	0.8596	0	0.943	0	0	608430
DMPH	Antelope Valley Hospital, Lancaster	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	30424	0	79858	0	0	0.381	0	0.2603	0	0	608430
DMPH	Antelope Valley Hospital, Lancaster	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	14	0	126	0	1	0.1111	0	0.1934	0	0	608430
DMPH	Antelope Valley Hospital, Lancaster	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR	6930	0	10000	0	0	0.693	0	0.588	0	0.592	608430
DMPH	Antelope Valley Hospital, Lancaster	3.2.2	Appropriate Emergency Department Utilization of CT for Pulmonary Embolism	176	0	314	0	1	0.5605	0	0.4266	0	0	608430
DMPH	Antelope Valley Hospital, Lancaster	3.2.3	Use of Imaging Studies for Low Back Pain	2768	0	3219	0	1	0.8599	0	0.8707	0	0	608430
DMPH	Antelope Valley Hospital, Lancaster	3.2.4	Use of Imaging Studies for Low Back Pain (anytime) Variation of HEDIS Use of Imaging Studies for Low Back Pain measures: Appropriate Score	302	0	302	0	1	1	0	0.9115	0	None	608430
DMPH	Antelope Valley Hospital, Lancaster	3.4.1	ePBM-01 Pre-op Anemia Screening, Selected Elective Surgical Patients	181	0	436	0	1	0.4151	0	0.2846	0	0	608430
DMPH	Antelope Valley Hospital, Lancaster	3.4.3	ePBM-03 Pre-op Type and Crossmatch, Type and Screen, Selected elective Surgical Patients	264	0	439	0	1	0.6014	0	0.2677	0	0	608430
DMPH	Antelope Valley Hospital, Lancaster	3.4.4	ePBM-04 Initial Transfusion Threshold	590	0	590	0	1	1	0	1	0	0	608430
DPH	Arrowhead Regional Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	519	0	20284	0	0	0.0256	0	None	1	0.0926	633537.715
DPH	Arrowhead Regional Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	101	0	20284	0	0	0.005	0	None	1	0.028	633537.715
DPH	Arrowhead Regional Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	2141	0	6013	0	0	0.3561	0	0.3266	0	0	1267075.43
DPH	Arrowhead Regional Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	6777	0	7505	0	1	0.903	0	0.8896	0	0	1267075.43
DPH	Arrowhead Regional Medical Center	1.1.6.t	Tobacco Assessment and Counseling	15388	0	15614	0	1	0.9855	0	0.9831	0	0	1267075.43
DPH	Arrowhead Regional Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	1	107	0	0	None	1	None	1	0.02	422358.4767
DPH	Arrowhead Regional Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	11	0	107	0	0	0.1028	0	0.3056	0	0.3178	422358.4767
DPH	Arrowhead Regional Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	1	107	0	1	None	1	None	1	0.0419	422358.4767
DPH	Arrowhead Regional Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	519	0	20284	0	0	0.0256	0	None	1	0.0902	633537.715
DPH	Arrowhead Regional Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	101	0	20284	0	0	0.005	0	None	1	0.0304	633537.715
DPH	Arrowhead Regional Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	1109	0	1948	0	1	0.5693	0	0.5086	0	0	1267075.42
DPH	Arrowhead Regional Medical Center	1.2.11	REAL data completeness	12286	0	14224	0	1	0.8638	0	0.8721	0	0	1267075.42
DPH	Arrowhead Regional Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	6777	0	7505	0	1	0.903	0	0.8896	0	0	1267075.42
DPH	Arrowhead Regional Medical Center	1.2.13	SO/GI data completeness	13208	0	13415	0	1	0.9846	0	0.9943	0	0	1267075.42
DPH	Arrowhead Regional Medical Center	1.2.14.t	Tobacco Assessment and Counseling	15388	0	15614	0	1	0.9855	0	0.9831	0	0	1267075.42
DPH	Arrowhead Regional Medical Center	1.2.2	CG-CAHPS: Provider Rating	1121	0	1366	0	0	0.8206	0	0.8269	0	0	1267075.43
DPH	Arrowhead Regional Medical Center	1.2.3.c	Colorectal Cancer Screening	5152	0	9173	0	0	0.5616	0	0.5892	0	0	1267075.43
DPH	Arrowhead Regional Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	2141	0	6013	0	0	0.3561	0	0.3266	0	0	1267075.42
DPH	Arrowhead Regional Medical Center	1.2.5.b	Controlling Blood Pressure	4169	0	7605	0	0	0.5482	0	0.6533	0	0	1267075.42
DPH	Arrowhead Regional Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	577	0	667	0	1	0.8651	0	0.8535	0	0	1267075.42
DPH	Arrowhead Regional Medical Center	1.2.8	Prevention Quality Overall Composite #90	535	0	6628	0	0	0.0807	0	0.1198	0	0	1267075.42
DPH	Arrowhead Regional Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	22314	0	26269	0	1	0.8494	0	0.6848	0	0	1267075.42
DPH	Arrowhead Regional Medical Center	1.3.2	DHCS All-Cause Readmissions	31	0	332	0	1	0.0934	0	0.1293	0	0	1267075.42
DPH	Arrowhead Regional Medical Center	1.3.3	Influenza Immunization	514	0	1305	0	0	0.3939	0	0.7067	0	0	1267075.42
DPH	Arrowhead Regional Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	43635	0	47225	0	1	0.924	0	0.6245	0	0	1267075.42
DPH	Arrowhead Regional Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	10399	0	28484	0	1	0.3651	0	0.0855	0	0	1267075.42
DPH	Arrowhead Regional Medical Center	1.3.7	Tobacco Assessment and Counseling	111	0	112	0	1	0.9911	0	0.9976	0	0	1267075.42
DPH	Arrowhead Regional Medical Center	1.7.1	BMI Screening and Follow-up	246	0	377	0	0	0.6525	0	0.6831	0	0	1267075.42
DPH	Arrowhead Regional Medical Center	1.7.2	Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met) Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 8)	8	0	8	0	1	1	0	1	0	None	1267075.42
DPH	Arrowhead Regional Medical Center	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI	2428	0	2537	0	1	0.957	0	0.9761	0	0.88	422358.4733
DPH	Arrowhead Regional Medical Center	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition	1903	0	2537	0	0	0.7501	0	0.7984	0	0.802	422358.4733
DPH	Arrowhead Regional Medical Center	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity	1653	0	2537	0	0	0.6516	0	0.7825	0	0.7826	422358.4733
DPH	Arrowhead Regional Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	0	0	0	0	None	1317758.4
DPH	Arrowhead Regional Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	95	0	132	0	0	0.7197	0	0.7225	0	0	1317758.4
DPH	Arrowhead Regional Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	617	0	1	None	1	None	1	0	1317758.4
DPH	Arrowhead Regional Medical Center	2.1.5	PC-02 Cesarean Section	41	0	164	0	0	0.25	0	0.1963	0	0	1317758.4
DPH	Arrowhead Regional Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	214	0	291	0	0	0.7354	0	0.2754	0	0.7689	658879.2
DPH	Arrowhead Regional Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	242	0	291	0	1	0.8316	0	0.6822	0	0.688	658879.2
DPH	Arrowhead Regional Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	35	0	71	0	1	0.493	0	0.4222	0	0	1317758.4
DPH	Arrowhead Regional Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	33	0	482	0	1	0.0685	0	0.0293	0	0	1317758.4
DPH	Arrowhead Regional Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	Yes	0	3 Safety Drills?	0	n/a	0	0	0	0	None	439252.8
DPH	Arrowhead Regional Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes	Yes	0	10 Debriefs?	0	n/a	0	0	0	0	None	439252.8
DPH	Arrowhead Regional Medical Center	2.1.9	OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16)	16	0	16	0	1	1	0	1	0	None	439252.8
DPH	Arrowhead Regional Medical Center	2.2.1	DHCS All-Cause Readmissions	78	0	795	0	1	0.0981	0	0.1265	0	0	1317758.4
DPH	Arrowhead Regional Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	741	0	1132	0	1	0.6546	0	0.4852	0	0	1317758.4
DPH	Arrowhead Regional Medical Center	2.2.3	Medication Reconciliation – 30 days	268	0	341	0	1	0.7859	0	0.7241	0	0	1317758.4
DPH	Arrowhead Regional Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	346	0	351	0	0	0.9858	0	0.9861	0	0	1317758.4
DPH	Arrowhead Regional Medical Center	2.2.5	Timely Transmission of Transition Record	3184	0	3298	0	1	0.9654	0	0.9314	0	0	1317758.4
DPH	Arrowhead Regional Medical Center	2.3.2	Medication Reconciliation – 30 days	178	0	260	0	0	0.6846	0	0.9242	0	0	1317758.4
DPH	Arrowhead Regional Medical Center	2.3.4	Timely Transmission of Transition Record	1186	0	1326	0	0	0.8944	0	0.9571	0	0	1317758.4
DPH	Arrowhead Regional Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	130	0	2821	0	0	0.0461	0	None	1	0.095	658879.2
DPH	Arrowhead Regional Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	27	0	2821	0	0	0.0096	0	None	1	0.0304	658879.2
DPH	Arrowhead Regional Medical Center	2.6.2	Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen	45	0	128	0	0	0.3516	0	0.4493	0	0	1317758.4
DPH	Arrowhead Regional Medical Center	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	60	0	128	0	0	0.4688	0	0.9275	0	0	1317758.4
DPH	Arrowhead Regional Medical Center	2.6.4	Screening for Clinical Depression and follow-up	1619	0	1810	0	1	0.8945	0	0.771	0	0	1317758.4
DPH	Arrowhead Regional Medical Center	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	1552	0	1743	0	1	0.8904	0	0.885	0	0	1317758.4
DPH	Arrowhead Regional Medical Center	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	30	0	72	0	1	0.4167	0	0.3759	0	0	2196264
DPH	Arrowhead Regional Medical Center	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	1156	0	4785	0	0	0.2416	0	0.0994	0	0	2196264
DPH	Arrowhead Regional Medical Center	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	None	1	1168	0	1	None	1	0.0848	0	0	2196264
DPH	Arrowhead Regional Medical Center	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR	1840	0	10000	0	1	0.184	0	0	0	0.592	0
DMPH	Bear Valley Community Hospital, Big Bear Lake	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	910	0	1298	0	1	0.7011	0	0.5681	0	0.5872	114750
DMPH	Bear Valley Community Hospital, Big Bear Lake	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	171	0	1298	0	0	0.1317	0	0.3089	0	0.1368	114750
DMPH	Bear Valley Community Hospital, Big Bear Lake	2.6.2	Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen	114	0	114	0	1	1	0	0.9701	0	0	229500
DMPH	Bear Valley Community Hospital, Big Bear Lake	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	114	0	114	0	1	1	0	1	0	0	229500
DMPH	Bear Valley Community Hospital, Big Bear Lake	2.6.4	Screening for Clinical Depression and follow-up	726	0	851	0	0	0.8531	0	0.9693	0	0	229500
DMPH	Bear Valley Community Hospital, Big Bear Lake	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	114	0	114	0	1	1	0	1	0	0	229500
DPH	Contra Costa Regional Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	25076	0	47289	0	0	0.5303	0	0.5733	0	0.5918	514089.55
DPH	Contra Costa Regional Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	7225	0	47289	0	1	0.1528	0	0.1645	0	0.1368	514089.55
DPH	Contra Costa Regional Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	2631	0	8680	0	0	0.3031	0	0.2538	0	0	1028179.15
DPH	Contra Costa Regional Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	18828	0	27370	0	0	0.6879	0	0.7326	0	0	1028179.15
DPH	Contra Costa Regional Medical Center	1.1.6.t	Tobacco Assessment and Counseling	35581	0	35878	0	1	0.9917	0	0.9751	0	0	1028179.15
DPH	Contra Costa Regional Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	622	0	2068	0	1	0.3008	0	0.1909	0	0.2146	342726.3833
DPH	Contra Costa Regional Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	86	0	2068	0	1	0.0416	0	0.0303	0	0.0347	342726.3833
DPH	Contra Costa Regional Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	193	0	2068	0	1	0.0933	0	0.0582	0	0.0637	342726.3833
DPH	Contra Costa Regional Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	25076	0	47289	0	0	0.5303	0	0.5733	0	0.5918	514089.575
DPH	Contra Costa Regional Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	7225	0	47289	0	1	0.1528	0	0.1645	0	0.1368	514089.575
DPH	Contra Costa Regional Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	1663	0	2463	0	0	0.6752	0	0.7146	0	0	1028179.14
DPH	Contra Costa Regional Medical Center	1.2.11	REAL data completeness	55634	0	55966	0	1	0.9941	0	0.9953	0	0	1028179.14
DPH	Contra Costa Regional Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	18828	0	27370	0	0	0.6879	0	0.7326	0	0	1028179.14
DPH	Contra Costa Regional Medical Center	1.2.13	SO/GI data completeness	39690	0	39879	0	1	0.9953	0	0.9987	0	0	1028179.14
DPH	Contra Costa Regional Medical Center	1.2.14.t	Tobacco Assessment and Counseling	35581	0	35878	0	1	0.9917	0	0.9751	0	0	1028179.14
DPH	Contra Costa Regional Medical Center	1.2.2	CG-CAHPS: Provider Rating	9373	0	11878	0	0.5	0.7891	0	0.7857	0	0	1028179.15
DPH	Contra Costa Regional Medical Center	1.2.3.c	Colorectal Cancer Screening	11150	0	18485	0	0	0.6032	0	0.6767	0	0	1028179.15
DPH	Contra Costa Regional Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	2631	0	8680	0	0	0.3031	0	0.2538	0	0	1028179.14
DPH	Contra Costa Regional Medical Center	1.2.5.b	Controlling Blood Pressure	8353	0	11764	0	1	0.71	0	0.7692	0	0	1028179.14
DPH	Contra Costa Regional Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	1136	0	1232	0	1	0.9221	0	0.9499	0	0	1028179.14
DPH	Contra Costa Regional Medical Center	1.2.8	Prevention Quality Overall Composite #90	430	0	62582	0	1	0.0069	0	0.0081	0	0	1028179.14
DPH	Contra Costa Regional Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	15772	0	15772	0	1	1	0	1	0	0	1028179.14
DPH	Contra Costa Regional Medical Center	1.3.2	DHCS All-Cause Readmissions	95	0	946	0	1	0.1004	0	0.0657	0	0	1028179.14
DPH	Contra Costa Regional Medical Center	1.3.3	Influenza Immunization	17729	0	18700	0	1	0.9481	0	0.8759	0	0	1028179.14
DPH	Contra Costa Regional Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	37774	0	45000	0	1	0.8394	0	0.8045	0	0	1028179.14
DPH	Contra Costa Regional Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	387	0	15985	0	0	0.0242	0	0.0282	0	0	1028179.14
DPH	Contra Costa Regional Medical Center	1.3.7	Tobacco Assessment and Counseling	25618	0	25814	0	1	0.9924	0	0.9827	0	0	1028179.14
DPH	Contra Costa Regional Medical Center	1.6.1	BIRADS to Biopsy	44	0	50	0	0	0.88	0	0.9016	0	0	1028179.14
DPH	Contra Costa Regional Medical Center	1.6.2	Breast Cancer Screening	8820	0	12356	0	1	0.7138	0	0.7844	0	0	1028179.14
DPH	Contra Costa Regional Medical Center	1.6.3	Cervical Cancer Screening	16101	0	25239	0	0	0.6379	0	0.6662	0	0	1028179.14
DPH	Contra Costa Regional Medical Center	1.6.4.c	Colorectal Cancer Screening	11150	0	18485	0	0	0.6032	0	0.6767	0	0	1028179.14
DPH	Contra Costa Regional Medical Center	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	174	0	289	0	0	0.6021	0	0.6316	0	0	1028179.14
DPH	Contra Costa Regional Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	0	0	0	0	None	853007.86
DPH	Contra Costa Regional Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	1063	0	1403	0	1	0.7577	0	0.7476	0	0	853007.86
DPH	Contra Costa Regional Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	0	0	1560	0	1	0	0	None	1	0	853007.86
DPH	Contra Costa Regional Medical Center	2.1.5	PC-02 Cesarean Section	80	0	507	0	1	0.1578	0	0.187	0	0	853007.86
DPH	Contra Costa Regional Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	1240	0	1331	0	1	0.9316	0	0.9295	0	0.9075	426503.93
DPH	Contra Costa Regional Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	1082	0	1331	0	1	0.8129	0	0.8527	0	0.7397	426503.93
DPH	Contra Costa Regional Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	36	0	202	0	1	0.1782	0	0.219	0	0	853007.85
DPH	Contra Costa Regional Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	41	0	1325	0	1	0.0309	0	0.0367	0	0	853007.85
DPH	Contra Costa Regional Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	Yes	0	3 Safety Drills?	0	n/a	0	0	0	0	None	284335.95
DPH	Contra Costa Regional Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes	Yes	0	10 Debriefs?	0	n/a	0	0	0	0	None	284335.95
DPH	Contra Costa Regional Medical Center	2.1.9	OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16)	16	0	16	0	1	1	0	1	0	None	284335.95
DPH	Contra Costa Regional Medical Center	2.2.1	DHCS All-Cause Readmissions	100	0	1076	0	1	0.0929	0	0.0641	0	0	853007.85
DPH	Contra Costa Regional Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	347	0	614	0	1	0.5651	0	0.5521	0	0	853007.85
DPH	Contra Costa Regional Medical Center	2.2.3	Medication Reconciliation – 30 days	2521	0	2529	0	0.5	0.9968	0	0.9966	0	0	853007.85
DPH	Contra Costa Regional Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	4272	0	4287	0	1	0.9965	0	0.996	0	0	853007.85
DPH	Contra Costa Regional Medical Center	2.2.5	Timely Transmission of Transition Record	2869	0	3637	0	0	0.7888	0	0.8205	0	0	853007.85
DPH	Contra Costa Regional Medical Center	2.3.2	Medication Reconciliation – 30 days	1045	0	1051	0	1	0.9943	0	0.9936	0	0	853007.85
DPH	Contra Costa Regional Medical Center	2.3.4	Timely Transmission of Transition Record	1256	0	1498	0	0	0.8385	0	0.8464	0	0	853007.85
DPH	Contra Costa Regional Medical Center	2.4.1	Adolescent Well-Care Visit	66	0	76	0	1	0.8684	0	0.8105	0	0	853007.85
DPH	Contra Costa Regional Medical Center	2.4.2	Developmental Screening in the First Three Years of Life	65	0	73	0	1	0.8904	0	0.5946	0	0	853007.85
DPH	Contra Costa Regional Medical Center	2.4.3	Documentation of Current Medications in the Medical Record (0-18 yo)	490	0	516	0	1	0.9496	0	1	0	0	853007.85
DPH	Contra Costa Regional Medical Center	2.4.4	Screening for Clinical Depression and follow-up	42	0	50	0	1	0.84	0	0.75	0	0	853007.85
DPH	Contra Costa Regional Medical Center	2.4.5	Tobacco Assessment and Counseling (13 yo and older)	52	0	52	0	1	1	0	1	0	0	853007.85
DPH	Contra Costa Regional Medical Center	2.4.7	Well Child Visits - Third, Fourth, Fifth, and Sixth Years of life	35	0	40	0	1	0.875	0	0.8571	0	0	853007.85
DPH	Contra Costa Regional Medical Center	2.4.8	Comprehensive Medical Evaluation Following Foster Youth Placement in Foster Care	41	0	64	0	0	0.6406	0	0.6308	0	0	853007.85
DPH	Contra Costa Regional Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	1193	0	2130	0	0	0.5601	0	0.659	0	0.669	426503.925
DPH	Contra Costa Regional Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	230	0	2130	0	0	0.108	0	0.1131	0	0.1155	426503.925
DPH	Contra Costa Regional Medical Center	2.6.2	Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen	132	0	164	0	0	0.8049	0	0.8492	0	0	853007.85
DPH	Contra Costa Regional Medical Center	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	162	0	164	0	1	0.9878	0	1	0	0	853007.85
DPH	Contra Costa Regional Medical Center	2.6.4	Screening for Clinical Depression and follow-up	575	0	832	0	0	0.6911	0	0.7952	0	0	853007.85
DPH	Contra Costa Regional Medical Center	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	1956	0	2172	0	1	0.9006	0	0.8195	0	0	853007.85
DPH	Contra Costa Regional Medical Center	3.2.2	Appropriate Emergency Department Utilization of CT for Pulmonary Embolism	279	0	289	0	1	0.9654	0	0.9416	0	0	1919267.67
DPH	Contra Costa Regional Medical Center	3.2.3	Use of Imaging Studies for Low Back Pain	2205	0	2649	0	1	0.8324	0	0.8324	0	0	1919267.67
DPH	Contra Costa Regional Medical Center	3.2.4	Use of Imaging Studies for Low Back Pain (anytime) Variation of HEDIS Use of Imaging Studies for Low Back Pain measures: Appropriate Score	1334	0	1535	0	1	0.8691	0	0.596	0	None	1919267.66
DMPH	Eastern Plumas Health Care, Portol	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	479	0	1088	0	0	0.4403	0	0.6516	0	0.6623	114750
DMPH	Eastern Plumas Health Care, Portol	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	462	0	1088	0	1	0.4246	0	0.4527	0	0.1368	114750
DMPH	Eastern Plumas Health Care, Portol	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	35	0	118	0	1	0.2966	0	0.2523	0	0	229500
DMPH	Eastern Plumas Health Care, Portol	1.1.5.f	Screening for Clinical Depression and follow-up	280	0	544	0	1	0.5147	0	0.4056	0	0	229500
DMPH	Eastern Plumas Health Care, Portol	1.1.6.t	Tobacco Assessment and Counseling	918	0	1110	0	1	0.827	0	0.8094	0	0	229500
DMPH	Eastern Plumas Health Care, Portol	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	75	0	105	0	1	0.7143	0	0.8148	0	0.4277	76500
DMPH	Eastern Plumas Health Care, Portol	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	1	105	0	1	None	1	None	1	0.0744	76500
DMPH	Eastern Plumas Health Care, Portol	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	23	0	105	0	1	0.219	0	0.2407	0	0.1134	76500
DMPH	Eastern Plumas Health Care, Portol	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	63	0	97	0	0	0.6495	0	0.8319	0	0.7587	114750
DMPH	Eastern Plumas Health Care, Portol	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	63	0	97	0	1	0.6495	0	0.7227	0	0.1368	114750
DMPH	Eastern Plumas Health Care, Portol	2.6.2	Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen	36	0	79	0	0	0.4557	0	0.7439	0	0	229500
DMPH	Eastern Plumas Health Care, Portol	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	60	0	79	0	1	0.7595	0	0.5122	0	0	229500
DMPH	Eastern Plumas Health Care, Portol	2.6.4	Screening for Clinical Depression and follow-up	31	0	57	0	0	0.5439	0	0.7119	0	0	229500
DMPH	Eastern Plumas Health Care, Portol	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	91	0	97	0	1	0.9381	0	0.6975	0	0	229500
DMPH	El Camino Hospital, Mountain View	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	3609	0	4040	0	1	0.8933	0	0.6537	0	0.6642	149175
DMPH	El Camino Hospital, Mountain View	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	206	0	4040	0	1	0.051	0	0.0162	0	0.0283	149175
DMPH	El Camino Hospital, Mountain View	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	155	0	599	0	1	0.2588	0	0.2167	0	0	298350
DMPH	El Camino Hospital, Mountain View	1.1.5.f	Screening for Clinical Depression and follow-up	3421	0	3986	0	0	0.8583	0	0.8964	0	0	298350
DMPH	El Camino Hospital, Mountain View	1.1.6.t	Tobacco Assessment and Counseling	3702	0	4040	0	0	0.9163	0	0.9157	0	0	298350
DMPH	El Camino Hospital, Mountain View	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	336	0	502	0	1	0.6693	0	0.6506	0	0.4277	99450
DMPH	El Camino Hospital, Mountain View	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	105	0	502	0	1	0.2092	0	0.3494	0	0.0744	99450
DMPH	El Camino Hospital, Mountain View	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	169	0	502	0	1	0.3367	0	0.3365	0	0.1134	99450
DMPH	El Camino Hospital, Mountain View	2.1.1	Baby Friendly Hospital designation: BFUSA Designation No	No	0	BFUSA Cert?	0	0	0	0	0	0	None	298350
DMPH	El Camino Hospital, Mountain View	2.1.2	Exclusive Breast Milk Feeding (PC-05)	41	0	84	0	0	0.4881	0	0.5476	0	0	298350
DMPH	El Camino Hospital, Mountain View	2.1.3	OB Hemorrhage: Massive Transfusion	0	0	91	0	1	0	0	0	0	0	298350
DMPH	El Camino Hospital, Mountain View	2.1.5	PC-02 Cesarean Section	None	1	None	4	0	None	1	None	1	0	0
DMPH	El Camino Hospital, Mountain View	2.1.6	Prenatal and Postpartum Care: Prenatal Care	48	0	81	0	0	0.5926	0	0.6707	0	0.7689	149175
DMPH	El Camino Hospital, Mountain View	2.1.6	Prenatal and Postpartum Care: Postpartum Care	60	0	81	0	1	0.7407	0	0.8537	0	0.7397	149175
DMPH	El Camino Hospital, Mountain View	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	1	None	1	0	None	1	None	1	0	0
DMPH	El Camino Hospital, Mountain View	2.1.8	Unexpected Newborn Complications (UNC)	None	1	84	0	1	None	1	None	1	0	298350
DMPH	El Camino Hospital, Mountain View	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter No	No	0	3 Safety Drills?	0	n/a	0	0	0	0	None	99450
DMPH	El Camino Hospital, Mountain View	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes	Yes	0	10 Debriefs?	0	n/a	0	0	0	0	None	99450
DMPH	El Camino Hospital, Mountain View	2.1.9	OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16)	32	0	32	0	0.75	1	0	1	0	None	99450
DMPH	El Camino Hospital, Mountain View	3.4.1	ePBM-01 Pre-op Anemia Screening, Selected Elective Surgical Patients	None	1	None	4	0	None	1	None	1	0	0
DMPH	El Camino Hospital, Mountain View	3.4.3	ePBM-03 Pre-op Type and Crossmatch, Type and Screen, Selected elective Surgical Patients	None	1	None	4	0	None	1	None	1	0	0
DMPH	El Camino Hospital, Mountain View	3.4.4	ePBM-04 Initial Transfusion Threshold	110	0	112	0	0	0.9821	0	1	0	0	298350
