Table: public_hospital_redesign_and_incentives_in_medi_cal_pri_cc3a2adb

year	dph_dmph	hospital	number	metric	numerator	numerator_annotation_code	denominator	denominator_annotation_code	achievement_value	achievement_rate	achievement_rate_annotation_code	baseline_rate	baseline_rate_annotation_code	target_rate	allocation
DY13	DPH	Alameda Health System	1.1.1.a	Alcohol and Drug Misuse (SBIRT)	2414	0	21101	0	1	0.1144	0	0.0156	0	0	1148975
DY13	DPH	Alameda Health System	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1357	0	4622	0	1	0.2936	0	0.2997	0	0.2991	1148975
DY13	DPH	Alameda Health System	1.1.5.f	Screening for Clinical Depression and follow-up	12285	0	17403	0	1	0.7059	0	0.1512	0	0.2206	1148975
DY13	DPH	Alameda Health System	1.1.6.t	Tobacco Assessment and Counseling	15854	0	15937	0	1	0.9948	0	0.947	0	0.9485	1148975
DY13	DPH	Alameda Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	47	0	173	0	1	0.271676301	0	None	None	None	382991.6667
DY13	DPH	Alameda Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	1	173	0	1	None	1	None	None	None	382991.6667
DY13	DPH	Alameda Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	1	173	0	1	None	1	None	None	None	382991.6667
DY13	DPH	Alameda Health System	1.2.1.a	Alcohol and Drug Misuse (SBIRT)	2414	0	21101	0	1	0.1144	0	0.0156	0	0	1148975
DY13	DPH	Alameda Health System	1.2.10	REAL and/or SO/GI disparity reduction	439	0	1240	0	0	0.354	0	None	None	0.3484	1148975
DY13	DPH	Alameda Health System	1.2.11	REAL data completeness	27027	0	27029	0	1	0.9999	0	1	0	None	1148975
DY13	DPH	Alameda Health System	1.2.12.f	Screening for Clinical Depression and follow-up	12285	0	17403	0	1	0.7059	0	0.1512	0	0.2206	1148975
DY13	DPH	Alameda Health System	1.2.13	SO/GI data completeness	13482	0	19334	0	1	0.6973	0	0.0012	0	None	1148975
DY13	DPH	Alameda Health System	1.2.14.t	Tobacco Assessment and Counseling	15854	0	15937	0	1	0.9948	0	0.947	0	0.9485	1148975
DY13	DPH	Alameda Health System	1.2.2	CG-CAHPS: Provider Rating	1294	0	1705	0	1	0.7589	0	0.724	0	0.7148	1148975
DY13	DPH	Alameda Health System	1.2.3.c	Colorectal Cancer Screening	6261	0	9729	0	1	0.6435	0	0.6225	0	0.626	1148975
DY13	DPH	Alameda Health System	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1357	0	4622	0	1	0.2936	0	0.2997	0	0.2991	1148975
DY13	DPH	Alameda Health System	1.2.5.b	Controlling Blood Pressure	4442	0	5903	0	1	0.7525	0	0.7075	0	0.7041	1148975
DY13	DPH	Alameda Health System	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	474	0	497	0	1	0.9537	0	0.9002	0	0.9173	1148975
DY13	DPH	Alameda Health System	1.2.8	Prevention Quality Overall Composite #90	352	0	42849	0	1	0.0082	0	0.0059	0	0	1148975
DY13	DPH	Alameda Health System	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	9268	0	10159	0	1	0.9123	0	0.7519	0	0.7599	1148975
DY13	DPH	Alameda Health System	1.3.2	DHCS All-Cause Readmissions	171	0	1394	0	1	0.1227	0	0.1069	0	0.129	1148975
DY13	DPH	Alameda Health System	1.3.3	Influenza Immunization	4058	0	5582	0	1	0.727	0	0.5697	0	0.5767	1148975
DY13	DPH	Alameda Health System	1.3.4	Post Procedure ED Visits	333	0	16371	0	1	0.0203	0	0.0165	0	0	1148975
DY13	DPH	Alameda Health System	1.3.5	Request for Specialty Care Expertise Turnaround Time	32416	0	33997	0	1	0.9535	0	0.8705	0	0	1148975
DY13	DPH	Alameda Health System	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	1473	0	34368	0	1	0.0429	0	0.0135	0	0	1148975
DY13	DPH	Alameda Health System	1.3.7	Tobacco Assessment and Counseling	6619	0	6667	0	1	0.9928	0	0.9418	0	0.9438	1148975
DY13	DPH	Alameda Health System	1.5.1.b	Controlling Blood Pressure	4442	0	5903	0	1	0.7525	0	0.7075	0	0.7041	1148975
DY13	DPH	Alameda Health System	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	474	0	497	0	1	0.9537	0	0.9002	0	0.9173	1148975
DY13	DPH	Alameda Health System	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	9260	0	11024	0	1	0.84	0	0.8363	0	0.6	1148975
DY13	DPH	Alameda Health System	1.5.4.t	Tobacco Assessment and Counseling	15854	0	15937	0	1	0.9948	0	0.947	0	0.9485	1148975
DY13	DPH	Alameda Health System	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	None	0	None	None	None	584932.73
DY13	DPH	Alameda Health System	2.1.1	Baby Friendly Hospital designation: Development Phase Complete Yes	Yes	0	Development Phase?	0	1	see specification	0	None	None	None	584932.73
DY13	DPH	Alameda Health System	2.1.2	Exclusive Breast Milk Feeding (PC-05)	515	0	685	0	1	0.7518	0	0.726	0	0.7313	1169865.46
DY13	DPH	Alameda Health System	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	923	0	1	None	1	None	1	0	1169865.46
DY13	DPH	Alameda Health System	2.1.4	OB Hemorrhage: Total Products Transfused	40	0	923	0	1	0.0433	0	0.0885	0	0	1169865.46
DY13	DPH	Alameda Health System	2.1.5	PC-02 Cesarean Section	52	0	313	0	1	0.1661	0	0.1437	0	0.22	1169865.46
DY13	DPH	Alameda Health System	2.1.6	Prenatal and Postpartum Care: Prenatal Care	823	0	941	0	1	0.874601488	0	0.8044	0	0.815	584932.73
DY13	DPH	Alameda Health System	2.1.6	Prenatal and Postpartum Care: Postpartum Care	612	0	941	0	1	0.650371945	0	0.5978	0	0.6116	584932.73
DY13	DPH	Alameda Health System	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	25	0	103	0	1	0.2427	0	0.3008	0	0	1169865.46
DY13	DPH	Alameda Health System	2.1.8	Unexpected Newborn Complications (UNC)	50	0	745	0	1	0.0671	0	0.093	0	0	1169865.46
DY13	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)	48	0	48	0	1	see specification	0	None	None	None	292466.365
DY13	DPH	Alameda Health System	2.1.9	OB Hemorrhage Safety Bundle: Please specify which elements have been completed in the textbox below No	0	0	0	0	0	see specification	0	None	None	None	292466.365
DY13	DPH	Alameda Health System	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	0	0	0	0	0	see specification	0	None	None	None	292466.365
DY13	DPH	Alameda Health System	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes	0	0	0	0	0	see specification	0	None	None	None	292466.365
DY13	DPH	Alameda Health System	2.2.1	DHCS All-Cause Readmissions	179	0	1521	0	1	0.1177	0	0.0852	0	0.129	1169865.46
DY13	DPH	Alameda Health System	2.2.2	H-CAHPS: Care Transition Metrics (3)	4600	0	10000	0	0	0.46	0	0.4647	0	0.48	1169865.45
DY13	DPH	Alameda Health System	2.2.3	Medication Reconciliation – 30 days	936	0	1017	0	1	0.9204	0	0.839	0	0.8541	1169865.45
DY13	DPH	Alameda Health System	2.2.4	Reconciled Medication List Received by Discharged Patients	1792	0	2995	0	1	0.5983	0	0.2937	0	0.3633	1169865.45
DY13	DPH	Alameda Health System	2.2.5	Timely Transmission of Transition Record	1409	0	2456	0	1	0.5737	0	0.026	0	0.1224	1169865.45
DY13	DPH	Alameda Health System	2.3.2	Medication Reconciliation – 30 days	904	0	983	0	1	0.9196	0	0.8545	0	0.8681	1169865.45
DY13	DPH	Alameda Health System	2.3.3	Prevention Quality Overall Composite #90	348	0	2307	0	1	0.1508	0	0.1048	0	0	1169865.45
DY13	DPH	Alameda Health System	2.3.4	Timely Transmission of Transition Record	1172	0	2024	0	1	0.5791	0	0.026	0	0.1224	1169865.45
DY13	DPH	Alameda Health System	2.6.1	Alcohol and Drug Misuse (SBIRT)	368	0	1785	0	1	0.2062	0	0.1253	0	0	1169865.45
DY13	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	76	0	133	0	1	0.5714	0	0.2404	0	0	1169865.45
DY13	DPH	Alameda Health System	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	102	0	133	0	1	0.7669	0	0.2514	0	0	1169865.45
DY13	DPH	Alameda Health System	2.6.4	Screening for Clinical Depression and follow-up	1144	0	1494	0	1	0.7657	0	0.1502	0	0.2197	1169865.45
DY13	DPH	Alameda Health System	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	1766	0	1796	0	1	0.9833	0	0.9043	0	0	1169865.45
DY13	DPH	Alameda Health System	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	59	0	77	0	1	0.7662	0	0.6822	0	0.387	1608565
DY13	DPH	Alameda Health System	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	31975	0	120874	0	1	0.2645	0	0.1387	0	0	1608565
DY13	DPH	Alameda Health System	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	103	0	344	0	1	0.2994	0	0.5698	0	0	1608565
DY13	DPH	Alameda Health System	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR No	6050	0	10000	0	1	0.605	0	None	None	None	1608565
DY13	DMPH	Antelope Valley Hospital, Lancaster	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	None	0	None	None	None	331388.89
DY13	DMPH	Antelope Valley Hospital, Lancaster	2.1.1	Baby Friendly Hospital designation: Development Phase Complete Yes	Yes	0	Development Phase?	0	1	see specification	0	None	None	None	331388.89
DY13	DMPH	Antelope Valley Hospital, Lancaster	2.1.2	Exclusive Breast Milk Feeding (PC-05)	220	0	382	0	0	0.5759	0	0.5717	0	0.5924	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	2515	0	1	None	1	None	1	0	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	2.1.4	OB Hemorrhage: Total Products Transfused	88	0	2515	0	1	0.035	0	0.0512	0	0	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	2.1.5	PC-02 Cesarean Section	194	0	681	0	0	0.2849	0	0.2679	0	0.2631	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	2.1.6	Prenatal and Postpartum Care: Prenatal Care	23	0	207	0	0	0.111111111	0	0.0977	0	0.7421	331388.89
DY13	DMPH	Antelope Valley Hospital, Lancaster	2.1.6	Prenatal and Postpartum Care: Postpartum Care	109	0	207	0	0	0.526570048	0	0.3721	0	0.5547	331388.89
DY13	DMPH	Antelope Valley Hospital, Lancaster	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	37	0	111	0	1	0.3333	0	0.3095	0	0	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	2.1.8	Unexpected Newborn Complications (UNC)	23	0	2060	0	1	0.0112	0	None	1	0	662777.76
DY13	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	see specification	0	None	None	None	165694.44
DY13	DMPH	Antelope Valley Hospital, Lancaster	2.1.9	OB Hemorrhage Safety Bundle: Please specify which elements have been completed in the textbox below No	0	0	0	0	0	see specification	0	None	None	None	165694.44
DY13	DMPH	Antelope Valley Hospital, Lancaster	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	0	0	0	0	0	see specification	0	None	None	None	165694.44
DY13	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	0	0	0	0	0	see specification	0	None	None	None	165694.44
DY13	DMPH	Antelope Valley Hospital, Lancaster	2.2.1	DHCS All-Cause Readmissions	612	0	8106	0	1	0.0755	0	0.0873	0	0.129	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	2.2.2	H-CAHPS: Care Transition Metrics (3)	1916	0	4332	0	0	0.4423	0	0.4342	0	0.48	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	2.2.3	Medication Reconciliation – 30 days	58	0	58	0	1	1	0	0	0	0.099	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	2.2.4	Reconciled Medication List Received by Discharged Patients	1027	0	1200	0	0	0.8558	0	0.8969	0	0.9062	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	2.2.5	Timely Transmission of Transition Record	1452	0	13227	0	1	0.1098	0	0	0	0.099	662777.76
DY13	DMPH	Antelope Valley Hospital, Lancaster	2.3.2	Medication Reconciliation – 30 days	58	0	58	0	1	1	0	0	0	0.099	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	2.3.3	Prevention Quality Overall Composite #90	682	0	7687	0	1	0.0887	0	0.1532	0	0	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	2.3.4	Timely Transmission of Transition Record	1452	0	13227	0	1	0.1098	0	0	0	0.099	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	2.7.1	Advance Care Plan	490	0	1232	0	0	0.3977	0	0.4961	0	0.5455	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	2.7.2	Ambulatory Palliative Care Team Established: Ambulatory Palliative Care Team Established? Yes	Yes	0	Team Established?	0	1	None	0	None	None	None	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	421	0	423	0	1	0.9953	0	0.3542	0	0.45	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	58	0	58	0	1	1	0	0	0	0	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	63	0	168	0	1	0.375	0	0	0	0	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	None	1	65	0	0	None	1	None	1	0.1432	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	242	0	324	0	1	0.7469	0	0.5	0	0.387	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	27413	0	83428	0	1	0.3286	0	0.384	0	0	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	192	0	462	0	1	0.4156	0	0.4854	0	0	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR No	9800	0	10000	0	0	0.98	0	None	None	None	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	3.2.1	Imaging for Routine Headaches (Choosing Wisely)	98	0	479	0	0	0.2046	0	0.1753	0	0.1724	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	3.2.2	Appropriate Emergency Department Utilization of CT for Pulmonary Embolism	128	0	382	0	1	0.3351	0	0.2679	0	0.3082	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	3.2.3	Use of Imaging Studies for Low Back Pain	1016	0	1306	0	1	0.7779	0	0.7147	0	0.7246	662777.78
DY13	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	134	0	206	0	1	0.650485437	0	None	None	None	331388.89
DY13	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: Inappropriate Score	102	0	206	0	1	0.495145631	0	None	None	None	331388.89
DY13	DMPH	Antelope Valley Hospital, Lancaster	3.4.1	ePBM-01 Pre-op Anemia Screening, Selected Elective Surgical Patients	145	0	372	0	0	0.3898	0	0.3945	0	0.4451	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	3.4.2	ePBM-02 Pre-op Hemoglobin Level, Selected Elective Surgical Patients	35	0	38	0	1	0.9211	0	0.9333	0	0	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	3.4.3	ePBM-03 Pre-op Type and Crossmatch, Type and Screen, Selected elective Surgical Patients	205	0	376	0	0	0.5452	0	0.7919	0	0.8027	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	3.4.4	ePBM-04 Initial Transfusion Threshold	385	0	385	0	1	1	0	1	0	0	662777.78
DY13	DMPH	Antelope Valley Hospital, Lancaster	3.4.5	ePBM-05 Outcome of Patient Blood Management, Selected Elective Surgical Patients	38	0	145	0	0	0.2621	0	None	1	0.0237	662777.76
DY13	DPH	Arrowhead Regional Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT)	319	0	14782	0	1	0.0216	0	None	1	0	1594962.97
DY13	DPH	Arrowhead Regional Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1259	0	4626	0	1	0.2722	0	0.3203	0	0.3176	1594962.97
DY13	DPH	Arrowhead Regional Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	7142	0	8740	0	1	0.8172	0	0.6313	0	0.6527	1594962.97
DY13	DPH	Arrowhead Regional Medical Center	1.1.6.t	Tobacco Assessment and Counseling	11122	0	11160	0	1	0.9966	0	0.8966	0	0.9031	1594962.97
DY13	DPH	Arrowhead Regional Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	None	1	136	0	1	None	1	None	None	None	531654.3233
DY13	DPH	Arrowhead Regional Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	1	136	0	1	None	1	None	None	None	531654.3233
DY13	DPH	Arrowhead Regional Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	1	136	0	1	None	1	None	None	None	531654.3233
DY13	DPH	Arrowhead Regional Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT)	319	0	14782	0	1	0.0216	0	None	1	0	1594962.97
DY13	DPH	Arrowhead Regional Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	987	0	1725	0	1	0.5722	0	None	None	0.4788	1594962.96
DY13	DPH	Arrowhead Regional Medical Center	1.2.11	REAL data completeness	19087	0	22440	0	1	0.8506	0	0.1733	0	None	1594962.96
DY13	DPH	Arrowhead Regional Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	7126	0	8715	0	1	0.8177	0	0.7765	0	0.7834	1594962.96
DY13	DPH	Arrowhead Regional Medical Center	1.2.13	SO/GI data completeness	15794	0	15818	0	1	0.9985	0	0.8838	0	None	1594962.96