DMPH	El Centro Regional Medical Center, El Centro	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	6496	0	7907	0	1	0.8216	0	0.6505	0	0.6613	192525
DMPH	El Centro Regional Medical Center, El Centro	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	766	0	7907	0	1	0.0969	0	0.0694	0	0.0761	192525
DMPH	El Centro Regional Medical Center, El Centro	1.2.10	REAL and/or SO/GI disparity reduction	129	0	729	0	0	0.177	0	0.6139	0	0	385050
DMPH	El Centro Regional Medical Center, El Centro	1.2.11	REAL data completeness	7168	0	9451	0	0.75	0.7584	0	0.7844	0	0	385050
DMPH	El Centro Regional Medical Center, El Centro	1.2.12.f	Screening for Clinical Depression and follow-up	3986	0	5710	0	0	0.6981	0	0.7498	0	0	385050
DMPH	El Centro Regional Medical Center, El Centro	1.2.13	SO/GI data completeness	5819	0	6852	0	1	0.8492	0	0.7211	0	0	385050
DMPH	El Centro Regional Medical Center, El Centro	1.2.14.t	Tobacco Assessment and Counseling	4862	0	6852	0	0	0.7096	0	0.8038	0	0	385050
DMPH	El Centro Regional Medical Center, El Centro	1.2.2	CG-CAHPS: Provider Rating	1526	0	2009	0	1	0.7596	0	0.7336	0	0	385050
DMPH	El Centro Regional Medical Center, El Centro	1.2.3.c	Colorectal Cancer Screening	933	0	2069	0	0.5	0.4509	0	0.4391	0	0	385050
DMPH	El Centro Regional Medical Center, El Centro	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	233	0	1102	0	1	0.2114	0	0.2618	0	0	385050
DMPH	El Centro Regional Medical Center, El Centro	1.2.5.b	Controlling Blood Pressure	1236	0	1688	0	1	0.7322	0	0.7724	0	0	385050
DMPH	El Centro Regional Medical Center, El Centro	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	178	0	228	0	0	0.7807	0	0.8558	0	0	385050
DMPH	El Centro Regional Medical Center, El Centro	1.2.8	Prevention Quality Overall Composite #90	475	0	9465	0	0	0.0502	0	0.0405	0	0	385050
DMPH	El Centro Regional Medical Center, El Centro	1.7.1	BMI Screening and Follow-up	4089	0	6709	0	1	0.6095	0	0.5508	0	0	385050
DMPH	El Centro Regional Medical Center, El Centro	1.7.2	Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met) Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 8)	8	0	8	0	1	1	0	0.75	0	None	385050
DMPH	El Centro Regional Medical Center, El Centro	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI	2345	0	2371	0	1	0.989	0	0.9869	0	0.88	128350
DMPH	El Centro Regional Medical Center, El Centro	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition	1197	0	2371	0	0	0.5049	0	0.5868	0	0.6116	128350
DMPH	El Centro Regional Medical Center, El Centro	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity	1197	0	2371	0	0	0.5049	0	0.5868	0	0.6065	128350
DMPH	El Centro Regional Medical Center, El Centro	3.2.2	Appropriate Emergency Department Utilization of CT for Pulmonary Embolism	254	0	271	0	1	0.9373	0	0.8326	0	0	385050
DMPH	El Centro Regional Medical Center, El Centro	3.2.3	Use of Imaging Studies for Low Back Pain	443	0	561	0	1	0.7897	0	0.7239	0	0	385050
DMPH	El Centro Regional Medical Center, El Centro	3.2.4	Use of Imaging Studies for Low Back Pain (anytime) Variation of HEDIS Use of Imaging Studies for Low Back Pain measures: Appropriate Score	149	0	260	0	0	0.5731	0	0.6438	0	None	385050
DMPH	Hazel Hawkins Memorial Hospital, Hollister	2.3.2	Medication Reconciliation – 30 days	24	0	30	0	0	0.8	0	0.9063	0	0	1002150
DMPH	Hazel Hawkins Memorial Hospital, Hollister	2.3.4	Timely Transmission of Transition Record	29	0	30	0	0	0.9667	0	1	0	0	1002150
DMPH	Healdsburg District Hospital, Healdsburg	1.5.1.b	Controlling Blood Pressure	29	0	50	0	0	0.58	0	0.7541	0	0	246985.72
DMPH	Healdsburg District Hospital, Healdsburg	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	69	0	75	0	1	0.92	0	0.9375	0	0	246985.72
DMPH	Healdsburg District Hospital, Healdsburg	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	27	0	75	0	0	0.36	0	0.169	0	0	246985.72
DMPH	Healdsburg District Hospital, Healdsburg	1.5.4.t	Tobacco Assessment and Counseling	268	0	275	0	1	0.9745	0	0.9894	0	0	246985.71
DMPH	Healdsburg District Hospital, Healdsburg	1.6.1	BIRADS to Biopsy	0	0	0	0	0	0	0	None	1	0	0
DMPH	Healdsburg District Hospital, Healdsburg	1.6.2	Breast Cancer Screening	156	0	215	0	1	0.7256	0	0.8207	0	0	246985.71
DMPH	Healdsburg District Hospital, Healdsburg	1.6.3	Cervical Cancer Screening	164	0	250	0	1	0.656	0	0.6364	0	0	246985.71
DMPH	Healdsburg District Hospital, Healdsburg	1.6.4.c	Colorectal Cancer Screening	133	0	200	0	1	0.665	0	0.7	0	0	246985.71
DMPH	Healdsburg District Hospital, Healdsburg	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	None	1	None	1	0	None	1	0	0	0	0
DMPH	Jerold Phelps Community Hospital, Garberville	1.5.1.b	Controlling Blood Pressure	24	0	45	0	0	0.5333	0	0.6481	0	0	382500
DMPH	Jerold Phelps Community Hospital, Garberville	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	1	None	1	0	None	1	None	1	0	0
DMPH	Jerold Phelps Community Hospital, Garberville	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	259	0	298	0	1	0.8691	0	0.8375	0	0	382500
DMPH	Jerold Phelps Community Hospital, Garberville	1.5.4.t	Tobacco Assessment and Counseling	149	0	161	0	0	0.9255	0	0.9385	0	0	382500
DMPH	John C. Fremont Healthcare District, Mariposa	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	663	0	693	0	1	0.9567	0	0.9421	0	0.7587	47812.5
DMPH	John C. Fremont Healthcare District, Mariposa	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	38	0	693	0	1	0.0548	0	0.0289	0	0.0397	47812.5
DMPH	John C. Fremont Healthcare District, Mariposa	1.2.10	REAL and/or SO/GI disparity reduction	17	0	74	0	0	0.2297	0	0.1644	0	0	95625
DMPH	John C. Fremont Healthcare District, Mariposa	1.2.11	REAL data completeness	753	0	771	0	1	0.9767	0	0.9824	0	0	95625
DMPH	John C. Fremont Healthcare District, Mariposa	1.2.12.f	Screening for Clinical Depression and follow-up	237	0	648	0	0	0.3657	0	0.5041	0	0	95625
DMPH	John C. Fremont Healthcare District, Mariposa	1.2.13	SO/GI data completeness	640	0	648	0	1	0.9877	0	0.9408	0	0	95625
DMPH	John C. Fremont Healthcare District, Mariposa	1.2.14.t	Tobacco Assessment and Counseling	528	0	648	0	0	0.8148	0	0.8127	0	0	95625
DMPH	John C. Fremont Healthcare District, Mariposa	1.2.2	CG-CAHPS: Provider Rating	360	0	434	0	1	0.8295	0	0.8133	0	0	95625
DMPH	John C. Fremont Healthcare District, Mariposa	1.2.3.c	Colorectal Cancer Screening	164	0	383	0	0	0.4282	0	0.4218	0	0	95625
DMPH	John C. Fremont Healthcare District, Mariposa	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	23	0	113	0	1	0.2035	0	0.2132	0	0	95625
DMPH	John C. Fremont Healthcare District, Mariposa	1.2.5.b	Controlling Blood Pressure	173	0	261	0	0	0.6628	0	0.7695	0	0	95625
DMPH	John C. Fremont Healthcare District, Mariposa	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	70	0	83	0	1	0.8434	0	0.8235	0	0	95625
DMPH	John C. Fremont Healthcare District, Mariposa	1.2.8	Prevention Quality Overall Composite #90	29	0	648	0	0	0.0448	0	0.073	0	0	95625
DMPH	Kaweah Delta Health Care District, Visalia	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	200	0	433	0	1	0.4619	0	0.4101	0	0.445	317877.635
DMPH	Kaweah Delta Health Care District, Visalia	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	122	0	433	0	1	0.2818	0	0.1843	0	0.1368	317877.635
DMPH	Kaweah Delta Health Care District, Visalia	1.2.10	REAL and/or SO/GI disparity reduction	137	0	199	0	1	0.6884	0	0.7606	0	0	635755.27
DMPH	Kaweah Delta Health Care District, Visalia	1.2.11	REAL data completeness	11056	0	11056	0	1	1	0	1	0	0	635755.27
DMPH	Kaweah Delta Health Care District, Visalia	1.2.12.f	Screening for Clinical Depression and follow-up	307	0	403	0	0.5	0.7618	0	0.7507	0	0	635755.27
DMPH	Kaweah Delta Health Care District, Visalia	1.2.13	SO/GI data completeness	2457	0	6585	0	1	0.3731	0	0.4426	0	0	635755.27
DMPH	Kaweah Delta Health Care District, Visalia	1.2.14.t	Tobacco Assessment and Counseling	403	0	431	0	1	0.935	0	0.9188	0	0	635755.27
DMPH	Kaweah Delta Health Care District, Visalia	1.2.2	CG-CAHPS: Provider Rating	1089	0	1366	0	1	0.7972	0	0.7826	0	0	635755.27
DMPH	Kaweah Delta Health Care District, Visalia	1.2.3.c	Colorectal Cancer Screening	171	0	400	0	1	0.4275	0	0.3466	0	0	635755.27
DMPH	Kaweah Delta Health Care District, Visalia	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	127	0	385	0	1	0.3299	0	0.3629	0	0	635755.27
DMPH	Kaweah Delta Health Care District, Visalia	1.2.5.b	Controlling Blood Pressure	241	0	358	0	1	0.6732	0	0.6837	0	0	635755.27
DMPH	Kaweah Delta Health Care District, Visalia	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	188	0	208	0	0	0.9038	0	0.9176	0	0	635755.27
DMPH	Kaweah Delta Health Care District, Visalia	1.2.8	Prevention Quality Overall Composite #90	604	0	21776	0	0	0.0277	0	0.0114	0	0	635755.27
DMPH	Kaweah Delta Health Care District, Visalia	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	225	0	417	0	1	0.5396	0	0.3384	0	0	635755.26
DMPH	Kaweah Delta Health Care District, Visalia	1.3.2	DHCS All-Cause Readmissions	183	0	1408	0	1	0.13	0	0.1954	0	0	635755.26
DMPH	Kaweah Delta Health Care District, Visalia	1.3.3	Influenza Immunization	164	0	377	0	0	0.435	0	0.3442	0	0	635755.26
DMPH	Kaweah Delta Health Care District, Visalia	1.3.5	Request for Specialty Care Expertise Turnaround Time	7561	0	11467	0	0	0.6594	0	0.8431	0	0	635755.26
DMPH	Kaweah Delta Health Care District, Visalia	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	446	0	11914	0	0	0.0374	0	0.033	0	0	635755.26
DMPH	Kaweah Delta Health Care District, Visalia	1.3.7	Tobacco Assessment and Counseling	376	0	403	0	0	0.933	0	0.9353	0	0	635755.26
DMPH	Kaweah Delta Health Care District, Visalia	1.5.1.b	Controlling Blood Pressure	241	0	358	0	1	0.6732	0	0.6837	0	0	635755.26
DMPH	Kaweah Delta Health Care District, Visalia	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	188	0	208	0	0	0.9038	0	0.9176	0	0	635755.26
DMPH	Kaweah Delta Health Care District, Visalia	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	314	0	370	0	1	0.8486	0	0.8073	0	0	635755.26
DMPH	Kaweah Delta Health Care District, Visalia	1.5.4.t	Tobacco Assessment and Counseling	403	0	431	0	1	0.935	0	0.9188	0	0	635755.26
DMPH	Kaweah Delta Health Care District, Visalia	2.2.1	DHCS All-Cause Readmissions	535	0	4120	0	1	0.1299	0	0.1899	0	0	635755.26
DMPH	Kaweah Delta Health Care District, Visalia	2.2.2	H-CAHPS: Care Transition Metrics (3)	4917	0	10000	0	0	0.4917	0	0.4878	0	0	635755.26
DMPH	Kaweah Delta Health Care District, Visalia	2.2.3	Medication Reconciliation – 30 days	295	0	359	0	0.5	0.8217	0	0.8086	0	0	635755.26
DMPH	Kaweah Delta Health Care District, Visalia	2.2.4	Reconciled Medication List Received by Discharged Patients	360	0	406	0	1	0.8867	0	0.3519	0	0	635755.26
DMPH	Kaweah Delta Health Care District, Visalia	2.2.5	Timely Transmission of Transition Record	151	0	406	0	1	0.3719	0	0.0873	0	0	635755.26
DMPH	Kaweah Delta Health Care District, Visalia	2.3.2	Medication Reconciliation – 30 days	205	0	214	0	1	0.9579	0	0.9061	0	0	635755.26
DMPH	Kaweah Delta Health Care District, Visalia	2.3.4	Timely Transmission of Transition Record	151	0	341	0	1	0.4428	0	0.2	0	0	635755.26
DMPH	Kaweah Delta Health Care District, Visalia	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	545	0	689	0	1	0.791	0	0.3579	0	0.1368	317877.63
DMPH	Kaweah Delta Health Care District, Visalia	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	580	0	689	0	1	0.8418	0	0.5899	0	0.6068	317877.63
DMPH	Kaweah Delta Health Care District, Visalia	2.6.2	Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen	159	0	251	0	0	0.6335	0	0.6327	0	0	635755.26
DMPH	Kaweah Delta Health Care District, Visalia	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	219	0	251	0	1	0.8725	0	0.8204	0	0	635755.26
DMPH	Kaweah Delta Health Care District, Visalia	2.6.4	Screening for Clinical Depression and follow-up	465	0	499	0	1	0.9319	0	0.8794	0	0	635755.26
DMPH	Kaweah Delta Health Care District, Visalia	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	649	0	740	0	1	0.877	0	0.8069	0	0	635755.26
DMPH	Kaweah Delta Health Care District, Visalia	2.7.1	Advance Care Plan	273	0	393	0	1	0.6947	0	0.5528	0	0	635755.26
DMPH	Kaweah Delta Health Care District, Visalia	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	250	0	250	0	1	1	0	0.9872	0	0	635755.26
DMPH	Kaweah Delta Health Care District, Visalia	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	23	0	None	4	0	None	4	None	1	0	0
DMPH	Kaweah Delta Health Care District, Visalia	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	152	0	1100	0	0	0.1382	0	0.1366	0	0	635755.26
DMPH	Kaweah Delta Health Care District, Visalia	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	18	0	85	0	0	0.2118	0	0.2131	0	0	635755.26
DPH	Kern Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	4805	0	11554	0	0	0.4159	0	0.49	0	0.5169	466461.715
DPH	Kern Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	4805	0	11554	0	1	0.4159	0	0.49	0	0.1368	466461.715
DPH	Kern Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	950	0	2529	0	0	0.3756	0	0.2749	0	0	932923.43
DPH	Kern Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	4122	0	6957	0	0	0.5925	0	0.6745	0	0	932923.43
DPH	Kern Medical Center	1.1.6.t	Tobacco Assessment and Counseling	8906	0	9099	0	1	0.9788	0	0.9727	0	0	932923.43
DPH	Kern Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	87	0	447	0	0	0.1946	0	0.2759	0	0.2911	310974.4767
DPH	Kern Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	12	0	447	0	0	0.0268	0	0.0759	0	0.0744	310974.4767
DPH	Kern Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	23	0	447	0	0	0.0515	0	0.1172	0	0.1134	310974.4767
DPH	Kern Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	4805	0	11554	0	0	0.4159	0	0.49	0	0.5169	466461.715
DPH	Kern Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	4805	0	11554	0	1	0.4159	0	0.49	0	0.1368	466461.715
DPH	Kern Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	155	0	168	0	1	0.9226	0	0.8768	0	0	932923.42
DPH	Kern Medical Center	1.2.11	REAL data completeness	15143	0	15593	0	1	0.9711	0	0.8081	0	0	932923.42
DPH	Kern Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	4122	0	6957	0	0	0.5925	0	0.6745	0	0	932923.42
DPH	Kern Medical Center	1.2.13	SO/GI data completeness	7716	0	9694	0	1	0.796	0	0.4187	0	0	932923.42
DPH	Kern Medical Center	1.2.14.t	Tobacco Assessment and Counseling	8906	0	9099	0	1	0.9788	0	0.9727	0	0	932923.42
DPH	Kern Medical Center	1.2.2	CG-CAHPS: Provider Rating	1225	0	1591	0	1	0.77	0	0.7407	0	0	932923.43
DPH	Kern Medical Center	1.2.3.c	Colorectal Cancer Screening	2386	0	3705	0	1	0.644	0	0.6747	0	0	932923.43
DPH	Kern Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	950	0	2529	0	0	0.3756	0	0.2749	0	0	932923.42
DPH	Kern Medical Center	1.2.5.b	Controlling Blood Pressure	2648	0	3790	0	1	0.6987	0	0.7706	0	0	932923.42
DPH	Kern Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	548	0	598	0	1	0.9164	0	0.8844	0	0	932923.42
DPH	Kern Medical Center	1.2.8	Prevention Quality Overall Composite #90	None	1	24038	0	1	None	1	0.0036	0	0	932923.42
DPH	Kern Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	21836	0	21836	0	1	1	0	1	0	0	932923.42
DPH	Kern Medical Center	1.3.2	DHCS All-Cause Readmissions	33	0	389	0	1	0.0848	0	0.1038	0	0	932923.42
DPH	Kern Medical Center	1.3.3	Influenza Immunization	1913	0	3266	0	0	0.5857	0	0.7139	0	0	932923.42
DPH	Kern Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	26885	0	76397	0	0	0.3519	0	0.3596	0	0	932923.42
DPH	Kern Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	5468	0	90344	0	0	0.0605	0	0.0583	0	0	932923.42
DPH	Kern Medical Center	1.3.7	Tobacco Assessment and Counseling	4077	0	4125	0	1	0.9884	0	0.9796	0	0	932923.42
DPH	Kern Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	6409	0	6659	0	1	0.9625	0	0.9343	0	0.9	310974.4733
DPH	Kern Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	848	0	956	0	1	0.887	0	0.8538	0	0.8584	310974.4733
DPH	Kern Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	448	0	846	0	0	0.5296	0	0.5216	0	0.5594	310974.4733
DPH	Kern Medical Center	1.4.2	Annual Monitoring for Patients on Persistent Medications	3897	0	4879	0	0	0.7987	0	0.9048	0	0	932923.42
DPH	Kern Medical Center	1.4.3	INR Monitoring for Individuals on Warfarin	63	0	70	0	1	0.9	0	0.956	0	0	932923.42
DPH	Kern Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	0	0	0	0	None	1021305.58
DPH	Kern Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	532	0	774	0	0	0.6873	0	0.6877	0	0	1021305.58
DPH	Kern Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	998	0	1	None	1	None	1	0	1021305.58
DPH	Kern Medical Center	2.1.5	PC-02 Cesarean Section	42	0	197	0	1	0.2132	0	0.2165	0	0	1021305.58
DPH	Kern Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	618	0	693	0	0	0.8918	0	0.9037	0	0.9041	510652.79
DPH	Kern Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	495	0	693	0	1	0.7143	0	0.6813	0	0.6871	510652.79
DPH	Kern Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	45	0	123	0	1	0.3659	0	0.3929	0	0	1021305.58
DPH	Kern Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	50	0	772	0	1	0.0648	0	0.0473	0	0	1021305.58
DPH	Kern Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	Yes	0	3 Safety Drills?	0	n/a	0	0	0	0	None	340435.1933
DPH	Kern Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes	Yes	0	10 Debriefs?	0	n/a	0	0	0	0	None	340435.1933
DPH	Kern Medical Center	2.1.9	OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16)	16	0	16	0	1	1	0	1	0	None	340435.1933
DPH	Kern Medical Center	2.2.1	DHCS All-Cause Readmissions	41	0	471	0	1	0.087	0	0.0936	0	0	1021305.58
DPH	Kern Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	5090	0	10000	0	0	0.509	0	0.537	0	0	1021305.58
DPH	Kern Medical Center	2.2.3	Medication Reconciliation – 30 days	462	0	682	0	1	0.6774	0	0.618	0	0	1021305.58
DPH	Kern Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	1327	0	1530	0	1	0.8673	0	0.8086	0	0	1021305.58
DPH	Kern Medical Center	2.2.5	Timely Transmission of Transition Record	1039	0	1177	0	1	0.8828	0	0.8606	0	0	1021305.58
DPH	Kern Medical Center	2.3.2	Medication Reconciliation – 30 days	133	0	179	0	1	0.743	0	0.6259	0	0	1021305.58
DPH	Kern Medical Center	2.3.4	Timely Transmission of Transition Record	303	0	309	0	1	0.9806	0	0.9863	0	0	1021305.58
DPH	Kern Medical Center	2.5.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	286	0	549	0	0	0.5209	0	0.6046	0	0.62	510652.79
DPH	Kern Medical Center	2.5.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	286	0	549	0	1	0.5209	0	0.6046	0	0.1368	510652.79
DPH	Kern Medical Center	2.5.2	Controlling Blood Pressure	138	0	190	0	1	0.7263	0	0.8028	0	0	1021305.58
DPH	Kern Medical Center	2.5.4	Screening for Clinical Depression and follow-up	200	0	303	0	0	0.6601	0	0.6982	0	0	1021305.57
DPH	Kern Medical Center	2.5.5	Tobacco Assessment and Counseling	433	0	437	0	1	0.9908	0	0.9684	0	0	1021305.57
DPH	Kern Medical Center	3.2.2	Appropriate Emergency Department Utilization of CT for Pulmonary Embolism	147	0	148	0	0	0.9932	0	1	0	1	1617067.34
DPH	Kern Medical Center	3.2.3	Use of Imaging Studies for Low Back Pain	476	0	586	0	1	0.8123	0	0.8636	0	0	1617067.33
DPH	Kern Medical Center	3.2.4	Use of Imaging Studies for Low Back Pain (anytime) Variation of HEDIS Use of Imaging Studies for Low Back Pain measures: Appropriate Score	508	0	644	0	1	0.7888	0	0.8621	0	None	1617067.33
DMPH	Kern Valley Healthcare District, Lake Isabella	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	561	0	719	0	1	0.7803	0	0.387	0	0.4242	114750
DMPH	Kern Valley Healthcare District, Lake Isabella	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	260	0	719	0	1	0.3616	0	0.4828	0	0.1368	114750
DMPH	Kern Valley Healthcare District, Lake Isabella	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	38	0	121	0	0	0.314	0	0.301	0	0	229500
DMPH	Kern Valley Healthcare District, Lake Isabella	1.1.5.f	Screening for Clinical Depression and follow-up	435	0	614	0	0	0.7085	0	0.811	0	0	229500
DMPH	Kern Valley Healthcare District, Lake Isabella	1.1.6.t	Tobacco Assessment and Counseling	863	0	884	0	1	0.9762	0	0.9533	0	0	229500
DMPH	Kern Valley Healthcare District, Lake Isabella	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	47	0	74	0	1	0.6351	0	0.6974	0	0.4277	76500
DMPH	Kern Valley Healthcare District, Lake Isabella	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	1	74	0	0	None	1	None	1	0.0744	76500
DMPH	Kern Valley Healthcare District, Lake Isabella	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	1	74	0	0	None	1	None	1	0.1134	76500
DMPH	Lompoc Valley Medical Center, Lompoc	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	2241	0	2811	0	1	0.7972	0	0.6646	0	0	280500
DMPH	Lompoc Valley Medical Center, Lompoc	1.3.2	DHCS All-Cause Readmissions	None	1	247	0	1	None	1	None	1	0	280500
DMPH	Lompoc Valley Medical Center, Lompoc	1.3.3	Influenza Immunization	163	0	307	0	1	0.5309	0	0.4614	0	0	280500
DMPH	Lompoc Valley Medical Center, Lompoc	1.3.5	Request for Specialty Care Expertise Turnaround Time	2263	0	3077	0	1	0.7355	0	0.6751	0	0	280500
DMPH	Lompoc Valley Medical Center, Lompoc	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	13	0	1986	0	0	0.0065	0	0.1126	0	0	280500
DMPH	Lompoc Valley Medical Center, Lompoc	1.3.7	Tobacco Assessment and Counseling	623	0	669	0	1	0.9312	0	0.8886	0	0	280500
DMPH	Lompoc Valley Medical Center, Lompoc	1.5.1.b	Controlling Blood Pressure	227	0	365	0	0	0.6219	0	0.7644	0	0	280500
DMPH	Lompoc Valley Medical Center, Lompoc	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	32	0	39	0	1	0.8205	0	None	4	0	0
DMPH	Lompoc Valley Medical Center, Lompoc	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	774	0	1343	0	0	0.5763	0	0.6022	0	0	280500
DMPH	Lompoc Valley Medical Center, Lompoc	1.5.4.t	Tobacco Assessment and Counseling	300	0	342	0	0	0.8772	0	0.9348	0	0	280500
DMPH	Lompoc Valley Medical Center, Lompoc	1.7.1	BMI Screening and Follow-up	177	0	301	0	0	0.588	0	0.9522	0	0	280500
DMPH	Lompoc Valley Medical Center, Lompoc	1.7.2	Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met) Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 8)	5	0	8	0	0.5	0.625	0	0.75	0	None	280500
DMPH	Lompoc Valley Medical Center, Lompoc	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI	251	0	264	0	1	0.9508	0	0.9934	0	0.88	93500
DMPH	Lompoc Valley Medical Center, Lompoc	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition	221	0	264	0	1	0.8371	0	0.8684	0	0.8345	93500
DMPH	Lompoc Valley Medical Center, Lompoc	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity	198	0	264	0	0	0.75	0	0.8684	0	0.7835	93500
DMPH	Lompoc Valley Medical Center, Lompoc	2.2.1	DHCS All-Cause Readmissions	25	0	416	0	1	0.0601	0	0.0589	0	0	280500
DMPH	Lompoc Valley Medical Center, Lompoc	2.2.2	H-CAHPS: Care Transition Metrics (3)	315	0	752	0	0	0.4189	0	0.4196	0	0	280500
DMPH	Lompoc Valley Medical Center, Lompoc	2.2.3	Medication Reconciliation – 30 days	39	0	39	0	1	1	0	None	4	1	0
DMPH	Lompoc Valley Medical Center, Lompoc	2.2.4	Reconciled Medication List Received by Discharged Patients	593	0	724	0	1	0.8191	0	0.7726	0	0	280500
DMPH	Lompoc Valley Medical Center, Lompoc	2.2.5	Timely Transmission of Transition Record	353	0	743	0	0	0.4751	0	0.7052	0	0	280500
DMPH	Lompoc Valley Medical Center, Lompoc	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	57	0	138	0	0	0.413	0	None	1	0	0
DMPH	Lompoc Valley Medical Center, Lompoc	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	1345	0	7416	0	0	0.1814	0	0.099	0	0	280500
DMPH	Lompoc Valley Medical Center, Lompoc	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	0	0	291	0	1	0	0	0.9529	0	0	280500
DMPH	Lompoc Valley Medical Center, Lompoc	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR	20750	0	10000	0	0	2.075	0	3.001	0	1.053	280500
DPH	Los Angeles County Health System	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	293	0	386	0	1	0.7591	0	0.8647	0	0.7587	2516724.06