DY13	DPH	Arrowhead Regional Medical Center	1.2.14.t	Tobacco Assessment and Counseling	11122	0	11160	0	1	0.9966	0	0.8966	0	0.9031	1594962.96
DY13	DPH	Arrowhead Regional Medical Center	1.2.2	CG-CAHPS: Provider Rating	1665	0	1953	0	1	0.8525	0	0.8301	0	0.7148	1594962.97
DY13	DPH	Arrowhead Regional Medical Center	1.2.3.c	Colorectal Cancer Screening	5330	0	9170	0	1	0.5812	0	0.5167	0	0.5307	1594962.97
DY13	DPH	Arrowhead Regional Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1259	0	4626	0	1	0.2722	0	0.3284	0	0.3249	1594962.96
DY13	DPH	Arrowhead Regional Medical Center	1.2.5.b	Controlling Blood Pressure	257	0	378	0	1	0.6799	0	0.6707	0	0.674	1594962.96
DY13	DPH	Arrowhead Regional Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	695	0	858	0	0.75	0.81	0	0.7818	0	0.8159	1594962.96
DY13	DPH	Arrowhead Regional Medical Center	1.2.8	Prevention Quality Overall Composite #90	404	0	31395	0	1	0.0129	0	0.016	0	0	1594962.96
DY13	DPH	Arrowhead Regional Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	15135	0	24601	0	1	0.6152	0	0.1411	0	0.2102	1594962.96
DY13	DPH	Arrowhead Regional Medical Center	1.3.2	DHCS All-Cause Readmissions	337	0	2137	0	0	0.1577	0	0.1424	0	0.1411	1594962.96
DY13	DPH	Arrowhead Regional Medical Center	1.3.3	Influenza Immunization	2794	0	4530	0	1	0.6168	0	0.4874	0	0.5027	1594962.96
DY13	DPH	Arrowhead Regional Medical Center	1.3.4	Post Procedure ED Visits	1073	0	15563	0	1	0.0689	0	0.0813	0	0	1594962.96
DY13	DPH	Arrowhead Regional Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	36862	0	55958	0	1	0.6587	0	0.5969	0	0	1594962.96
DY13	DPH	Arrowhead Regional Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	441	0	55958	0	1	0.0079	0	None	1	0	1594962.96
DY13	DPH	Arrowhead Regional Medical Center	1.3.7	Tobacco Assessment and Counseling	8099	0	8610	0	1	0.9407	0	0.7243	0	0.759	1594962.96
DY13	DPH	Arrowhead Regional Medical Center	1.7.1	BMI Screening and Follow-up	331	0	377	0	1	0.878	0	0.6737	0	0.8697	1594962.96
DY13	DPH	Arrowhead Regional Medical Center	1.7.2	Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Please specify which critera have been met in the textbox below. No	0	0	0	0	N/A	N/A - see narrative	0	N/A	0	None	797481.48
DY13	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 5)	8	0	8	0	1	see specification	0	N/A	0	None	797481.48
DY13	DPH	Arrowhead Regional Medical Center	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI	341	0	341	0	1	1	0	0.9895	0	0.8637	531654.32
DY13	DPH	Arrowhead Regional Medical Center	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition	341	0	341	0	1	1	0	0.9765	0	0.7952	531654.32
DY13	DPH	Arrowhead Regional Medical Center	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity	340	0	341	0	1	0.997067449	0	0.9443	0	0.7158	531654.32
DY13	DPH	Arrowhead Regional Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	None	0	None	None	None	782981.82
DY13	DPH	Arrowhead Regional Medical Center	2.1.1	Baby Friendly Hospital designation: Development Phase Complete Yes	Yes	0	Development Phase?	0	1	see specification	0	None	None	None	782981.82
DY13	DPH	Arrowhead Regional Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	357	0	608	0	1	0.5872	0	0.4689	0	0.4999	1565963.64
DY13	DPH	Arrowhead Regional Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	729	0	1	None	1	None	1	0	1565963.64
DY13	DPH	Arrowhead Regional Medical Center	2.1.4	OB Hemorrhage: Total Products Transfused	35	0	729	0	1	0.048	0	0.1023	0	0	1565963.64
DY13	DPH	Arrowhead Regional Medical Center	2.1.5	PC-02 Cesarean Section	54	0	210	0	0	0.2571	0	0.2064	0	0.2042	1565963.64
DY13	DPH	Arrowhead Regional Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	100	0	132	0	1	0.757575758	0	0.1316	0	0.7421	782981.82
DY13	DPH	Arrowhead Regional Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	78	0	132	0	1	0.590909091	0	0.4754	0	0.5547	782981.82
DY13	DPH	Arrowhead Regional Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	14	0	39	0	1	0.359	0	0.5	0	0	1565963.64
DY13	DPH	Arrowhead Regional Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	16	0	573	0	1	0.0279	0	0.0535	0	0	1565963.64
DY13	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	see specification	0	None	None	None	391490.91
DY13	DPH	Arrowhead Regional Medical Center	2.1.9	OB Hemorrhage Safety Bundle: Please specify which elements have been completed in the textbox below No	0	0	0	0	0	see specification	0	None	None	None	391490.91
DY13	DPH	Arrowhead Regional Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	0	0	0	0	0	see specification	0	None	None	None	391490.91
DY13	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	0	0	0	0	0	see specification	0	None	None	None	391490.91
DY13	DPH	Arrowhead Regional Medical Center	2.2.1	DHCS All-Cause Readmissions	397	0	2762	0	0	0.1437	0	0.1311	0	0.1309	1565963.64
DY13	DPH	Arrowhead Regional Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	687	0	1391	0	0	0.4939	0	0.5029	0	0.5136	1565963.64
DY13	DPH	Arrowhead Regional Medical Center	2.2.3	Medication Reconciliation – 30 days	252	0	262	0	1	0.9618	0	0.933	0	0.9387	1565963.64
DY13	DPH	Arrowhead Regional Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	324	0	341	0	1	0.9501	0	0.0664	0	0.1588	1565963.64
DY13	DPH	Arrowhead Regional Medical Center	2.2.5	Timely Transmission of Transition Record	3330	0	3591	0	1	0.9273	0	0.9191	0	0.9262	1565963.64
DY13	DPH	Arrowhead Regional Medical Center	2.3.2	Medication Reconciliation – 30 days	333	0	343	0	1	0.9708	0	0.9645	0	0.9671	1565963.63
DY13	DPH	Arrowhead Regional Medical Center	2.3.3	Prevention Quality Overall Composite #90	97	0	422	0	1	0.2299	0	0.2655	0	0	1565963.63
DY13	DPH	Arrowhead Regional Medical Center	2.3.4	Timely Transmission of Transition Record	947	0	1033	0	1	0.9167	0	0.8911	0	0.901	1565963.63
DY13	DPH	Arrowhead Regional Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT)	22	0	1639	0	1	0.0134	0	0.0123	0	0	1565963.63
DY13	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	69	0	278	0	1	0.2482	0	0.0482	0	0	1565963.63
DY13	DPH	Arrowhead Regional Medical Center	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	41	0	278	0	1	0.1475	0	0.1245	0	0	1565963.63
DY13	DPH	Arrowhead Regional Medical Center	2.6.4	Screening for Clinical Depression and follow-up	746	0	902	0	1	0.8271	0	0.8136	0	0.8168	1565963.63
DY13	DPH	Arrowhead Regional Medical Center	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	1496	0	1758	0	1	0.851	0	0.8853	0	0	1565963.63
DY13	DPH	Arrowhead Regional Medical Center	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	120	0	246	0	1	0.4878	0	0.4219	0	0.387	2153200
DY13	DPH	Arrowhead Regional Medical Center	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	44857	0	448222	0	1	0.1001	0	0.1567	0	0	2153200
DY13	DPH	Arrowhead Regional Medical Center	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	1740	0	2565	0	1	0.6784	0	0.6713	0	0	2153200
DY13	DPH	Arrowhead Regional Medical Center	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR No	2520	0	10000	0	1	0.252	0	None	None	None	2153200
DY13	DMPH	Bear Valley Community Hospital, Big Bear Lake	2.6.1	Alcohol and Drug Misuse (SBIRT)	147	0	1400	0	1	0.105	0	None	1	0	300000
DY13	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	83	0	102	0	1	0.8137	0	0.806	0	0	300000
DY13	DMPH	Bear Valley Community Hospital, Big Bear Lake	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	94	0	102	0	1	0.9216	0	0.8731	0	0	300000
DY13	DMPH	Bear Valley Community Hospital, Big Bear Lake	2.6.4	Screening for Clinical Depression and follow-up	603	0	973	0	1	0.6197	0	0.5177	0	0.5505	300000
DY13	DMPH	Bear Valley Community Hospital, Big Bear Lake	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	98	0	102	0	1	0.9608	0	0.8806	0	0	300000
DY13	DMPH	Coalinga Regional Medical Center, Coalinga	1.5.1.b	Controlling Blood Pressure	0	0	0	0	None	None	0	None	4	None	214285.72
DY13	DMPH	Coalinga Regional Medical Center, Coalinga	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	0	0	0	0	None	None	0	None	1	None	214285.72
DY13	DMPH	Coalinga Regional Medical Center, Coalinga	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	0	0	0	0	None	None	0	None	None	None	214285.71
DY13	DMPH	Coalinga Regional Medical Center, Coalinga	1.5.4.t	Tobacco Assessment and Counseling	0	0	0	0	None	None	0	None	None	None	214285.71
DY13	DMPH	Coalinga Regional Medical Center, Coalinga	1.7.1	BMI Screening and Follow-up	0	0	0	0	None	None	0	None	None	None	214285.72
DY13	DMPH	Coalinga Regional Medical Center, Coalinga	1.7.2	Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Please specify which critera have been met in the textbox below.	0	0	0	0	None	None	0	N/A	0	None	107142.855
DY13	DMPH	Coalinga Regional Medical Center, Coalinga	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 5)	0	0	0	0	None	None	0	N/A	0	None	107142.855
DY13	DMPH	Coalinga Regional Medical Center, Coalinga	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition	0	0	0	0	None	None	0	None	None	None	71428.57
DY13	DMPH	Coalinga Regional Medical Center, Coalinga	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity	0	0	0	0	None	None	0	None	None	None	71428.57
DY13	DMPH	Coalinga Regional Medical Center, Coalinga	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI	0	0	0	0	None	None	0	None	None	None	71428.57
DY13	DPH	Contra Costa Regional Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT)	7370	0	48576	0	1	0.1517	0	0.1021	0	0	1297679.32
DY13	DPH	Contra Costa Regional Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	2019	0	7978	0	1	0.2531	0	0.2991	0	0.2986	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	18789	0	32103	0	1	0.5853	0	0.3898	0	0.4354	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	1.1.6.t	Tobacco Assessment and Counseling	37001	0	37929	0	1	0.9755	0	0.8839	0	0.8917	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	159	0	1059	0	1	0.150141643	0	None	None	None	432559.77
DY13	DPH	Contra Costa Regional Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	21	0	1059	0	1	0.019830028	0	None	None	None	432559.77
DY13	DPH	Contra Costa Regional Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	46	0	1059	0	1	0.043437205	0	None	None	None	432559.77
DY13	DPH	Contra Costa Regional Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT)	7370	0	48576	0	1	0.1517	0	0.1021	0	0	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	1485	0	2168	0	1	0.685	0	None	None	0.6649	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	1.2.11	REAL data completeness	56868	0	57269	0	1	0.993	0	0.5124	0	None	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	18789	0	32103	0	1	0.5853	0	0.3898	0	0.4354	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	1.2.13	SO/GI data completeness	40187	0	40365	0	1	0.9956	0	0.4169	0	None	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	1.2.14.t	Tobacco Assessment and Counseling	37001	0	37929	0	1	0.9755	0	0.8839	0	0.8917	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	1.2.2	CG-CAHPS: Provider Rating	2865	0	3783	0	1	0.7573	0	0.7226	0	0.7148	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	1.2.3.c	Colorectal Cancer Screening	12375	0	18351	0	1	0.6744	0	0.6496	0	0.6504	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	2019	0	7978	0	1	0.2531	0	0.2991	0	0.2986	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	1.2.5.b	Controlling Blood Pressure	7854	0	10294	0	1	0.763	0	0.7079	0	0.7041	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	1188	0	1257	0	1	0.9451	0	0.8675	0	0.9125	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	1.2.8	Prevention Quality Overall Composite #90	532	0	63113	0	1	0.0084	0	0.0072	0	0	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	22300	0	22300	0	1	1	0	1	0	0.832	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	1.3.2	DHCS All-Cause Readmissions	123	0	1679	0	1	0.0733	0	0.0634	0	0.129	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	1.3.3	Influenza Immunization	16884	0	26348	0	1	0.6408	0	0.6335	0	0.6342	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	1.3.4	Post Procedure ED Visits	169	0	16040	0	1	0.0105	0	0.0141	0	0	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	42666	0	55490	0	1	0.7689	0	0.6912	0	0	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	291	0	53772	0	1	0.0054	0	0.0024	0	0	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	1.3.7	Tobacco Assessment and Counseling	14903	0	15201	0	1	0.9804	0	0.8997	0	0.9059	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	1.6.1	BIRADS to Biopsy	61	0	67	0	1	0.9104	0	0.8636	0	0	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	1.6.2	Breast Cancer Screening	9430	0	12524	0	1	0.753	0	0.7005	0	0.7019	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	1.6.3	Cervical Cancer Screening	16288	0	25741	0	1	0.6328	0	0.5933	0	0.6038	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	1.6.4.c	Colorectal Cancer Screening	12375	0	18351	0	1	0.6744	0	0.6496	0	0.6504	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	163	0	289	0	1	0.564	0	0.4923	0	0	1297679.31
DY13	DPH	Contra Costa Regional Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation No	No	0	BFUSA Cert?	0	0	see specification	0	None	None	None	519071.725
DY13	DPH	Contra Costa Regional Medical Center	2.1.1	Baby Friendly Hospital designation: Development Phase Complete Yes	Yes	0	Development Phase?	0	1	see specification	0	None	None	None	519071.725
DY13	DPH	Contra Costa Regional Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	1116	0	1501	0	1	0.7435	0	0.6867	0	0.6959	1038143.45
DY13	DPH	Contra Costa Regional Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	1627	0	1	None	1	None	1	0	1038143.45
DY13	DPH	Contra Costa Regional Medical Center	2.1.4	OB Hemorrhage: Total Products Transfused	56	0	1627	0	1	0.0344	0	0.0266	0	0	1038143.45
DY13	DPH	Contra Costa Regional Medical Center	2.1.5	PC-02 Cesarean Section	112	0	533	0	1	0.2101	0	0.2174	0	0.22	1038143.45
DY13	DPH	Contra Costa Regional Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	1325	0	1401	0	1	0.945753034	0	0.9005	0	0.9015	519071.725
DY13	DPH	Contra Costa Regional Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	1176	0	1401	0	1	0.839400428	0	0.8315	0	0.5506	519071.725
DY13	DPH	Contra Costa Regional Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	35	0	216	0	1	0.162	0	0.1575	0	0	1038143.45
DY13	DPH	Contra Costa Regional Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	52	0	1390	0	1	0.0374	0	0.0631	0	0	1038143.45
DY13	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	see specification	0	None	None	None	259535.8625
DY13	DPH	Contra Costa Regional Medical Center	2.1.9	OB Hemorrhage Safety Bundle: Please specify which elements have been completed in the textbox below No	0	0	0	0	0	see specification	0	None	None	None	259535.8625
DY13	DPH	Contra Costa Regional Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	0	0	0	0	0	see specification	0	None	None	None	259535.8625
DY13	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	0	0	0	0	0	see specification	0	None	None	None	259535.8625
DY13	DPH	Contra Costa Regional Medical Center	2.2.1	DHCS All-Cause Readmissions	127	0	1774	0	1	0.0716	0	0.0588	0	0.129	1038143.45
DY13	DPH	Contra Costa Regional Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	317	0	613	0	0	0.5171	0	0.5361	0	0.5435	1038143.45
DY13	DPH	Contra Costa Regional Medical Center	2.2.3	Medication Reconciliation – 30 days	2881	0	2901	0	1	0.9931	0	0.9837	0	0.9843	1038143.45