DPH	Los Angeles County Health System	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	44	0	386	0	0	0.114	0	0.1273	0	0.1283	2516724.06
DPH	Los Angeles County Health System	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	11351	0	37598	0	0	0.3019	0	0.283	0	0	5033448.12
DPH	Los Angeles County Health System	1.1.5.f	Screening for Clinical Depression and follow-up	85766	0	99848	0	0	0.859	0	0.8608	0	0	5033448.12
DPH	Los Angeles County Health System	1.1.6.t	Tobacco Assessment and Counseling	99483	0	103100	0	1	0.9649	0	0.9453	0	0	5033448.12
DPH	Los Angeles County Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	858	0	1997	0	1	0.4296	0	0.2951	0	0.3084	1677816.04
DPH	Los Angeles County Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	247	0	1997	0	1	0.1237	0	0.0672	0	0.0679	1677816.04
DPH	Los Angeles County Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	370	0	1997	0	1	0.1853	0	0.1044	0	0.1053	1677816.04
DPH	Los Angeles County Health System	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	293	0	386	0	1	0.7591	0	0.8647	0	0.7587	2516724.06
DPH	Los Angeles County Health System	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	44	0	386	0	0	0.114	0	0.1273	0	0.1283	2516724.06
DPH	Los Angeles County Health System	1.2.10	REAL and/or SO/GI disparity reduction	4470	0	7294	0	0	0.6128	0	0.6838	0	0	5033448.12
DPH	Los Angeles County Health System	1.2.11	REAL data completeness	137452	0	137557	0	1	0.9992	0	0.9985	0	0	5033448.12
DPH	Los Angeles County Health System	1.2.12.f	Screening for Clinical Depression and follow-up	85766	0	99848	0	0	0.859	0	0.8608	0	0	5033448.12
DPH	Los Angeles County Health System	1.2.13	SO/GI data completeness	100860	0	115676	0	1	0.8719	0	0.8644	0	0	5033448.12
DPH	Los Angeles County Health System	1.2.14.t	Tobacco Assessment and Counseling	99483	0	103100	0	1	0.9649	0	0.9453	0	0	5033448.12
DPH	Los Angeles County Health System	1.2.2	CG-CAHPS: Provider Rating	4570	0	6033	0	0	0.7575	0	0.7689	0	0	5033448.12
DPH	Los Angeles County Health System	1.2.3.c	Colorectal Cancer Screening	39713	0	58808	0	1	0.6753	0	0.7545	0	0	5033448.12
DPH	Los Angeles County Health System	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	11351	0	37598	0	0	0.3019	0	0.283	0	0	5033448.12
DPH	Los Angeles County Health System	1.2.5.b	Controlling Blood Pressure	33133	0	50409	0	0	0.6573	0	0.7437	0	0	5033448.12
DPH	Los Angeles County Health System	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	4444	0	5024	0	0	0.8846	0	0.8986	0	0	5033448.12
DPH	Los Angeles County Health System	1.2.8	Prevention Quality Overall Composite #90	2029	0	227787	0	0	0.0089	0	0.0083	0	0	5033448.12
DPH	Los Angeles County Health System	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	71455	0	77376	0	1	0.9235	0	0.8594	0	0	5033448.12
DPH	Los Angeles County Health System	1.3.2	DHCS All-Cause Readmissions	944	0	6042	0	0	0.1562	0	0.1503	0	0	5033448.12
DPH	Los Angeles County Health System	1.3.3	Influenza Immunization	25897	0	32659	0	1	0.793	0	0.7624	0	0	5033448.12
DPH	Los Angeles County Health System	1.3.5	Request for Specialty Care Expertise Turnaround Time	139729	0	158410	0	1	0.8821	0	0.8431	0	0	5033448.12
DPH	Los Angeles County Health System	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	49696	0	187026	0	1	0.2657	0	0.2502	0	0	5033448.12
DPH	Los Angeles County Health System	1.3.7	Tobacco Assessment and Counseling	41990	0	44197	0	1	0.9501	0	0.9464	0	0	5033448.12
DPH	Los Angeles County Health System	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	66128	0	69955	0	1	0.9453	0	0.9516	0	0.9	1677816.04
DPH	Los Angeles County Health System	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	28259	0	30266	0	1	0.9337	0	0.9423	0	0.9	1677816.04
DPH	Los Angeles County Health System	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	13108	0	20087	0	0	0.6526	0	0.6456	0	0.671	1677816.04
DPH	Los Angeles County Health System	1.4.2	Annual Monitoring for Patients on Persistent Medications	38760	0	42028	0	0	0.9222	0	0.9543	0	0	5033448.12
DPH	Los Angeles County Health System	1.4.3	INR Monitoring for Individuals on Warfarin	1392	0	1585	0	0	0.8782	0	0.9148	0	0	5033448.12
DPH	Los Angeles County Health System	1.6.1	BIRADS to Biopsy	453	0	742	0	1	0.6105	0	0.5462	0	0	5033448.11
DPH	Los Angeles County Health System	1.6.2	Breast Cancer Screening	35483	0	47149	0	1	0.7526	0	0.758	0	0	5033448.11
DPH	Los Angeles County Health System	1.6.3	Cervical Cancer Screening	43642	0	82664	0	0	0.5279	0	0.5418	0	0	5033448.11
DPH	Los Angeles County Health System	1.6.4.c	Colorectal Cancer Screening	39713	0	58808	0	1	0.6753	0	0.7545	0	0	5033448.11
DPH	Los Angeles County Health System	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	554	0	1283	0	0	0.4318	0	0.4928	0	0	5033448.11
DPH	Los Angeles County Health System	1.7.1	BMI Screening and Follow-up	106481	0	120407	0	0	0.8843	0	0.8987	0	0	5033448.11
DPH	Los Angeles County Health System	1.7.2	Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met) Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 8)	32	0	32	0	1	1	0	1	0	None	5033448.11
DPH	Los Angeles County Health System	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI	11548	0	17160	0	0	0.673	0	0.9556	0	0.88	1677816.037
DPH	Los Angeles County Health System	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition	13240	0	17160	0	0	0.7716	0	0.8171	0	0.8188	1677816.037
DPH	Los Angeles County Health System	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity	13044	0	17160	0	0	0.7601	0	0.805	0	0.7835	1677816.037
DPH	Los Angeles County Health System	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	0	0	0	0	None	5704574.417
DPH	Los Angeles County Health System	2.1.2	Exclusive Breast Milk Feeding (PC-05)	957	0	1525	0	0	0.6275	0	0.6569	0	0	5704574.417
DPH	Los Angeles County Health System	2.1.3	OB Hemorrhage: Massive Transfusion	18	0	2231	0	1	0.0081	0	None	1	0	5704574.417
DPH	Los Angeles County Health System	2.1.5	PC-02 Cesarean Section	155	0	730	0	1	0.2123	0	0.2159	0	0	5704574.417
DPH	Los Angeles County Health System	2.1.6	Prenatal and Postpartum Care: Prenatal Care	1930	0	2020	0	1	0.9554	0	0.9403	0	0.9075	2852287.208
DPH	Los Angeles County Health System	2.1.6	Prenatal and Postpartum Care: Postpartum Care	1409	0	2020	0	1	0.6975	0	0.6849	0	0.6904	2852287.208
DPH	Los Angeles County Health System	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	164	0	460	0	1	0.3565	0	0.367	0	0	5704574.417
DPH	Los Angeles County Health System	2.1.8	Unexpected Newborn Complications (UNC)	83	0	1541	0	1	0.0539	0	0.0878	0	0	5704574.417
DPH	Los Angeles County Health System	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	Yes	0	3 Safety Drills?	0	n/a	0	0	0	0	None	1901524.806
DPH	Los Angeles County Health System	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes	Yes	0	10 Debriefs?	0	n/a	0	0	0	0	None	1901524.806
DPH	Los Angeles County Health System	2.1.9	OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16)	48	0	48	0	1	1	0	1	0	None	1901524.806
DPH	Los Angeles County Health System	2.2.1	DHCS All-Cause Readmissions	1022	0	6740	0	0	0.1516	0	0.148	0	0	5704574.417
DPH	Los Angeles County Health System	2.2.2	H-CAHPS: Care Transition Metrics (3)	3242	0	6096	0	0	0.5318	0	0.5731	0	0	5704574.417
DPH	Los Angeles County Health System	2.2.3	Medication Reconciliation – 30 days	7971	0	9246	0	0.5	0.8621	0	0.8542	0	0	5704574.417
DPH	Los Angeles County Health System	2.2.4	Reconciled Medication List Received by Discharged Patients	346	0	377	0	0	0.9178	0	0.9682	0	0	5704574.417
DPH	Los Angeles County Health System	2.2.5	Timely Transmission of Transition Record	7596	0	9999	0	1	0.7597	0	0.7143	0	0	5704574.417
DPH	Los Angeles County Health System	2.3.2	Medication Reconciliation – 30 days	5518	0	6370	0	0	0.8662	0	0.8673	0	0	5704574.417
DPH	Los Angeles County Health System	2.3.4	Timely Transmission of Transition Record	5094	0	6345	0	1	0.8028	0	0.7672	0	0	5704574.417
DPH	Los Angeles County Health System	2.5.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	175	0	218	0	1	0.8028	0	0.8853	0	0.7587	2852287.208
DPH	Los Angeles County Health System	2.5.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	62	0	218	0	1	0.2844	0	0.1835	0	0.1368	2852287.208
DPH	Los Angeles County Health System	2.5.2	Controlling Blood Pressure	48	0	93	0	0	0.5161	0	0.6724	0	0	5704574.417
DPH	Los Angeles County Health System	2.5.4	Screening for Clinical Depression and follow-up	226	0	354	0	1	0.6384	0	0.5831	0	0	5704574.417
DPH	Los Angeles County Health System	2.5.5	Tobacco Assessment and Counseling	302	0	354	0	0	0.8531	0	0.8807	0	0	5704574.417
DPH	Los Angeles County Health System	2.7.1	Advance Care Plan	17493	0	17612	0	1	0.9932	0	0.9833	0	0	5704574.417
DPH	Los Angeles County Health System	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	195	0	208	0	1	0.9375	0	0.9111	0	0	5704574.417
DPH	Los Angeles County Health System	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	79	0	81	0	1	0.9753	0	0.9565	0	0	5704574.417
DPH	Los Angeles County Health System	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	162	0	5211	0	0	0.0311	0	0.0324	0	0	5704574.417
DPH	Los Angeles County Health System	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	13	0	125	0	0	0.104	0	None	1	0	5704574.417
DPH	Los Angeles County Health System	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	132	0	209	0	1	0.6316	0	0.5546	0	0	4889635.15
DPH	Los Angeles County Health System	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	44404	0	528665	0	1	0.084	0	0.0832	0	0	4889635.15
DPH	Los Angeles County Health System	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	56	0	377	0	1	0.1485	0	0.1724	0	0	4889635.14
DPH	Los Angeles County Health System	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR	4564	0	10000	0	1	0.4564	0	0.498	0	0.592	4889635.14
DPH	Los Angeles County Health System	3.3.1	Adherence to Medications: Rate 1	247	0	279	0	0	0.8853	0	0.8316	0	0.8997	4889635.14
DPH	Los Angeles County Health System	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 1	278	0	281	0	1	0.9893	0	0.8129	0	0.8864	4889635.14
DPH	Los Angeles County Health System	3.3.4	Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 1	2091	0	3308	0	1	0.6321	0	0.5668	0	0.59	4889635.14
DMPH	Mammoth Hospital, Mammoth Lakes	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	179	0	328	0	1	0.5457	0	0.1714	0	0.2301	95566.155
DMPH	Mammoth Hospital, Mammoth Lakes	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	74	0	328	0	1	0.2256	0	0.1714	0	0.1368	95566.155
DMPH	Mammoth Hospital, Mammoth Lakes	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	21	0	83	0	1	0.253	0	0.2738	0	0	191132.31
DMPH	Mammoth Hospital, Mammoth Lakes	1.1.5.f	Screening for Clinical Depression and follow-up	216	0	343	0	1	0.6297	0	0.4969	0	0	191132.31
DMPH	Mammoth Hospital, Mammoth Lakes	1.1.6.t	Tobacco Assessment and Counseling	256	0	279	0	1	0.9176	0	0.8421	0	0	191132.31
DMPH	Mammoth Hospital, Mammoth Lakes	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	43	0	65	0	1	0.6615	0	0.5185	0	0.4277	63710.77
DMPH	Mammoth Hospital, Mammoth Lakes	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	1	65	0	1	None	1	None	1	0.0575	63710.77
DMPH	Mammoth Hospital, Mammoth Lakes	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	15	0	65	0	1	0.2308	0	None	1	0.1134	63710.77
DMPH	Mammoth Hospital, Mammoth Lakes	1.5.1.b	Controlling Blood Pressure	69	0	131	0	0	0.5267	0	0.5982	0	0	191132.31
DMPH	Mammoth Hospital, Mammoth Lakes	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	1	None	4	0	None	1	None	1	0	0
DMPH	Mammoth Hospital, Mammoth Lakes	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	198	0	331	0	1	0.5982	0	0.5585	0	0	191132.31
DMPH	Mammoth Hospital, Mammoth Lakes	1.5.4.t	Tobacco Assessment and Counseling	256	0	279	0	1	0.9176	0	0.8421	0	0	191132.31
DMPH	Mammoth Hospital, Mammoth Lakes	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	54	0	66	0	1	0.8182	0	0.4557	0	0.486	95566.155
DMPH	Mammoth Hospital, Mammoth Lakes	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	20	0	66	0	1	0.303	0	0.5063	0	0.1368	95566.155
DMPH	Mammoth Hospital, Mammoth Lakes	2.6.2	Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen	29	0	None	4	0	None	4	0.9688	0	0	191132.31
DMPH	Mammoth Hospital, Mammoth Lakes	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	29	0	None	4	0	None	4	0.9688	0	0	191132.3
DMPH	Mammoth Hospital, Mammoth Lakes	2.6.4	Screening for Clinical Depression and follow-up	24	0	None	4	0	None	4	0.8889	0	0	191132.3
DMPH	Mammoth Hospital, Mammoth Lakes	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	66	0	66	0	1	1	0	1	0	0	191132.3
DMPH	Marin General Hospital, Greenbrae	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	0	0	None	4	None	296285.72
DMPH	Marin General Hospital, Greenbrae	2.1.2	Exclusive Breast Milk Feeding (PC-05)	134	0	167	0	1	0.8024	0	0.8844	0	0	296285.72
DMPH	Marin General Hospital, Greenbrae	2.1.3	OB Hemorrhage: Massive Transfusion	0	0	326	0	1	0	0	0	0	0	296285.72
DMPH	Marin General Hospital, Greenbrae	2.1.5	PC-02 Cesarean Section	28	0	94	0	0	0.2979	0	0.1642	0	0	296285.72
DMPH	Marin General Hospital, Greenbrae	2.1.6	Prenatal and Postpartum Care: Prenatal Care	277	0	277	0	1	1	0	0.997	0	0.9075	148142.855
DMPH	Marin General Hospital, Greenbrae	2.1.6	Prenatal and Postpartum Care: Postpartum Care	266	0	277	0	1	0.9603	0	0.8047	0	0.7397	148142.855
DMPH	Marin General Hospital, Greenbrae	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	1	40	0	1	None	1	None	1	0	296285.71
DMPH	Marin General Hospital, Greenbrae	2.1.8	Unexpected Newborn Complications (UNC)	None	1	292	0	1	None	1	None	1	0	296285.71
DMPH	Marin General Hospital, Greenbrae	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	Yes	0	3 Safety Drills?	0	n/a	0	0	0	0	None	98761.90333
DMPH	Marin General Hospital, Greenbrae	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) No	No	0	10 Debriefs?	0	n/a	0	0	0	0	None	98761.90333
DMPH	Marin General Hospital, Greenbrae	2.1.9	OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16)	16	0	16	0	0.75	1	0	1	0	None	98761.90333
DMPH	Marin General Hospital, Greenbrae	2.2.1	DHCS All-Cause Readmissions	84	0	375	0	0	0.224	0	0.1802	0	0	296285.71
DMPH	Marin General Hospital, Greenbrae	2.2.2	H-CAHPS: Care Transition Metrics (3)	5238	0	10000	0	1	0.5238	0	0.4952	0	0	296285.71
DMPH	Marin General Hospital, Greenbrae	2.2.3	Medication Reconciliation – 30 days	572	0	613	0	1	0.9331	0	0.8645	0	0	296285.71
DMPH	Marin General Hospital, Greenbrae	2.2.4	Reconciled Medication List Received by Discharged Patients	27	0	340	0	0	0.0794	0	0	0	0	296285.71
DMPH	Marin General Hospital, Greenbrae	2.2.5	Timely Transmission of Transition Record	174	0	338	0	0	0.5148	0	0.5088	0	0	296285.71
DMPH	Marin General Hospital, Greenbrae	2.3.2	Medication Reconciliation – 30 days	262	0	287	0	1	0.9129	0	0.8158	0	0	296285.71
DMPH	Marin General Hospital, Greenbrae	2.3.4	Timely Transmission of Transition Record	212	0	340	0	0	0.6235	0	0.6099	0	0	296285.71
DMPH	Marin General Hospital, Greenbrae	2.7.1	Advance Care Plan	301	0	307	0	1	0.9805	0	0.9536	0	0	296285.71
DMPH	Marin General Hospital, Greenbrae	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	221	0	221	0	1	1	0	1	0	0	296285.71
DMPH	Marin General Hospital, Greenbrae	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	16	0	None	4	0	None	4	None	4	0	0
DMPH	Marin General Hospital, Greenbrae	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	94	0	273	0	1	0.3443	0	0.2473	0	0	296285.71
DMPH	Marin General Hospital, Greenbrae	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	None	1	None	1	0	None	1	None	1	0	0
DMPH	Mayers Memorial Hospital District, Fall River Mills	1.7.1	BMI Screening and Follow-up	None	1	None	1	0	None	1	None	1	0	0
DMPH	Mayers Memorial Hospital District, Fall River Mills	1.7.2	Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met) Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 8)	8	0	8	0	1	1	0	1	0	None	1147500
DMPH	Mayers Memorial Hospital District, Fall River Mills	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI	0	0	0	0	0	0	0	0	0	0.66	0
DMPH	Mayers Memorial Hospital District, Fall River Mills	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition	0	0	0	0	0	0	0	0	0	0.5985	0
DMPH	Mayers Memorial Hospital District, Fall River Mills	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity	0	0	0	0	0	0	0	0	0	0.5231	0
DMPH	Mendocino Coast District Hospital, Fort Bragg	1.6.1	BIRADS to Biopsy	None	1	None	1	0	None	1	None	1	0	0
DMPH	Mendocino Coast District Hospital, Fort Bragg	1.6.2	Breast Cancer Screening	282	0	474	0	0	0.5949	0	0.6274	0	0	382500
DMPH	Mendocino Coast District Hospital, Fort Bragg	1.6.3	Cervical Cancer Screening	506	0	843	0	1	0.6002	0	0.457	0	0	382500
DMPH	Mendocino Coast District Hospital, Fort Bragg	1.6.4.c	Colorectal Cancer Screening	459	0	934	0	0	0.4914	0	0.5332	0	0	382500
DMPH	Mendocino Coast District Hospital, Fort Bragg	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	None	1	None	4	0	None	1	None	1	0	0
DMPH	Modoc Medical Center, Alturas	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	440	0	571	0	1	0.7706	0	0.6908	0	0.6976	57375
DMPH	Modoc Medical Center, Alturas	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	136	0	571	0	1	0.2382	0	None	1	0.0282	57375
DMPH	Modoc Medical Center, Alturas	1.2.10	REAL and/or SO/GI disparity reduction	None	1	None	4	0	None	1	None	4	0	0
DMPH	Modoc Medical Center, Alturas	1.2.11	REAL data completeness	745	0	758	0	1	0.9828	0	0.9975	0	0	114750
DMPH	Modoc Medical Center, Alturas	1.2.12.f	Screening for Clinical Depression and follow-up	371	0	411	0	1	0.9027	0	0.8991	0	0	114750
DMPH	Modoc Medical Center, Alturas	1.2.13	SO/GI data completeness	438	0	506	0	1	0.8656	0	0.4075	0	0	114750
DMPH	Modoc Medical Center, Alturas	1.2.14.t	Tobacco Assessment and Counseling	485	0	495	0	1	0.9798	0	0.9944	0	0	114750
DMPH	Modoc Medical Center, Alturas	1.2.2	CG-CAHPS: Provider Rating	175	0	207	0	1	0.8454	0	0.7536	0	0	114750
DMPH	Modoc Medical Center, Alturas	1.2.3.c	Colorectal Cancer Screening	116	0	213	0	1	0.5446	0	0.3966	0	0	114750
DMPH	Modoc Medical Center, Alturas	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	25	0	83	0	0	0.3012	0	0.2368	0	0	114750
DMPH	Modoc Medical Center, Alturas	1.2.5.b	Controlling Blood Pressure	87	0	167	0	0	0.521	0	0.6051	0	0	114750
DMPH	Modoc Medical Center, Alturas	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	25	0	34	0	1	0.7353	0	None	4	0	0
DMPH	Modoc Medical Center, Alturas	1.2.8	Prevention Quality Overall Composite #90	None	1	506	0	1	None	1	0.0206	0	0	114750
DPH	Natividad Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	4988	0	6055	0	1	0.8238	0	0.8083	0	0.7587	225247.17
DPH	Natividad Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	3356	0	6055	0	1	0.5543	0	0.1147	0	0.1169	225247.17
DPH	Natividad Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	210	0	643	0	1	0.3266	0	0.3327	0	0	450494.34
DPH	Natividad Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	2733	0	3464	0	1	0.789	0	0.7687	0	0	450494.34
DPH	Natividad Medical Center	1.1.6.t	Tobacco Assessment and Counseling	4243	0	4285	0	1	0.9902	0	0.9922	0	0	450494.34
DPH	Natividad Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	44	0	97	0	1	0.4536	0	0.2632	0	0.2797	150164.78
DPH	Natividad Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	11	0	97	0	1	0.1134	0	None	1	0.0264	150164.78
DPH	Natividad Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	20	0	97	0	1	0.2062	0	None	1	0.0871	150164.78
DPH	Natividad Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	4988	0	6055	0	1	0.8238	0	0.8083	0	0.7587	225247.17
DPH	Natividad Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	3356	0	6055	0	1	0.5543	0	0.1147	0	0.1169	225247.17
DPH	Natividad Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	388	0	632	0	0	0.6139	0	0.6841	0	0	450494.33
DPH	Natividad Medical Center	1.2.11	REAL data completeness	7816	0	8708	0	1	0.8976	0	0.8838	0	0	450494.33
DPH	Natividad Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	2733	0	3464	0	1	0.789	0	0.7687	0	0	450494.33
DPH	Natividad Medical Center	1.2.13	SO/GI data completeness	5490	0	5701	0	1	0.963	0	0.9564	0	0	450494.33
DPH	Natividad Medical Center	1.2.14.t	Tobacco Assessment and Counseling	4243	0	4285	0	1	0.9902	0	0.9922	0	0	450494.33
DPH	Natividad Medical Center	1.2.2	CG-CAHPS: Provider Rating	7554	0	10000	0	1	0.7554	0	0.7425	0	0	450494.34
DPH	Natividad Medical Center	1.2.3.c	Colorectal Cancer Screening	977	0	1494	0	1	0.6539	0	0.7163	0	0	450494.34
DPH	Natividad Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	210	0	643	0	1	0.3266	0	0.3327	0	0	450494.34
DPH	Natividad Medical Center	1.2.5.b	Controlling Blood Pressure	226	0	304	0	1	0.7434	0	0.7361	0	0	450494.33
DPH	Natividad Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	151	0	175	0	0	0.8629	0	0.9186	0	0	450494.33
DPH	Natividad Medical Center	1.2.8	Prevention Quality Overall Composite #90	62	0	6782	0	0	0.0091	0	0.0089	0	0	450494.33
DPH	Natividad Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	3339	0	3550	0	1	0.9406	0	0.9335	0	0	450494.33
DPH	Natividad Medical Center	1.3.2	DHCS All-Cause Readmissions	14	0	152	0	1	0.0921	0	0.0959	0	0	450494.33
DPH	Natividad Medical Center	1.3.3	Influenza Immunization	549	0	760	0	1	0.7224	0	0.7022	0	0	450494.33
DPH	Natividad Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	4247	0	6451	0	1	0.6583	0	0.562	0	0	450494.33
DPH	Natividad Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	18	0	6506	0	0	0.0028	0	0.001	0	0	450494.33
DPH	Natividad Medical Center	1.3.7	Tobacco Assessment and Counseling	1101	0	1107	0	1	0.9946	0	0.9977	0	0	450494.33
DPH	Natividad Medical Center	1.5.1.b	Controlling Blood Pressure	226	0	304	0	1	0.7434	0	0.7361	0	0	450494.33
DPH	Natividad Medical Center	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	151	0	175	0	0	0.8629	0	0.9186	0	0	450494.33
DPH	Natividad Medical Center	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	3201	0	3462	0	1	0.9246	0	0.9227	0	0	450494.33
DPH	Natividad Medical Center	1.5.4.t	Tobacco Assessment and Counseling	4243	0	4285	0	1	0.9902	0	0.9922	0	0	450494.33
DPH	Natividad Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	0	0	0	0	None	486533.9
DPH	Natividad Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	177	0	453	0	0	0.3907	0	0.4917	0	0	486533.9
DPH	Natividad Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	0	0	516	0	1	0	0	0	0	0	486533.9
DPH	Natividad Medical Center	2.1.5	PC-02 Cesarean Section	21	0	108	0	1	0.1944	0	0.2014	0	0	486533.9
DPH	Natividad Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	426	0	442	0	1	0.9638	0	0.9708	0	0.9075	243266.95
DPH	Natividad Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	375	0	442	0	1	0.8484	0	0.8542	0	0.7397	243266.95
DPH	Natividad Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	11	0	84	0	1	0.131	0	0.156	0	0	486533.9
DPH	Natividad Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	19	0	440	0	1	0.0432	0	0.0535	0	0	486533.9
DPH	Natividad Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter No	No	0	3 Safety Drills?	0	n/a	0	0	0	0	None	162177.9667
DPH	Natividad Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes	Yes	0	10 Debriefs?	0	n/a	0	0	0	0	None	162177.9667
DPH	Natividad Medical Center	2.1.9	OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16)	16	0	16	0	0.75	1	0	1	0	None	162177.9667
DPH	Natividad Medical Center	2.2.1	DHCS All-Cause Readmissions	27	0	286	0	1	0.0944	0	0.0898	0	0	486533.9
DPH	Natividad Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	4516	0	10000	0	0	0.4516	0	0.4462	0	0	486533.9