DY13	DPH	Contra Costa Regional Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	4568	0	4645	0	1	0.9834	0	0.9787	0	0.9798	1038143.45
DY13	DPH	Contra Costa Regional Medical Center	2.2.5	Timely Transmission of Transition Record	2524	0	3937	0	1	0.6411	0	0.0229	0	0.1196	1038143.45
DY13	DPH	Contra Costa Regional Medical Center	2.3.2	Medication Reconciliation – 30 days	1193	0	1207	0	1	0.9884	0	0.9725	0	0.9743	1038143.45
DY13	DPH	Contra Costa Regional Medical Center	2.3.3	Prevention Quality Overall Composite #90	427	0	17922	0	1	0.0238	0	0.0201	0	0	1038143.45
DY13	DPH	Contra Costa Regional Medical Center	2.3.4	Timely Transmission of Transition Record	1055	0	1577	0	1	0.669	0	0.0453	0	0.1398	1038143.45
DY13	DPH	Contra Costa Regional Medical Center	2.4.1	Adolescent Well-Care Visit	77	0	91	0	1	0.8462	0	0.8958	0	0.6604	1038143.45
DY13	DPH	Contra Costa Regional Medical Center	2.4.2	Developmental Screening in the First Three Years of Life	36	0	75	0	1	0.48	0	None	1	0.1267	1038143.45
DY13	DPH	Contra Costa Regional Medical Center	2.4.3	Documentation of Current Medications in the Medical Record (0-18 yo)	598	0	598	0	1	1	0	1	0	0	1038143.45
DY13	DPH	Contra Costa Regional Medical Center	2.4.4	Screening for Clinical Depression and follow-up	34	0	50	0	1	0.68	0	0.6579	0	0.6767	1038143.45
DY13	DPH	Contra Costa Regional Medical Center	2.4.5	Tobacco Assessment and Counseling (13 yo and older)	87	0	91	0	1	0.956	0	None	4	0.9144	1038143.45
DY13	DPH	Contra Costa Regional Medical Center	2.4.7	Well Child Visits - Third, Fourth, Fifth, and Sixth Years of life	37	0	39	0	1	0.9487	0	0.8485	0	0.8297	1038143.45
DY13	DPH	Contra Costa Regional Medical Center	2.4.8	Comprehensive Medical Evaluation Following Foster Youth Placement in Foster Care	56	0	118	0	1	0.4746	0	None	None	0	1038143.45
DY13	DPH	Contra Costa Regional Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT)	624	0	6165	0	1	0.1012	0	0.0768	0	0	1038143.44
DY13	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	389	0	1216	0	1	0.3199	0	0.469	0	0	1038143.44
DY13	DPH	Contra Costa Regional Medical Center	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	785	0	1214	0	1	0.6466	0	0.5387	0	0	1038143.44
DY13	DPH	Contra Costa Regional Medical Center	2.6.4	Screening for Clinical Depression and follow-up	2319	0	3498	0	1	0.663	0	0.4259	0	0.4679	1038143.44
DY13	DPH	Contra Costa Regional Medical Center	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	5310	0	6722	0	1	0.7899	0	0.81	0	0	1038143.44
DY13	DPH	Contra Costa Regional Medical Center	3.2.1	Imaging for Routine Headaches (Choosing Wisely)	549	0	4607	0	1	0.1192	0	0.112	0	0.1464	1881635
DY13	DPH	Contra Costa Regional Medical Center	3.2.2	Appropriate Emergency Department Utilization of CT for Pulmonary Embolism	296	0	325	0	1	0.9108	0	0.8759	0	0.6707	1881635
DY13	DPH	Contra Costa Regional Medical Center	3.2.3	Use of Imaging Studies for Low Back Pain	2451	0	2808	0	1	0.8729	0	0.8687	0	0.8141	1881635
DY13	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	501	0	6370	0	1	0.078649922	0	None	None	None	940817.5
DY13	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: Inappropriate Score	704	0	6370	0	1	0.110518053	0	None	None	None	940817.5
DY13	DMPH	Eastern Plumas Health Care, Portol	1.1.1.a	Alcohol and Drug Misuse (SBIRT)	68	0	1285	0	1	0.0529	0	0.0719	0	0	300000
DY13	DMPH	Eastern Plumas Health Care, Portol	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	28	0	106	0	1	0.2642	0	0.2353	0	0.2936	300000
DY13	DMPH	Eastern Plumas Health Care, Portol	1.1.5.f	Screening for Clinical Depression and follow-up	135	0	926	0	0	0.1458	0	None	1	0.1814	300000
DY13	DMPH	Eastern Plumas Health Care, Portol	1.1.6.t	Tobacco Assessment and Counseling	892	0	1173	0	1	0.7604	0	0.2312	0	0.759	300000
DY13	DMPH	Eastern Plumas Health Care, Portol	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	13	0	54	0	1	0.240740741	0	None	None	None	100000
DY13	DMPH	Eastern Plumas Health Care, Portol	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	1	54	0	1	None	1	None	None	None	100000
DY13	DMPH	Eastern Plumas Health Care, Portol	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	1	54	0	1	None	1	None	None	None	100000
DY13	DMPH	El Camino Hospital, Mountain View	1.1.1.a	Alcohol and Drug Misuse (SBIRT)	None	1	2729	0	1	None	1	0	0	0	360000
DY13	DMPH	El Camino Hospital, Mountain View	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	54	0	280	0	1	0.1929	0	0.1922	0	0.2936	360000
DY13	DMPH	El Camino Hospital, Mountain View	1.1.5.f	Screening for Clinical Depression and follow-up	2451	0	2598	0	1	0.9434	0	0.5334	0	0.5646	360000
DY13	DMPH	El Camino Hospital, Mountain View	1.1.6.t	Tobacco Assessment and Counseling	2447	0	2840	0	1	0.8616	0	0.5808	0	0.759	360000
DY13	DMPH	El Camino Hospital, Mountain View	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	264	0	545	0	1	0.48440367	0	None	None	None	120000
DY13	DMPH	El Camino Hospital, Mountain View	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	1	545	0	1	None	1	None	None	None	120000
DY13	DMPH	El Camino Hospital, Mountain View	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	14	0	545	0	1	0.025688073	0	None	None	None	120000
DY13	DMPH	El Camino Hospital, Mountain View	2.1.1	Baby Friendly Hospital designation: BFUSA Designation No	No	0	BFUSA Cert?	0	0	see specification	0	None	None	None	180000
DY13	DMPH	El Camino Hospital, Mountain View	2.1.1	Baby Friendly Hospital designation: Development Phase Complete No	No	0	Development Phase?	0	0	see specification	0	None	None	None	180000
DY13	DMPH	El Camino Hospital, Mountain View	2.1.2	Exclusive Breast Milk Feeding (PC-05)	18	0	45	0	0	0.4	0	0.5455	0	0.5689	360000
DY13	DMPH	El Camino Hospital, Mountain View	2.1.3	OB Hemorrhage: Massive Transfusion	0	0	53	0	1	0	0	0	0	0	360000
DY13	DMPH	El Camino Hospital, Mountain View	2.1.4	OB Hemorrhage: Total Products Transfused	None	1	53	0	1	None	1	0	0	0	360000
DY13	DMPH	El Camino Hospital, Mountain View	2.1.5	PC-02 Cesarean Section	None	1	None	4	0	None	1	None	1	0.2743	0
DY13	DMPH	El Camino Hospital, Mountain View	2.1.6	Prenatal and Postpartum Care: Prenatal Care	40	0	53	0	0	0.754716981	0	0.8485	0	0.8547	180000
DY13	DMPH	El Camino Hospital, Mountain View	2.1.6	Prenatal and Postpartum Care: Postpartum Care	46	0	53	0	1	0.867924528	0	0.7879	0	0.7361	180000
DY13	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	0	0	0	0
DY13	DMPH	El Camino Hospital, Mountain View	2.1.8	Unexpected Newborn Complications (UNC)	0	0	45	0	1	0	0	0	0	0	360000
DY13	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	1	see specification	0	None	None	None	90000
DY13	DMPH	El Camino Hospital, Mountain View	2.1.9	OB Hemorrhage Safety Bundle: Please specify which elements have been completed in the textbox below No	0	0	0	0	0	see specification	0	None	None	None	90000
DY13	DMPH	El Camino Hospital, Mountain View	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter No	0	0	0	0	0	see specification	0	None	None	None	90000
DY13	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	0	0	0	0	0	see specification	0	None	None	None	90000
DY13	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	0.1247	0
DY13	DMPH	El Camino Hospital, Mountain View	3.4.2	ePBM-02 Pre-op Hemoglobin Level, Selected Elective Surgical Patients	0	0	None	1	0	None	1	None	1	0	0
DY13	DMPH	El Camino Hospital, Mountain View	3.4.3	ePBM-03 Pre-op Type and Crossmatch, Type and Screen, Selected elective Surgical Patients	16	0	None	4	0	None	4	None	4	0.7823	0
DY13	DMPH	El Camino Hospital, Mountain View	3.4.4	ePBM-04 Initial Transfusion Threshold	120	0	120	0	1	1	0	1	0	0	360000
DY13	DMPH	El Camino Hospital, Mountain View	3.4.5	ePBM-05 Outcome of Patient Blood Management, Selected Elective Surgical Patients	0	0	None	1	0	None	1	None	1	0.0347	0
DY13	DMPH	El Centro Regional Medical Center, El Centro	1.2.1.a	Alcohol and Drug Misuse (SBIRT)	493	0	7819	0	1	0.0631	0	0	0	0	476842.11
DY13	DMPH	El Centro Regional Medical Center, El Centro	1.2.10	REAL and/or SO/GI disparity reduction	153	0	925	0	0	0.1654	0	None	None	None	476842.1
DY13	DMPH	El Centro Regional Medical Center, El Centro	1.2.11	REAL data completeness	8893	0	9162	0	1	0.9706	0	0	0	None	476842.1
DY13	DMPH	El Centro Regional Medical Center, El Centro	1.2.12.f	Screening for Clinical Depression and follow-up	4202	0	6860	0	1	0.6125	0	0.2393	0	0.2999	476842.1
DY13	DMPH	El Centro Regional Medical Center, El Centro	1.2.13	SO/GI data completeness	3385	0	6860	0	1	0.4934	0	0	0	None	476842.1
DY13	DMPH	El Centro Regional Medical Center, El Centro	1.2.14.t	Tobacco Assessment and Counseling	5353	0	6860	0	1	0.7803	0	0.3888	0	0.759	476842.1
DY13	DMPH	El Centro Regional Medical Center, El Centro	1.2.2	CG-CAHPS: Provider Rating	2676	0	3743	0	1	0.7149	0	0.8595	0	0.7148	476842.11
DY13	DMPH	El Centro Regional Medical Center, El Centro	1.2.3.c	Colorectal Cancer Screening	993	0	3164	0	1	0.3138	0	0.1019	0	0.2669	476842.11
DY13	DMPH	El Centro Regional Medical Center, El Centro	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	311	0	1097	0	1	0.2835	0	0.1829	0	0.2936	476842.11
DY13	DMPH	El Centro Regional Medical Center, El Centro	1.2.5.b	Controlling Blood Pressure	383	0	435	0	1	0.8805	0	0.9712	0	0.7041	476842.1
DY13	DMPH	El Centro Regional Medical Center, El Centro	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	336	0	403	0	0	0.8337	0	0.9896	0	0.9173	476842.1
DY13	DMPH	El Centro Regional Medical Center, El Centro	1.2.8	Prevention Quality Overall Composite #90	378	0	10990	0	1	0.0344	0	0.03	0	0	476842.1
DY13	DMPH	El Centro Regional Medical Center, El Centro	1.7.1	BMI Screening and Follow-up	1111	0	10990	0	0	0.1011	0	0.2914	0	0.4249	476842.11
DY13	DMPH	El Centro Regional Medical Center, El Centro	1.7.2	Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Please specify which critera have been met in the textbox below. No	0	0	0	0	N/A	N/A - see narrative	0	N/A	0	None	238421.055
DY13	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 5)	5	0	8	0	1	see specification	0	N/A	0	None	238421.055
DY13	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	2318	0	2320	0	1	0.999137931	0	0.9924	0	0.8637	158947.37
DY13	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	667	0	2320	0	0	0.2875	0	0.3489	0	0.5184	158947.37
DY13	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	640	0	2320	0	0	0.275862069	0	0.3489	0	0.4509	158947.37
DY13	DMPH	El Centro Regional Medical Center, El Centro	3.2.1	Imaging for Routine Headaches (Choosing Wisely)	368	0	1305	0	0	0.282	0	0.2837	0	0.2687	476842.11
DY13	DMPH	El Centro Regional Medical Center, El Centro	3.2.2	Appropriate Emergency Department Utilization of CT for Pulmonary Embolism	99	0	146	0	1	0.6781	0	0.6519	0	0.6538	476842.11
DY13	DMPH	El Centro Regional Medical Center, El Centro	3.2.3	Use of Imaging Studies for Low Back Pain	312	0	467	0	0	0.6681	0	0.5431	0	0.6989	476842.11
DY13	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	278	0	1200	0	1	0.231666667	0	None	None	None	238421.05
DY13	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: Inappropriate Score	226	0	1200	0	1	0.188333333	0	None	None	None	238421.05
DY13	DMPH	Hazel Hawkins Memorial Hospital, Hollister	2.3.2	Medication Reconciliation – 30 days	30	0	46	0	1	0.6522	0	0.2083	0	0.2865	873333.34
DY13	DMPH	Hazel Hawkins Memorial Hospital, Hollister	2.3.3	Prevention Quality Overall Composite #90	11	0	44	0	1	0.25	0	0.0238	0	0	873333.33
DY13	DMPH	Hazel Hawkins Memorial Hospital, Hollister	2.3.4	Timely Transmission of Transition Record	43	0	46	0	1	0.9348	0	0.3056	0	0.374	873333.33
DY13	DMPH	Healdsburg District Hospital, Healdsburg	1.5.1.b	Controlling Blood Pressure	61	0	85	0	1	0.7176	0	0.0457	0	0.4687	376666.66
DY13	DMPH	Healdsburg District Hospital, Healdsburg	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	17	0	None	4	0	None	4	None	1	0.7022	0
DY13	DMPH	Healdsburg District Hospital, Healdsburg	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	154	0	717	0	0	0.2148	0	0	0	0.28	376666.66
DY13	DMPH	Healdsburg District Hospital, Healdsburg	1.5.4.t	Tobacco Assessment and Counseling	193	0	840	0	0	0.2298	0	0.1018	0	0.759	376666.67
DY13	DMPH	Healdsburg District Hospital, Healdsburg	1.6.1	BIRADS to Biopsy	None	1	None	1	0	None	1	0	0	0	0
DY13	DMPH	Healdsburg District Hospital, Healdsburg	1.6.2	Breast Cancer Screening	63	0	238	0	0	0.2647	0	0.1392	0	0.5228	376666.67
DY13	DMPH	Healdsburg District Hospital, Healdsburg	1.6.3	Cervical Cancer Screening	77	0	375	0	0	0.2053	0	0.0544	0	0.4834	376666.67
DY13	DMPH	Healdsburg District Hospital, Healdsburg	1.6.4.c	Colorectal Cancer Screening	85	0	430	0	0	0.1977	0	0.0638	0	0.2669	376666.67
DY13	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
DY13	DMPH	Jerold Phelps Community Hospital, Garberville	1.5.1.b	Controlling Blood Pressure	26	0	43	0	0	0.6047	0	None	4	0.7041	500000
DY13	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	0.9173	0
DY13	DMPH	Jerold Phelps Community Hospital, Garberville	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	102	0	108	0	1	0.9444	0	0.375	0	0.3975	500000
DY13	DMPH	Jerold Phelps Community Hospital, Garberville	1.5.4.t	Tobacco Assessment and Counseling	138	0	150	0	1	0.92	0	0.8257	0	0.8393	500000
DY13	DMPH	John C. Fremont Healthcare District, Mariposa	1.2.1.a	Alcohol and Drug Misuse (SBIRT)	62	0	1120	0	1	0.0554	0	None	1	0	125000
DY13	DMPH	John C. Fremont Healthcare District, Mariposa	1.2.10	REAL and/or SO/GI disparity reduction	50	0	92	0	0	0.5435	0	None	None	None	125000
DY13	DMPH	John C. Fremont Healthcare District, Mariposa	1.2.11	REAL data completeness	583	0	1290	0	1	0.4519	0	0	0	None	125000
DY13	DMPH	John C. Fremont Healthcare District, Mariposa	1.2.12.f	Screening for Clinical Depression and follow-up	86	0	1018	0	0	0.0845	0	0.0446	0	0.1814	125000
DY13	DMPH	John C. Fremont Healthcare District, Mariposa	1.2.13	SO/GI data completeness	491	0	1018	0	1	0.4823	0	0	0	None	125000
DY13	DMPH	John C. Fremont Healthcare District, Mariposa	1.2.14.t	Tobacco Assessment and Counseling	576	0	1018	0	0	0.5658	0	0.6497	0	0.759	125000
DY13	DMPH	John C. Fremont Healthcare District, Mariposa	1.2.2	CG-CAHPS: Provider Rating	86	0	237	0	0	0.3629	0	None	1	0.7144	125000
DY13	DMPH	John C. Fremont Healthcare District, Mariposa	1.2.3.c	Colorectal Cancer Screening	93	0	529	0	0	0.1758	0	0.2263	0	0.2694	125000
DY13	DMPH	John C. Fremont Healthcare District, Mariposa	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	76	0	145	0	0	0.5241	0	0.4174	0	0.405	125000
DY13	DMPH	John C. Fremont Healthcare District, Mariposa	1.2.5.b	Controlling Blood Pressure	72	0	185	0	0	0.3892	0	0.5581	0	0.5727	125000
DY13	DMPH	John C. Fremont Healthcare District, Mariposa	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	81	0	166	0	0	0.488	0	0.6531	0	0.7022	125000
DY13	DMPH	John C. Fremont Healthcare District, Mariposa	1.2.8	Prevention Quality Overall Composite #90	58	0	1018	0	1	0.057	0	0.1126	0	0	125000
DY13	DMPH	Kaweah Delta Health Care District, Visalia	1.2.1.a	Alcohol and Drug Misuse (SBIRT)	29	0	431	0	1	0.0673	0	None	1	0	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	1.2.10	REAL and/or SO/GI disparity reduction	140	0	234	0	0	0.5983	0	None	None	None	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	1.2.11	REAL data completeness	9336	0	13724	0	1	0.6803	0	0	0	None	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	1.2.12.f	Screening for Clinical Depression and follow-up	174	0	389	0	1	0.4473	0	0.0424	0	0.1814	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	1.2.13	SO/GI data completeness	3140	0	8848	0	1	0.3549	0	0.0826	0	None	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	1.2.14.t	Tobacco Assessment and Counseling	389	0	434	0	1	0.8963	0	0.7696	0	0.7888	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	1.2.2	CG-CAHPS: Provider Rating	927	0	1256	0	1	0.7381	0	0.7259	0	0.7148	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	1.2.3.c	Colorectal Cancer Screening	96	0	357	0	1	0.2689	0	0.1725	0	0.2669	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	181	0	380	0	1	0.4763	0	0.5583	0	0.522	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	1.2.5.b	Controlling Blood Pressure	291	0	441	0	0	0.6599	0	0.6888	0	0.6903	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	168	0	190	0	1	0.8842	0	0.8571	0	0.8631	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	1.2.8	Prevention Quality Overall Composite #90	709	0	23422	0	1	0.0303	0	0.0362	0	0	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	131	0	327	0	0	0.4006	0	0.6576	0	0.675	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	1.3.2	DHCS All-Cause Readmissions	66	0	382	0	0	0.1728	0	None	4	0.129	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	1.3.3	Influenza Immunization	55	0	357	0	0	0.1541	0	0.0506	0	0.24	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	1.3.4	Post Procedure ED Visits	877	0	17895	0	1	0.049	0	0.0278	0	0	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	1.3.5	Request for Specialty Care Expertise Turnaround Time	89	0	363	0	1	0.2452	0	0.2186	0	0	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	27	0	1584	0	1	0.017	0	0	0	0	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	1.3.7	Tobacco Assessment and Counseling	321	0	370	0	1	0.8676	0	0.8222	0	0.8362	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	1.5.1.b	Controlling Blood Pressure	291	0	441	0	0	0.6599	0	0.6888	0	0.6903	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	168	0	190	0	1	0.8842	0	0.8571	0	0.8631	770243.9
DY13	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	291	0	373	0	1	0.7802	0	0.2108	0	0.28	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	1.5.4.t	Tobacco Assessment and Counseling	389	0	434	0	1	0.8963	0	0.7696	0	0.7888	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	2.2.1	DHCS All-Cause Readmissions	769	0	4120	0	0	0.1867	0	0.4988	0	0.1745	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	2.2.2	H-CAHPS: Care Transition Metrics (3)	4880	0	10000	0	0	0.488	0	0.5071	0	0.5174	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	2.2.3	Medication Reconciliation – 30 days	172	0	206	0	1	0.835	0	0.144	0	0.2286	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	2.2.4	Reconciled Medication List Received by Discharged Patients	49	0	416	0	1	0.1178	0	0	0	0.099	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	2.2.5	Timely Transmission of Transition Record	None	1	399	0	0	None	1	0	0	0.099	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	2.3.2	Medication Reconciliation – 30 days	98	0	120	0	1	0.8167	0	0.4107	0	0.4686	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	2.3.3	Prevention Quality Overall Composite #90	200	0	1216	0	1	0.1645	0	0.2723	0	0	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	2.3.4	Timely Transmission of Transition Record	None	1	341	0	0	None	1	0	0	0.099	770243.9
DY13	DMPH	Kaweah Delta Health Care District, Visalia	2.6.1	Alcohol and Drug Misuse (SBIRT)	177	0	369	0	1	0.4797	0	0	0	0	770243.91
DY13	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	61	0	222	0	1	0.2748	0	0.1111	0	0	770243.91
DY13	DMPH	Kaweah Delta Health Care District, Visalia	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	70	0	222	0	1	0.3153	0	0	0	0	770243.91
DY13	DMPH	Kaweah Delta Health Care District, Visalia	2.6.4	Screening for Clinical Depression and follow-up	221	0	305	0	1	0.7246	0	None	1	0.1814	770243.91
DY13	DMPH	Kaweah Delta Health Care District, Visalia	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	129	0	372	0	1	0.3468	0	0	0	0	770243.91
DY13	DMPH	Kaweah Delta Health Care District, Visalia	2.7.1	Advance Care Plan	68	0	368	0	1	0.1848	0	None	1	0.1136	770243.91
DY13	DMPH	Kaweah Delta Health Care District, Visalia	2.7.2	Ambulatory Palliative Care Team Established: Ambulatory Palliative Care Team Established? Yes	Yes	0	Team Established?	0	1	None	0	None	None	None	770243.91
DY13	DMPH	Kaweah Delta Health Care District, Visalia	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	245	0	265	0	1	0.9245	0	0.6519	0	0.6647	770243.91
DY13	DMPH	Kaweah Delta Health Care District, Visalia	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	19	0	None	4	0	None	4	0	0	0	0
DY13	DMPH	Kaweah Delta Health Care District, Visalia	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	229	0	582	0	1	0.3935	0	0.1818	0	0	770243.91
DY13	DMPH	Kaweah Delta Health Care District, Visalia	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	23	0	106	0	0	0.217	0	None	1	0.1286	770243.91
DY13	DPH	Kern Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT)	5604	0	9826	0	1	0.5703	0	0.4312	0	0	1174340.75
DY13	DPH	Kern Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	583	0	2125	0	1	0.2744	0	0.2938	0	0.2938	1174340.75
DY13	DPH	Kern Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	3596	0	6496	0	1	0.5536	0	0.4798	0	0.5164	1174340.74
DY13	DPH	Kern Medical Center	1.1.6.t	Tobacco Assessment and Counseling	6789	0	7099	0	1	0.9563	0	0.888	0	0.8954	1174340.74
DY13	DPH	Kern Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	63	0	308	0	1	0.204545455	0	None	None	None	391446.9133
DY13	DPH	Kern Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	15	0	308	0	1	0.048701299	0	None	None	None	391446.9133
DY13	DPH	Kern Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	24	0	308	0	1	0.077922078	0	None	None	None	391446.9133
DY13	DPH	Kern Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT)	5604	0	9826	0	1	0.5703	0	0.4312	0	0	1174340.74
DY13	DPH	Kern Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	87	0	104	0	1	0.8365	0	None	None	0.7438	1174340.74
DY13	DPH	Kern Medical Center	1.2.11	REAL data completeness	7904	0	13618	0	1	0.5804	0	0.2809	0	None	1174340.74
DY13	DPH	Kern Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	3596	0	6496	0	1	0.5536	0	0.4798	0	0.5164	1174340.74
DY13	DPH	Kern Medical Center	1.2.13	SO/GI data completeness	2048	0	7468	0	1	0.2742	0	None	1	None	1174340.74
DY13	DPH	Kern Medical Center	1.2.14.t	Tobacco Assessment and Counseling	6789	0	7099	0	1	0.9563	0	0.888	0	0.8954	1174340.74
DY13	DPH	Kern Medical Center	1.2.2	CG-CAHPS: Provider Rating	145	0	200	0	1	0.725	0	0.6528	0	0.659	1174340.74
DY13	DPH	Kern Medical Center	1.2.3.c	Colorectal Cancer Screening	2224	0	3325	0	1	0.6689	0	0.6435	0	0.6449	1174340.74
DY13	DPH	Kern Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	583	0	2125	0	1	0.2744	0	0.2938	0	0.2938	1174340.74
DY13	DPH	Kern Medical Center	1.2.5.b	Controlling Blood Pressure	1943	0	2825	0	1	0.6878	0	0.6195	0	0.628	1174340.74
DY13	DPH	Kern Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	383	0	459	0	1	0.8344	0	0.7261	0	0.7452	1174340.74
DY13	DPH	Kern Medical Center	1.2.8	Prevention Quality Overall Composite #90	125	0	12343	0	1	0.0101	0	0.0099	0	0	1174340.74
DY13	DPH	Kern Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	19820	0	19820	0	1	1	0	1	0	0.832	1174340.74
DY13	DPH	Kern Medical Center	1.3.2	DHCS All-Cause Readmissions	21	0	274	0	1	0.0766	0	0.0891	0	0.129	1174340.74
DY13	DPH	Kern Medical Center	1.3.3	Influenza Immunization	1693	0	2876	0	1	0.5887	0	0.541	0	0.5509	1174340.74
DY13	DPH	Kern Medical Center	1.3.4	Post Procedure ED Visits	521	0	14881	0	1	0.035	0	0.0217	0	0	1174340.74
DY13	DPH	Kern Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	17071	0	120009	0	1	0.1422	0	None	1	0	1174340.74
DY13	DPH	Kern Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	21	0	94089	0	1	0.0002	0	None	1	0	1174340.74
DY13	DPH	Kern Medical Center	1.3.7	Tobacco Assessment and Counseling	2757	0	2854	0	1	0.966	0	0.8976	0	0.904	1174340.74
DY13	DPH	Kern Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	2183	0	2504	0	1	0.871805112	0	0.8859	0	None	391446.9133
DY13	DPH	Kern Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	29	0	76	0	1	0.381578947	0	0.4853	0	None	391446.9133
DY13	DPH	Kern Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	460	0	1080	0	1	0.425925926	0	0.4707	0	None	391446.9133
DY13	DPH	Kern Medical Center	1.4.2	Annual Monitoring for Patients on Persistent Medications	3467	0	3877	0	1	0.8942	0	0.8607	0	0.8668	1174340.74
DY13	DPH	Kern Medical Center	1.4.3	INR Monitoring for Individuals on Warfarin	76	0	89	0	1	0.8539	0	0.6602	0	0.6732	1174340.74
DY13	DPH	Kern Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation No	No	0	BFUSA Cert?	0	0	see specification	0	None	None	None	576494.55
DY13	DPH	Kern Medical Center	2.1.1	Baby Friendly Hospital designation: Development Phase Complete Yes	Yes	0	Development Phase?	0	1	see specification	0	None	None	None	576494.55
DY13	DPH	Kern Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	428	0	815	0	0.5	0.5252	0	0.5074	0	0.5346	1152989.1
DY13	DPH	Kern Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	1069	0	1	None	1	None	1	0	1152989.09
DY13	DPH	Kern Medical Center	2.1.4	OB Hemorrhage: Total Products Transfused	130	0	1069	0	1	0.1216	0	0.1245	0	0	1152989.09
DY13	DPH	Kern Medical Center	2.1.5	PC-02 Cesarean Section	41	0	229	0	1	0.179	0	0.1792	0	0.22	1152989.09
DY13	DPH	Kern Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	734	0	980	0	1	0.748979592	0	0.7297	0	0.7477	576494.545
DY13	DPH	Kern Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	643	0	980	0	1	0.656122449	0	0.4706	0	0.5547	576494.545
DY13	DPH	Kern Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	51	0	113	0	1	0.4513	0	0.4951	0	0	1152989.09
DY13	DPH	Kern Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	33	0	787	0	1	0.0419	0	0.0644	0	0	1152989.09
DY13	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	see specification	0	None	None	None	288247.2725
DY13	DPH	Kern Medical Center	2.1.9	OB Hemorrhage Safety Bundle: Please specify which elements have been completed in the textbox below No	0	0	0	0	0	see specification	0	None	None	None	288247.2725
DY13	DPH	Kern Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	0	0	0	0	0	see specification	0	None	None	None	288247.2725
DY13	DPH	Kern Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes	0	0	0	0	0	see specification	0	None	None	None	288247.2725
DY13	DPH	Kern Medical Center	2.2.1	DHCS All-Cause Readmissions	30	0	304	0	1	0.0987	0	0.0919	0	0.129	1152989.09
DY13	DPH	Kern Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	5233	0	10000	0	1	0.5233	0	0.4943	0	0.5059	1152989.09
DY13	DPH	Kern Medical Center	2.2.3	Medication Reconciliation – 30 days	330	0	762	0	1	0.4331	0	0.3258	0	0.3922	1152989.09
DY13	DPH	Kern Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	1315	0	1701	0	1	0.7731	0	0.6133	0	0.651	1152989.09
DY13	DPH	Kern Medical Center	2.2.5	Timely Transmission of Transition Record	940	0	1181	0	1	0.7959	0	0.6211	0	0.658	1152989.09
DY13	DPH	Kern Medical Center	2.3.2	Medication Reconciliation – 30 days	94	0	190	0	1	0.4947	0	0.4176	0	0.4748	1152989.09
DY13	DPH	Kern Medical Center	2.3.3	Prevention Quality Overall Composite #90	37	0	1142	0	1	0.0324	0	0.0271	0	0	1152989.09
DY13	DPH	Kern Medical Center	2.3.4	Timely Transmission of Transition Record	255	0	261	0	1	0.977	0	0.8486	0	0.8627	1152989.09
DY13	DPH	Kern Medical Center	2.5.1	Alcohol and Drug Misuse (SBIRT)	163	0	260	0	1	0.6269	0	0.4506	0	0	1152989.09
DY13	DPH	Kern Medical Center	2.5.2	Controlling Blood Pressure	39	0	54	0	1	0.7222	0	0.6923	0	0.6935	1152989.09
DY13	DPH	Kern Medical Center	2.5.3	Prevention Quality Overall Composite #90	None	1	511	0	1	None	1	None	1	0	1152989.09
DY13	DPH	Kern Medical Center	2.5.4	Screening for Clinical Depression and follow-up	113	0	203	0	1	0.5567	0	0.4348	0	0.4759	1152989.09
DY13	DPH	Kern Medical Center	2.5.5	Tobacco Assessment and Counseling	192	0	201	0	1	0.9552	0	0.9231	0	0.927	1152989.09
DY13	DPH	Kern Medical Center	3.2.1	Imaging for Routine Headaches (Choosing Wisely)	145	0	1818	0	1	0.0798	0	0.18	0	0.1766	1585360
DY13	DPH	Kern Medical Center	3.2.2	Appropriate Emergency Department Utilization of CT for Pulmonary Embolism	235	0	235	0	1	1	0	0.5714	0	0.5813	1585360
DY13	DPH	Kern Medical Center	3.2.3	Use of Imaging Studies for Low Back Pain	1181	0	1187	0	1	0.9949	0	0.8718	0	0.8141	1585360
DY13	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	637	0	1972	0	1	0.323022312	0	None	None	None	792680
DY13	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: Inappropriate Score	None	1	1972	0	1	None	1	None	None	None	792680
DY13	DMPH	Kern Valley Healthcare District, Lake Isabella	1.1.1.a	Alcohol and Drug Misuse (SBIRT)	415	0	819	0	1	0.5067	0	0.2796	0	0	300000
DY13	DMPH	Kern Valley Healthcare District, Lake Isabella	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	39	0	111	0	1	0.3514	0	0.4628	0	0.4459	300000
DY13	DMPH	Kern Valley Healthcare District, Lake Isabella	1.1.5.f	Screening for Clinical Depression and follow-up	282	0	608	0	1	0.4638	0	0.3506	0	0.4001	300000
DY13	DMPH	Kern Valley Healthcare District, Lake Isabella	1.1.6.t	Tobacco Assessment and Counseling	626	0	727	0	1	0.8611	0	0.5901	0	0.759	300000
DY13	DMPH	Kern Valley Healthcare District, Lake Isabella	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	24	0	52	0	1	0.461538462	0	None	None	None	100000
DY13	DMPH	Kern Valley Healthcare District, Lake Isabella	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	1	52	0	1	None	1	None	None	None	100000
DY13	DMPH	Kern Valley Healthcare District, Lake Isabella	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	1	52	0	1	None	1	None	None	None	100000
DY13	DMPH	Lompoc Valley Medical Center, Lompoc	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	322	0	542	0	1	0.5941	0	0.4555	0	0.4932	316666.66
DY13	DMPH	Lompoc Valley Medical Center, Lompoc	1.3.2	DHCS All-Cause Readmissions	None	1	183	0	1	None	1	None	1	0.129	316666.66
DY13	DMPH	Lompoc Valley Medical Center, Lompoc	1.3.3	Influenza Immunization	98	0	240	0	1	0.4083	0	0.3587	0	0.3868	316666.66
DY13	DMPH	Lompoc Valley Medical Center, Lompoc	1.3.4	Post Procedure ED Visits	99	0	3360	0	1	0.0295	0	0.0295	0	0	316666.66
DY13	DMPH	Lompoc Valley Medical Center, Lompoc	1.3.5	Request for Specialty Care Expertise Turnaround Time	290	0	542	0	1	0.5351	0	0.4555	0	0	316666.66
DY13	DMPH	Lompoc Valley Medical Center, Lompoc	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	156	0	698	0	1	0.2235	0	0	0	0	316666.66
DY13	DMPH	Lompoc Valley Medical Center, Lompoc	1.3.7	Tobacco Assessment and Counseling	205	0	241	0	1	0.8506	0	0.5405	0	0.759	316666.67
DY13	DMPH	Lompoc Valley Medical Center, Lompoc	1.5.1.b	Controlling Blood Pressure	88	0	117	0	1	0.7521	0	0.8351	0	0.7041	316666.67
DY13	DMPH	Lompoc Valley Medical Center, Lompoc	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	1	None	4	0	None	1	None	1	0.7022	0
DY13	DMPH	Lompoc Valley Medical Center, Lompoc	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	206	0	370	0	1	0.5568	0	0.5382	0	0.5444	316666.67
DY13	DMPH	Lompoc Valley Medical Center, Lompoc	1.5.4.t	Tobacco Assessment and Counseling	202	0	220	0	1	0.9182	0	0.5746	0	0.759	316666.67