DPH	Natividad Medical Center	2.2.3	Medication Reconciliation – 30 days	181	0	199	0	1	0.9095	0	0.8801	0	0	486533.9
DPH	Natividad Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	348	0	351	0	1	0.9915	0	0.9885	0	0	486533.9
DPH	Natividad Medical Center	2.2.5	Timely Transmission of Transition Record	341	0	347	0	0	0.9827	0	0.9838	0	0	486533.9
DPH	Natividad Medical Center	2.3.2	Medication Reconciliation – 30 days	23	0	None	4	0	None	4	0.9592	0	0	486533.9
DPH	Natividad Medical Center	2.3.4	Timely Transmission of Transition Record	48	0	50	0	0	0.96	0	0.9857	0	0	486533.9
DPH	Natividad Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	267	0	288	0	1	0.9271	0	0.8896	0	0.7587	243266.95
DPH	Natividad Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	182	0	288	0	1	0.6319	0	0.097	0	0.101	243266.95
DPH	Natividad Medical Center	2.6.2	Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen	61	0	128	0	0	0.4766	0	0.4755	0	0	486533.9
DPH	Natividad Medical Center	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	81	0	128	0	1	0.6328	0	0.5734	0	0	486533.9
DPH	Natividad Medical Center	2.6.4	Screening for Clinical Depression and follow-up	84	0	97	0	1	0.866	0	0.8174	0	0	486533.9
DPH	Natividad Medical Center	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	289	0	311	0	1	0.9293	0	0.9429	0	0	486533.9
DPH	Natividad Medical Center	3.4.1	ePBM-01 Pre-op Anemia Screening, Selected Elective Surgical Patients	34	0	63	0	1	0.5397	0	0.4742	0	0	810889.67
DPH	Natividad Medical Center	3.4.3	ePBM-03 Pre-op Type and Crossmatch, Type and Screen, Selected elective Surgical Patients	29	0	37	0	0	0.7838	0	0.8333	0	0	810889.67
DPH	Natividad Medical Center	3.4.4	ePBM-04 Initial Transfusion Threshold	212	0	212	0	1	1	0	1	0	0	810889.66
DMPH	Northern Inyo Hospital, Bishop	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	None	1	None	1	0	None	1	None	1	0	0
DMPH	Northern Inyo Hospital, Bishop	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	723	0	2955	0	1	0.2447	0	0.442	0	0	1514700
DMPH	Northern Inyo Hospital, Bishop	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	21	0	197	0	1	0.1066	0	None	1	0	0
DMPH	Northern Inyo Hospital, Bishop	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR	58685	0	10000	0	0	5.8685	0	0	0	1.053	1514700
DMPH	Oak Valley Hospital District, Oakdale	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	1961	0	3957	0	1	0.4956	0	0.4486	0	0.4796	97264.29
DMPH	Oak Valley Hospital District, Oakdale	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	729	0	3957	0	1	0.1842	0	0.1382	0	0.1368	97264.29
DMPH	Oak Valley Hospital District, Oakdale	1.2.10	REAL and/or SO/GI disparity reduction	63	0	353	0	1	0.1785	0	0.3265	0	0	194528.57
DMPH	Oak Valley Hospital District, Oakdale	1.2.11	REAL data completeness	4053	0	4075	0	1	0.9946	0	0.9926	0	0	194528.57
DMPH	Oak Valley Hospital District, Oakdale	1.2.12.f	Screening for Clinical Depression and follow-up	2229	0	3295	0	1	0.6765	0	0.6436	0	0	194528.57
DMPH	Oak Valley Hospital District, Oakdale	1.2.13	SO/GI data completeness	2606	0	2682	0	1	0.9717	0	0.9155	0	0	194528.57
DMPH	Oak Valley Hospital District, Oakdale	1.2.14.t	Tobacco Assessment and Counseling	2500	0	2601	0	1	0.9612	0	0.9263	0	0	194528.57
DMPH	Oak Valley Hospital District, Oakdale	1.2.2	CG-CAHPS: Provider Rating	12906	0	13667	0	1	0.9443	0	0.9095	0	0	194528.58
DMPH	Oak Valley Hospital District, Oakdale	1.2.3.c	Colorectal Cancer Screening	637	0	1113	0	1	0.5723	0	0.5341	0	0	194528.57
DMPH	Oak Valley Hospital District, Oakdale	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	152	0	598	0	1	0.2542	0	0.2853	0	0	194528.57
DMPH	Oak Valley Hospital District, Oakdale	1.2.5.b	Controlling Blood Pressure	522	0	742	0	1	0.7035	0	0.6667	0	0	194528.57
DMPH	Oak Valley Hospital District, Oakdale	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	137	0	150	0	1	0.9133	0	0.8519	0	0	194528.57
DMPH	Oak Valley Hospital District, Oakdale	1.2.8	Prevention Quality Overall Composite #90	72	0	3192	0	0	0.0226	0	0.0244	0	0	194528.57
DMPH	Oak Valley Hospital District, Oakdale	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	1495	0	1556	0	1	0.9608	0	0.9122	0	0.9	64842.85667
DMPH	Oak Valley Hospital District, Oakdale	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	None	1	None	4	0	None	1	0.9756	0	0.9	64842.85667
DMPH	Oak Valley Hospital District, Oakdale	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	1577	0	1624	0	1	0.9711	0	0.9601	0	0.9	64842.85667
DMPH	Oak Valley Hospital District, Oakdale	1.4.2	Annual Monitoring for Patients on Persistent Medications	828	0	906	0	1	0.9139	0	0.8912	0	0	194528.57
DMPH	Oak Valley Hospital District, Oakdale	1.4.3	INR Monitoring for Individuals on Warfarin	None	1	None	4	0	None	1	None	1	0	0
DMPH	Palo Verde Hospital, Blythe	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	76	0	149	0	0	0.5101	0	0.7739	0	0.7587	111562.5
DMPH	Palo Verde Hospital, Blythe	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	11	0	149	0	0	0.0738	0	0.1264	0	0.1274	111562.5
DMPH	Palo Verde Hospital, Blythe	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	309	0	511	0	0	0.6047	0	0.2631	0	0	223125
DMPH	Palo Verde Hospital, Blythe	1.1.5.f	Screening for Clinical Depression and follow-up	18	0	57	0	0	0.3158	0	0.3945	0	0	223125
DMPH	Palo Verde Hospital, Blythe	1.1.6.t	Tobacco Assessment and Counseling	477	0	510	0	1	0.9353	0	0.9293	0	0	223125
DMPH	Palo Verde Hospital, Blythe	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	11	0	64	0	0	0.1719	0	0.2099	0	0.2317	74375
DMPH	Palo Verde Hospital, Blythe	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	1	64	0	1	None	1	0.1358	0	0.0744	74375
DMPH	Palo Verde Hospital, Blythe	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	1	64	0	0	None	1	0.1358	0	0.1134	74375
DMPH	Palo Verde Hospital, Blythe	1.7.1	BMI Screening and Follow-up	19	0	52	0	0	0.3654	0	None	1	0	223125
DMPH	Palo Verde Hospital, Blythe	1.7.2	Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met) Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 8)	8	0	8	0	1	1	0	0.125	0	None	223125
DMPH	Palo Verde Hospital, Blythe	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI	22	0	61	0	0	0.3607	0	0.6389	0	0.663	74375
DMPH	Palo Verde Hospital, Blythe	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition	22	0	61	0	0	0.3607	0	0.6389	0	0.6585	74375
DMPH	Palo Verde Hospital, Blythe	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity	22	0	61	0	0	0.3607	0	0.6389	0	0.6534	74375
DMPH	Palo Verde Hospital, Blythe	2.2.1	DHCS All-Cause Readmissions	24	0	168	0	1	0.1429	0	0.1397	0	0	223125
DMPH	Palo Verde Hospital, Blythe	2.2.2	H-CAHPS: Care Transition Metrics (3)	82	0	142	0	1	0.5775	0	0.5081	0	0	223125
DMPH	Palo Verde Hospital, Blythe	2.2.3	Medication Reconciliation – 30 days	175	0	273	0	0	0.641	0	0.3855	0	0	223125
DMPH	Palo Verde Hospital, Blythe	2.2.4	Reconciled Medication List Received by Discharged Patients	297	0	409	0	1	0.7262	0	0.3198	0	0	223125
DMPH	Palo Verde Hospital, Blythe	2.2.5	Timely Transmission of Transition Record	167	0	381	0	1	0.4383	0	0.3171	0	0	223125
DMPH	Palo Verde Hospital, Blythe	2.3.2	Medication Reconciliation – 30 days	145	0	204	0	1	0.7108	0	0.4547	0	0	223125
DMPH	Palo Verde Hospital, Blythe	2.3.4	Timely Transmission of Transition Record	87	0	139	0	1	0.6259	0	0.5663	0	0	223125
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	1.7.1	BMI Screening and Follow-up	353	0	353	0	1	1	0	0.505	0	0	618120
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	1.7.2	Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met) Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 8)	16	0	16	0	1	1	0	1	0	None	618120
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI	200	0	200	0	1	1	0	0.9828	0	0.88	206040
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition	200	0	200	0	1	1	0	0.9511	0	0.8345	206040
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity	200	0	200	0	1	1	0	0.9511	0	0.7835	206040
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.2.1	DHCS All-Cause Readmissions	53	0	365	0	0	0.1452	0	0.1323	0	0	618120
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.2.2	H-CAHPS: Care Transition Metrics (3)	5399	0	10000	0	0	0.5399	0	0.5623	0	0	618120
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.2.3	Medication Reconciliation – 30 days	422	0	461	0	0	0.9154	0	0.9362	0	0	618120
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.2.4	Reconciled Medication List Received by Discharged Patients	5376	0	5392	0	1	0.997	0	0.9929	0	0	618120
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.2.5	Timely Transmission of Transition Record	3200	0	3200	0	1	1	0	0.4667	0	0	618120
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.3.2	Medication Reconciliation – 30 days	599	0	622	0	1	0.963	0	0.9494	0	0	618120
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.3.4	Timely Transmission of Transition Record	3059	0	3059	0	1	1	0	0.4788	0	0	618120
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.7.1	Advance Care Plan	269	0	269	0	1	1	0	1	0	0	618120
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	289	0	289	0	1	1	0	1	0	0	618120
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	59	0	59	0	1	1	0	1	0	0	618120
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	171	0	1170	0	0	0.1462	0	0.1743	0	0	618120
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	12	0	34	0	0	0.3529	0	0.2241	0	0	618120
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	68	0	77	0	1	0.8831	0	0.8966	0	0	618120
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	22436	0	163809	0	1	0.137	0	0.1573	0	0	618120
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	765	0	2091	0	1	0.3659	0	0.4881	0	0	618120
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR	5730	0	10000	0	1	0.573	0	0.5311	0	0.592	618120
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.2.2	Appropriate Emergency Department Utilization of CT for Pulmonary Embolism	693	0	694	0	1	0.9986	0	0.8949	0	0	618120
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.2.3	Use of Imaging Studies for Low Back Pain	3023	0	3859	0	1	0.7834	0	0.7704	0	0	618120
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.2.4	Use of Imaging Studies for Low Back Pain (anytime) Variation of HEDIS Use of Imaging Studies for Low Back Pain measures: Appropriate Score	1163	0	2577	0	1	0.4513	0	0.409	0	None	618120
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.3.1	Adherence to Medications: Rate 1	117	0	186	0	1	0.629	0	0.4971	0	0.556	618120
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 1	75	0	79	0	1	0.9494	0	0.7424	0	0.7361	618120
DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.3.4	Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 1	1500	0	1949	0	1	0.7696	0	0.6962	0	0.7137	618120
DMPH	Pioneers Memorial Healthcare District, Brawley	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	925	0	982	0	1	0.942	0	0.94	0	0.9	112200
DMPH	Pioneers Memorial Healthcare District, Brawley	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	22	0	35	0	0	0.6286	0	0.8654	0	0.8689	112200
DMPH	Pioneers Memorial Healthcare District, Brawley	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	53	0	115	0	0	0.4609	0	0.6255	0	0.653	112200
DMPH	Pioneers Memorial Healthcare District, Brawley	1.4.2	Annual Monitoring for Patients on Persistent Medications	774	0	1181	0	0	0.6554	0	0.8834	0	0	336600
DMPH	Pioneers Memorial Healthcare District, Brawley	1.4.3	INR Monitoring for Individuals on Warfarin	None	1	None	1	0	None	1	None	1	0	0
DMPH	Pioneers Memorial Healthcare District, Brawley	1.6.1	BIRADS to Biopsy	None	1	None	1	0	None	1	None	1	0	0
DMPH	Pioneers Memorial Healthcare District, Brawley	1.6.2	Breast Cancer Screening	362	0	543	0	0	0.6667	0	0.7848	0	0	336600
DMPH	Pioneers Memorial Healthcare District, Brawley	1.6.3	Cervical Cancer Screening	608	0	1354	0	0	0.449	0	0.5762	0	0	336600
DMPH	Pioneers Memorial Healthcare District, Brawley	1.6.4.c	Colorectal Cancer Screening	377	0	900	0	1	0.4189	0	0.3666	0	0	336600
DMPH	Pioneers Memorial Healthcare District, Brawley	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	None	1	None	1	0	None	1	None	1	0	0
DMPH	Pioneers Memorial Healthcare District, Brawley	2.2.1	DHCS All-Cause Readmissions	25	0	233	0	1	0.1073	0	0.0969	0	0	336600
DMPH	Pioneers Memorial Healthcare District, Brawley	2.2.2	H-CAHPS: Care Transition Metrics (3)	55	0	100	0	0	0.55	0	0.59	0	0	336600
DMPH	Pioneers Memorial Healthcare District, Brawley	2.2.3	Medication Reconciliation – 30 days	43	0	288	0	0	0.1493	0	0.1337	0	0	336600
DMPH	Pioneers Memorial Healthcare District, Brawley	2.2.4	Reconciled Medication List Received by Discharged Patients	473	0	642	0	1	0.7368	0	0.6153	0	0	336600
DMPH	Pioneers Memorial Healthcare District, Brawley	2.2.5	Timely Transmission of Transition Record	105	0	449	0	0	0.2339	0	0.2539	0	0	336600
DMPH	Pioneers Memorial Healthcare District, Brawley	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	15	0	49	0	0	0.3061	0	0.4722	0	0	336600
DMPH	Pioneers Memorial Healthcare District, Brawley	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	5357	0	25874	0	0.75	0.207	0	0.2171	0	0	336600
DMPH	Pioneers Memorial Healthcare District, Brawley	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	222	0	4327	0	1	0.0513	0	0.0717	0	0	336600
DMPH	Pioneers Memorial Healthcare District, Brawley	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR	8510	0	10000	0	1	0.851	0	1.061	0	1.053	336600
DMPH	Plumas District Hospital, Quincy	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	283	0	393	0	0	0.7201	0	0.7342	0	0.7367	114750
DMPH	Plumas District Hospital, Quincy	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	58	0	393	0	1	0.1476	0	0.1873	0	0.1368	114750
DMPH	Plumas District Hospital, Quincy	2.6.2	Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen	71	0	115	0	0	0.6174	0	0.6931	0	0	229500
DMPH	Plumas District Hospital, Quincy	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	99	0	115	0	1	0.8609	0	0.7831	0	0	229500
DMPH	Plumas District Hospital, Quincy	2.6.4	Screening for Clinical Depression and follow-up	163	0	300	0	1	0.5433	0	0.463	0	0	229500
DMPH	Plumas District Hospital, Quincy	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	354	0	393	0	1	0.9008	0	0.9571	0	0	229500
DPH	Riverside University Health System	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	27945	0	41556	0	0	0.6725	0	0.794	0	0.7587	472876.26
DPH	Riverside University Health System	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	1734	0	41556	0	0	0.0417	0	0.0488	0	0.0576	472876.26
DPH	Riverside University Health System	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	2515	0	7964	0	0	0.3158	0	0.29	0	0	945752.52
DPH	Riverside University Health System	1.1.5.f	Screening for Clinical Depression and follow-up	24235	0	26133	0	1	0.9274	0	0.9468	0	0	945752.52
DPH	Riverside University Health System	1.1.6.t	Tobacco Assessment and Counseling	386	0	400	0	1	0.965	0	0.958	0	0	945752.52
DPH	Riverside University Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	591	0	2005	0	0.75	0.2948	0	0.2808	0	0.2955	315250.84
DPH	Riverside University Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	74	0	2005	0	1	0.0369	0	0.0228	0	0.028	315250.84
DPH	Riverside University Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	145	0	2005	0	1	0.0723	0	0.0531	0	0.0591	315250.84
DPH	Riverside University Health System	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	27945	0	41556	0	0	0.6725	0	0.794	0	0.7587	472876.26
DPH	Riverside University Health System	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	1734	0	41556	0	0	0.0417	0	0.0488	0	0.0576	472876.26
DPH	Riverside University Health System	1.2.10	REAL and/or SO/GI disparity reduction	28	0	64	0	0	0.4375	0	0.3488	0	0	945752.52
DPH	Riverside University Health System	1.2.11	REAL data completeness	36831	0	36880	0	1	0.9987	0	0.997	0	0	945752.52
DPH	Riverside University Health System	1.2.12.f	Screening for Clinical Depression and follow-up	24235	0	26133	0	1	0.9274	0	0.9468	0	0	945752.52
DPH	Riverside University Health System	1.2.13	SO/GI data completeness	31555	0	37573	0	1	0.8398	0	0.7789	0	0	945752.52
DPH	Riverside University Health System	1.2.14.t	Tobacco Assessment and Counseling	386	0	400	0	1	0.965	0	0.958	0	0	945752.52
DPH	Riverside University Health System	1.2.2	CG-CAHPS: Provider Rating	791	0	999	0	0	0.7918	0	0.7922	0	0	945752.52
DPH	Riverside University Health System	1.2.3.c	Colorectal Cancer Screening	238	0	400	0	1	0.595	0	0.5669	0	0	945752.52
DPH	Riverside University Health System	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	2515	0	7964	0	0	0.3158	0	0.29	0	0	945752.52
DPH	Riverside University Health System	1.2.5.b	Controlling Blood Pressure	7263	0	11265	0	0	0.6447	0	0.7213	0	0	945752.52
DPH	Riverside University Health System	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	270	0	298	0	1	0.906	0	0.8833	0	0	945752.52
DPH	Riverside University Health System	1.2.8	Prevention Quality Overall Composite #90	401	0	63267	0	1	0.0063	0	0.0043	0	0	945752.52
DPH	Riverside University Health System	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	10032	0	10656	0	1	0.9414	0	0.9121	0	0	945752.52
DPH	Riverside University Health System	1.3.2	DHCS All-Cause Readmissions	90	0	683	0	1	0.1318	0	0.1026	0	0	945752.52
DPH	Riverside University Health System	1.3.3	Influenza Immunization	3819	0	5577	0	1	0.6848	0	0.6565	0	0	945752.52
DPH	Riverside University Health System	1.3.5	Request for Specialty Care Expertise Turnaround Time	19725	0	26926	0	1	0.7326	0	0.6874	0	0	945752.52
DPH	Riverside University Health System	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	2860	0	26466	0	1	0.1081	0	0.0739	0	0	945752.52
DPH	Riverside University Health System	1.3.7	Tobacco Assessment and Counseling	5407	0	5551	0	1	0.9741	0	0.9711	0	0	945752.52
DPH	Riverside University Health System	1.5.1.b	Controlling Blood Pressure	7263	0	11265	0	0	0.6447	0	0.7213	0	0	945752.51
DPH	Riverside University Health System	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	270	0	298	0	1	0.906	0	0.8833	0	0	945752.51
DPH	Riverside University Health System	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	218	0	400	0	0	0.545	0	0.5415	0	0	945752.51
DPH	Riverside University Health System	1.5.4.t	Tobacco Assessment and Counseling	386	0	400	0	1	0.965	0	0.958	0	0	945752.51
DPH	Riverside University Health System	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	0	0	0	0	None	1021412.7
DPH	Riverside University Health System	2.1.2	Exclusive Breast Milk Feeding (PC-05)	156	0	207	0	1	0.7536	0	0.8304	0	0	1021412.7
DPH	Riverside University Health System	2.1.3	OB Hemorrhage: Massive Transfusion	0	0	265	0	1	0	0	0	0	0	1021412.7
DPH	Riverside University Health System	2.1.5	PC-02 Cesarean Section	14	0	62	0	0	0.2258	0	0.1798	0	0	1021412.7
DPH	Riverside University Health System	2.1.6	Prenatal and Postpartum Care: Prenatal Care	315	0	385	0	1	0.8182	0	0.7938	0	0.8052	510706.35
DPH	Riverside University Health System	2.1.6	Prenatal and Postpartum Care: Postpartum Care	274	0	385	0	1	0.7117	0	0.6804	0	0.6863	510706.35
DPH	Riverside University Health System	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	1	None	4	0	None	1	None	1	0	1021412.7
DPH	Riverside University Health System	2.1.8	Unexpected Newborn Complications (UNC)	None	1	200	0	1	None	1	None	1	0	1021412.7
DPH	Riverside University Health System	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter No	No	0	3 Safety Drills?	0	n/a	0	0	0	0	None	340470.9
DPH	Riverside University Health System	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) No	No	0	10 Debriefs?	0	n/a	0	0	0	0	None	340470.9
DPH	Riverside University Health System	2.1.9	OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16)	16	0	16	0	0.5	1	0	1	0	None	340470.9
DPH	Riverside University Health System	2.2.1	DHCS All-Cause Readmissions	157	0	1173	0	0	0.1338	0	0.093	0	0	1021412.7
DPH	Riverside University Health System	2.2.2	H-CAHPS: Care Transition Metrics (3)	594	0	1112	0	1	0.5342	0	0.5159	0	0	1021412.7
DPH	Riverside University Health System	2.2.3	Medication Reconciliation – 30 days	346	0	355	0	1	0.9746	0	0.9446	0	0	1021412.7
DPH	Riverside University Health System	2.2.4	Reconciled Medication List Received by Discharged Patients	385	0	400	0	1	0.9625	0	0.9471	0	0	1021412.7
DPH	Riverside University Health System	2.2.5	Timely Transmission of Transition Record	3392	0	3465	0	1	0.9789	0	0.9762	0	0	1021412.7
DPH	Riverside University Health System	2.3.2	Medication Reconciliation – 30 days	182	0	186	0	1	0.9785	0	0.9731	0	0	1021412.7
DPH	Riverside University Health System	2.3.4	Timely Transmission of Transition Record	533	0	539	0	1	0.9889	0	0.9846	0	0	1021412.7
DPH	Riverside University Health System	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	5997	0	7790	0	1	0.7698	0	0.8705	0	0.7587	510706.35
DPH	Riverside University Health System	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	185	0	7790	0	0	0.0237	0	0.0482	0	0.0571	510706.35
DPH	Riverside University Health System	2.6.2	Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen	48	0	126	0	1	0.381	0	0.3148	0	0	1021412.7
DPH	Riverside University Health System	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	126	0	126	0	1	1	0	0.8704	0	0	1021412.7
DPH	Riverside University Health System	2.6.4	Screening for Clinical Depression and follow-up	4004	0	4133	0	1	0.9688	0	0.9746	0	0	1021412.7
DPH	Riverside University Health System	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	6921	0	7604	0	1	0.9102	0	0.9153	0	0	1021412.7
DPH	Riverside University Health System	3.3.1	Adherence to Medications: Rate 1	2423	0	4282	0	1	0.5659	0	0.4947	0	0.5414	1702354.67
DPH	Riverside University Health System	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 1	4858	0	8054	0	0	0.6032	0	0.6309	0	0.6513	1702354.67
DPH	Riverside University Health System	3.3.4	Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 1	13033	0	14200	0	1	0.9178	0	0.9681	0	0.9	1702354.66
DMPH	Salinas Valley Memorial Healthcare System	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	2862	0	3084	0	1	0.928	0	0.9152	0	0.9	86530
DMPH	Salinas Valley Memorial Healthcare System	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	1260	0	1337	0	1	0.9424	0	0.9676	0	0.9	86530
DMPH	Salinas Valley Memorial Healthcare System	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	1081	0	1463	0	0	0.7389	0	0.743	0	0.7587	86530
DMPH	Salinas Valley Memorial Healthcare System	1.4.2	Annual Monitoring for Patients on Persistent Medications	1816	0	2202	0	0	0.8247	0	0.9124	0	0	259590
DMPH	Salinas Valley Memorial Healthcare System	1.4.3	INR Monitoring for Individuals on Warfarin	376	0	495	0	0	0.7596	0	0.8107	0	0	259590
DMPH	Salinas Valley Memorial Healthcare System	1.5.1.b	Controlling Blood Pressure	1762	0	2794	0	0	0.6306	0	0.6808	0	0	259590
DMPH	Salinas Valley Memorial Healthcare System	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	1199	0	1305	0	1	0.9188	0	0.8245	0	0	259590
DMPH	Salinas Valley Memorial Healthcare System	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	12302	0	13739	0	1	0.8954	0	0.8762	0	0	259590
DMPH	Salinas Valley Memorial Healthcare System	1.5.4.t	Tobacco Assessment and Counseling	12810	0	13185	0	1	0.9716	0	0.9651	0	0	259590
DMPH	Salinas Valley Memorial Healthcare System	1.6.1	BIRADS to Biopsy	105	0	112	0	1	0.9375	0	0.9126	0	0	259590
DMPH	Salinas Valley Memorial Healthcare System	1.6.2	Breast Cancer Screening	1689	0	2715	0	0	0.6221	0	0.6335	0	0	259590
DMPH	Salinas Valley Memorial Healthcare System	1.6.3	Cervical Cancer Screening	3284	0	5708	0	0	0.5753	0	0.6263	0	0	259590
DMPH	Salinas Valley Memorial Healthcare System	1.6.4.c	Colorectal Cancer Screening	3083	0	5052	0	1	0.6103	0	0.5362	0	0	259590