DY13	DMPH	Lompoc Valley Medical Center, Lompoc	1.7.1	BMI Screening and Follow-up	131	0	197	0	1	0.665	0	0.2407	0	0.4249	316666.67
DY13	DMPH	Lompoc Valley Medical Center, Lompoc	1.7.2	Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Please specify which critera have been met in the textbox below. No	0	0	0	0	N/A	N/A - see narrative	0	N/A	0	None	158333.335
DY13	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 5)	5	0	8	0	1	see specification	0	N/A	0	None	158333.335
DY13	DMPH	Lompoc Valley Medical Center, Lompoc	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI	142	0	178	0	1	0.797752809	0	0.7388	0	0.7513	105555.5567
DY13	DMPH	Lompoc Valley Medical Center, Lompoc	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition	112	0	178	0	1	0.629213483	0	0.5461	0	0.571	105555.5567
DY13	DMPH	Lompoc Valley Medical Center, Lompoc	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity	100	0	178	0	1	0.561797753	0	0.5329	0	0.5512	105555.5567
DY13	DMPH	Lompoc Valley Medical Center, Lompoc	2.2.1	DHCS All-Cause Readmissions	56	0	530	0	1	0.1057	0	0.2481	0	0.1745	316666.67
DY13	DMPH	Lompoc Valley Medical Center, Lompoc	2.2.2	H-CAHPS: Care Transition Metrics (3)	412	0	911	0	0	0.4523	0	0.48	0	0.493	316666.67
DY13	DMPH	Lompoc Valley Medical Center, Lompoc	2.2.3	Medication Reconciliation – 30 days	36	0	36	0	1	1	0	None	1	0.339	316666.67
DY13	DMPH	Lompoc Valley Medical Center, Lompoc	2.2.4	Reconciled Medication List Received by Discharged Patients	530	0	748	0	1	0.7086	0	0.1396	0	0.2246	316666.67
DY13	DMPH	Lompoc Valley Medical Center, Lompoc	2.2.5	Timely Transmission of Transition Record	486	0	831	0	1	0.5848	0	0.5275	0	0.5738	316666.67
DY13	DPH	Los Angeles County Health System	1.1.1.a	Alcohol and Drug Misuse (SBIRT)	38	0	377	0	1	0.1008	0	0.0477	0	0	6391679.95
DY13	DPH	Los Angeles County Health System	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	8735	0	33840	0	1	0.2581	0	0.2738	0	0.2936	6391679.95
DY13	DPH	Los Angeles County Health System	1.1.5.f	Screening for Clinical Depression and follow-up	79377	0	95008	0	1	0.8355	0	0.7933	0	0.7985	6391679.95
DY13	DPH	Los Angeles County Health System	1.1.6.t	Tobacco Assessment and Counseling	94346	0	104121	0	1	0.9061	0	0.8748	0	0.8835	6391679.95
DY13	DPH	Los Angeles County Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	280	0	1223	0	1	0.228945217	0	None	None	None	2130559.983
DY13	DPH	Los Angeles County Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	45	0	1223	0	1	0.036794767	0	None	None	None	2130559.983
DY13	DPH	Los Angeles County Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	74	0	1223	0	1	0.06050695	0	None	None	None	2130559.983
DY13	DPH	Los Angeles County Health System	1.2.1.a	Alcohol and Drug Misuse (SBIRT)	38	0	377	0	1	0.1008	0	0.0477	0	0	6391679.95
DY13	DPH	Los Angeles County Health System	1.2.10	REAL and/or SO/GI disparity reduction	5105	0	8016	0	1	0.6369	0	None	None	0.5986	6391679.94
DY13	DPH	Los Angeles County Health System	1.2.11	REAL data completeness	126445	0	128660	0	1	0.9828	0	0.7267	0	None	6391679.94
DY13	DPH	Los Angeles County Health System	1.2.12.f	Screening for Clinical Depression and follow-up	79377	0	95008	0	1	0.8355	0	0.7933	0	0.7985	6391679.94
DY13	DPH	Los Angeles County Health System	1.2.13	SO/GI data completeness	70352	0	105752	0	1	0.6653	0	0	0	None	6391679.94
DY13	DPH	Los Angeles County Health System	1.2.14.t	Tobacco Assessment and Counseling	94346	0	104121	0	1	0.9061	0	0.8748	0	0.8835	6391679.94
DY13	DPH	Los Angeles County Health System	1.2.2	CG-CAHPS: Provider Rating	6048	0	8014	0	1	0.7547	0	0.7401	0	0.7148	6391679.95
DY13	DPH	Los Angeles County Health System	1.2.3.c	Colorectal Cancer Screening	43815	0	61279	0	1	0.715	0	0.6714	0	0.6571	6391679.95
DY13	DPH	Los Angeles County Health System	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	8856	0	34390	0	1	0.2575	0	0.2738	0	0.2936	6391679.95
DY13	DPH	Los Angeles County Health System	1.2.5.b	Controlling Blood Pressure	29578	0	40782	0	1	0.7253	0	0.6958	0	0.6966	6391679.95
DY13	DPH	Los Angeles County Health System	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	5596	0	6379	0	1	0.8773	0	0.8382	0	0.8435	6391679.94
DY13	DPH	Los Angeles County Health System	1.2.8	Prevention Quality Overall Composite #90	1645	0	217125	0	1	0.0076	0	0.006	0	0	6391679.94
DY13	DPH	Los Angeles County Health System	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	70542	0	88620	0	1	0.796	0	0.7352	0	0.7449	6391679.94
DY13	DPH	Los Angeles County Health System	1.3.2	DHCS All-Cause Readmissions	1166	0	8547	0	0	0.1364	0	0.1276	0	0.129	6391679.94
DY13	DPH	Los Angeles County Health System	1.3.3	Influenza Immunization	23713	0	35348	0	1	0.6708	0	0.5685	0	0.5757	6391679.94
DY13	DPH	Los Angeles County Health System	1.3.4	Post Procedure ED Visits	1287	0	57046	0	1	0.0226	0	0.0244	0	0	6391679.94
DY13	DPH	Los Angeles County Health System	1.3.5	Request for Specialty Care Expertise Turnaround Time	138616	0	171963	0	1	0.8061	0	0.8411	0	0	6391679.94
DY13	DPH	Los Angeles County Health System	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	44810	0	178235	0	1	0.2514	0	0.223	0	0	6391679.94
DY13	DPH	Los Angeles County Health System	1.3.7	Tobacco Assessment and Counseling	46163	0	49185	0	1	0.9386	0	0.9062	0	0.9118	6391679.94
DY13	DPH	Los Angeles County Health System	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	96548	0	101392	0	1	0.952225028	0	0.95	0	None	2130559.98
DY13	DPH	Los Angeles County Health System	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	35599	0	37695	0	1	0.944395808	0	0.935	0	None	2130559.98
DY13	DPH	Los Angeles County Health System	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	12085	0	20008	0	1	0.604008397	0	0.6446	0	None	2130559.98
DY13	DPH	Los Angeles County Health System	1.4.2	Annual Monitoring for Patients on Persistent Medications	49741	0	53083	0	1	0.937	0	0.9329	0	0.9213	6391679.94
DY13	DPH	Los Angeles County Health System	1.4.3	INR Monitoring for Individuals on Warfarin	1518	0	1675	0	1	0.9063	0	0.8837	0	0.79	6391679.94
DY13	DPH	Los Angeles County Health System	1.6.1	BIRADS to Biopsy	268	0	640	0	1	0.4188	0	0.4761	0	0	6391679.94
DY13	DPH	Los Angeles County Health System	1.6.2	Breast Cancer Screening	32222	0	45377	0	1	0.7101	0	0.6863	0	0.6891	6391679.94
DY13	DPH	Los Angeles County Health System	1.6.3	Cervical Cancer Screening	40837	0	78901	0	1	0.5176	0	0.4763	0	0.4985	6391679.94
DY13	DPH	Los Angeles County Health System	1.6.4.c	Colorectal Cancer Screening	43815	0	61279	0	1	0.715	0	0.6714	0	0.6571	6391679.94
DY13	DPH	Los Angeles County Health System	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	440	0	1158	0	1	0.38	0	0.344	0	0	6391679.94
DY13	DPH	Los Angeles County Health System	1.7.1	BMI Screening and Follow-up	96112	0	109098	0	1	0.881	0	0.5259	0	0.6002	6391679.94
DY13	DPH	Los Angeles County Health System	1.7.2	Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Please specify which critera have been met in the textbox below. No	0	0	0	0	N/A	N/A - see narrative	0	N/A	0	None	3195839.97
DY13	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 5)	33	0	40	0	1	see specification	0	N/A	0	None	3195839.97
DY13	DPH	Los Angeles County Health System	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI	17118	0	18141	0	1	0.943608401	0	0.9526	0	0.8637	2130559.98
DY13	DPH	Los Angeles County Health System	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition	14543	0	18141	0	1	0.801664737	0	0.6771	0	0.6889	2130559.98
DY13	DPH	Los Angeles County Health System	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity	13837	0	18141	0	1	0.762747368	0	0.6581	0	0.6639	2130559.98
DY13	DPH	Los Angeles County Health System	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	None	0	None	None	None	3195839.985
DY13	DPH	Los Angeles County Health System	2.1.1	Baby Friendly Hospital designation: Development Phase Complete Yes	Yes	0	Development Phase?	0	1	see specification	0	None	None	None	3195839.985
DY13	DPH	Los Angeles County Health System	2.1.2	Exclusive Breast Milk Feeding (PC-05)	723	0	1174	0	1	0.6158	0	0.5028	0	0.5304	6391679.97
DY13	DPH	Los Angeles County Health System	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	1844	0	1	None	1	0.0114	0	0	6391679.97
DY13	DPH	Los Angeles County Health System	2.1.4	OB Hemorrhage: Total Products Transfused	207	0	1844	0	1	0.1123	0	0.1687	0	0	6391679.97
DY13	DPH	Los Angeles County Health System	2.1.5	PC-02 Cesarean Section	141	0	678	0	1	0.208	0	0.2409	0	0.2388	6391679.97
DY13	DPH	Los Angeles County Health System	2.1.6	Prenatal and Postpartum Care: Prenatal Care	1598	0	1816	0	1	0.879955947	0	0.8648	0	0.8693	3195839.985
DY13	DPH	Los Angeles County Health System	2.1.6	Prenatal and Postpartum Care: Postpartum Care	1223	0	1816	0	1	0.67345815	0	0.5757	0	0.5917	3195839.985
DY13	DPH	Los Angeles County Health System	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	100	0	299	0	1	0.3344	0	0.3991	0	0	6391679.97
DY13	DPH	Los Angeles County Health System	2.1.8	Unexpected Newborn Complications (UNC)	102	0	1284	0	1	0.0794	0	0.0967	0	0	6391679.97
DY13	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	see specification	0	None	None	None	1597919.993
DY13	DPH	Los Angeles County Health System	2.1.9	OB Hemorrhage Safety Bundle: Please specify which elements have been completed in the textbox below No	0	0	0	0	0	see specification	0	None	None	None	1597919.993
DY13	DPH	Los Angeles County Health System	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	0	0	0	0	0	see specification	0	None	None	None	1597919.993
DY13	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	0	0	0	0	0	see specification	0	None	None	None	1597919.993
DY13	DPH	Los Angeles County Health System	2.2.1	DHCS All-Cause Readmissions	1254	0	9266	0	0	0.1353	0	0.1261	0	0.129	6391679.97
DY13	DPH	Los Angeles County Health System	2.2.2	H-CAHPS: Care Transition Metrics (3)	4249	0	7430	0	0	0.5719	0	0.5751	0	0.5786	6391679.97
DY13	DPH	Los Angeles County Health System	2.2.3	Medication Reconciliation – 30 days	5973	0	9550	0	1	0.6254	0	0.5463	0	0.5907	6391679.97
DY13	DPH	Los Angeles County Health System	2.2.4	Reconciled Medication List Received by Discharged Patients	309	0	378	0	1	0.8175	0	0.7772	0	0.7985	6391679.96
DY13	DPH	Los Angeles County Health System	2.2.5	Timely Transmission of Transition Record	8696	0	13441	0	1	0.647	0	0.1931	0	0.2728	6391679.96
DY13	DPH	Los Angeles County Health System	2.3.2	Medication Reconciliation – 30 days	4678	0	7135	0	1	0.6556	0	0.5794	0	0.6205	6391679.96
DY13	DPH	Los Angeles County Health System	2.3.3	Prevention Quality Overall Composite #90	1412	0	62958	0	1	0.0224	0	0.0184	0	0	6391679.96
DY13	DPH	Los Angeles County Health System	2.3.4	Timely Transmission of Transition Record	6446	0	9674	0	1	0.6663	0	0.1961	0	0.2755	6391679.96
DY13	DPH	Los Angeles County Health System	2.5.1	Alcohol and Drug Misuse (SBIRT)	44	0	235	0	1	0.1872	0	0.0423	0	0	6391679.96
DY13	DPH	Los Angeles County Health System	2.5.2	Controlling Blood Pressure	67	0	118	0	0	0.5678	0	0.6215	0	0.6298	6391679.96
DY13	DPH	Los Angeles County Health System	2.5.3	Prevention Quality Overall Composite #90	27	0	832	0	1	0.0325	0	0.0308	0	0	6391679.96
DY13	DPH	Los Angeles County Health System	2.5.4	Screening for Clinical Depression and follow-up	294	0	423	0	1	0.695	0	0.6538	0	0.673	6391679.96
DY13	DPH	Los Angeles County Health System	2.5.5	Tobacco Assessment and Counseling	322	0	482	0	0	0.668	0	0.7925	0	0.8094	6391679.96
DY13	DPH	Los Angeles County Health System	2.7.1	Advance Care Plan	16799	0	16924	0	1	0.9926	0	0.9888	0	0.9889	6391679.96
DY13	DPH	Los Angeles County Health System	2.7.2	Ambulatory Palliative Care Team Established: Ambulatory Palliative Care Team Established? Yes	Yes	0	Team Established?	0	1	None	0	None	None	None	6391679.96
DY13	DPH	Los Angeles County Health System	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	53	0	65	0	1	0.8154	0	0.7913	0	0.78	6391679.96
DY13	DPH	Los Angeles County Health System	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	72	0	78	0	1	0.9231	0	0.7007	0	0	6391679.96
DY13	DPH	Los Angeles County Health System	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	56	0	157	0	1	0.3567	0	0.4461	0	0	6391679.96
DY13	DPH	Los Angeles County Health System	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	13	0	116	0	1	0.1121	0	0.1451	0	0.1306	6391679.96
DY13	DPH	Los Angeles County Health System	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	224	0	437	0	1	0.5126	0	0.4147	0	0.3081	6391680.43
DY13	DPH	Los Angeles County Health System	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	52270	0	503390	0	1	0.1038	0	0.2053	0	0	6391680.43
DY13	DPH	Los Angeles County Health System	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	78	0	377	0	1	0.2069	0	0.7374	0	0	6391680.43
DY13	DPH	Los Angeles County Health System	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR No	7142	0	10000	0	1	0.7142	0	None	None	None	6391680.43
DY13	DPH	Los Angeles County Health System	3.3.1	Adherence to Medications: Rate 1	71	0	89	0	1	0.797752809	0	0.8079	0	None	3195840.215
DY13	DPH	Los Angeles County Health System	3.3.1	Adherence to Medications: Rate 2	109	0	146	0	N/A	0.746575342	0	0.8079	0	None	3195840.215
DY13	DPH	Los Angeles County Health System	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 1	22	0	103	0	1	0.213592233	0	0.349	0	None	3195840.215
DY13	DPH	Los Angeles County Health System	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 2	22	0	173	0	N/A	0.12716763	0	0.349	0	None	3195840.215
DY13	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	414	0	1100	0	1	0.376363636	0	0.3341	0	None	3195840.21
DY13	DPH	Los Angeles County Health System	3.3.4	Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 2	666	0	1990	0	N/A	0.334673367	0	0.3341	0	None	3195840.21
DY13	DMPH	Mammoth Hospital, Mammoth Lakes	1.1.1.a	Alcohol and Drug Misuse (SBIRT)	219	0	1052	0	1	0.2082	0	0.0899	0	0	232000
DY13	DMPH	Mammoth Hospital, Mammoth Lakes	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	13	0	58	0	1	0.2241	0	0.2667	0	0.2936	232000
DY13	DMPH	Mammoth Hospital, Mammoth Lakes	1.1.5.f	Screening for Clinical Depression and follow-up	178	0	631	0	1	0.2821	0	0.1259	0	0.1979	232000
DY13	DMPH	Mammoth Hospital, Mammoth Lakes	1.1.6.t	Tobacco Assessment and Counseling	234	0	300	0	1	0.78	0	0.1316	0	0.759	232000
DY13	DMPH	Mammoth Hospital, Mammoth Lakes	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	22	0	63	0	1	0.349206349	0	None	None	None	77333.33333
DY13	DMPH	Mammoth Hospital, Mammoth Lakes	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	1	63	0	1	None	1	None	None	None	77333.33333
DY13	DMPH	Mammoth Hospital, Mammoth Lakes	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	11	0	63	0	1	0.174603175	0	None	None	None	77333.33333
DY13	DMPH	Mammoth Hospital, Mammoth Lakes	2.6.1	Alcohol and Drug Misuse (SBIRT)	46	0	68	0	1	0.6765	0	0.5745	0	0	232000
DY13	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	None	1	33	0	1	None	1	None	1	0	232000
DY13	DMPH	Mammoth Hospital, Mammoth Lakes	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	19	0	33	0	1	0.5758	0	None	1	0	232000
DY13	DMPH	Mammoth Hospital, Mammoth Lakes	2.6.4	Screening for Clinical Depression and follow-up	30	0	41	0	1	0.7317	0	0.6	0	0.6245	232000
DY13	DMPH	Mammoth Hospital, Mammoth Lakes	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	68	0	68	0	1	1	0	0.8723	0	0	232000
DY13	DMPH	Marin General Hospital, Greenbrae	2.3.2	Medication Reconciliation – 30 days	248	0	337	0	1	0.7359	0	0	0	0.099	348571.43
DY13	DMPH	Marin General Hospital, Greenbrae	2.3.3	Prevention Quality Overall Composite #90	133	0	1722	0	1	0.0772	0	0.1028	0	0	348571.43
DY13	DMPH	Marin General Hospital, Greenbrae	2.3.4	Timely Transmission of Transition Record	35	0	330	0	1	0.1061	0	0	0	0.099	348571.43
DY13	DMPH	Marin General Hospital, Greenbrae	2.7.1	Advance Care Plan	246	0	284	0	1	0.8662	0	0	0	0.099	348571.43
DY13	DMPH	Marin General Hospital, Greenbrae	2.7.2	Ambulatory Palliative Care Team Established: Ambulatory Palliative Care Team Established? Yes	Yes	0	Team Established?	0	1	None	0	None	None	None	348571.43
DY13	DMPH	Marin General Hospital, Greenbrae	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	99	0	99	0	1	1	0	0	0	0.45	348571.43
DY13	DMPH	Marin General Hospital, Greenbrae	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	None	1	None	4	0	None	1	0	0	0	0
DY13	DMPH	Marin General Hospital, Greenbrae	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	77	0	427	0	1	0.1803	0	0	0	0	348571.42
DY13	DMPH	Marin General Hospital, Greenbrae	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	0	0	None	4	0	None	4	0	0	0	0
DY13	DMPH	Mayers Memorial Hospital District, Fall River Mills	1.7.1	BMI Screening and Follow-up	0	0	None	1	0	None	1	None	None	0	0
DY13	DMPH	Mayers Memorial Hospital District, Fall River Mills	1.7.2	Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Please specify which critera have been met in the textbox below. No	0	0	0	0	N/A	N/A - see narrative	0	N/A	0	None	750000
DY13	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 5)	5	0	8	0	1	see specification	0	N/A	0	None	750000
DY13	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	None	None	0.545	0
DY13	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	None	None	0.5184	0
DY13	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	None	None	0.4509	0
DY13	DMPH	Mendocino Coast District Hospital, Fort Bragg	1.6.1	BIRADS to Biopsy	None	1	None	1	0	None	1	None	1	0	0
DY13	DMPH	Mendocino Coast District Hospital, Fort Bragg	1.6.2	Breast Cancer Screening	253	0	466	0	1	0.5429	0	0.4514	0	0.5228	500000
DY13	DMPH	Mendocino Coast District Hospital, Fort Bragg	1.6.3	Cervical Cancer Screening	188	0	891	0	0	0.211	0	0.1239	0	0.4834	500000
DY13	DMPH	Mendocino Coast District Hospital, Fort Bragg	1.6.4.c	Colorectal Cancer Screening	426	0	1005	0	1	0.4239	0	0.3777	0	0.4056	500000
DY13	DMPH	Mendocino Coast District Hospital, Fort Bragg	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	0	0	None	1	0	None	1	None	1	0	0
DY13	DMPH	Modoc Medical Center, Alturas	1.2.1.a	Alcohol and Drug Misuse (SBIRT)	11	0	695	0	1	0.0158	0	0	0	0	125000
DY13	DMPH	Modoc Medical Center, Alturas	1.2.10	REAL and/or SO/GI disparity reduction	None	1	None	4	0	None	1	None	None	0.5204	125000
DY13	DMPH	Modoc Medical Center, Alturas	1.2.11	REAL data completeness	865	0	870	0	1	0.9943	0	0.9422	0	None	125000
DY13	DMPH	Modoc Medical Center, Alturas	1.2.12.f	Screening for Clinical Depression and follow-up	460	0	671	0	1	0.6855	0	0.4	0	0.4445	125000
DY13	DMPH	Modoc Medical Center, Alturas	1.2.13	SO/GI data completeness	870	0	870	0	1	1	0	0	0	None	125000
DY13	DMPH	Modoc Medical Center, Alturas	1.2.14.t	Tobacco Assessment and Counseling	650	0	671	0	1	0.9687	0	0.9839	0	0.9619	125000
DY13	DMPH	Modoc Medical Center, Alturas	1.2.2	CG-CAHPS: Provider Rating	189	0	228	0	1	0.8289	0	0.7556	0	0.7148	125000
DY13	DMPH	Modoc Medical Center, Alturas	1.2.3.c	Colorectal Cancer Screening	101	0	255	0	1	0.3961	0	0.2839	0	0.3212	125000
DY13	DMPH	Modoc Medical Center, Alturas	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	50	0	76	0	0	0.6579	0	0.3143	0	0.3122	125000
DY13	DMPH	Modoc Medical Center, Alturas	1.2.5.b	Controlling Blood Pressure	115	0	213	0	1	0.5399	0	0.5211	0	0.5394	125000
DY13	DMPH	Modoc Medical Center, Alturas	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	25	0	None	4	0	None	4	None	4	0.9173	125000
DY13	DMPH	Modoc Medical Center, Alturas	1.2.8	Prevention Quality Overall Composite #90	12	0	671	0	1	0.0179	0	0.042	0	0	125000
DY13	DPH	Natividad Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT)	575	0	6713	0	1	0.0857	0	0.0699	0	0	567850
DY13	DPH	Natividad Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	372	0	1024	0	1	0.3633	0	0.3953	0	0.3851	567850
DY13	DPH	Natividad Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	2961	0	4084	0	1	0.725	0	0.6494	0	0.669	567850
DY13	DPH	Natividad Medical Center	1.1.6.t	Tobacco Assessment and Counseling	5103	0	5274	0	1	0.9676	0	0.9678	0	0.9619	567850
DY13	DPH	Natividad Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	18	0	93	0	1	0.193548387	0	None	None	None	189283.3333
DY13	DPH	Natividad Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	1	93	0	1	None	1	None	None	None	189283.3333
DY13	DPH	Natividad Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	1	93	0	1	None	1	None	None	None	189283.3333
DY13	DPH	Natividad Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT)	575	0	6713	0	1	0.0857	0	0.5758	0	0	567850
DY13	DPH	Natividad Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	500	0	761	0	1	0.657	0	None	None	0.5465	567850
DY13	DPH	Natividad Medical Center	1.2.11	REAL data completeness	8286	0	9338	0	1	0.8873	0	0.8912	0	None	567850
DY13	DPH	Natividad Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	2961	0	4084	0	1	0.725	0	0.6494	0	0.669	567850
DY13	DPH	Natividad Medical Center	1.2.13	SO/GI data completeness	5853	0	6370	0	1	0.9188	0	0.5475	0	None	567850
DY13	DPH	Natividad Medical Center	1.2.14.t	Tobacco Assessment and Counseling	5103	0	5274	0	1	0.9676	0	0.9678	0	0.9619	567850
DY13	DPH	Natividad Medical Center	1.2.2	CG-CAHPS: Provider Rating	7587	0	10000	0	1	0.7587	0	0.7108	0	0.7112	567850
DY13	DPH	Natividad Medical Center	1.2.3.c	Colorectal Cancer Screening	1175	0	1706	0	1	0.6887	0	0.5835	0	0.5909	567850
DY13	DPH	Natividad Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	372	0	1024	0	1	0.3633	0	0.3953	0	0.3851	567850
DY13	DPH	Natividad Medical Center	1.2.5.b	Controlling Blood Pressure	1212	0	1663	0	1	0.7288	0	0.6906	0	0.692	567850
DY13	DPH	Natividad Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	212	0	232	0	1	0.9138	0	0.8964	0	0.8998	567850
DY13	DPH	Natividad Medical Center	1.2.8	Prevention Quality Overall Composite #90	71	0	7436	0	1	0.0095	0	0.0072	0	0	567850
DY13	DPH	Natividad Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	2114	0	2257	0	1	0.9366	0	0.9319	0	0.832	567850
DY13	DPH	Natividad Medical Center	1.3.2	DHCS All-Cause Readmissions	36	0	243	0	0	0.1481	0	0.1	0	0.129	567850
DY13	DPH	Natividad Medical Center	1.3.3	Influenza Immunization	543	0	882	0	1	0.6156	0	0.5327	0	0.5434	567850
DY13	DPH	Natividad Medical Center	1.3.4	Post Procedure ED Visits	113	0	5660	0	1	0.02	0	0.0262	0	0	567850
DY13	DPH	Natividad Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	2102	0	8756	0	1	0.2401	0	0.234	0	0	567850
DY13	DPH	Natividad Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	20	0	4429	0	1	0.0045	0	None	1	0	567850
DY13	DPH	Natividad Medical Center	1.3.7	Tobacco Assessment and Counseling	1244	0	1273	0	1	0.9772	0	0.9711	0	0.9619	567850
DY13	DPH	Natividad Medical Center	1.5.1.b	Controlling Blood Pressure	1212	0	1663	0	1	0.7288	0	0.6906	0	0.692	567850
DY13	DPH	Natividad Medical Center	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	212	0	232	0	1	0.9138	0	0.8964	0	0.8998	567850
DY13	DPH	Natividad Medical Center	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	3544	0	3959	0	1	0.8952	0	0.4937	0	0.5043	567850
DY13	DPH	Natividad Medical Center	1.5.4.t	Tobacco Assessment and Counseling	5103	0	5274	0	1	0.9676	0	0.9678	0	0.9619	567850
DY13	DPH	Natividad Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	None	0	None	None	None	289087.275
DY13	DPH	Natividad Medical Center	2.1.1	Baby Friendly Hospital designation: Development Phase Complete No	No	0	Development Phase?	0	0	see specification	0	None	None	None	289087.275
DY13	DPH	Natividad Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	317	0	667	0	0	0.4753	0	0.5241	0	0.5496	578174.55
DY13	DPH	Natividad Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	0	0	742	0	1	0	0	0	0	0	578174.55
DY13	DPH	Natividad Medical Center	2.1.4	OB Hemorrhage: Total Products Transfused	None	1	742	0	1	None	1	None	1	0	578174.55
DY13	DPH	Natividad Medical Center	2.1.5	PC-02 Cesarean Section	32	0	138	0	0	0.2319	0	0.197	0	0.22	578174.55
DY13	DPH	Natividad Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	551	0	559	0	1	0.98568873	0	0.4322	0	0.7421	289087.275
DY13	DPH	Natividad Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	462	0	559	0	1	0.82647585	0	0.7693	0	0.7361	289087.275
DY13	DPH	Natividad Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	1	80	0	1	None	1	0.1667	0	0	578174.55
DY13	DPH	Natividad Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	28	0	632	0	1	0.0443	0	0.0873	0	0	578174.55
DY13	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	1	see specification	0	None	None	None	144543.6375
DY13	DPH	Natividad Medical Center	2.1.9	OB Hemorrhage Safety Bundle: Please specify which elements have been completed in the textbox below No	0	0	0	0	0	see specification	0	None	None	None	144543.6375
DY13	DPH	Natividad Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter No	0	0	0	0	0	see specification	0	None	None	None	144543.6375
DY13	DPH	Natividad Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes	0	0	0	0	0	see specification	0	None	None	None	144543.6375
DY13	DPH	Natividad Medical Center	2.2.1	DHCS All-Cause Readmissions	41	0	434	0	1	0.0945	0	0.0748	0	0.129	578174.55
DY13	DPH	Natividad Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	3841	0	10000	0	0	0.3841	0	0.4571	0	0.48	578174.55
DY13	DPH	Natividad Medical Center	2.2.3	Medication Reconciliation – 30 days	281	0	337	0	1	0.8338	0	0.644	0	0.6786	578174.55
DY13	DPH	Natividad Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	460	0	468	0	1	0.9829	0	0.8986	0	0.9077	578174.54
DY13	DPH	Natividad Medical Center	2.2.5	Timely Transmission of Transition Record	458	0	465	0	1	0.9849	0	0.8979	0	0.9071	578174.54
DY13	DPH	Natividad Medical Center	2.3.2	Medication Reconciliation – 30 days	46	0	48	0	1	0.9583	0	0.9167	0	0.924	578174.54
DY13	DPH	Natividad Medical Center	2.3.3	Prevention Quality Overall Composite #90	23	0	181	0	1	0.1271	0	0.1006	0	0	578174.54
DY13	DPH	Natividad Medical Center	2.3.4	Timely Transmission of Transition Record	80	0	82	0	1	0.9756	0	0.8592	0	0.8723	578174.54
DY13	DPH	Natividad Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT)	20	0	310	0	1	0.0645	0	0.6722	0	0	578174.54
DY13	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	80	0	226	0	1	0.354	0	0.2595	0	0	578174.54
DY13	DPH	Natividad Medical Center	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	95	0	190	0	1	0.5	0	0.2982	0	0	578174.54
DY13	DPH	Natividad Medical Center	2.6.4	Screening for Clinical Depression and follow-up	82	0	110	0	1	0.7455	0	0.6732	0	0.6904	578174.54
DY13	DPH	Natividad Medical Center	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	295	0	322	0	1	0.9161	0	0.8871	0	0	578174.54
DY13	DPH	Natividad Medical Center	3.4.1	ePBM-01 Pre-op Anemia Screening, Selected Elective Surgical Patients	45	0	102	0	1	0.4412	0	0.1133	0	0.192	794990
DY13	DPH	Natividad Medical Center	3.4.2	ePBM-02 Pre-op Hemoglobin Level, Selected Elective Surgical Patients	None	1	None	1	0	None	1	None	1	0	0
DY13	DPH	Natividad Medical Center	3.4.3	ePBM-03 Pre-op Type and Crossmatch, Type and Screen, Selected elective Surgical Patients	38	0	49	0	1	0.7755	0	0.6374	0	0.6637	794990
DY13	DPH	Natividad Medical Center	3.4.4	ePBM-04 Initial Transfusion Threshold	189	0	190	0	1	0.9947	0	1	0	0	794990
DY13	DPH	Natividad Medical Center	3.4.5	ePBM-05 Outcome of Patient Blood Management, Selected Elective Surgical Patients	None	1	45	0	1	None	1	None	1	0	794990
DY13	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	4	0.387	0
DY13	DMPH	Northern Inyo Hospital, Bishop	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	15	0	149	0	1	0.1007	0	0.0936	0	0	3960000
DY13	DMPH	Northern Inyo Hospital, Bishop	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	None	1	None	1	0	None	1	None	1	0	0
DY13	DMPH	Northern Inyo Hospital, Bishop	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR No	0	0	0	0	None	None	0	None	None	None	0
DY13	DMPH	Oak Valley Hospital District, Oakdale	1.2.1.a	Alcohol and Drug Misuse (SBIRT)	1623	0	5323	0	1	0.3049	0	0.0268	0	0	254285.71
DY13	DMPH	Oak Valley Hospital District, Oakdale	1.2.10	REAL and/or SO/GI disparity reduction	74	0	118	0	1	0.6271	0	None	None	0.5133	254285.71
DY13	DMPH	Oak Valley Hospital District, Oakdale	1.2.11	REAL data completeness	6967	0	7038	0	1	0.9899	0	0.9752	0	0.4	254285.72
DY13	DMPH	Oak Valley Hospital District, Oakdale	1.2.12.f	Screening for Clinical Depression and follow-up	2337	0	4513	0	1	0.5178	0	0.0561	0	0.1814	254285.72
DY13	DMPH	Oak Valley Hospital District, Oakdale	1.2.13	SO/GI data completeness	6324	0	7038	0	1	0.8986	0	0.7942	0	0.1	254285.72
DY13	DMPH	Oak Valley Hospital District, Oakdale	1.2.14.t	Tobacco Assessment and Counseling	3195	0	3570	0	1	0.895	0	0.8415	0	0.8535	254285.72
DY13	DMPH	Oak Valley Hospital District, Oakdale	1.2.2	CG-CAHPS: Provider Rating	233	0	316	0	1	0.7373	0	0.6619	0	0.6672	254285.71
DY13	DMPH	Oak Valley Hospital District, Oakdale	1.2.3.c	Colorectal Cancer Screening	575	0	1427	0	1	0.4029	0	0.35	0	0.3807	254285.71
DY13	DMPH	Oak Valley Hospital District, Oakdale	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	226	0	740	0	1	0.3054	0	0.7332	0	0.522	254285.71
DY13	DMPH	Oak Valley Hospital District, Oakdale	1.2.5.b	Controlling Blood Pressure	577	0	952	0	1	0.6061	0	0.5327	0	0.5498	254285.71
DY13	DMPH	Oak Valley Hospital District, Oakdale	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	122	0	168	0	1	0.7262	0	0.6308	0	0.7022	254285.71
DY13	DMPH	Oak Valley Hospital District, Oakdale	1.2.8	Prevention Quality Overall Composite #90	94	0	4407	0	1	0.0213	0	0.0161	0	0	254285.71
DY13	DMPH	Oak Valley Hospital District, Oakdale	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	2451	0	2768	0	1	0.885476879	0	0.8652	0	None	84761.90667
DY13	DMPH	Oak Valley Hospital District, Oakdale	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	83	0	130	0	1	0.638461538	0	0.8655	0	None	84761.90667
DY13	DMPH	Oak Valley Hospital District, Oakdale	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	2003	0	2061	0	1	0.971858321	0	0.9829	0	None	84761.90667
DY13	DMPH	Oak Valley Hospital District, Oakdale	1.4.2	Annual Monitoring for Patients on Persistent Medications	1235	0	1582	0	0	0.7807	0	0.4492	0	0.8563	254285.72
DY13	DMPH	Oak Valley Hospital District, Oakdale	1.4.3	INR Monitoring for Individuals on Warfarin	14	0	None	4	0	None	4	None	1	0.458	0
DY13	DMPH	Palo Verde Hospital, Blythe	1.1.1.a	Alcohol and Drug Misuse (SBIRT)	28	0	256	0	1	0.1094	0	0.0777	0	0	269230.77
DY13	DMPH	Palo Verde Hospital, Blythe	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	97	0	691	0	1	0.1404	0	0.0836	0	0.2936	269230.77
DY13	DMPH	Palo Verde Hospital, Blythe	1.1.5.f	Screening for Clinical Depression and follow-up	18	0	97	0	1	0.1856	0	0.104	0	0.1814	269230.77