DMPH	Salinas Valley Memorial Healthcare System	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	None	1	None	1	0	None	1	None	1	0	0
DMPH	Salinas Valley Memorial Healthcare System	2.2.1	DHCS All-Cause Readmissions	218	0	1143	0	0	0.1907	0	0.1819	0	0	259590
DMPH	Salinas Valley Memorial Healthcare System	2.2.2	H-CAHPS: Care Transition Metrics (3)	2941	0	5237	0	0	0.5616	0	0.5667	0	0	259590
DMPH	Salinas Valley Memorial Healthcare System	2.2.3	Medication Reconciliation – 30 days	989	0	1084	0	1	0.9124	0	0.8662	0	0	259590
DMPH	Salinas Valley Memorial Healthcare System	2.2.4	Reconciled Medication List Received by Discharged Patients	4551	0	4673	0	1	0.9739	0	0.9649	0	0	259590
DMPH	Salinas Valley Memorial Healthcare System	2.2.5	Timely Transmission of Transition Record	284	0	450	0	0	0.6311	0	0.7083	0	0	259590
DMPH	Salinas Valley Memorial Healthcare System	2.3.2	Medication Reconciliation – 30 days	593	0	661	0	1	0.8971	0	0.7772	0	0	259590
DMPH	Salinas Valley Memorial Healthcare System	2.3.4	Timely Transmission of Transition Record	278	0	400	0	0	0.695	0	0.722	0	0	259590
DMPH	Salinas Valley Memorial Healthcare System	2.7.1	Advance Care Plan	1027	0	1053	0	1	0.9753	0	1	0	0	259590
DMPH	Salinas Valley Memorial Healthcare System	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	87	0	89	0	1	0.9775	0	0.9765	0	0	259590
DMPH	Salinas Valley Memorial Healthcare System	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	216	0	272	0	1	0.7941	0	0.6276	0	0	259590
DMPH	Salinas Valley Memorial Healthcare System	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	266	0	1179	0	1	0.2256	0	0.1277	0	0	259590
DMPH	Salinas Valley Memorial Healthcare System	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	21	0	58	0	0	0.3621	0	None	1	0	259590
DMPH	Salinas Valley Memorial Healthcare System	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	82	0	110	0	1	0.7455	0	0.6894	0	0	259590
DMPH	Salinas Valley Memorial Healthcare System	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	9201	0	33096	0	0	0.278	0	0.1623	0	0	259590
DMPH	Salinas Valley Memorial Healthcare System	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	101	0	313	0	0	0.3227	0	0.3327	0	0	259590
DMPH	Salinas Valley Memorial Healthcare System	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR	6883	0	10000	0	0	0.6883	0	0.61	0	0.6082	259590
DMPH	Salinas Valley Memorial Healthcare System	3.4.1	ePBM-01 Pre-op Anemia Screening, Selected Elective Surgical Patients	22	0	68	0	1	0.3235	0	0.2626	0	0	259590
DMPH	Salinas Valley Memorial Healthcare System	3.4.3	ePBM-03 Pre-op Type and Crossmatch, Type and Screen, Selected elective Surgical Patients	35	0	67	0	1	0.5224	0	0.449	0	0	259590
DMPH	Salinas Valley Memorial Healthcare System	3.4.4	ePBM-04 Initial Transfusion Threshold	227	0	227	0	1	1	0	1	0	0	259590
DMPH	San Bernardino Mountains Community Hospital, Lake Arrowhead	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	380	0	390	0	1	0.9744	0	0.9521	0	0.9	127500
DMPH	San Bernardino Mountains Community Hospital, Lake Arrowhead	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	15	0	None	4	0	None	4	0.8788	0	0.8809	127500
DMPH	San Bernardino Mountains Community Hospital, Lake Arrowhead	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	129	0	154	0	1	0.8377	0	0.8028	0	0.8125	127500
DMPH	San Bernardino Mountains Community Hospital, Lake Arrowhead	1.4.2	Annual Monitoring for Patients on Persistent Medications	336	0	358	0	1	0.9385	0	0.9556	0	0	382500
DMPH	San Bernardino Mountains Community Hospital, Lake Arrowhead	1.4.3	INR Monitoring for Individuals on Warfarin	22	0	None	4	0	None	4	0.8481	0	0	382500
DPH	San Francisco General Hospital	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	18654	0	32792	0	1	0.5689	0	0.4998	0	0.5257	484726.69
DPH	San Francisco General Hospital	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	5262	0	32792	0	1	0.1605	0	0.0435	0	0.0528	484726.69
DPH	San Francisco General Hospital	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1983	0	6435	0	0	0.3082	0	0.2446	0	0	969453.37
DPH	San Francisco General Hospital	1.1.5.f	Screening for Clinical Depression and follow-up	14136	0	21852	0	0	0.6469	0	0.6657	0	0	969453.37
DPH	San Francisco General Hospital	1.1.6.t	Tobacco Assessment and Counseling	25614	0	26087	0	1	0.9819	0	0.9771	0	0	969453.37
DPH	San Francisco General Hospital	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	641	0	2053	0	0	0.3122	0	0.333	0	0.3425	323151.1233
DPH	San Francisco General Hospital	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	68	0	2053	0	0	0.0331	0	0.0432	0	0.0463	323151.1233
DPH	San Francisco General Hospital	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	154	0	2053	0	0	0.075	0	0.0955	0	0.0973	323151.1233
DPH	San Francisco General Hospital	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	18654	0	32792	0	1	0.5689	0	0.4998	0	0.5257	484726.685
DPH	San Francisco General Hospital	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	5262	0	32792	0	1	0.1605	0	0.0435	0	0.0528	484726.685
DPH	San Francisco General Hospital	1.2.10	REAL and/or SO/GI disparity reduction	2014	0	3779	0	0	0.5329	0	0.745	0	0	969453.37
DPH	San Francisco General Hospital	1.2.11	REAL data completeness	33873	0	34359	0	1	0.9859	0	0.7859	0	0	969453.37
DPH	San Francisco General Hospital	1.2.12.f	Screening for Clinical Depression and follow-up	14136	0	21852	0	0	0.6469	0	0.6657	0	0	969453.37
DPH	San Francisco General Hospital	1.2.13	SO/GI data completeness	16875	0	28687	0	1	0.5882	0	0.5818	0	0	969453.37
DPH	San Francisco General Hospital	1.2.14.t	Tobacco Assessment and Counseling	25614	0	26087	0	1	0.9819	0	0.9771	0	0	969453.37
DPH	San Francisco General Hospital	1.2.2	CG-CAHPS: Provider Rating	3194	0	3975	0	1	0.8035	0	0.7749	0	0	969453.37
DPH	San Francisco General Hospital	1.2.3.c	Colorectal Cancer Screening	10933	0	17764	0	0	0.6155	0	0.6677	0	0	969453.37
DPH	San Francisco General Hospital	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1983	0	6435	0	0	0.3082	0	0.2446	0	0	969453.37
DPH	San Francisco General Hospital	1.2.5.b	Controlling Blood Pressure	7361	0	10438	0	0	0.7052	0	0.8094	0	0	969453.37
DPH	San Francisco General Hospital	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	1771	0	1966	0	0	0.9008	0	0.9289	0	0	969453.37
DPH	San Francisco General Hospital	1.2.8	Prevention Quality Overall Composite #90	643	0	40234	0	0	0.016	0	0.0131	0	0	969453.37
DPH	San Francisco General Hospital	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	12588	0	12614	0	1	0.9979	0	0.8073	0	0	969453.37
DPH	San Francisco General Hospital	1.3.2	DHCS All-Cause Readmissions	187	0	1289	0	1	0.1451	0	0.1462	0	0	969453.37
DPH	San Francisco General Hospital	1.3.3	Influenza Immunization	6112	0	6871	0	1	0.8895	0	0.884	0	0	969453.37
DPH	San Francisco General Hospital	1.3.5	Request for Specialty Care Expertise Turnaround Time	30409	0	32726	0	1	0.9292	0	0.9051	0	0	969453.37
DPH	San Francisco General Hospital	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	9839	0	41103	0	1	0.2394	0	0.2885	0	0	969453.37
DPH	San Francisco General Hospital	1.3.7	Tobacco Assessment and Counseling	9551	0	9650	0	1	0.9897	0	0.9748	0	0	969453.37
DPH	San Francisco General Hospital	1.5.1.b	Controlling Blood Pressure	7361	0	10438	0	0	0.7052	0	0.8094	0	0	969453.37
DPH	San Francisco General Hospital	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	1771	0	1966	0	0	0.9008	0	0.9289	0	0	969453.37
DPH	San Francisco General Hospital	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	15348	0	16487	0	1	0.9309	0	0.9507	0	0	969453.37
DPH	San Francisco General Hospital	1.5.4.t	Tobacco Assessment and Counseling	25614	0	26087	0	1	0.9819	0	0.9771	0	0	969453.37
DPH	San Francisco General Hospital	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	0	0	0	0	None	1047009.6
DPH	San Francisco General Hospital	2.1.2	Exclusive Breast Milk Feeding (PC-05)	530	0	662	0	1	0.8006	0	0.8288	0	0	1047009.6
DPH	San Francisco General Hospital	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	833	0	1	None	1	None	1	0	1047009.6
DPH	San Francisco General Hospital	2.1.5	PC-02 Cesarean Section	44	0	260	0	1	0.1692	0	0.1429	0	0	1047009.6
DPH	San Francisco General Hospital	2.1.6	Prenatal and Postpartum Care: Prenatal Care	622	0	677	0	1	0.9188	0	0.934	0	0.9075	523504.8
DPH	San Francisco General Hospital	2.1.6	Prenatal and Postpartum Care: Postpartum Care	485	0	677	0	0	0.7164	0	0.7372	0	0.7375	523504.8
DPH	San Francisco General Hospital	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	47	0	142	0	1	0.331	0	0.2169	0	0	1047009.6
DPH	San Francisco General Hospital	2.1.8	Unexpected Newborn Complications (UNC)	40	0	649	0	1	0.0616	0	0.0892	0	0	1047009.6
DPH	San Francisco General Hospital	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	Yes	0	3 Safety Drills?	0	n/a	0	0	0	0	None	349003.2
DPH	San Francisco General Hospital	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes	Yes	0	10 Debriefs?	0	n/a	0	0	0	0	None	349003.2
DPH	San Francisco General Hospital	2.1.9	OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16)	16	0	16	0	1	1	0	1	0	None	349003.2
DPH	San Francisco General Hospital	2.2.1	DHCS All-Cause Readmissions	306	0	2057	0	1	0.1488	0	0.1471	0	0	1047009.6
DPH	San Francisco General Hospital	2.2.2	H-CAHPS: Care Transition Metrics (3)	416	0	812	0	0	0.5123	0	0.518	0	0	1047009.6
DPH	San Francisco General Hospital	2.2.3	Medication Reconciliation – 30 days	3119	0	3211	0	1	0.9713	0	0.8163	0	0	1047009.6
DPH	San Francisco General Hospital	2.2.4	Reconciled Medication List Received by Discharged Patients	3364	0	3378	0	1	0.9959	0	0.9887	0	0	1047009.6
DPH	San Francisco General Hospital	2.2.5	Timely Transmission of Transition Record	4366	0	5033	0	1	0.8675	0	0.8227	0	0	1047009.6
DPH	San Francisco General Hospital	2.3.2	Medication Reconciliation – 30 days	911	0	933	0	1	0.9764	0	0.848	0	0	1047009.6
DPH	San Francisco General Hospital	2.3.4	Timely Transmission of Transition Record	1441	0	1549	0	1	0.9303	0	0.9021	0	0	1047009.6
DPH	San Francisco General Hospital	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	3373	0	5460	0	1	0.6178	0	0.5366	0	0.5588	523504.8
DPH	San Francisco General Hospital	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	1147	0	5460	0	1	0.2101	0	0.0328	0	0.0432	523504.8
DPH	San Francisco General Hospital	2.6.2	Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen	426	0	1067	0	0	0.3993	0	0.6363	0	0	1047009.6
DPH	San Francisco General Hospital	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	1051	0	1067	0	1	0.985	0	0.8634	0	0	1047009.6
DPH	San Francisco General Hospital	2.6.4	Screening for Clinical Depression and follow-up	852	0	1266	0	0	0.673	0	0.6679	0	0	1047009.6
DPH	San Francisco General Hospital	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	5153	0	5824	0	0	0.8848	0	0.9057	0	0	1047009.6
DPH	San Francisco General Hospital	3.3.1	Adherence to Medications: Rate 1	341	0	451	0	0.75	0.7561	0	0.6852	0	0.7577	1745016
DPH	San Francisco General Hospital	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 1	147	0	219	0	1	0.6712	0	0.3803	0	0.3051	1745016
DPH	San Francisco General Hospital	3.3.4	Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 1	1497	0	1843	0	1	0.8123	0	0.7241	0	0.779	1745016
DMPH	San Gorgonio Memorial Hospital, Banning	1.7.1	BMI Screening and Follow-up	73	0	94	0	1	0.7766	0	0.6182	0	0	243409.1
DMPH	San Gorgonio Memorial Hospital, Banning	1.7.2	Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met) Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 8)	8	0	8	0	1	1	0	1	0	None	243409.09
DMPH	San Gorgonio Memorial Hospital, Banning	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI	76	0	82	0	1	0.9268	0	0.7826	0	0.7923	81136.36333
DMPH	San Gorgonio Memorial Hospital, Banning	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition	76	0	82	0	1	0.9268	0	0.7826	0	0.7878	81136.36333
DMPH	San Gorgonio Memorial Hospital, Banning	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity	76	0	82	0	1	0.9268	0	0.7717	0	0.7729	81136.36333
DMPH	San Gorgonio Memorial Hospital, Banning	2.2.1	DHCS All-Cause Readmissions	31	0	333	0	1	0.0931	0	0.1366	0	0	243409.09
DMPH	San Gorgonio Memorial Hospital, Banning	2.2.2	H-CAHPS: Care Transition Metrics (3)	4821	0	10000	0	0	0.4821	0	0.5298	0	0	243409.09
DMPH	San Gorgonio Memorial Hospital, Banning	2.2.3	Medication Reconciliation – 30 days	27	0	None	4	0	None	4	1	0	1	243409.09
DMPH	San Gorgonio Memorial Hospital, Banning	2.2.4	Reconciled Medication List Received by Discharged Patients	27	0	None	4	0	None	4	1	0	0	243409.09
DMPH	San Gorgonio Memorial Hospital, Banning	2.2.5	Timely Transmission of Transition Record	27	0	None	4	0	None	4	1	0	0	243409.09
DMPH	San Gorgonio Memorial Hospital, Banning	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	35	0	40	0	1	0.875	0	0.8934	0	0	243409.09
DMPH	San Gorgonio Memorial Hospital, Banning	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	5055	0	10951	0	0	0.4616	0	0.4494	0	0	243409.09
DMPH	San Gorgonio Memorial Hospital, Banning	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	28	0	56	0	0	0.5	0	0	0	0	0
DMPH	San Gorgonio Memorial Hospital, Banning	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR	8770	0	10000	0	0	0.877	0	0	0	0.8485	243409.09
DPH	San Joaquin General Hospital	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	4225	0	15252	0	0	0.277	0	0.5471	0	0.5683	274128.2
DPH	San Joaquin General Hospital	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	827	0	15252	0	0	0.0542	0	0.0809	0	0.0865	274128.2
DPH	San Joaquin General Hospital	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1192	0	2979	0	0	0.4001	0	0.2903	0	0	548256.4
DPH	San Joaquin General Hospital	1.1.5.f	Screening for Clinical Depression and follow-up	186	0	370	0	0	0.5027	0	0.7459	0	0	548256.4
DPH	San Joaquin General Hospital	1.1.6.t	Tobacco Assessment and Counseling	331	0	377	0	0	0.878	0	0.9867	0	0	548256.4
DPH	San Joaquin General Hospital	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	116	0	572	0	0	0.2028	0	0.3574	0	0.3644	182752.1333
DPH	San Joaquin General Hospital	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	40	0	572	0	0	0.0699	0	0.1064	0	0.0744	182752.1333
DPH	San Joaquin General Hospital	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	55	0	572	0	0	0.0962	0	0.1447	0	0.1134	182752.1333
DPH	San Joaquin General Hospital	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	4225	0	15252	0	0	0.277	0	0.5471	0	0.5683	274128.2
DPH	San Joaquin General Hospital	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	827	0	15252	0	0	0.0542	0	0.0809	0	0.0865	274128.2
DPH	San Joaquin General Hospital	1.2.10	REAL and/or SO/GI disparity reduction	448	0	767	0	0.5	0.5841	0	0.5462	0	0	548256.39
DPH	San Joaquin General Hospital	1.2.11	REAL data completeness	17948	0	18021	0	1	0.9959	0	0.9913	0	0	548256.39
DPH	San Joaquin General Hospital	1.2.12.f	Screening for Clinical Depression and follow-up	186	0	370	0	0	0.5027	0	0.7459	0	0	548256.39
DPH	San Joaquin General Hospital	1.2.13	SO/GI data completeness	7669	0	13383	0	1	0.573	0	0.744	0	0	548256.39
DPH	San Joaquin General Hospital	1.2.14.t	Tobacco Assessment and Counseling	331	0	377	0	0	0.878	0	0.9867	0	0	548256.39
DPH	San Joaquin General Hospital	1.2.2	CG-CAHPS: Provider Rating	7777	0	10000	0	0.75	0.7777	0	0.771	0	0	548256.4
DPH	San Joaquin General Hospital	1.2.3.c	Colorectal Cancer Screening	191	0	370	0	1	0.5162	0	0.5014	0	0	548256.4
DPH	San Joaquin General Hospital	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1192	0	2979	0	0	0.4001	0	0.2903	0	0	548256.39
DPH	San Joaquin General Hospital	1.2.5.b	Controlling Blood Pressure	3031	0	5087	0	0	0.5958	0	0.6527	0	0	548256.39
DPH	San Joaquin General Hospital	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	813	0	939	0	0	0.8658	0	0.8871	0	0	548256.39
DPH	San Joaquin General Hospital	1.2.8	Prevention Quality Overall Composite #90	153	0	23719	0	1	0.0065	0	0.0078	0	0	548256.39
DPH	San Joaquin General Hospital	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	273	0	351	0	1	0.7778	0	0.5418	0	0	548256.39
DPH	San Joaquin General Hospital	1.3.2	DHCS All-Cause Readmissions	74	0	602	0	1	0.1229	0	0.1263	0	0	548256.39
DPH	San Joaquin General Hospital	1.3.3	Influenza Immunization	203	0	351	0	0	0.5783	0	0.7273	0	0	548256.39
DPH	San Joaquin General Hospital	1.3.5	Request for Specialty Care Expertise Turnaround Time	259	0	377	0	0	0.687	0	0.8678	0	0	548256.39
DPH	San Joaquin General Hospital	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	None	1	377	0	0	None	1	0.1676	0	0	548256.39
DPH	San Joaquin General Hospital	1.3.7	Tobacco Assessment and Counseling	314	0	341	0	0	0.9208	0	0.9648	0	0	548256.39
DPH	San Joaquin General Hospital	1.6.1	BIRADS to Biopsy	17	0	None	4	0	None	4	0.6047	0	0	548256.39
DPH	San Joaquin General Hospital	1.6.2	Breast Cancer Screening	248	0	341	0	1	0.7273	0	0.6895	0	0	548256.39
DPH	San Joaquin General Hospital	1.6.3	Cervical Cancer Screening	228	0	369	0	1	0.6179	0	0.4811	0	0	548256.39
DPH	San Joaquin General Hospital	1.6.4.c	Colorectal Cancer Screening	191	0	370	0	1	0.5162	0	0.5014	0	0	548256.39
DPH	San Joaquin General Hospital	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	None	1	30	0	0	None	1	None	1	0	548256.39
DPH	San Joaquin General Hospital	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	0	0	0	0	None	646365.43
DPH	San Joaquin General Hospital	2.1.2	Exclusive Breast Milk Feeding (PC-05)	435	0	614	0	0	0.7085	0	0.7112	0	0	646365.43
DPH	San Joaquin General Hospital	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	879	0	1	None	1	0	0	0	646365.42
DPH	San Joaquin General Hospital	2.1.5	PC-02 Cesarean Section	41	0	229	0	1	0.179	0	0.2158	0	0	646365.42
DPH	San Joaquin General Hospital	2.1.6	Prenatal and Postpartum Care: Postpartum Care	252	0	411	0	1	0.6131	0	0.4963	0	0.5961	323182.71
DPH	San Joaquin General Hospital	2.1.6	Prenatal and Postpartum Care: Prenatal Care	218	0	411	0	0	0.5304	0	0.6	0	0.7689	323182.71
DPH	San Joaquin General Hospital	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	25	0	59	0	1	0.4237	0	0.3623	0	0	646365.42
DPH	San Joaquin General Hospital	2.1.8	Unexpected Newborn Complications (UNC)	25	0	655	0	1	0.0382	0	0.035	0	0	646365.42
DPH	San Joaquin General Hospital	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	Yes	0	3 Safety Drills?	0	n/a	0	0	0	0	None	215455.14
DPH	San Joaquin General Hospital	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes	Yes	0	10 Debriefs?	0	n/a	0	0	0	0	None	215455.14
DPH	San Joaquin General Hospital	2.1.9	OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16)	16	0	16	0	1	1	0	1	0	None	215455.14
DPH	San Joaquin General Hospital	2.2.1	DHCS All-Cause Readmissions	135	0	1204	0	0	0.1121	0	0.107	0	0	646365.42
DPH	San Joaquin General Hospital	2.2.2	H-CAHPS: Care Transition Metrics (3)	4000	0	10000	0	0	0.4	0	0.382	0	0	646365.42
DPH	San Joaquin General Hospital	2.2.3	Medication Reconciliation – 30 days	204	0	278	0	0	0.7338	0	0.8418	0	0	646365.42
DPH	San Joaquin General Hospital	2.2.4	Reconciled Medication List Received by Discharged Patients	341	0	341	0	1	1	0	0.9355	0	0	646365.42
DPH	San Joaquin General Hospital	2.2.5	Timely Transmission of Transition Record	307	0	411	0	0	0.747	0	0.7801	0	0	646365.42
DPH	San Joaquin General Hospital	2.3.2	Medication Reconciliation – 30 days	172	0	249	0	0	0.6908	0	0.8991	0	0	646365.42
DPH	San Joaquin General Hospital	2.3.4	Timely Transmission of Transition Record	310	0	411	0	0	0.7543	0	0.7625	0	0	646365.42
DPH	San Joaquin General Hospital	2.7.1	Advance Care Plan	217	0	323	0	1	0.6718	0	0.3313	0	0	646365.42
DPH	San Joaquin General Hospital	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	92	0	132	0	0	0.697	0	0.7851	0	0	646365.42
DPH	San Joaquin General Hospital	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	34	0	40	0	0	0.85	0	0.9322	0	0	646365.42
DPH	San Joaquin General Hospital	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	38	0	132	0	0	0.2879	0	0.367	0	0	646365.42
DPH	San Joaquin General Hospital	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	None	1	None	1	0	None	1	None	1	0	0
DPH	San Joaquin General Hospital	3.2.2	Appropriate Emergency Department Utilization of CT for Pulmonary Embolism	147	0	219	0	0	0.6712	0	0.8084	0	0	1023412
DPH	San Joaquin General Hospital	3.2.3	Use of Imaging Studies for Low Back Pain	62	0	449	0	0	0.1381	0	0.8648	0	0	1023412
DPH	San Joaquin General Hospital	3.2.4	Use of Imaging Studies for Low Back Pain (anytime) Variation of HEDIS Use of Imaging Studies for Low Back Pain measures: Appropriate Score	235	0	302	0	1	0.7781	0	0.6828	0	None	1023412
DPH	San Mateo Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	3707	0	22564	0	1	0.1643	0	0.0135	0	0.088	285775.325
DPH	San Mateo Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	4636	0	22564	0	1	0.2055	0	0.0447	0	0.0539	285775.325
DPH	San Mateo Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1209	0	4169	0	1	0.29	0	0.2367	0	0	571550.65
DPH	San Mateo Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	8525	0	14988	0	1	0.5688	0	0.397	0	0	571550.65
DPH	San Mateo Medical Center	1.1.6.t	Tobacco Assessment and Counseling	15023	0	15796	0	0	0.9511	0	0.9651	0	0	571550.65
DPH	San Mateo Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	257	0	706	0	1	0.364	0	0.3224	0	0.3329	190516.8833
DPH	San Mateo Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	40	0	706	0	0	0.0567	0	0.0692	0	0.0697	190516.8833
DPH	San Mateo Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	77	0	706	0	1	0.1091	0	0.1056	0	0.1064	190516.8833
DPH	San Mateo Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	3707	0	22564	0	1	0.1643	0	0.0135	0	0.088	285775.325
DPH	San Mateo Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	4636	0	22564	0	1	0.2055	0	0.0447	0	0.0539	285775.325
DPH	San Mateo Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	176	0	283	0	1	0.6219	0	0.7228	0	0	571550.64
DPH	San Mateo Medical Center	1.2.11	REAL data completeness	21839	0	31268	0	0.75	0.6984	0	0.951	0	0	571550.64
DPH	San Mateo Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	8525	0	14988	0	1	0.5688	0	0.397	0	0	571550.64
DPH	San Mateo Medical Center	1.2.13	SO/GI data completeness	17259	0	19997	0	1	0.8631	0	0.8676	0	0	571550.64
DPH	San Mateo Medical Center	1.2.14.t	Tobacco Assessment and Counseling	15023	0	15796	0	0	0.9511	0	0.9651	0	0	571550.64
DPH	San Mateo Medical Center	1.2.2	CG-CAHPS: Provider Rating	634	0	764	0	1	0.8298	0	0.7828	0	0	571550.65
DPH	San Mateo Medical Center	1.2.3.c	Colorectal Cancer Screening	4647	0	7794	0	0	0.5962	0	0.6353	0	0	571550.65
DPH	San Mateo Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1209	0	4169	0	1	0.29	0	0.2367	0	0	571550.64
DPH	San Mateo Medical Center	1.2.5.b	Controlling Blood Pressure	4030	0	6167	0	1	0.6535	0	0.7909	0	0	571550.64
DPH	San Mateo Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	690	0	722	0	1	0.9557	0	0.9523	0	0	571550.64
DPH	San Mateo Medical Center	1.2.8	Prevention Quality Overall Composite #90	155	0	19771	0	1	0.0078	0	0.0107	0	0	571550.64
DPH	San Mateo Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	12285	0	12285	0	1	1	0	1	0	0	571550.64
DPH	San Mateo Medical Center	1.3.2	DHCS All-Cause Readmissions	14	0	187	0	1	0.0749	0	0.0775	0	0	571550.64
DPH	San Mateo Medical Center	1.3.3	Influenza Immunization	7978	0	10402	0	1	0.767	0	0.7126	0	0	571550.64
DPH	San Mateo Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	6758	0	19459	0	1	0.3473	0	0.2501	0	0	571550.64
DPH	San Mateo Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	4601	0	35109	0	1	0.131	0	0.0121	0	0	571550.64
DPH	San Mateo Medical Center	1.3.7	Tobacco Assessment and Counseling	4573	0	4788	0	0	0.9551	0	0.9724	0	0	571550.64
DPH	San Mateo Medical Center	1.6.1	BIRADS to Biopsy	84	0	137	0	1	0.6131	0	0.5227	0	0	571550.64
DPH	San Mateo Medical Center	1.6.2	Breast Cancer Screening	3920	0	5138	0	1	0.7629	0	0.7746	0	0	571550.64
DPH	San Mateo Medical Center	1.6.3	Cervical Cancer Screening	5915	0	9291	0	0	0.6366	0	0.6428	0	0	571550.64
DPH	San Mateo Medical Center	1.6.4.c	Colorectal Cancer Screening	4647	0	7794	0	0	0.5962	0	0.6353	0	0	571550.64
DPH	San Mateo Medical Center	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	256	0	439	0	1	0.5831	0	0.3725	0	0	571550.64
DPH	San Mateo Medical Center	2.2.1	DHCS All-Cause Readmissions	19	0	222	0	1	0.0856	0	0.0773	0	0	1163884.91
DPH	San Mateo Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	5300	0	10000	0	0	0.53	0	0.529	0	0	1163884.91
DPH	San Mateo Medical Center	2.2.3	Medication Reconciliation – 30 days	442	0	587	0	1	0.753	0	0.6788	0	0	1163884.91
DPH	San Mateo Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	724	0	738	0	1	0.981	0	0.9772	0	0	1163884.91
DPH	San Mateo Medical Center	2.2.5	Timely Transmission of Transition Record	1751	0	1757	0	1	0.9966	0	0.993	0	0	1163884.91
DPH	San Mateo Medical Center	2.3.2	Medication Reconciliation – 30 days	78	0	99	0	1	0.7879	0	0.6273	0	0	1163884.91
DPH	San Mateo Medical Center	2.3.4	Timely Transmission of Transition Record	237	0	237	0	1	1	0	1	0	0	1163884.91
DPH	San Mateo Medical Center	2.4.1	Adolescent Well-Care Visit	29	0	36	0	1	0.8056	0	0.697	0	0	0
DPH	San Mateo Medical Center	2.4.2	Developmental Screening in the First Three Years of Life	None	1	None	1	0	None	1	None	1	0	0
DPH	San Mateo Medical Center	2.4.3	Documentation of Current Medications in the Medical Record (0-18 yo)	208	0	240	0	1	0.8667	0	0.7733	0	0	1163884.91
DPH	San Mateo Medical Center	2.4.4	Screening for Clinical Depression and follow-up	19	0	None	4	0	None	4	None	4	0	0
DPH	San Mateo Medical Center	2.4.5	Tobacco Assessment and Counseling (13 yo and older)	27	0	None	4	0	None	4	None	4	0	0
DPH	San Mateo Medical Center	2.4.7	Well Child Visits - Third, Fourth, Fifth, and Sixth Years of life	14	0	None	4	0	None	4	None	4	0	0
DPH	San Mateo Medical Center	2.4.8	Comprehensive Medical Evaluation Following Foster Youth Placement in Foster Care	12	0	30	0	0	0.4	0	None	1	0	0
DPH	San Mateo Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	119	0	373	0	1	0.319	0	0.1202	0	0.1841	581942.455
DPH	San Mateo Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	143	0	373	0	1	0.3834	0	0.1612	0	0.1368	581942.455
DPH	San Mateo Medical Center	2.6.2	Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen	None	1	None	1	0	None	1	None	1	0	0
DPH	San Mateo Medical Center	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	None	1	None	1	0	None	1	None	1	0	0
DPH	San Mateo Medical Center	2.6.4	Screening for Clinical Depression and follow-up	108	0	201	0	1	0.5373	0	0.4773	0	0	1163884.91
DPH	San Mateo Medical Center	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	348	0	382	0	1	0.911	0	0.8827	0	0	1163884.9
DPH	San Mateo Medical Center	3.2.2	Appropriate Emergency Department Utilization of CT for Pulmonary Embolism	148	0	151	0	1	0.9801	0	0.9478	0	0	1066894.67
DPH	San Mateo Medical Center	3.2.3	Use of Imaging Studies for Low Back Pain	239	0	261	0	1	0.9157	0	0.8785	0	0	1066894.67
DPH	San Mateo Medical Center	3.2.4	Use of Imaging Studies for Low Back Pain (anytime) Variation of HEDIS Use of Imaging Studies for Low Back Pain measures: Appropriate Score	85	0	141	0	0	0.6028	0	0.7023	0	None	1066894.66
DPH	Santa Clara Valley Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	28392	0	54008	0	0.5	0.5257	0	0.5119	0	0.5366	881834.655
DPH	Santa Clara Valley Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	7167	0	54008	0	1	0.1327	0	0.0874	0	0.0923	881834.655
DPH	Santa Clara Valley Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	3008	0	10702	0	1	0.2811	0	0.252	0	0	1763669.31
DPH	Santa Clara Valley Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	20583	0	36799	0	0	0.5593	0	0.6244	0	0	1763669.31
DPH	Santa Clara Valley Medical Center	1.1.6.t	Tobacco Assessment and Counseling	33235	0	33750	0	1	0.9847	0	0.9917	0	0	1763669.31
DPH	Santa Clara Valley Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	863	0	2052	0	0	0.4206	0	0.4262	0	0.4264	587889.77
DPH	Santa Clara Valley Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	107	0	2052	0	0	0.0521	0	0.052	0	0.0542	587889.77
DPH	Santa Clara Valley Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	227	0	2052	0	1	0.1106	0	0.1049	0	0.1058	587889.77
DPH	Santa Clara Valley Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	28392	0	54008	0	0.5	0.5257	0	0.5119	0	0.5366	881834.655
DPH	Santa Clara Valley Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	7167	0	54008	0	1	0.1327	0	0.0874	0	0.0923	881834.655
DPH	Santa Clara Valley Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	1467	0	4672	0	0	0.314	0	0.2971	0	0	1763669.31
DPH	Santa Clara Valley Medical Center	1.2.11	REAL data completeness	47362	0	59477	0	0.75	0.7963	0	0.7728	0	0	1763669.31
DPH	Santa Clara Valley Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	20583	0	36799	0	0	0.5593	0	0.6244	0	0	1763669.31
DPH	Santa Clara Valley Medical Center	1.2.13	SO/GI data completeness	34161	0	38906	0	1	0.878	0	0.9078	0	0	1763669.31
DPH	Santa Clara Valley Medical Center	1.2.14.t	Tobacco Assessment and Counseling	33235	0	33750	0	1	0.9847	0	0.9917	0	0	1763669.31
DPH	Santa Clara Valley Medical Center	1.2.2	CG-CAHPS: Provider Rating	7880	0	10000	0	1	0.788	0	0.744	0	0	1763669.31
DPH	Santa Clara Valley Medical Center	1.2.3.c	Colorectal Cancer Screening	14390	0	22536	0	1	0.6385	0	0.7128	0	0	1763669.31
DPH	Santa Clara Valley Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	3008	0	10702	0	1	0.2811	0	0.252	0	0	1763669.31
DPH	Santa Clara Valley Medical Center	1.2.5.b	Controlling Blood Pressure	6492	0	10705	0	0	0.6064	0	0.6971	0	0	1763669.31
DPH	Santa Clara Valley Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	1665	0	1761	0	1	0.9455	0	0.9462	0	0	1763669.31
DPH	Santa Clara Valley Medical Center	1.2.8	Prevention Quality Overall Composite #90	756	0	67405	0	0	0.0112	0	0.0117	0	0	1763669.31
DPH	Santa Clara Valley Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	29229	0	29640	0	1	0.9861	0	0.9896	0	0	1763669.31
DPH	Santa Clara Valley Medical Center	1.3.2	DHCS All-Cause Readmissions	200	0	1403	0	0	0.1426	0	0.1316	0	0	1763669.31
DPH	Santa Clara Valley Medical Center	1.3.3	Influenza Immunization	14184	0	19062	0	0	0.7441	0	0.8561	0	0	1763669.31
DPH	Santa Clara Valley Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	49236	0	63397	0	1	0.7766	0	0.7222	0	0	1763669.3
DPH	Santa Clara Valley Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	11256	0	80515	0	1	0.1398	0	0.1092	0	0	1763669.3
DPH	Santa Clara Valley Medical Center	1.3.7	Tobacco Assessment and Counseling	21082	0	21230	0	1	0.993	0	0.9941	0	0	1763669.3
DPH	Santa Clara Valley Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	14377	0	15576	0	1	0.923	0	0.9164	0	0.9	587889.7667
DPH	Santa Clara Valley Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	6737	0	7184	0	1	0.9378	0	0.9474	0	0.9	587889.7667
DPH	Santa Clara Valley Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	3037	0	6381	0	0	0.4759	0	0.5757	0	0.6081	587889.7667
DPH	Santa Clara Valley Medical Center	1.4.2	Annual Monitoring for Patients on Persistent Medications	17541	0	19790	0	0	0.8864	0	0.9048	0	0	1763669.3
DPH	Santa Clara Valley Medical Center	1.4.3	INR Monitoring for Individuals on Warfarin	516	0	708	0	0	0.7288	0	0.8669	0	0	1763669.3
DPH	Santa Clara Valley Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	0	0	0	0	None	1667469.1
DPH	Santa Clara Valley Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	1387	0	1947	0	1	0.7124	0	0.6951	0	0	1667469.1
DPH	Santa Clara Valley Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	2193	0	1	None	1	None	1	0	1667469.09
DPH	Santa Clara Valley Medical Center	2.1.5	PC-02 Cesarean Section	150	0	683	0	1	0.2196	0	0.2169	0	0	1667469.09
DPH	Santa Clara Valley Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	791	0	894	0	0	0.8848	0	0.8931	0	0.8945	833734.545
DPH	Santa Clara Valley Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	629	0	894	0	0	0.7036	0	0.7244	0	0.7259	833734.545
DPH	Santa Clara Valley Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	75	0	321	0	1	0.2336	0	0.0864	0	0	1667469.09
DPH	Santa Clara Valley Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	61	0	1850	0	1	0.033	0	0.0238	0	0	1667469.09
DPH	Santa Clara Valley Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter No	No	0	3 Safety Drills?	0	n/a	0	0	0	0	None	555823.03
DPH	Santa Clara Valley Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) No	No	0	10 Debriefs?	0	n/a	0	0	0	0	None	555823.03
DPH	Santa Clara Valley Medical Center	2.1.9	OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16)	16	0	16	0	0.5	1	0	1	0	None	555823.03
DPH	Santa Clara Valley Medical Center	2.2.1	DHCS All-Cause Readmissions	234	0	1583	0	0	0.1478	0	0.132	0	0	1667469.09
DPH	Santa Clara Valley Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	4808	0	10000	0	0	0.4808	0	0.481	0	0	1667469.09
DPH	Santa Clara Valley Medical Center	2.2.3	Medication Reconciliation – 30 days	3026	0	3060	0	0	0.9889	0	0.9995	0	0	1667469.09
DPH	Santa Clara Valley Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	6762	0	7050	0	0	0.9591	0	0.962	0	0	1667469.09
DPH	Santa Clara Valley Medical Center	2.2.5	Timely Transmission of Transition Record	3826	0	5414	0	1	0.7067	0	0.6661	0	0	1667469.09
DPH	Santa Clara Valley Medical Center	2.3.2	Medication Reconciliation – 30 days	187	0	189	0	0	0.9894	0	1	0	0	1667469.09
DPH	Santa Clara Valley Medical Center	2.3.4	Timely Transmission of Transition Record	210	0	305	0	1	0.6885	0	0.6218	0	0	1667469.09
DPH	Santa Clara Valley Medical Center	2.4.1	Adolescent Well-Care Visit	76	0	89	0	1	0.8539	0	0.9123	0	0	1667469.09
DPH	Santa Clara Valley Medical Center	2.4.2	Developmental Screening in the First Three Years of Life	111	0	135	0	1	0.8222	0	0.4044	0	0	1667469.09
DPH	Santa Clara Valley Medical Center	2.4.3	Documentation of Current Medications in the Medical Record (0-18 yo)	1382	0	1700	0	0	0.8129	0	0.8808	0	0	1667469.09
DPH	Santa Clara Valley Medical Center	2.4.4	Screening for Clinical Depression and follow-up	26	0	59	0	0	0.4407	0	0.8101	0	0	1667469.09
DPH	Santa Clara Valley Medical Center	2.4.5	Tobacco Assessment and Counseling (13 yo and older)	30	0	35	0	0	0.8571	0	0.8654	0	0	1667469.09
DPH	Santa Clara Valley Medical Center	2.4.7	Well Child Visits - Third, Fourth, Fifth, and Sixth Years of life	103	0	115	0	1	0.8957	0	0.9505	0	0	1667469.09
DPH	Santa Clara Valley Medical Center	2.4.8	Comprehensive Medical Evaluation Following Foster Youth Placement in Foster Care	106	0	115	0	1	0.9217	0	0.8511	0	0	1667469.09
DPH	Santa Clara Valley Medical Center	3.3.1	Adherence to Medications: Rate 1	216	0	274	0	0	0.7883	0	0.9889	0	0.8328	3057026.67
DPH	Santa Clara Valley Medical Center	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 1	222	0	229	0	1	0.9694	0	0.9533	0	0.8017	3057026.67
DPH	Santa Clara Valley Medical Center	3.3.4	Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 1	2927	0	6628	0	1	0.4416	0	0.3687	0	0.4181	3057026.66
DMPH	Seneca Healthcare District, Chester	2.2.1	DHCS All-Cause Readmissions	0	0	None	4	0	None	4	None	1	0	229500
DMPH	Seneca Healthcare District, Chester	2.2.2	H-CAHPS: Care Transition Metrics (3)	5300	0	10000	0	1	0.53	0	0.39	0	0	229500
DMPH	Seneca Healthcare District, Chester	2.2.3	Medication Reconciliation – 30 days	38	0	45	0	0	0.8444	0	0.9359	0	0	229500
DMPH	Seneca Healthcare District, Chester	2.2.4	Reconciled Medication List Received by Discharged Patients	34	0	66	0	0	0.5152	0	0.6032	0	0	229500
DMPH	Seneca Healthcare District, Chester	2.2.5	Timely Transmission of Transition Record	51	0	51	0	1	1	0	0.9901	0	0	229500
DMPH	Sierra View District Hospital, Porterville	1.7.1	BMI Screening and Follow-up	2603	0	2702	0	1	0.9634	0	0.9124	0	0	479400
DMPH	Sierra View District Hospital, Porterville	1.7.2	Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met) Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 8)	8	0	8	0	1	1	0	1	0	None	479400
DMPH	Sierra View District Hospital, Porterville	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI	529	0	540	0	1	0.9796	0	0.9883	0	0.88	159800
DMPH	Sierra View District Hospital, Porterville	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition	528	0	540	0	1	0.9778	0	0.9707	0	0.8345	159800
DMPH	Sierra View District Hospital, Porterville	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity	528	0	540	0	1	0.9778	0	0.9707	0	0.7835	159800
DMPH	Sierra View District Hospital, Porterville	2.2.1	DHCS All-Cause Readmissions	130	0	642	0	0	0.2025	0	0.1485	0	0	479400
DMPH	Sierra View District Hospital, Porterville	2.2.2	H-CAHPS: Care Transition Metrics (3)	4280	0	10000	0	0	0.428	0	0.411	0	0	479400
DMPH	Sierra View District Hospital, Porterville	2.2.3	Medication Reconciliation – 30 days	326	0	326	0	1	1	0	0.9965	0	0	479400
DMPH	Sierra View District Hospital, Porterville	2.2.4	Reconciled Medication List Received by Discharged Patients	543	0	561	0	1	0.9679	0	0.9619	0	0	479400
DMPH	Sierra View District Hospital, Porterville	2.2.5	Timely Transmission of Transition Record	1345	0	3246	0	0	0.4144	0	0.3931	0	0	479400
DMPH	Sierra View District Hospital, Porterville	2.3.2	Medication Reconciliation – 30 days	111	0	111	0	1	1	0	1	0	0	479400
DMPH	Sierra View District Hospital, Porterville	2.3.4	Timely Transmission of Transition Record	410	0	486	0	1	0.8436	0	0.8277	0	0	479400
DMPH	Sierra View District Hospital, Porterville	2.7.1	Advance Care Plan	33	0	55	0	1	0.6	0	0.2803	0	0	479400
DMPH	Sierra View District Hospital, Porterville	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	23	0	34	0	0	0.6765	0	0.8615	0	0	479400
DMPH	Sierra View District Hospital, Porterville	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	None	1	None	4	0	None	1	0.9796	0	0	479400
DMPH	Sierra View District Hospital, Porterville	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	104	0	367	0	0	0.2834	0	0.3173	0	0	479400
DMPH	Sierra View District Hospital, Porterville	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	14	0	46	0	0	0.3043	0	None	1	0	479400
DMPH	Sonoma Valley Hospital, Sonoma	2.2.1	DHCS All-Cause Readmissions	None	1	82	0	1	None	1	0.1261	0	0	229500
DMPH	Sonoma Valley Hospital, Sonoma	2.2.2	H-CAHPS: Care Transition Metrics (3)	82	0	173	0	0	0.474	0	0.5342	0	0	229500
DMPH	Sonoma Valley Hospital, Sonoma	2.2.3	Medication Reconciliation – 30 days	138	0	160	0	1	0.8625	0	0.2283	0	0	229500
DMPH	Sonoma Valley Hospital, Sonoma	2.2.4	Reconciled Medication List Received by Discharged Patients	79	0	87	0	1	0.908	0	0.8145	0	0	229500
DMPH	Sonoma Valley Hospital, Sonoma	2.2.5	Timely Transmission of Transition Record	100	0	160	0	0	0.625	0	0.6087	0	0	229500
DMPH	Southern Inyo Hospital, Lone Pine	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	63	0	208	0	0	0.3029	0	0.6452	0	0.6566	47812.5
DMPH	Southern Inyo Hospital, Lone Pine	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	1	208	0	0	None	1	0.0507	0	0.0593	47812.5
DMPH	Southern Inyo Hospital, Lone Pine	1.2.10	REAL and/or SO/GI disparity reduction	None	1	None	1	0	None	1	None	1	0	0
DMPH	Southern Inyo Hospital, Lone Pine	1.2.11	REAL data completeness	228	0	228	0	1	1	0	0.9628	0	0	95625
DMPH	Southern Inyo Hospital, Lone Pine	1.2.12.f	Screening for Clinical Depression and follow-up	41	0	169	0	0	0.2426	0	0.4747	0	0	95625
DMPH	Southern Inyo Hospital, Lone Pine	1.2.13	SO/GI data completeness	111	0	196	0	1	0.5663	0	0.6232	0	0	95625
DMPH	Southern Inyo Hospital, Lone Pine	1.2.14.t	Tobacco Assessment and Counseling	86	0	196	0	0	0.4388	0	0.5268	0	0	95625
DMPH	Southern Inyo Hospital, Lone Pine	1.2.2	CG-CAHPS: Provider Rating	0	0	0	0	0	0	0	0.8377	0	0	95625
DMPH	Southern Inyo Hospital, Lone Pine	1.2.3.c	Colorectal Cancer Screening	28	0	78	0	0	0.359	0	0.3647	0	0	95625
DMPH	Southern Inyo Hospital, Lone Pine	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	1	None	4	0	None	1	None	1	0	0
DMPH	Southern Inyo Hospital, Lone Pine	1.2.5.b	Controlling Blood Pressure	24	0	41	0	0	0.5854	0	0.7115	0	0	95625
DMPH	Southern Inyo Hospital, Lone Pine	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	1	None	1	0	None	1	0	0	0	0
DMPH	Southern Inyo Hospital, Lone Pine	1.2.8	Prevention Quality Overall Composite #90	None	1	196	0	1	None	1	None	1	0	95625
DMPH	Southern Inyo Hospital, Lone Pine	1.6.1	BIRADS to Biopsy	0	0	0	0	0	0	0	0	0	0	0
DMPH	Southern Inyo Hospital, Lone Pine	1.6.2	Breast Cancer Screening	None	1	39	0	0	None	1	0.3696	0	0	95625
DMPH	Southern Inyo Hospital, Lone Pine	1.6.3	Cervical Cancer Screening	18	0	58	0	0	0.3103	0	0.1857	0	0	95625
DMPH	Southern Inyo Hospital, Lone Pine	1.6.4.c	Colorectal Cancer Screening	28	0	78	0	0	0.359	0	0.3647	0	0	95625
DMPH	Southern Inyo Hospital, Lone Pine	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	0	0	None	1	0	None	1	None	1	0	0
DMPH	Tahoe Forest Hospital District, Truckee	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	211	0	1043	0	1	0.2023	0	0.1307	0	0.1935	77807.695
DMPH	Tahoe Forest Hospital District, Truckee	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	116	0	1043	0	0	0.1112	0	0.1297	0	0.1304	77807.695
DMPH	Tahoe Forest Hospital District, Truckee	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	15	0	83	0	1	0.1807	0	0.2105	0	0	155615.39
DMPH	Tahoe Forest Hospital District, Truckee	1.1.5.f	Screening for Clinical Depression and follow-up	144	0	446	0	0	0.3229	0	0.2976	0	0	155615.39
DMPH	Tahoe Forest Hospital District, Truckee	1.1.6.t	Tobacco Assessment and Counseling	726	0	761	0	1	0.954	0	0.9505	0	0	155615.39
DMPH	Tahoe Forest Hospital District, Truckee	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	18	0	54	0	1	0.3333	0	None	1	0.1935	0
DMPH	Tahoe Forest Hospital District, Truckee	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	1	54	0	1	None	1	None	1	0.0396	0
DMPH	Tahoe Forest Hospital District, Truckee	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	0	0	54	0	0	0	0	None	1	0.0435	0
DMPH	Tahoe Forest Hospital District, Truckee	1.5.1.b	Controlling Blood Pressure	108	0	153	0	1	0.7059	0	0.6691	0	0	155615.39
DMPH	Tahoe Forest Hospital District, Truckee	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	34	0	39	0	1	0.8718	0	0.8478	0	0	155615.39
DMPH	Tahoe Forest Hospital District, Truckee	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	329	0	496	0	1	0.6633	0	0.6369	0	0	155615.38
DMPH	Tahoe Forest Hospital District, Truckee	1.5.4.t	Tobacco Assessment and Counseling	726	0	761	0	1	0.954	0	0.9505	0	0	155615.38
DMPH	Tahoe Forest Hospital District, Truckee	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	67	0	180	0	1	0.3722	0	0.2105	0	0.2653	77807.69
DMPH	Tahoe Forest Hospital District, Truckee	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	30	0	180	0	1	0.1667	0	0.1353	0	0.1355	77807.69
DMPH	Tahoe Forest Hospital District, Truckee	2.6.2	Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen	38	0	93	0	1	0.4086	0	0.3511	0	0	155615.38
DMPH	Tahoe Forest Hospital District, Truckee	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	82	0	93	0	1	0.8817	0	0.6383	0	0	155615.38
DMPH	Tahoe Forest Hospital District, Truckee	2.6.4	Screening for Clinical Depression and follow-up	58	0	137	0	0	0.4234	0	0.4068	0	0	155615.38
DMPH	Tahoe Forest Hospital District, Truckee	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	211	0	226	0	1	0.9336	0	0.8867	0	0	155615.38
DMPH	Tri-City Medical Center, Oceanside	1.5.1.b	Controlling Blood Pressure	1449	0	2800	0	0	0.5175	0	0.5334	0	0	335643.75
DMPH	Tri-City Medical Center, Oceanside	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	68	0	68	0	1	1	0	1	0	0	335643.75
DMPH	Tri-City Medical Center, Oceanside	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	3412	0	4136	0	1	0.825	0	0.3463	0	0	335643.75
DMPH	Tri-City Medical Center, Oceanside	1.5.4.t	Tobacco Assessment and Counseling	346	0	357	0	1	0.9692	0	0.9612	0	0	335643.75
DMPH	Tri-City Medical Center, Oceanside	1.7.1	BMI Screening and Follow-up	2097	0	2708	0	0.5	0.7744	0	0.7649	0	0	335643.75
DMPH	Tri-City Medical Center, Oceanside	1.7.2	Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met) Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 8)	8	0	8	0	1	1	0	1	0	None	335643.75
DMPH	Tri-City Medical Center, Oceanside	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI	0	0	0	0	0	0	0	0	0	0.66	111881.25
DMPH	Tri-City Medical Center, Oceanside	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition	0	0	0	0	0	0	0	0	0	0.5985	111881.25
DMPH	Tri-City Medical Center, Oceanside	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity	0	0	0	0	0	0	0	0	0	0.5231	111881.25
DMPH	Tri-City Medical Center, Oceanside	2.1.1	Baby Friendly Hospital designation: BFUSA Designation No	No	0	BFUSA Cert?	0	0	0	0	0	0	None	335643.75
DMPH	Tri-City Medical Center, Oceanside	2.1.2	Exclusive Breast Milk Feeding (PC-05)	657	0	1123	0	0	0.585	0	0.5937	0	0	335643.75
DMPH	Tri-City Medical Center, Oceanside	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	1435	0	1	None	1	None	1	0	335643.75
DMPH	Tri-City Medical Center, Oceanside	2.1.5	PC-02 Cesarean Section	67	0	373	0	1	0.1796	0	0.2176	0	0	335643.75
DMPH	Tri-City Medical Center, Oceanside	2.1.6	Prenatal and Postpartum Care: Prenatal Care	0	0	667	0	0	0	0	0	0	0.7689	167821.875
DMPH	Tri-City Medical Center, Oceanside	2.1.6	Prenatal and Postpartum Care: Postpartum Care	0	0	667	0	0	0	0	0	0	0.5961	167821.875
DMPH	Tri-City Medical Center, Oceanside	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	27	0	103	0	1	0.2621	0	0.2804	0	0	335643.75
DMPH	Tri-City Medical Center, Oceanside	2.1.8	Unexpected Newborn Complications (UNC)	74	0	1192	0	1	0.0621	0	0.0649	0	0	335643.75
DMPH	Tri-City Medical Center, Oceanside	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter No	No	0	3 Safety Drills?	0	n/a	0	0	0	0	None	111881.25
DMPH	Tri-City Medical Center, Oceanside	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) No	No	0	10 Debriefs?	0	n/a	0	0	1	0	None	111881.25
DMPH	Tri-City Medical Center, Oceanside	2.1.9	OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16)	15	0	16	0	0	0.9375	0	0	0	None	111881.25
DMPH	Tri-City Medical Center, Oceanside	2.2.1	DHCS All-Cause Readmissions	54	0	493	0	1	0.1095	0	0.051	0	0	335643.75
DMPH	Tri-City Medical Center, Oceanside	2.2.2	H-CAHPS: Care Transition Metrics (3)	826	0	1822	0	0	0.4533	0	0.49	0	0	335643.75
DMPH	Tri-City Medical Center, Oceanside	2.2.3	Medication Reconciliation – 30 days	69	0	2677	0	0	0.0258	0	0	0	0	0
DMPH	Tri-City Medical Center, Oceanside	2.2.4	Reconciled Medication List Received by Discharged Patients	11186	0	11371	0	1	0.9837	0	0.9706	0	0	335643.75
DMPH	Tri-City Medical Center, Oceanside	2.2.5	Timely Transmission of Transition Record	4976	0	5230	0	0	0.9514	0	0.9797	0	0	335643.75
DMPH	Tri-City Medical Center, Oceanside	2.3.2	Medication Reconciliation – 30 days	49	0	1326	0	0	0.037	0	0	0	0	0
DMPH	Tri-City Medical Center, Oceanside	2.3.4	Timely Transmission of Transition Record	775	0	1291	0	0.75	0.6003	0	0.5661	0	0	335643.75
DMPH	Tri-City Medical Center, Oceanside	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	39	0	47	0	1	0.8298	0	0.8148	0	0	335643.75
DMPH	Tri-City Medical Center, Oceanside	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	14650	0	46357	0	0	0.316	0	0.3077	0	0	335643.75
DMPH	Tri-City Medical Center, Oceanside	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	1270	0	1365	0	0	0.9304	0	0.0503	0	0	335643.75