DY13	DMPH	Palo Verde Hospital, Blythe	1.1.6.t	Tobacco Assessment and Counseling	370	0	416	0	1	0.8894	0	0.1106	0	0.759	269230.77
DY13	DMPH	Palo Verde Hospital, Blythe	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	16	0	97	0	1	0.164948454	0	None	None	None	89743.58667
DY13	DMPH	Palo Verde Hospital, Blythe	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	11	0	97	0	1	0.113402062	0	None	None	None	89743.58667
DY13	DMPH	Palo Verde Hospital, Blythe	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	11	0	97	0	1	0.113402062	0	None	None	None	89743.58667
DY13	DMPH	Palo Verde Hospital, Blythe	2.2.1	DHCS All-Cause Readmissions	51	0	360	0	1	0.1417	0	0.224	0	0.1745	269230.77
DY13	DMPH	Palo Verde Hospital, Blythe	2.2.2	H-CAHPS: Care Transition Metrics (3)	307	0	618	0	1	0.4968	0	0.2992	0	0.48	269230.77
DY13	DMPH	Palo Verde Hospital, Blythe	2.2.3	Medication Reconciliation – 30 days	128	0	713	0	1	0.1795	0	0.0713	0	0.1632	269230.77
DY13	DMPH	Palo Verde Hospital, Blythe	2.2.4	Reconciled Medication List Received by Discharged Patients	116	0	601	0	1	0.193	0	0.0566	0	0.1499	269230.77
DY13	DMPH	Palo Verde Hospital, Blythe	2.2.5	Timely Transmission of Transition Record	98	0	676	0	1	0.145	0	0.0351	0	0.1306	269230.77
DY13	DMPH	Palo Verde Hospital, Blythe	2.3.2	Medication Reconciliation – 30 days	95	0	610	0	1	0.1557	0	0.0171	0	0.1144	269230.77
DY13	DMPH	Palo Verde Hospital, Blythe	2.3.3	Prevention Quality Overall Composite #90	21	0	93	0	1	0.2258	0	0.2394	0	0	269230.77
DY13	DMPH	Palo Verde Hospital, Blythe	2.3.4	Timely Transmission of Transition Record	97	0	235	0	1	0.4128	0	0.0846	0	0.1751	269230.77
DY13	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	1.7.1	BMI Screening and Follow-up	22	0	49	0	1	0.449	0	None	1	0.4249	776923.07
DY13	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: Please specify which critera have been met in the textbox below. No	0	0	0	0	N/A	N/A - see narrative	0	N/A	0	None	388461.535
DY13	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 5)	9	0	16	0	0.75	see specification	0	N/A	0	None	388461.535
DY13	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	None	1	None	1	0	None	1	0	0	0.545	0
DY13	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	None	1	None	1	0	None	1	0	0	0.5184	0
DY13	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	None	1	None	1	0	None	1	0	0	0.4509	0
DY13	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.2.1	DHCS All-Cause Readmissions	41	0	293	0	1	0.1399	0	0.2508	0	0.1745	776923.07
DY13	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.2.2	H-CAHPS: Care Transition Metrics (3)	5507	0	10000	0	0	0.5507	0	0.5485	0	0.5547	776923.07
DY13	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.2.3	Medication Reconciliation – 30 days	171	0	196	0	1	0.8724	0	0.5789	0	0.62	776923.07
DY13	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.2.4	Reconciled Medication List Received by Discharged Patients	2392	0	2405	0	1	0.9946	0	0.9758	0	0.9772	776923.07
DY13	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.2.5	Timely Transmission of Transition Record	24	0	3285	0	0	0.0073	0	0	0	0.099	776923.07
DY13	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.3.2	Medication Reconciliation – 30 days	179	0	198	0	1	0.904	0	0.6471	0	0.6814	776923.07
DY13	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.3.3	Prevention Quality Overall Composite #90	2356	0	3190	0	1	0.7386	0	0.5119	0	0	776923.08
DY13	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.3.4	Timely Transmission of Transition Record	27	0	3103	0	0	0.0087	0	0	0	0.099	776923.08
DY13	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.7.1	Advance Care Plan	267	0	267	0	1	1	0	0.6568	0	0.6901	776923.08
DY13	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.7.2	Ambulatory Palliative Care Team Established: Ambulatory Palliative Care Team Established? Yes	Yes	0	Team Established?	0	1	None	0	None	None	None	776923.08
DY13	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	132	0	134	0	1	0.9851	0	0.825	0	0.78	776923.08
DY13	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	17	0	None	4	0	None	4	0	0	0	0
DY13	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	11	0	249	0	1	0.0442	0	None	1	0	776923.08
DY13	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	28	0	82	0	0	0.3415	0	None	1	0.25	776923.08
DY13	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	73	0	74	0	1	0.9865	0	0.702	0	0.387	776923.08
DY13	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	28877	0	175774	0	1	0.1643	0	0.1475	0	0	776923.08
DY13	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	2575	0	3677	0	1	0.7003	0	0.9585	0	0	776923.08
DY13	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR No	6420	0	10000	0	1	0.642	0	None	None	None	776923.08
DY13	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.2.1	Imaging for Routine Headaches (Choosing Wisely)	1434	0	2618	0	0	0.5477	0	0.3526	0	0.2687	776923.08
DY13	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.2.2	Appropriate Emergency Department Utilization of CT for Pulmonary Embolism	1528	0	2634	0	1	0.5801	0	0.2093	0	0.2554	776923.08
DY13	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.2.3	Use of Imaging Studies for Low Back Pain	3032	0	4006	0	1	0.7569	0	0.2182	0	0.6989	776923.08
DY13	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	227	0	7466	0	1	0.0304045	0	None	None	None	388461.54
DY13	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: Inappropriate Score	2195	0	7466	0	1	0.293999464	0	None	None	None	388461.54
DY13	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.3.1	Adherence to Medications: Rate 1	28	0	88	0	1	0.318181818	0	0.5941	0	None	388461.54
DY13	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.3.1	Adherence to Medications: Rate 2	31	0	95	0	N/A	0.326315789	0	0.5941	0	None	388461.54
DY13	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 1	None	1	36	0	1	None	1	0	0	None	388461.54
DY13	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 2	None	1	41	0	N/A	None	1	0	0	None	388461.54
DY13	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	528	0	743	0	1	0.710632571	0	None	4	None	388461.54
DY13	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 2	540	0	757	0	N/A	0.71334214	0	None	4	None	388461.54
DY13	DMPH	Pioneers Memorial Healthcare District, Brawley	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	912	0	976	0	1	0.93442623	0	0.141	0	None	157948.7167
DY13	DMPH	Pioneers Memorial Healthcare District, Brawley	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	79	0	87	0	1	0.908045977	0	0.7368	0	None	157948.7167
DY13	DMPH	Pioneers Memorial Healthcare District, Brawley	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	48	0	74	0	1	0.648648649	0	0.6415	0	None	157948.7167
DY13	DMPH	Pioneers Memorial Healthcare District, Brawley	1.4.2	Annual Monitoring for Patients on Persistent Medications	916	0	1065	0	1	0.8601	0	0.7413	0	0.8563	473846.15
DY13	DMPH	Pioneers Memorial Healthcare District, Brawley	1.4.3	INR Monitoring for Individuals on Warfarin	None	1	None	1	0	None	1	None	1	0.57	0
DY13	DMPH	Pioneers Memorial Healthcare District, Brawley	1.6.1	BIRADS to Biopsy	None	1	None	1	0	None	1	None	1	0	0
DY13	DMPH	Pioneers Memorial Healthcare District, Brawley	1.6.2	Breast Cancer Screening	287	0	424	0	1	0.6769	0	0.4645	0	0.5228	473846.15
DY13	DMPH	Pioneers Memorial Healthcare District, Brawley	1.6.3	Cervical Cancer Screening	444	0	809	0	1	0.5488	0	0.1067	0	0.4834	473846.15
DY13	DMPH	Pioneers Memorial Healthcare District, Brawley	1.6.4.c	Colorectal Cancer Screening	225	0	697	0	1	0.3228	0	0.0926	0	0.2669	473846.15
DY13	DMPH	Pioneers Memorial Healthcare District, Brawley	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	0	0	0	0	0	0	0	None	1	0	0
DY13	DMPH	Pioneers Memorial Healthcare District, Brawley	2.2.1	DHCS All-Cause Readmissions	58	0	497	0	1	0.1167	0	0.1356	0	0.1349	473846.15
DY13	DMPH	Pioneers Memorial Healthcare District, Brawley	2.2.2	H-CAHPS: Care Transition Metrics (3)	52	0	100	0	0	0.52	0	0.5418	0	0.5486	473846.15
DY13	DMPH	Pioneers Memorial Healthcare District, Brawley	2.2.3	Medication Reconciliation – 30 days	21	0	202	0	0.75	0.104	0	None	1	0.1107	473846.15
DY13	DMPH	Pioneers Memorial Healthcare District, Brawley	2.2.4	Reconciled Medication List Received by Discharged Patients	475	0	768	0	1	0.6185	0	0.5049	0	0.5534	473846.16
DY13	DMPH	Pioneers Memorial Healthcare District, Brawley	2.2.5	Timely Transmission of Transition Record	34	0	579	0	0	0.0587	0	None	1	0.1172	473846.16
DY13	DMPH	Pioneers Memorial Healthcare District, Brawley	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	None	1	None	1	1	None	1	None	1	0.3762	0
DY13	DMPH	Pioneers Memorial Healthcare District, Brawley	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	7198	0	29614	0	1	0.2431	0	0.1908	0	0	473846.16
DY13	DMPH	Pioneers Memorial Healthcare District, Brawley	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	400	0	3841	0	1	0.1041	0	0.1499	0	0	473846.16
DY13	DMPH	Pioneers Memorial Healthcare District, Brawley	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR No	8540	0	10000	0	1	0.854	0	None	None	None	473846.16
DY13	DMPH	Plumas District Hospital, Quincy	2.6.1	Alcohol and Drug Misuse (SBIRT)	28	0	359	0	1	0.078	0	0	0	0	300000
DY13	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	58	0	211	0	1	0.2749	0	0.1434	0	0	300000
DY13	DMPH	Plumas District Hospital, Quincy	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	70	0	211	0	1	0.3318	0	0.2209	0	0	300000
DY13	DMPH	Plumas District Hospital, Quincy	2.6.4	Screening for Clinical Depression and follow-up	38	0	202	0	1	0.1881	0	0	0	0.1814	300000
DY13	DMPH	Plumas District Hospital, Quincy	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	346	0	359	0	1	0.9638	0	0.7907	0	0	300000
DY13	DPH	Riverside University Health System	1.1.1.a	Alcohol and Drug Misuse (SBIRT)	38	0	30599	0	1	0.0012	0	0.0128	0	0	1192125
DY13	DPH	Riverside University Health System	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1816	0	6411	0	1	0.2833	0	0.3684	0	0.3609	1192125
DY13	DPH	Riverside University Health System	1.1.5.f	Screening for Clinical Depression and follow-up	21898	0	24035	0	1	0.9111	0	0.4975	0	0.5323	1192125
DY13	DPH	Riverside University Health System	1.1.6.t	Tobacco Assessment and Counseling	25657	0	27023	0	1	0.9495	0	0.8125	0	0.8274	1192125
DY13	DPH	Riverside University Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	104	0	421	0	1	0.247030879	0	None	None	None	397375
DY13	DPH	Riverside University Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	1	421	0	1	None	1	None	None	None	397375
DY13	DPH	Riverside University Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	22	0	421	0	1	0.052256532	0	None	None	None	397375
DY13	DPH	Riverside University Health System	1.2.1.a	Alcohol and Drug Misuse (SBIRT)	38	0	30599	0	1	0.0012	0	0.0128	0	0	1192125
DY13	DPH	Riverside University Health System	1.2.10	REAL and/or SO/GI disparity reduction	12	0	40	0	1	0.3	0	None	None	0.522	1192125
DY13	DPH	Riverside University Health System	1.2.11	REAL data completeness	31598	0	32061	0	1	0.9856	0	0.8528	0	None	1192125
DY13	DPH	Riverside University Health System	1.2.12.f	Screening for Clinical Depression and follow-up	21898	0	24035	0	1	0.9111	0	0.4975	0	0.5323	1192125
DY13	DPH	Riverside University Health System	1.2.13	SO/GI data completeness	15917	0	29182	0	1	0.5454	0	0.6166	0	None	1192125
DY13	DPH	Riverside University Health System	1.2.14.t	Tobacco Assessment and Counseling	25657	0	27023	0	1	0.9495	0	0.8125	0	0.8274	1192125
DY13	DPH	Riverside University Health System	1.2.2	CG-CAHPS: Provider Rating	926	0	1222	0	1	0.7578	0	0.7	0	0.7015	1192125
DY13	DPH	Riverside University Health System	1.2.3.c	Colorectal Cancer Screening	6755	0	12788	0	1	0.5282	0	0.4901	0	0.5068	1192125
DY13	DPH	Riverside University Health System	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1816	0	6411	0	1	0.2833	0	0.3684	0	0.3609	1192125
DY13	DPH	Riverside University Health System	1.2.5.b	Controlling Blood Pressure	4463	0	6233	0	1	0.716	0	0.62	0	0.6284	1192125
DY13	DPH	Riverside University Health System	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	890	0	1020	0	1	0.8725	0	0.6898	0	0.7126	1192125
DY13	DPH	Riverside University Health System	1.2.8	Prevention Quality Overall Composite #90	205	0	50388	0	1	0.0041	0	0.0042	0	0	1192125
DY13	DPH	Riverside University Health System	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	334	0	397	0	1	0.8413	0	0.9776	0	0.832	1192125
DY13	DPH	Riverside University Health System	1.3.2	DHCS All-Cause Readmissions	30	0	242	0	1	0.124	0	0.1111	0	0.129	1192125
DY13	DPH	Riverside University Health System	1.3.3	Influenza Immunization	2685	0	5286	0	1	0.5079	0	0.4554	0	0.4739	1192125
DY13	DPH	Riverside University Health System	1.3.4	Post Procedure ED Visits	51	0	3719	0	1	0.0137	0	0.0439	0	0	1192125
DY13	DPH	Riverside University Health System	1.3.5	Request for Specialty Care Expertise Turnaround Time	3961	0	22392	0	1	0.1769	0	0.2755	0	0	1192125
DY13	DPH	Riverside University Health System	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	944	0	7722	0	1	0.1222	0	0.045	0	0	1192125
DY13	DPH	Riverside University Health System	1.3.7	Tobacco Assessment and Counseling	4242	0	4423	0	1	0.9591	0	0.9251	0	0.9288	1192125
DY13	DPH	Riverside University Health System	1.5.1.b	Controlling Blood Pressure	4463	0	6233	0	1	0.716	0	0.62	0	0.6284	1192125
DY13	DPH	Riverside University Health System	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	890	0	1020	0	1	0.8725	0	0.6898	0	0.7126	1192125
DY13	DPH	Riverside University Health System	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	8247	0	17122	0	1	0.4817	0	0.3709	0	0.3938	1192125
DY13	DPH	Riverside University Health System	1.5.4.t	Tobacco Assessment and Counseling	25657	0	27023	0	1	0.9495	0	0.8125	0	0.8274	1192125
DY13	DPH	Riverside University Health System	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	None	0	None	None	None	606900
DY13	DPH	Riverside University Health System	2.1.1	Baby Friendly Hospital designation: Development Phase Complete Yes	Yes	0	Development Phase?	0	1	see specification	0	None	None	None	606900
DY13	DPH	Riverside University Health System	2.1.2	Exclusive Breast Milk Feeding (PC-05)	197	0	260	0	1	0.7577	0	0.6318	0	0.6465	1213800
DY13	DPH	Riverside University Health System	2.1.3	OB Hemorrhage: Massive Transfusion	0	0	367	0	1	0	0	None	1	0	1213800
DY13	DPH	Riverside University Health System	2.1.4	OB Hemorrhage: Total Products Transfused	12	0	367	0	1	0.0327	0	0.0614	0	0	1213800
DY13	DPH	Riverside University Health System	2.1.5	PC-02 Cesarean Section	35	0	121	0	0	0.2893	0	0.1494	0	0.22	1213800
DY13	DPH	Riverside University Health System	2.1.6	Prenatal and Postpartum Care: Prenatal Care	224	0	301	0	1	0.744186047	0	0.6015	0	0.7421	606900
DY13	DPH	Riverside University Health System	2.1.6	Prenatal and Postpartum Care: Postpartum Care	192	0	301	0	1	0.637873754	0	0.3653	0	0.5547	606900
DY13	DPH	Riverside University Health System	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	1	31	0	1	None	1	None	1	0	1213800
DY13	DPH	Riverside University Health System	2.1.8	Unexpected Newborn Complications (UNC)	18	0	306	0	1	0.0588	0	0.0588	0	0	1213800
DY13	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	1	see specification	0	None	None	None	303450