DMPH	Tri-City Medical Center, Oceanside	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR	10615	0	10000	0	0	1.0615	0	0.8202	0	0.7974	335643.75
DMPH	Trinity Hospital, Weaverville	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	456	0	483	0	1	0.9441	0	0.9593	0	0.9	76500
DMPH	Trinity Hospital, Weaverville	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	35	0	38	0	1	0.9211	0	1	0	0.9	76500
DMPH	Trinity Hospital, Weaverville	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	99	0	104	0	1	0.9519	0	0.956	0	0.9	76500
DMPH	Trinity Hospital, Weaverville	1.4.2	Annual Monitoring for Patients on Persistent Medications	183	0	192	0	1	0.9531	0	0.9286	0	0	229500
DMPH	Trinity Hospital, Weaverville	1.4.3	INR Monitoring for Individuals on Warfarin	None	1	None	4	0	None	1	None	1	0	0
DMPH	Trinity Hospital, Weaverville	1.6.1	BIRADS to Biopsy	None	1	None	1	0	None	1	None	1	0	0
DMPH	Trinity Hospital, Weaverville	1.6.2	Breast Cancer Screening	115	0	204	0	0	0.5637	0	0.3684	0	0	229500
DMPH	Trinity Hospital, Weaverville	1.6.3	Cervical Cancer Screening	194	0	352	0	0	0.5511	0	0.5634	0	0	229500
DMPH	Trinity Hospital, Weaverville	1.6.4.c	Colorectal Cancer Screening	169	0	380	0	0	0.4447	0	0.4558	0	0	229500
DMPH	Trinity Hospital, Weaverville	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	None	1	None	1	0	None	1	None	1	0	0
DPH	UC Davis Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	1364	0	63849	0	0	0.0214	0	0.0157	0	0.09	413901.855
DPH	UC Davis Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	1454	0	63849	0	0.5	0.0228	0	0.0157	0	0.0278	413901.855
DPH	UC Davis Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1631	0	7329	0	1	0.2225	0	0.1947	0	0	827803.71
DPH	UC Davis Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	27284	0	42021	0	0	0.6493	0	0.684	0	0	827803.71
DPH	UC Davis Medical Center	1.1.6.t	Tobacco Assessment and Counseling	52808	0	53962	0	1	0.9786	0	0.9802	0	0	827803.71
DPH	UC Davis Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	841	0	3321	0	1	0.2532	0	0.2305	0	0.2502	275934.57
DPH	UC Davis Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	117	0	3321	0	0	0.0352	0	0.0446	0	0.0476	275934.57
DPH	UC Davis Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	206	0	3321	0	0	0.062	0	0.09	0	0.0923	275934.57
DPH	UC Davis Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	1364	0	63849	0	0	0.0214	0	0.0157	0	0.09	413901.855
DPH	UC Davis Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	1454	0	63849	0	0.5	0.0228	0	0.0157	0	0.0278	413901.855
DPH	UC Davis Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	215	0	803	0	0	0.2677	0	0.2425	0	0	827803.7
DPH	UC Davis Medical Center	1.2.11	REAL data completeness	55145	0	70260	0	0.75	0.7849	0	0.7866	0	0	827803.7
DPH	UC Davis Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	27284	0	42021	0	0	0.6493	0	0.684	0	0	827803.7
DPH	UC Davis Medical Center	1.2.13	SO/GI data completeness	55739	0	60230	0	1	0.9254	0	0.8953	0	0	827803.7
DPH	UC Davis Medical Center	1.2.14.t	Tobacco Assessment and Counseling	52808	0	53962	0	1	0.9786	0	0.9802	0	0	827803.7
DPH	UC Davis Medical Center	1.2.2	CG-CAHPS: Provider Rating	25431	0	28847	0	1	0.8816	0	0.8697	0	0	827803.71
DPH	UC Davis Medical Center	1.2.3.c	Colorectal Cancer Screening	23906	0	30741	0	1	0.7777	0	0.773	0	0	827803.71
DPH	UC Davis Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1631	0	7329	0	1	0.2225	0	0.1947	0	0	827803.71
DPH	UC Davis Medical Center	1.2.5.b	Controlling Blood Pressure	11232	0	16163	0	0	0.6949	0	0.8259	0	0	827803.71
DPH	UC Davis Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	2587	0	2956	0	0	0.8752	0	0.9033	0	0	827803.7
DPH	UC Davis Medical Center	1.2.8	Prevention Quality Overall Composite #90	479	0	60616	0	1	0.0079	0	0.0083	0	0	827803.7
DPH	UC Davis Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	64325	0	82403	0	0	0.7806	0	0.7855	0	0	827803.7
DPH	UC Davis Medical Center	1.3.2	DHCS All-Cause Readmissions	113	0	662	0	0	0.1707	0	0.1256	0	0	827803.7
DPH	UC Davis Medical Center	1.3.3	Influenza Immunization	22516	0	24792	0	1	0.9082	0	0.7722	0	0	827803.7
DPH	UC Davis Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	79275	0	108869	0	0	0.7282	0	0.7355	0	0	827803.7
DPH	UC Davis Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	4557	0	121135	0	0.75	0.0376	0	0.021	0	0	827803.7
DPH	UC Davis Medical Center	1.3.7	Tobacco Assessment and Counseling	23463	0	23783	0	1	0.9865	0	0.9866	0	0	827803.7
DPH	UC Davis Medical Center	1.5.1.b	Controlling Blood Pressure	11232	0	16163	0	0	0.6949	0	0.8259	0	0	827803.7
DPH	UC Davis Medical Center	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	2587	0	2956	0	0	0.8752	0	0.9033	0	0	827803.7
DPH	UC Davis Medical Center	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	27303	0	33851	0	0	0.8066	0	0.8391	0	0	827803.7
DPH	UC Davis Medical Center	1.5.4.t	Tobacco Assessment and Counseling	52808	0	53962	0	1	0.9786	0	0.9802	0	0	827803.7
DPH	UC Davis Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	0	0	0	0	None	894027.95
DPH	UC Davis Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	198	0	304	0	0	0.6513	0	0.6741	0	0	894027.95
DPH	UC Davis Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	1253	0	1	None	1	None	1	0	894027.95
DPH	UC Davis Medical Center	2.1.5	PC-02 Cesarean Section	108	0	412	0	0	0.2621	0	0.2216	0	0	894027.95
DPH	UC Davis Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	500	0	688	0	0	0.7267	0	0.7857	0	0.7397	447013.975
DPH	UC Davis Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	595	0	688	0	0	0.8648	0	0.8723	0	0.8758	447013.975
DPH	UC Davis Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	64	0	191	0	1	0.3351	0	0.2222	0	0	894027.95
DPH	UC Davis Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	26	0	890	0	1	0.0292	0	0.042	0	0	894027.95
DPH	UC Davis Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	Yes	0	3 Safety Drills?	0	n/a	0	0	0	0	None	298009.3167
DPH	UC Davis Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes	Yes	0	10 Debriefs?	0	n/a	0	0	0	0	None	298009.3167
DPH	UC Davis Medical Center	2.1.9	OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16)	16	0	16	0	1	1	0	1	0	None	298009.3167
DPH	UC Davis Medical Center	2.2.1	DHCS All-Cause Readmissions	119	0	699	0	0	0.1702	0	0.1276	0	0	894027.95
DPH	UC Davis Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	2287	0	3985	0	0	0.5739	0	0.5729	0	0	894027.95
DPH	UC Davis Medical Center	2.2.3	Medication Reconciliation – 30 days	2629	0	2756	0	0	0.9539	0	0.9587	0	0	894027.95
DPH	UC Davis Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	6171	0	6174	0	1	0.9995	0	0.9907	0	0	894027.95
DPH	UC Davis Medical Center	2.2.5	Timely Transmission of Transition Record	4670	0	4894	0	0	0.9542	0	0.9611	0	0	894027.95
DPH	UC Davis Medical Center	2.3.2	Medication Reconciliation – 30 days	961	0	1003	0	0	0.9581	0	0.9641	0	0	894027.95
DPH	UC Davis Medical Center	2.3.4	Timely Transmission of Transition Record	1585	0	1644	0	0	0.9641	0	0.9659	0	0	894027.95
DPH	UC Davis Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	156	0	6445	0	0	0.0242	0	0.0314	0	0.1041	447013.975
DPH	UC Davis Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	261	0	6445	0	0	0.0405	0	0.0366	0	0.0466	447013.975
DPH	UC Davis Medical Center	2.6.2	Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen	1848	0	2881	0	0	0.6414	0	0.6697	0	0	894027.95
DPH	UC Davis Medical Center	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	2791	0	2881	0	1	0.9688	0	0.9868	0	0	894027.95
DPH	UC Davis Medical Center	2.6.4	Screening for Clinical Depression and follow-up	2401	0	3450	0	0	0.6959	0	0.7298	0	0	894027.95
DPH	UC Davis Medical Center	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	5490	0	6492	0	0	0.8457	0	0.873	0	0	894027.95
DPH	UC Davis Medical Center	3.2.2	Appropriate Emergency Department Utilization of CT for Pulmonary Embolism	1117	0	1142	0	0	0.9781	0	0.9799	0	0	1490046.67
DPH	UC Davis Medical Center	3.2.3	Use of Imaging Studies for Low Back Pain	675	0	940	0	1	0.7181	0	0.6971	0	0	1490046.67
DPH	UC Davis Medical Center	3.2.4	Use of Imaging Studies for Low Back Pain (anytime) Variation of HEDIS Use of Imaging Studies for Low Back Pain measures: Appropriate Score	2229	0	2790	0	1	0.7989	0	0.5187	0	None	1490046.66
DPH	UC Irvine Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	852	0	21916	0	0	0.0389	0	0.0214	0	0.0951	267945.675
DPH	UC Irvine Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	5652	0	21916	0	1	0.2579	0	0.2299	0	0.1368	267945.675
DPH	UC Irvine Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	934	0	3287	0	1	0.2841	0	0.2547	0	0	535891.35
DPH	UC Irvine Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	12189	0	16011	0	0	0.7613	0	0.8658	0	0	535891.35
DPH	UC Irvine Medical Center	1.1.6.t	Tobacco Assessment and Counseling	20029	0	20646	0	0	0.9701	0	0.9868	0	0	535891.35
DPH	UC Irvine Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	294	0	768	0	1	0.3828	0	0.3031	0	0.3156	178630.45
DPH	UC Irvine Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	137	0	768	0	1	0.1784	0	0.0859	0	0.0744	178630.45
DPH	UC Irvine Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	166	0	768	0	1	0.2161	0	0.1337	0	0.1134	178630.45
DPH	UC Irvine Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	852	0	21916	0	0	0.0389	0	0.0214	0	0.0951	267945.675
DPH	UC Irvine Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	5652	0	21916	0	1	0.2579	0	0.2299	0	0.1368	267945.675
DPH	UC Irvine Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	1659	0	2773	0	0	0.5983	0	0.6226	0	0	535891.35
DPH	UC Irvine Medical Center	1.2.11	REAL data completeness	25869	0	26172	0	1	0.9884	0	0.7266	0	0	535891.35
DPH	UC Irvine Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	12189	0	16011	0	0	0.7613	0	0.8658	0	0	535891.35
DPH	UC Irvine Medical Center	1.2.13	SO/GI data completeness	8239	0	19971	0	1	0.4125	0	0.4463	0	0	535891.35
DPH	UC Irvine Medical Center	1.2.14.t	Tobacco Assessment and Counseling	20029	0	20646	0	0	0.9701	0	0.9868	0	0	535891.34
DPH	UC Irvine Medical Center	1.2.2	CG-CAHPS: Provider Rating	21479	0	24402	0	1	0.8802	0	0.8727	0	0	535891.35
DPH	UC Irvine Medical Center	1.2.3.c	Colorectal Cancer Screening	4663	0	7503	0	0	0.6215	0	0.6923	0	0	535891.35
DPH	UC Irvine Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	934	0	3287	0	1	0.2841	0	0.2547	0	0	535891.35
DPH	UC Irvine Medical Center	1.2.5.b	Controlling Blood Pressure	3466	0	5230	0	0	0.6627	0	0.7074	0	0	535891.35
DPH	UC Irvine Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	768	0	969	0	0	0.7926	0	0.8424	0	0	535891.35
DPH	UC Irvine Medical Center	1.2.8	Prevention Quality Overall Composite #90	294	0	23237	0	0	0.0127	0	0.0147	0	0	535891.35
DPH	UC Irvine Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	6017	0	6398	0	1	0.9405	0	0.6073	0	0	535891.34
DPH	UC Irvine Medical Center	1.3.2	DHCS All-Cause Readmissions	171	0	1272	0	1	0.1344	0	0.1227	0	0	535891.34
DPH	UC Irvine Medical Center	1.3.3	Influenza Immunization	7250	0	9876	0	0	0.7341	0	0.7843	0	0	535891.34
DPH	UC Irvine Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	428	0	15290	0	0	0.028	0	0.0292	0	0	535891.34
DPH	UC Irvine Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	3794	0	59362	0	1	0.0639	0	0.0013	0	0	535891.34
DPH	UC Irvine Medical Center	1.3.7	Tobacco Assessment and Counseling	10079	0	10188	0	1	0.9893	0	0.9939	0	0	535891.34
DPH	UC Irvine Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	12145	0	12190	0	1	0.9963	0	0.9434	0	0.9	178630.4467
DPH	UC Irvine Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	1883	0	1926	0	1	0.9777	0	0.986	0	0.9	178630.4467
DPH	UC Irvine Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	515	0	640	0	1	0.8047	0	0.7741	0	0.7867	178630.4467
DPH	UC Irvine Medical Center	1.4.2	Annual Monitoring for Patients on Persistent Medications	5937	0	6812	0	0	0.8716	0	0.9183	0	0	535891.34
DPH	UC Irvine Medical Center	1.4.3	INR Monitoring for Individuals on Warfarin	148	0	234	0	0	0.6325	0	0.6746	0	0	535891.34
DPH	UC Irvine Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	0	0	0	0	None	557327
DPH	UC Irvine Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	142	0	190	0	1	0.7474	0	0.66	0	0	557327
DPH	UC Irvine Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	1365	0	1	None	1	0.0075	0	0	557327
DPH	UC Irvine Medical Center	2.1.5	PC-02 Cesarean Section	90	0	493	0	1	0.1826	0	0.212	0	0	557327
DPH	UC Irvine Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	650	0	677	0	1	0.9601	0	0.835	0	0.8423	278663.5
DPH	UC Irvine Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	504	0	677	0	1	0.7445	0	0.7116	0	0.7144	278663.5
DPH	UC Irvine Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	63	0	207	0	1	0.3043	0	0.2864	0	0	557327
DPH	UC Irvine Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	26	0	861	0	1	0.0302	0	0.0369	0	0	557327
DPH	UC Irvine Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	Yes	0	3 Safety Drills?	0	n/a	0	0	0	0	None	185775.6667
DPH	UC Irvine Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes	Yes	0	10 Debriefs?	0	n/a	0	0	0	0	None	185775.6667
DPH	UC Irvine Medical Center	2.1.9	OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16)	16	0	16	0	1	1	0	1	0	None	185775.6667
DPH	UC Irvine Medical Center	2.2.1	DHCS All-Cause Readmissions	181	0	1385	0	1	0.1307	0	0.1209	0	0	557327
DPH	UC Irvine Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	5959	0	10000	0	1	0.5959	0	0.5819	0	0	557327
DPH	UC Irvine Medical Center	2.2.3	Medication Reconciliation – 30 days	1797	0	1888	0	1	0.9518	0	0.9008	0	0	557327
DPH	UC Irvine Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	3569	0	3762	0	0	0.9487	0	0.9667	0	0	557327
DPH	UC Irvine Medical Center	2.2.5	Timely Transmission of Transition Record	1682	0	2345	0	0	0.7173	0	0.8395	0	0	557327
DPH	UC Irvine Medical Center	2.3.2	Medication Reconciliation – 30 days	1368	0	1423	0	1	0.9613	0	0.9153	0	0	557327
DPH	UC Irvine Medical Center	2.3.4	Timely Transmission of Transition Record	1395	0	1809	0	0	0.7711	0	0.8931	0	0	557327
DPH	UC Irvine Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	32	0	1040	0	0	0.0308	0	0.0276	0	0.1007	278663.5
DPH	UC Irvine Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	468	0	1040	0	1	0.45	0	0.4604	0	0.1368	278663.5
DPH	UC Irvine Medical Center	2.6.2	Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen	60	0	486	0	0	0.1235	0	0.2581	0	0	557327
DPH	UC Irvine Medical Center	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	375	0	486	0	0	0.7716	0	0.8349	0	0	557327
DPH	UC Irvine Medical Center	2.6.4	Screening for Clinical Depression and follow-up	569	0	636	0	0	0.8947	0	0.9101	0	0	557327
DPH	UC Irvine Medical Center	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	932	0	1013	0	1	0.92	0	0.8857	0	0	557327
DPH	UC Irvine Medical Center	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	79	0	187	0	0	0.4225	0	0.4359	0	0	696658.75
DPH	UC Irvine Medical Center	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	76036	0	152516	0	0	0.4985	0	0.1933	0	0	696658.75
DPH	UC Irvine Medical Center	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	967	0	4248	0	0	0.2276	0	0.1719	0	0	696658.75
DPH	UC Irvine Medical Center	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR	4677	0	10000	0	1	0.4677	0	0.468	0	0.592	696658.75
DPH	UC Los Angeles Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	115551	0	125034	0	1	0.9242	0	0.0699	0	0.1388	192141.52
DPH	UC Los Angeles Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	10738	0	125034	0	1	0.0859	0	0.0595	0	0.0672	192141.52
DPH	UC Los Angeles Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1370	0	9260	0	1	0.1479	0	0.124	0	0	384283.04
DPH	UC Los Angeles Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	65262	0	95958	0	0	0.6801	0	0.7019	0	0	384283.04
DPH	UC Los Angeles Medical Center	1.1.6.t	Tobacco Assessment and Counseling	113528	0	117326	0	0	0.9676	0	0.9678	0	0	384283.04
DPH	UC Los Angeles Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	1843	0	4845	0	1	0.3804	0	0.3548	0	0.3621	128094.3467
DPH	UC Los Angeles Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	619	0	4845	0	1	0.1278	0	0.1061	0	0.0744	128094.3467
DPH	UC Los Angeles Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	885	0	4845	0	1	0.1827	0	0.1528	0	0.1134	128094.3467
DPH	UC Los Angeles Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	115551	0	125034	0	1	0.9242	0	0.0699	0	0.1388	192141.52
DPH	UC Los Angeles Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	10738	0	125034	0	1	0.0859	0	0.0595	0	0.0672	192141.52
DPH	UC Los Angeles Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	1625	0	2741	0	0	0.5928	0	0.6742	0	0	384283.04
DPH	UC Los Angeles Medical Center	1.2.11	REAL data completeness	40768	0	143407	0	0	0.2843	0	0.2466	0	0	384283.04
DPH	UC Los Angeles Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	65262	0	95958	0	0	0.6801	0	0.7019	0	0	384283.04
DPH	UC Los Angeles Medical Center	1.2.13	SO/GI data completeness	19291	0	118477	0	0	0.1628	0	0.0631	0	0	384283.04
DPH	UC Los Angeles Medical Center	1.2.14.t	Tobacco Assessment and Counseling	113528	0	117326	0	0	0.9676	0	0.9678	0	0	384283.04
DPH	UC Los Angeles Medical Center	1.2.2	CG-CAHPS: Provider Rating	344	0	406	0	1	0.8473	0	0.7918	0	0	384283.04
DPH	UC Los Angeles Medical Center	1.2.3.c	Colorectal Cancer Screening	32426	0	50685	0	1	0.6398	0	0.6246	0	0	384283.04
DPH	UC Los Angeles Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1370	0	9260	0	1	0.1479	0	0.124	0	0	384283.04
DPH	UC Los Angeles Medical Center	1.2.5.b	Controlling Blood Pressure	18383	0	29130	0	0	0.6311	0	0.7271	0	0	384283.04
DPH	UC Los Angeles Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	5781	0	8214	0	0	0.7038	0	0.7449	0	0	384283.04
DPH	UC Los Angeles Medical Center	1.2.8	Prevention Quality Overall Composite #90	532	0	118164	0	1	0.0045	0	0.0057	0	0	384283.04
DPH	UC Los Angeles Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	32102	0	32176	0	1	0.9977	0	1	0	0	384283.04
DPH	UC Los Angeles Medical Center	1.3.2	DHCS All-Cause Readmissions	190	0	1610	0	1	0.118	0	0.146	0	0	384283.04
DPH	UC Los Angeles Medical Center	1.3.3	Influenza Immunization	55694	0	81681	0	0.75	0.6818	0	0.6621	0	0	384283.04
DPH	UC Los Angeles Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	4527	0	10105	0	0	0.448	0	0.5088	0	0	384283.04
DPH	UC Los Angeles Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	1672	0	9325	0	0	0.1793	0	0.1962	0	0	384283.04
DPH	UC Los Angeles Medical Center	1.3.7	Tobacco Assessment and Counseling	50741	0	51689	0	1	0.9817	0	0.9807	0	0	384283.03
DPH	UC Los Angeles Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	73021	0	76261	0	1	0.9575	0	0.9277	0	0.9	128094.3433
DPH	UC Los Angeles Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	14309	0	15071	0	1	0.9494	0	0.9538	0	0.9	128094.3433
DPH	UC Los Angeles Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	6703	0	8858	0	1	0.7567	0	0.7135	0	0.7322	128094.3433
DPH	UC Los Angeles Medical Center	1.4.2	Annual Monitoring for Patients on Persistent Medications	36162	0	40068	0	0	0.9025	0	0.9166	0	0	384283.03
DPH	UC Los Angeles Medical Center	1.4.3	INR Monitoring for Individuals on Warfarin	561	0	948	0	0	0.5918	0	0.6659	0	0	384283.03
DPH	UC Los Angeles Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	0	0	0	0	None	399654.35
DPH	UC Los Angeles Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	322	0	430	0	1	0.7488	0	0.7526	0	0	399654.35
DPH	UC Los Angeles Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	496	0	1	None	1	0	0	0	399654.35
DPH	UC Los Angeles Medical Center	2.1.5	PC-02 Cesarean Section	50	0	254	0	1	0.1969	0	0.2	0	0	399654.35
DPH	UC Los Angeles Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	1836	0	1949	0	1	0.942	0	0.9645	0	0.9075	199827.175
DPH	UC Los Angeles Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	1352	0	1949	0	0	0.6937	0	0.8557	0	0.7397	199827.175
DPH	UC Los Angeles Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	13	0	60	0	1	0.2167	0	None	1	0	399654.35
DPH	UC Los Angeles Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	None	1	407	0	1	None	1	0.045	0	0	399654.35
DPH	UC Los Angeles Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	Yes	0	3 Safety Drills?	0	n/a	0	0	0	0	None	133218.1167
DPH	UC Los Angeles Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes	Yes	0	10 Debriefs?	0	n/a	0	0	0	0	None	133218.1167
DPH	UC Los Angeles Medical Center	2.1.9	OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16)	32	0	32	0	1	1	0	1	0	None	133218.1167
DPH	UC Los Angeles Medical Center	2.2.1	DHCS All-Cause Readmissions	196	0	1652	0	1	0.1186	0	0.147	0	0	399654.35
DPH	UC Los Angeles Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	6280	0	10000	0	1	0.628	0	0.623	0	0	399654.35
DPH	UC Los Angeles Medical Center	2.2.3	Medication Reconciliation – 30 days	5068	0	5069	0	1	0.9998	0	0.9993	0	0	399654.35
DPH	UC Los Angeles Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	8960	0	9143	0	0	0.98	0	0.9804	0	0	399654.35
DPH	UC Los Angeles Medical Center	2.2.5	Timely Transmission of Transition Record	6821	0	6839	0	1	0.9974	0	0.9981	0	0	399654.35
DPH	UC Los Angeles Medical Center	2.3.2	Medication Reconciliation – 30 days	2629	0	2630	0	1	0.9996	0	0.9994	0	0	399654.35
DPH	UC Los Angeles Medical Center	2.3.4	Timely Transmission of Transition Record	3373	0	3419	0	1	0.9865	0	0.9825	0	0	399654.35
DPH	UC Los Angeles Medical Center	2.7.1	Advance Care Plan	14008	0	37031	0	0	0.3783	0	0.4128	0	0	399654.35
DPH	UC Los Angeles Medical Center	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	436	0	459	0	1	0.9499	0	0.9659	0	0	399654.35
DPH	UC Los Angeles Medical Center	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	271	0	279	0	1	0.9713	0	0.9849	0	0	399654.35
DPH	UC Los Angeles Medical Center	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	179	0	3199	0	0	0.056	0	0.0622	0	0	399654.35
DPH	UC Los Angeles Medical Center	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	15	0	177	0	1	0.0847	0	0.1386	0	0	399654.35
DPH	UC Los Angeles Medical Center	3.3.1	Adherence to Medications: Rate 1	500	0	611	0	1	0.8183	0	0.7963	0	0.8103	666090.67
DPH	UC Los Angeles Medical Center	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 1	47	0	887	0	0	0.053	0	0.0276	0	0.25	666090.67
DPH	UC Los Angeles Medical Center	3.3.4	Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 1	2393	0	2675	0	0	0.8946	0	0.9372	0	0.9	666090.66
DPH	UC San Diego Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	22262	0	39783	0	1	0.5596	0	0.5097	0	0.5346	248224.095
DPH	UC San Diego Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	6096	0	39783	0	1	0.1532	0	0.1389	0	0.1368	248224.095
DPH	UC San Diego Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	589	0	3485	0	1	0.169	0	0.1463	0	0	496448.19
DPH	UC San Diego Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	19021	0	26549	0	0	0.7164	0	0.7249	0	0	496448.19
DPH	UC San Diego Medical Center	1.1.6.t	Tobacco Assessment and Counseling	37782	0	38213	0	1	0.9887	0	0.985	0	0	496448.19
DPH	UC San Diego Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	1254	0	2567	0	1	0.4885	0	0.5079	0	0.4277	165482.73
DPH	UC San Diego Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	312	0	2567	0	1	0.1215	0	0.1131	0	0.0744	165482.73
DPH	UC San Diego Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	493	0	2567	0	1	0.1921	0	0.1917	0	0.1134	165482.73
DPH	UC San Diego Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	22262	0	39783	0	1	0.5596	0	0.5097	0	0.5346	248224.095
DPH	UC San Diego Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	6096	0	39783	0	1	0.1532	0	0.1389	0	0.1368	248224.095
DPH	UC San Diego Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	1422	0	1436	0	1	0.9903	0	0.9825	0	0	496448.19
DPH	UC San Diego Medical Center	1.2.11	REAL data completeness	36535	0	38718	0	1	0.9436	0	0.947	0	0	496448.19
DPH	UC San Diego Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	19021	0	26549	0	0	0.7164	0	0.7249	0	0	496448.18
DPH	UC San Diego Medical Center	1.2.13	SO/GI data completeness	26448	0	37264	0	1	0.7097	0	0.649	0	0	496448.18
DPH	UC San Diego Medical Center	1.2.14.t	Tobacco Assessment and Counseling	37782	0	38213	0	1	0.9887	0	0.985	0	0	496448.18
DPH	UC San Diego Medical Center	1.2.2	CG-CAHPS: Provider Rating	8711	0	9656	0	1	0.9021	0	0.8962	0	0	496448.19
DPH	UC San Diego Medical Center	1.2.3.c	Colorectal Cancer Screening	15502	0	19001	0	1	0.8159	0	0.8247	0	0	496448.19
DPH	UC San Diego Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	589	0	3485	0	1	0.169	0	0.1463	0	0	496448.19
DPH	UC San Diego Medical Center	1.2.5.b	Controlling Blood Pressure	6836	0	10185	0	0	0.6712	0	0.7645	0	0	496448.19
DPH	UC San Diego Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	3283	0	3556	0	1	0.9232	0	0.9401	0	0	496448.19
DPH	UC San Diego Medical Center	1.2.8	Prevention Quality Overall Composite #90	253	0	40053	0	1	0.0063	0	0.0075	0	0	496448.19
DPH	UC San Diego Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	59676	0	65784	0	1	0.9072	0	0.8975	0	0	496448.18
DPH	UC San Diego Medical Center	1.3.2	DHCS All-Cause Readmissions	243	0	1559	0	0	0.1559	0	0.1509	0	0	496448.18
DPH	UC San Diego Medical Center	1.3.3	Influenza Immunization	15431	0	16856	0	1	0.9155	0	0.8716	0	0	496448.18
DPH	UC San Diego Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	136380	0	218988	0	1	0.6228	0	0.5736	0	0	496448.18
DPH	UC San Diego Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	5110	0	226577	0	0.5	0.0226	0	0.0089	0	0	496448.18
DPH	UC San Diego Medical Center	1.3.7	Tobacco Assessment and Counseling	23676	0	23878	0	1	0.9915	0	0.9882	0	0	496448.18
DPH	UC San Diego Medical Center	1.5.1.b	Controlling Blood Pressure	6836	0	10185	0	0	0.6712	0	0.7645	0	0	496448.18
DPH	UC San Diego Medical Center	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	3283	0	3556	0	1	0.9232	0	0.9401	0	0	496448.18
DPH	UC San Diego Medical Center	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	18532	0	20283	0	1	0.9137	0	0.8962	0	0	496448.18
DPH	UC San Diego Medical Center	1.5.4.t	Tobacco Assessment and Counseling	37782	0	38213	0	1	0.9887	0	0.985	0	0	496448.18
DPH	UC San Diego Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	0	0	0	0	None	536164
DPH	UC San Diego Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	2155	0	2565	0	1	0.8402	0	0.7037	0	0	536164
DPH	UC San Diego Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	3276	0	1	None	1	None	1	0	536164
DPH	UC San Diego Medical Center	2.1.5	PC-02 Cesarean Section	282	0	1240	0	1	0.2274	0	0.2308	0	0	536164
DPH	UC San Diego Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	2481	0	2492	0	1	0.9956	0	0.9934	0	0.9075	268082
DPH	UC San Diego Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	1828	0	2492	0	0	0.7335	0	0.7491	0	0.7397	268082
DPH	UC San Diego Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	91	0	264	0	1	0.3447	0	0.4189	0	0	536164
DPH	UC San Diego Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	115	0	2453	0	1	0.0469	0	0.061	0	0	536164
DPH	UC San Diego Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	Yes	0	3 Safety Drills?	0	n/a	0	0	0	0	None	178721.3333
DPH	UC San Diego Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes	Yes	0	10 Debriefs?	0	n/a	0	0	0	0	None	178721.3333
DPH	UC San Diego Medical Center	2.1.9	OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16)	16	0	16	0	1	1	0	1	0	None	178721.3333
DPH	UC San Diego Medical Center	2.2.1	DHCS All-Cause Readmissions	265	0	1717	0	0	0.1543	0	0.1469	0	0	536164
DPH	UC San Diego Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	6328	0	10000	0	1	0.6328	0	0.6262	0	0	536164
DPH	UC San Diego Medical Center	2.2.3	Medication Reconciliation – 30 days	2296	0	2371	0	1	0.9684	0	0.9139	0	0	536164
DPH	UC San Diego Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	2950	0	2960	0	1	0.9966	0	0.9974	0	0	536164
DPH	UC San Diego Medical Center	2.2.5	Timely Transmission of Transition Record	4045	0	4045	0	1	1	0	1	0	0	536164
DPH	UC San Diego Medical Center	2.3.2	Medication Reconciliation – 30 days	132	0	135	0	1	0.9778	0	0.9379	0	0	536164
DPH	UC San Diego Medical Center	2.3.4	Timely Transmission of Transition Record	211	0	211	0	1	1	0	1	0	0	536164
DPH	UC San Diego Medical Center	2.7.1	Advance Care Plan	10966	0	15847	0	1	0.692	0	0.6281	0	0	536164
DPH	UC San Diego Medical Center	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	141	0	144	0	1	0.9792	0	0.9449	0	0	536164
DPH	UC San Diego Medical Center	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	47	0	48	0	1	0.9792	0	0.9167	0	0	536164
DPH	UC San Diego Medical Center	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	144	0	1641	0	0	0.0878	0	0.0772	0	0	536164
DPH	UC San Diego Medical Center	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	None	1	86	0	1	None	1	None	1	0	536164
DPH	UC San Diego Medical Center	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	85	0	114	0	1	0.7456	0	0.6846	0	0	382974.29
DPH	UC San Diego Medical Center	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	68179	0	210693	0	0	0.3236	0	0.3029	0	0	382974.29
DPH	UC San Diego Medical Center	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	1919	0	5734	0	1	0.3347	0	0.4467	0	0	382974.29
DPH	UC San Diego Medical Center	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR	6630	0	10000	0	1	0.663	0	0.922	0	0.889	382974.29
DPH	UC San Diego Medical Center	3.3.1	Adherence to Medications: Rate 1	2709	0	3453	0	1	0.7845	0	0.7452	0	0.7593	382974.28
DPH	UC San Diego Medical Center	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 1	484	0	1705	0	1	0.2839	0	0.2038	0	0.2697	382974.28
DPH	UC San Diego Medical Center	3.3.4	Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 1	20524	0	21137	0	1	0.971	0	0.9277	0	0.9	382974.28
DPH	UC San Francisco Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	34972	0	36765	0	1	0.9512	0	0.9344	0	0.7587	302041.125
DPH	UC San Francisco Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	1185	0	36765	0	0	0.0322	0	0.0387	0	0.0485	302041.125
DPH	UC San Francisco Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	611	0	2742	0	1	0.2228	0	0.2438	0	0	604082.25
DPH	UC San Francisco Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	21454	0	30077	0	1	0.7133	0	0.6064	0	0	604082.25
DPH	UC San Francisco Medical Center	1.1.6.t	Tobacco Assessment and Counseling	32895	0	33821	0	0	0.9726	0	0.9755	0	0	604082.25
DPH	UC San Francisco Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	790	0	1407	0	1	0.5615	0	0.3522	0	0.3598	201360.75
DPH	UC San Francisco Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	135	0	1407	0	1	0.0959	0	0.0514	0	0.0537	201360.75
DPH	UC San Francisco Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	138	0	1407	0	1	0.0981	0	0.0501	0	0.0564	201360.75
DPH	UC San Francisco Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	34972	0	36765	0	1	0.9512	0	0.9344	0	0.7587	302041.125
DPH	UC San Francisco Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	1185	0	36765	0	0	0.0322	0	0.0387	0	0.0485	302041.125
DPH	UC San Francisco Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	576	0	930	0	1	0.6194	0	0.668	0	0	604082.25
DPH	UC San Francisco Medical Center	1.2.11	REAL data completeness	44377	0	44453	0	1	0.9983	0	0.9997	0	0	604082.25
DPH	UC San Francisco Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	21454	0	30077	0	1	0.7133	0	0.6064	0	0	604082.25
DPH	UC San Francisco Medical Center	1.2.13	SO/GI data completeness	23783	0	34553	0	1	0.6883	0	0.3695	0	0	604082.25
DPH	UC San Francisco Medical Center	1.2.14.t	Tobacco Assessment and Counseling	32895	0	33821	0	0	0.9726	0	0.9755	0	0	604082.25
DPH	UC San Francisco Medical Center	1.2.2	CG-CAHPS: Provider Rating	8313	0	9499	0	1	0.8751	0	0.8501	0	0	604082.25
DPH	UC San Francisco Medical Center	1.2.3.c	Colorectal Cancer Screening	10962	0	14676	0	1	0.7469	0	0.7624	0	0	604082.25
DPH	UC San Francisco Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	611	0	2742	0	1	0.2228	0	0.2438	0	0	604082.25
DPH	UC San Francisco Medical Center	1.2.5.b	Controlling Blood Pressure	4654	0	6957	0	0	0.669	0	0.7688	0	0	604082.25
DPH	UC San Francisco Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	1071	0	1154	0	1	0.9281	0	0.9033	0	0	604082.25
DPH	UC San Francisco Medical Center	1.2.8	Prevention Quality Overall Composite #90	256	0	36252	0	1	0.0071	0	0.0094	0	0	604082.25
DPH	UC San Francisco Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	62427	0	69663	0	0	0.8961	0	0.9024	0	0	604082.25
DPH	UC San Francisco Medical Center	1.3.2	DHCS All-Cause Readmissions	114	0	867	0	0	0.1315	0	0.1245	0	0	604082.25
DPH	UC San Francisco Medical Center	1.3.3	Influenza Immunization	13451	0	15109	0	1	0.8903	0	0.8705	0	0	604082.25
DPH	UC San Francisco Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	170857	0	200217	0	1	0.8534	0	0.8233	0	0	604082.25
DPH	UC San Francisco Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	179466	0	305074	0	1	0.5883	0	0.3626	0	0	604082.25
DPH	UC San Francisco Medical Center	1.3.7	Tobacco Assessment and Counseling	15811	0	16076	0	1	0.9835	0	0.9827	0	0	604082.25
DPH	UC San Francisco Medical Center	1.6.1	BIRADS to Biopsy	90	0	128	0	1	0.7031	0	0.6239	0	0	604082.25
DPH	UC San Francisco Medical Center	1.6.2	Breast Cancer Screening	6063	0	8101	0	1	0.7484	0	0.7863	0	0	604082.25
DPH	UC San Francisco Medical Center	1.6.3	Cervical Cancer Screening	9914	0	13158	0	1	0.7535	0	0.7534	0	0	604082.25
DPH	UC San Francisco Medical Center	1.6.4.c	Colorectal Cancer Screening	10962	0	14676	0	1	0.7469	0	0.7624	0	0	604082.25
DPH	UC San Francisco Medical Center	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	31	0	71	0	0	0.4366	0	0.5357	0	0	604082.25
DPH	UC San Francisco Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation No	No	0	BFUSA Cert?	0	0	0	0	0	0	None	676572.1
DPH	UC San Francisco Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	1561	0	1880	0	1	0.8303	0	0.8356	0	0	676572.1
DPH	UC San Francisco Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	12	0	2419	0	1	0.005	0	None	1	0	676572.1
DPH	UC San Francisco Medical Center	2.1.5	PC-02 Cesarean Section	227	0	1216	0	1	0.1867	0	0.2351	0	0	676572.1
DPH	UC San Francisco Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	2261	0	2359	0	1	0.9585	0	0.9605	0	0.9075	338286.05
DPH	UC San Francisco Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	1897	0	2359	0	1	0.8042	0	0.7968	0	0.7397	338286.05
DPH	UC San Francisco Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	178	0	519	0	1	0.343	0	0.2419	0	0	676572.1
DPH	UC San Francisco Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	89	0	1839	0	1	0.0484	0	0.0393	0	0	676572.1
DPH	UC San Francisco Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	Yes	0	3 Safety Drills?	0	n/a	0	0	0	0	None	225524.0333
DPH	UC San Francisco Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes	Yes	0	10 Debriefs?	0	n/a	0	0	0	0	None	225524.0333
DPH	UC San Francisco Medical Center	2.1.9	OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16)	16	0	16	0	1	1	0	1	0	None	225524.0333
DPH	UC San Francisco Medical Center	2.2.1	DHCS All-Cause Readmissions	122	0	930	0	1	0.1312	0	0.1269	0	0	676572.1
DPH	UC San Francisco Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	6536	0	10000	0	1	0.6536	0	0.6509	0	0	676572.1
DPH	UC San Francisco Medical Center	2.2.3	Medication Reconciliation – 30 days	1570	0	1574	0	0	0.9975	0	0.9974	0	0	676572.1
DPH	UC San Francisco Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	4020	0	4040	0	1	0.995	0	0.9906	0	0	676572.1
DPH	UC San Francisco Medical Center	2.2.5	Timely Transmission of Transition Record	4758	0	4841	0	1	0.9829	0	0.9785	0	0	676572.1
DPH	UC San Francisco Medical Center	2.3.2	Medication Reconciliation – 30 days	79	0	81	0	0	0.9753	0	1	0	0	676572.1
DPH	UC San Francisco Medical Center	2.3.4	Timely Transmission of Transition Record	204	0	204	0	1	1	0	0.9964	0	0	676572.1
DPH	UC San Francisco Medical Center	2.7.1	Advance Care Plan	10450	0	11018	0	1	0.9484	0	0.9258	0	0	676572.1
DPH	UC San Francisco Medical Center	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	71	0	77	0	1	0.9221	0	0.9266	0	0	676572.1
DPH	UC San Francisco Medical Center	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	32	0	34	0	1	0.9412	0	0.908	0	0	676572.1
DPH	UC San Francisco Medical Center	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	94	0	1201	0	0	0.0783	0	0.1053	0	0	676572.1
DPH	UC San Francisco Medical Center	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	None	1	89	0	0	None	1	None	1	0	676572.1
DPH	UC San Francisco Medical Center	3.3.1	Adherence to Medications: Rate 1	189	0	207	0	1	0.913	0	0.8642	0	0.8827	1127620.34
DPH	UC San Francisco Medical Center	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 1	35	0	49	0	0	0.7143	0	0.8302	0	0.8775	1127620.33
DPH	UC San Francisco Medical Center	3.3.4	Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 1	29	0	40	0	1	0.725	0	0.4569	0	0.5102	1127620.33
DPH	Ventura County Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	28723	0	48194	0	1	0.596	0	0.5217	0	0.5454	668244.52
DPH	Ventura County Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	9870	0	48194	0	1	0.2048	0	0.1803	0	0.1368	668244.52
DPH	Ventura County Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1520	0	6215	0	1	0.2446	0	0.1971	0	0	1336489.04
DPH	Ventura County Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	19607	0	32631	0	0	0.6009	0	0.6238	0	0	1336489.04
DPH	Ventura County Medical Center	1.1.6.t	Tobacco Assessment and Counseling	33148	0	33656	0	1	0.9849	0	0.9821	0	0	1336489.04
DPH	Ventura County Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	435	0	1600	0	1	0.2719	0	0.2225	0	0.243	445496.3467
DPH	Ventura County Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	67	0	1600	0	0	0.0419	0	0.0419	0	0.0452	445496.3467
DPH	Ventura County Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	135	0	1600	0	0.75	0.0844	0	0.0813	0	0.0845	445496.3467
DPH	Ventura County Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	28723	0	48194	0	1	0.596	0	0.5217	0	0.5454	668244.52
DPH	Ventura County Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	9870	0	48194	0	1	0.2048	0	0.1803	0	0.1368	668244.52
DPH	Ventura County Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	577	0	911	0	0	0.6334	0	0.65	0	0	1336489.04
DPH	Ventura County Medical Center	1.2.11	REAL data completeness	60944	0	61003	0	1	0.999	0	0.9999	0	0	1336489.04
DPH	Ventura County Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	19607	0	32631	0	0	0.6009	0	0.6238	0	0	1336489.04
DPH	Ventura County Medical Center	1.2.13	SO/GI data completeness	32772	0	35393	0	1	0.9259	0	0.9187	0	0	1336489.04
DPH	Ventura County Medical Center	1.2.14.t	Tobacco Assessment and Counseling	33148	0	33656	0	1	0.9849	0	0.9821	0	0	1336489.04
DPH	Ventura County Medical Center	1.2.2	CG-CAHPS: Provider Rating	21590	0	26292	0	1	0.8212	0	0.8072	0	0	1336489.04
DPH	Ventura County Medical Center	1.2.3.c	Colorectal Cancer Screening	7797	0	14414	0	0	0.5409	0	0.5804	0	0	1336489.04
DPH	Ventura County Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1520	0	6215	0	1	0.2446	0	0.1971	0	0	1336489.04
DPH	Ventura County Medical Center	1.2.5.b	Controlling Blood Pressure	7476	0	11040	0	0	0.6772	0	0.7254	0	0	1336489.04
DPH	Ventura County Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	711	0	764	0	1	0.9306	0	0.9278	0	0	1336489.04
DPH	Ventura County Medical Center	1.2.8	Prevention Quality Overall Composite #90	342	0	46781	0	1	0.0073	0	0.0081	0	0	1336489.04
DPH	Ventura County Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	19730	0	20044	0	1	0.9843	0	0.4702	0	0	1336489.04
DPH	Ventura County Medical Center	1.3.2	DHCS All-Cause Readmissions	77	0	771	0	1	0.0999	0	0.1143	0	0	1336489.04
DPH	Ventura County Medical Center	1.3.3	Influenza Immunization	8123	0	10017	0	1	0.8109	0	0.7155	0	0	1336489.03
DPH	Ventura County Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	27284	0	36348	0	1	0.7506	0	0.6851	0	0	1336489.03
DPH	Ventura County Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	7228	0	38572	0	1	0.1874	0	0.0889	0	0	1336489.03
DPH	Ventura County Medical Center	1.3.7	Tobacco Assessment and Counseling	15651	0	15812	0	1	0.9898	0	0.9888	0	0	1336489.03
DPH	Ventura County Medical Center	1.5.1.b	Controlling Blood Pressure	7476	0	11040	0	0	0.6772	0	0.7254	0	0	1336489.03
DPH	Ventura County Medical Center	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	711	0	764	0	1	0.9306	0	0.9278	0	0	1336489.03
DPH	Ventura County Medical Center	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	19661	0	22099	0	0	0.8897	0	0.9254	0	0	1336489.03
DPH	Ventura County Medical Center	1.5.4.t	Tobacco Assessment and Counseling	33148	0	33656	0	1	0.9849	0	0.9821	0	0	1336489.03
DPH	Ventura County Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	0	0	0	0	None	1312189.19
DPH	Ventura County Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	875	0	1223	0	1	0.7155	0	0.6364	0	0	1312189.19
DPH	Ventura County Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	1452	0	1	None	1	None	1	0	1312189.19
DPH	Ventura County Medical Center	2.1.5	PC-02 Cesarean Section	79	0	416	0	1	0.1899	0	0.1711	0	0	1312189.19
DPH	Ventura County Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	1290	0	1386	0	1	0.9307	0	0.9423	0	0.9075	656094.59
DPH	Ventura County Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	1168	0	1386	0	1	0.8427	0	0.7737	0	0.7397	656094.59
DPH	Ventura County Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	30	0	155	0	1	0.1935	0	0.1844	0	0	1312189.18
DPH	Ventura County Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	43	0	1226	0	1	0.0351	0	0.0369	0	0	1312189.18
DPH	Ventura County Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	Yes	0	3 Safety Drills?	0	n/a	0	0	0	0	None	437396.3933
DPH	Ventura County Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes	Yes	0	10 Debriefs?	0	n/a	0	0	0	0	None	437396.3933
DPH	Ventura County Medical Center	2.1.9	OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16)	32	0	32	0	1	1	0	1	0	None	437396.3933
DPH	Ventura County Medical Center	2.2.1	DHCS All-Cause Readmissions	95	0	1045	0	1	0.0909	0	0.1207	0	0	1312189.18
DPH	Ventura County Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	5720	0	10000	0	1	0.572	0	0.548	0	0	1312189.18
DPH	Ventura County Medical Center	2.2.3	Medication Reconciliation – 30 days	1826	0	1982	0	0.75	0.9213	0	0.9137	0	0	1312189.18
DPH	Ventura County Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	4735	0	5211	0	1	0.9087	0	0.8475	0	0	1312189.18
DPH	Ventura County Medical Center	2.2.5	Timely Transmission of Transition Record	3445	0	3964	0	1	0.8691	0	0.8279	0	0	1312189.18
DPH	Ventura County Medical Center	2.3.2	Medication Reconciliation – 30 days	275	0	296	0	1	0.9291	0	0.9083	0	0	1312189.18
DPH	Ventura County Medical Center	2.3.4	Timely Transmission of Transition Record	469	0	541	0	1	0.8669	0	0.7432	0	0	1312189.18
DPH	Ventura County Medical Center	2.4.1	Adolescent Well-Care Visit	65	0	114	0	0	0.5702	0	0.7193	0	0	1312189.18
DPH	Ventura County Medical Center	2.4.2	Developmental Screening in the First Three Years of Life	96	0	113	0	1	0.8496	0	0.5762	0	0	1312189.18
DPH	Ventura County Medical Center	2.4.3	Documentation of Current Medications in the Medical Record (0-18 yo)	1169	0	1333	0	1	0.877	0	0.8524	0	0	1312189.18
DPH	Ventura County Medical Center	2.4.4	Screening for Clinical Depression and follow-up	46	0	76	0	0.75	0.6053	0	0.5769	0	0	1312189.18
DPH	Ventura County Medical Center	2.4.5	Tobacco Assessment and Counseling (13 yo and older)	42	0	45	0	0	0.9333	0	1	0	0	1312189.18
DPH	Ventura County Medical Center	2.4.7	Well Child Visits - Third, Fourth, Fifth, and Sixth Years of life	122	0	157	0	0	0.7771	0	0.8443	0	0	1312189.18
DPH	Ventura County Medical Center	2.4.8	Comprehensive Medical Evaluation Following Foster Youth Placement in Foster Care	22	0	93	0	0	0.2366	0	0.8333	0	0	1312189.18
DPH	Ventura County Medical Center	3.4.1	ePBM-01 Pre-op Anemia Screening, Selected Elective Surgical Patients	87	0	192	0	0	0.4531	0	0.5676	0	0	2405680.34
DPH	Ventura County Medical Center	3.4.3	ePBM-03 Pre-op Type and Crossmatch, Type and Screen, Selected elective Surgical Patients	201	0	218	0	1	0.922	0	0.9048	0	0	2405680.33
DPH	Ventura County Medical Center	3.4.4	ePBM-04 Initial Transfusion Threshold	353	0	356	0	1	0.9916	0	1	0	0	2405680.33
DMPH	Washington Hospital Healthcare System, Fremont	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	0	0	0	0	None	476030.78
DMPH	Washington Hospital Healthcare System, Fremont	2.1.2	Exclusive Breast Milk Feeding (PC-05)	66	0	93	0	1	0.7097	0	0.6917	0	0	476030.77
DMPH	Washington Hospital Healthcare System, Fremont	2.1.3	OB Hemorrhage: Massive Transfusion	0	0	115	0	1	0	0	0	0	0	476030.77
DMPH	Washington Hospital Healthcare System, Fremont	2.1.5	PC-02 Cesarean Section	None	1	39	0	1	None	1	None	1	0	476030.77
DMPH	Washington Hospital Healthcare System, Fremont	2.1.6	Prenatal and Postpartum Care: Prenatal Care	514	0	547	0	1	0.9397	0	0.9482	0	0.9075	238015.385
DMPH	Washington Hospital Healthcare System, Fremont	2.1.6	Prenatal and Postpartum Care: Postpartum Care	469	0	547	0	1	0.8574	0	0.8392	0	0.7397	238015.385
DMPH	Washington Hospital Healthcare System, Fremont	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	1	None	1	0	None	1	None	1	0	0
DMPH	Washington Hospital Healthcare System, Fremont	2.1.8	Unexpected Newborn Complications (UNC)	None	1	92	0	1	None	1	None	1	0	476030.77
DMPH	Washington Hospital Healthcare System, Fremont	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	Yes	0	3 Safety Drills?	0	n/a	0	0	0	0	None	158676.9233
DMPH	Washington Hospital Healthcare System, Fremont	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes	Yes	0	10 Debriefs?	0	n/a	0	0	0	0	None	158676.9233
DMPH	Washington Hospital Healthcare System, Fremont	2.1.9	OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16)	16	0	16	0	1	1	0	1	0	None	158676.9233
DMPH	Washington Hospital Healthcare System, Fremont	2.2.1	DHCS All-Cause Readmissions	190	0	1209	0	1	0.1572	0	0.2024	0	0	476030.77
DMPH	Washington Hospital Healthcare System, Fremont	2.2.2	H-CAHPS: Care Transition Metrics (3)	2295	0	4223	0	1	0.5435	0	0.5223	0	0	476030.77
DMPH	Washington Hospital Healthcare System, Fremont	2.2.3	Medication Reconciliation – 30 days	723	0	806	0	1	0.897	0	0.8544	0	0	476030.77
DMPH	Washington Hospital Healthcare System, Fremont	2.2.4	Reconciled Medication List Received by Discharged Patients	3021	0	3228	0	1	0.9359	0	0.8732	0	0	476030.77
DMPH	Washington Hospital Healthcare System, Fremont	2.2.5	Timely Transmission of Transition Record	3016	0	3166	0	1	0.9526	0	0.9173	0	0	476030.77
DMPH	Washington Hospital Healthcare System, Fremont	2.7.1	Advance Care Plan	181	0	217	0	1	0.8341	0	0.7566	0	0	476030.77
DMPH	Washington Hospital Healthcare System, Fremont	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	124	0	127	0	1	0.9764	0	0.9508	0	0	476030.77
DMPH	Washington Hospital Healthcare System, Fremont	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	43	0	45	0	1	0.9556	0	0.9355	0	0	476030.77
DMPH	Washington Hospital Healthcare System, Fremont	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	58	0	476	0	0	0.1218	0	0.1382	0	0	476030.77
DMPH	Washington Hospital Healthcare System, Fremont	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	None	1	40	0	1	None	1	None	1	0	476030.77