DY13	DPH	Riverside University Health System	2.1.9	OB Hemorrhage Safety Bundle: Please specify which elements have been completed in the textbox below No	0	0	0	0	0	see specification	0	None	None	None	303450
DY13	DPH	Riverside University Health System	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	0	0	0	0	0	see specification	0	None	None	None	303450
DY13	DPH	Riverside University Health System	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes	0	0	0	0	0	see specification	0	None	None	None	303450
DY13	DPH	Riverside University Health System	2.2.1	DHCS All-Cause Readmissions	83	0	715	0	1	0.1161	0	0.1238	0	0.129	1213800
DY13	DPH	Riverside University Health System	2.2.2	H-CAHPS: Care Transition Metrics (3)	695	0	1525	0	0	0.4557	0	0.4395	0	0.48	1213800
DY13	DPH	Riverside University Health System	2.2.3	Medication Reconciliation – 30 days	1536	0	1608	0	1	0.9552	0	0.8286	0	0.8447	1213800
DY13	DPH	Riverside University Health System	2.2.4	Reconciled Medication List Received by Discharged Patients	368	0	400	0	1	0.92	0	0.8148	0	0.8323	1213800
DY13	DPH	Riverside University Health System	2.2.5	Timely Transmission of Transition Record	2743	0	2859	0	1	0.9594	0	0.8119	0	0.8297	1213800
DY13	DPH	Riverside University Health System	2.3.2	Medication Reconciliation – 30 days	178	0	186	0	1	0.957	0	0.9206	0	0.9275	1213800
DY13	DPH	Riverside University Health System	2.3.3	Prevention Quality Overall Composite #90	37	0	715	0	1	0.0517	0	0.0555	0	0	1213800
DY13	DPH	Riverside University Health System	2.3.4	Timely Transmission of Transition Record	275	0	285	0	1	0.9649	0	0.9305	0	0.9365	1213800
DY13	DPH	Riverside University Health System	2.6.1	Alcohol and Drug Misuse (SBIRT)	15	0	6390	0	1	0.0023	0	None	1	0	1213800
DY13	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	19	0	1449	0	1	0.0131	0	None	1	0	1213800
DY13	DPH	Riverside University Health System	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	127	0	1449	0	1	0.0876	0	0.0297	0	0	1213800
DY13	DPH	Riverside University Health System	2.6.4	Screening for Clinical Depression and follow-up	4041	0	4424	0	1	0.9134	0	0.5994	0	0.624	1213800
DY13	DPH	Riverside University Health System	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	5332	0	6412	0	1	0.8316	0	0.6346	0	0	1213800
DY13	DPH	Riverside University Health System	3.3.1	Adherence to Medications: Rate 1	1555	0	2833	0	1	0.548888104	0	0.7702	0	None	1112650
DY13	DPH	Riverside University Health System	3.3.1	Adherence to Medications: Rate 2	1844	0	3491	0	N/A	0.528215411	0	0.7702	0	None	1112650
DY13	DPH	Riverside University Health System	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 1	1974	0	3757	0	1	0.525419217	0	0.4601	0	None	1112650
DY13	DPH	Riverside University Health System	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 2	1974	0	5259	0	N/A	0.375356532	0	0.4601	0	None	1112650
DY13	DPH	Riverside University Health System	3.3.4	Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 1	7332	0	7726	0	1	0.949003365	0	0.4432	0	None	1112650
DY13	DPH	Riverside University Health System	3.3.4	Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 2	9225	0	9699	0	N/A	0.951128982	0	0.4432	0	None	1112650
DY13	DMPH	Salinas Valley Memorial Healthcare System	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	1027	0	1156	0	1	0.888408304	0	0.8738	0	None	109462.3667
DY13	DMPH	Salinas Valley Memorial Healthcare System	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	922	0	993	0	1	0.928499496	0	0.8125	0	None	109462.3667
DY13	DMPH	Salinas Valley Memorial Healthcare System	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	1087	0	1566	0	1	0.69412516	0	0.8026	0	None	109462.3667
DY13	DMPH	Salinas Valley Memorial Healthcare System	1.4.2	Annual Monitoring for Patients on Persistent Medications	1284	0	1435	0	1	0.8948	0	0.5857	0	0.8563	328387.1
DY13	DMPH	Salinas Valley Memorial Healthcare System	1.4.3	INR Monitoring for Individuals on Warfarin	613	0	798	0	1	0.7682	0	0.746	0	0.7504	328387.1
DY13	DMPH	Salinas Valley Memorial Healthcare System	1.5.1.b	Controlling Blood Pressure	260	0	427	0	1	0.6089	0	0.3911	0	0.4687	328387.1
DY13	DMPH	Salinas Valley Memorial Healthcare System	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	311	0	408	0	1	0.7623	0	0.6757	0	0.7022	328387.1
DY13	DMPH	Salinas Valley Memorial Healthcare System	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	6015	0	6913	0	1	0.8701	0	0.4031	0	0.4228	328387.1
DY13	DMPH	Salinas Valley Memorial Healthcare System	1.5.4.t	Tobacco Assessment and Counseling	9461	0	9842	0	1	0.9613	0	0.8862	0	0.8938	328387.1
DY13	DMPH	Salinas Valley Memorial Healthcare System	1.6.1	BIRADS to Biopsy	70	0	78	0	1	0.8974	0	0.8714	0	0	328387.1
DY13	DMPH	Salinas Valley Memorial Healthcare System	1.6.2	Breast Cancer Screening	687	0	1140	0	1	0.6026	0	0.4378	0	0.5228	328387.1
DY13	DMPH	Salinas Valley Memorial Healthcare System	1.6.3	Cervical Cancer Screening	1596	0	2841	0	1	0.5618	0	0.2953	0	0.4834	328387.1
DY13	DMPH	Salinas Valley Memorial Healthcare System	1.6.4.c	Colorectal Cancer Screening	501	0	1096	0	1	0.4571	0	0.2572	0	0.2972	328387.1
DY13	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	4	0	0
DY13	DMPH	Salinas Valley Memorial Healthcare System	2.2.1	DHCS All-Cause Readmissions	257	0	1431	0	0	0.1796	0	0.127	0	0.129	328387.1
DY13	DMPH	Salinas Valley Memorial Healthcare System	2.2.2	H-CAHPS: Care Transition Metrics (3)	2074	0	3775	0	1	0.5494	0	0.5365	0	0.5439	328387.1
DY13	DMPH	Salinas Valley Memorial Healthcare System	2.2.3	Medication Reconciliation – 30 days	845	0	996	0	1	0.8484	0	0.2095	0	0.2876	328387.1
DY13	DMPH	Salinas Valley Memorial Healthcare System	2.2.4	Reconciled Medication List Received by Discharged Patients	5188	0	5862	0	1	0.885	0	0.807	0	0.8253	328387.1
DY13	DMPH	Salinas Valley Memorial Healthcare System	2.2.5	Timely Transmission of Transition Record	83	0	421	0	1	0.1971	0	None	1	0.1013	328387.1
DY13	DMPH	Salinas Valley Memorial Healthcare System	2.3.2	Medication Reconciliation – 30 days	279	0	615	0	1	0.4537	0	0.2321	0	0.3079	328387.1
DY13	DMPH	Salinas Valley Memorial Healthcare System	2.3.3	Prevention Quality Overall Composite #90	658	0	4508	0	1	0.146	0	0.0184	0	0	328387.1
DY13	DMPH	Salinas Valley Memorial Healthcare System	2.3.4	Timely Transmission of Transition Record	121	0	463	0	1	0.2613	0	None	1	0.1059	328387.1
DY13	DMPH	Salinas Valley Memorial Healthcare System	2.7.1	Advance Care Plan	593	0	962	0	1	0.6164	0	0.4104	0	0.4684	328387.1
DY13	DMPH	Salinas Valley Memorial Healthcare System	2.7.2	Ambulatory Palliative Care Team Established: Ambulatory Palliative Care Team Established? Yes	Yes	0	Team Established?	0	1	None	0	None	None	None	328387.1
DY13	DMPH	Salinas Valley Memorial Healthcare System	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	74	0	75	0	1	0.9867	0	0.6364	0	0.6508	328387.09
DY13	DMPH	Salinas Valley Memorial Healthcare System	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	70	0	220	0	1	0.3182	0	0.1726	0	0	328387.09
DY13	DMPH	Salinas Valley Memorial Healthcare System	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	163	0	715	0	1	0.228	0	0.1018	0	0	328387.09
DY13	DMPH	Salinas Valley Memorial Healthcare System	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	None	1	None	4	0	None	1	0	0	0	0
DY13	DMPH	Salinas Valley Memorial Healthcare System	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	160	0	212	0	1	0.7547	0	0.6543	0	0.387	328387.09
DY13	DMPH	Salinas Valley Memorial Healthcare System	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	4895	0	27873	0	1	0.1756	0	0.3933	0	0	328387.09
DY13	DMPH	Salinas Valley Memorial Healthcare System	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	189	0	374	0	1	0.5053	0	0.6367	0	0	328387.09
DY13	DMPH	Salinas Valley Memorial Healthcare System	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR No	11700	0	10000	0	0	1.17	0	None	None	None	328387.09
DY13	DMPH	Salinas Valley Memorial Healthcare System	3.4.1	ePBM-01 Pre-op Anemia Screening, Selected Elective Surgical Patients	16	0	120	0	0	0.1333	0	0.2381	0	0.3043	328387.09
DY13	DMPH	Salinas Valley Memorial Healthcare System	3.4.2	ePBM-02 Pre-op Hemoglobin Level, Selected Elective Surgical Patients	18	0	None	4	1	None	4	None	1	0	0
DY13	DMPH	Salinas Valley Memorial Healthcare System	3.4.3	ePBM-03 Pre-op Type and Crossmatch, Type and Screen, Selected elective Surgical Patients	52	0	117	0	0	0.4444	0	0.4466	0	0.4919	328387.09
DY13	DMPH	Salinas Valley Memorial Healthcare System	3.4.4	ePBM-04 Initial Transfusion Threshold	184	0	185	0	1	0.9946	0	1	0	0	328387.09
DY13	DMPH	Salinas Valley Memorial Healthcare System	3.4.5	ePBM-05 Outcome of Patient Blood Management, Selected Elective Surgical Patients	None	1	None	4	0	None	1	None	1	0.1875	0
DY13	DMPH	San Bernardino Mountains Community Hospital, Lake Arrowhead	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	270	0	294	0	1	0.918367347	0	0.9091	0	None	166666.6667
DY13	DMPH	San Bernardino Mountains Community Hospital, Lake Arrowhead	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	68	0	82	0	1	0.829268293	0	0.7692	0	None	166666.6667
DY13	DMPH	San Bernardino Mountains Community Hospital, Lake Arrowhead	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	111	0	159	0	1	0.698113208	0	0.5072	0	None	166666.6667
DY13	DMPH	San Bernardino Mountains Community Hospital, Lake Arrowhead	1.4.2	Annual Monitoring for Patients on Persistent Medications	159	0	173	0	1	0.9191	0	0.819	0	0.8563	500000
DY13	DMPH	San Bernardino Mountains Community Hospital, Lake Arrowhead	1.4.3	INR Monitoring for Individuals on Warfarin	84	0	105	0	1	0.8	0	0.7867	0	0.787	500000
DY13	DPH	San Francisco General Hospital	1.1.1.a	Alcohol and Drug Misuse (SBIRT)	1030	0	37915	0	1	0.0272	0	None	1	0	1222000
DY13	DPH	San Francisco General Hospital	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1612	0	6835	0	1	0.2358	0	0.2537	0	0.2936	1222000
DY13	DPH	San Francisco General Hospital	1.1.5.f	Screening for Clinical Depression and follow-up	14403	0	27313	0	1	0.5273	0	0.4029	0	0.4472	1222000
DY13	DPH	San Francisco General Hospital	1.1.6.t	Tobacco Assessment and Counseling	31327	0	32325	0	1	0.9691	0	0.9639	0	0.9619	1222000
DY13	DPH	San Francisco General Hospital	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	333	0	1299	0	1	0.256351039	0	None	None	None	407333.3333
DY13	DPH	San Francisco General Hospital	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	40	0	1299	0	1	0.030792918	0	None	None	None	407333.3333
DY13	DPH	San Francisco General Hospital	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	90	0	1299	0	1	0.069284065	0	None	None	None	407333.3333
DY13	DPH	San Francisco General Hospital	1.2.1.a	Alcohol and Drug Misuse (SBIRT)	1030	0	37915	0	1	0.0272	0	None	1	0	1222000
DY13	DPH	San Francisco General Hospital	1.2.10	REAL and/or SO/GI disparity reduction	1909	0	2663	0	1	0.7169	0	None	None	0.7041	1222000
DY13	DPH	San Francisco General Hospital	1.2.11	REAL data completeness	30818	0	40590	0	1	0.7593	0	0.603	0	None	1222000
DY13	DPH	San Francisco General Hospital	1.2.12.f	Screening for Clinical Depression and follow-up	14403	0	27313	0	1	0.5273	0	0.4029	0	0.4472	1222000
DY13	DPH	San Francisco General Hospital	1.2.13	SO/GI data completeness	8516	0	33986	0	1	0.2506	0	0	0	None	1222000
DY13	DPH	San Francisco General Hospital	1.2.14.t	Tobacco Assessment and Counseling	31327	0	32325	0	1	0.9691	0	0.9639	0	0.9619	1222000
DY13	DPH	San Francisco General Hospital	1.2.2	CG-CAHPS: Provider Rating	1910	0	2533	0	1	0.754	0	0.7511	0	0.7148	1222000
DY13	DPH	San Francisco General Hospital	1.2.3.c	Colorectal Cancer Screening	13630	0	19835	0	1	0.6872	0	0.7057	0	0.6571	1222000
DY13	DPH	San Francisco General Hospital	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1612	0	6835	0	1	0.2358	0	0.2537	0	0.2936	1222000
DY13	DPH	San Francisco General Hospital	1.2.5.b	Controlling Blood Pressure	9885	0	12567	0	1	0.7866	0	0.7874	0	0.7041	1222000
DY13	DPH	San Francisco General Hospital	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	2036	0	2207	0	1	0.9225	0	0.9157	0	0.9159	1222000
DY13	DPH	San Francisco General Hospital	1.2.8	Prevention Quality Overall Composite #90	619	0	45567	0	1	0.0136	0	0.0082	0	0	1222000
DY13	DPH	San Francisco General Hospital	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	106016	0	145100	0	1	0.7306	0	0.6852	0	0.6999	1222000
DY13	DPH	San Francisco General Hospital	1.3.2	DHCS All-Cause Readmissions	363	0	2386	0	0	0.1521	0	0.1385	0	0.1376	1222000
DY13	DPH	San Francisco General Hospital	1.3.3	Influenza Immunization	9742	0	11441	0	1	0.8515	0	0.7143	0	0.64	1222000
DY13	DPH	San Francisco General Hospital	1.3.4	Post Procedure ED Visits	614	0	27213	0	1	0.0226	0	0.0182	0	0	1222000
DY13	DPH	San Francisco General Hospital	1.3.5	Request for Specialty Care Expertise Turnaround Time	38053	0	42828	0	1	0.8885	0	0.9202	0	0	1222000
DY13	DPH	San Francisco General Hospital	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	13297	0	47214	0	1	0.2816	0	0.2107	0	0	1222000
DY13	DPH	San Francisco General Hospital	1.3.7	Tobacco Assessment and Counseling	12918	0	13366	0	1	0.9665	0	0.9655	0	0.9619	1222000
DY13	DPH	San Francisco General Hospital	1.5.1.b	Controlling Blood Pressure	9885	0	12567	0	1	0.7866	0	0.7874	0	0.7041	1222000
DY13	DPH	San Francisco General Hospital	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	2036	0	2207	0	1	0.9225	0	0.9157	0	0.781	1222000
DY13	DPH	San Francisco General Hospital	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	17172	0	20009	0	1	0.8582	0	0.8388	0	0.6	1222000
DY13	DPH	San Francisco General Hospital	1.5.4.t	Tobacco Assessment and Counseling	31327	0	32325	0	1	0.9691	0	0.9639	0	0.9619	1222000
DY13	DPH	San Francisco General Hospital	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	None	0	None	None	None	622109.095
DY13	DPH	San Francisco General Hospital	2.1.1	Baby Friendly Hospital designation: Development Phase Complete Yes	Yes	0	Development Phase?	0	1	see specification	0	None	None	None	622109.095
DY13	DPH	San Francisco General Hospital	2.1.2	Exclusive Breast Milk Feeding (PC-05)	587	0	789	0	1	0.744	0	0.7317	0	0.7364	1244218.19
DY13	DPH	San Francisco General Hospital	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	1034	0	1	None	1	None	1	0	1244218.19
DY13	DPH	San Francisco General Hospital	2.1.4	OB Hemorrhage: Total Products Transfused	61	0	1034	0	1	0.059	0	0.1746	0	0	1244218.19
DY13	DPH	San Francisco General Hospital	2.1.5	PC-02 Cesarean Section	56	0	352	0	1	0.1591	0	0.165	0	0.22	1244218.18
DY13	DPH	San Francisco General Hospital	2.1.6	Prenatal and Postpartum Care: Prenatal Care	743	0	813	0	1	0.913899139	0	0.9398	0	0.91	622109.09
DY13	DPH	San Francisco General Hospital	2.1.6	Prenatal and Postpartum Care: Postpartum Care	593	0	813	0	1	0.729397294	0	0.6	0	0.6136	622109.09
DY13	DPH	San Francisco General Hospital	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	23	0	154	0	1	0.1494	0	0.2324	0	0	1244218.18
DY13	DPH	San Francisco General Hospital	2.1.8	Unexpected Newborn Complications (UNC)	91	0	828	0	1	0.1099	0	0.1313	0	0	1244218.18
DY13	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	see specification	0	None	None	None	311054.545
DY13	DPH	San Francisco General Hospital	2.1.9	OB Hemorrhage Safety Bundle: Please specify which elements have been completed in the textbox below No	0	0	0	0	0	see specification	0	None	None	None	311054.545
DY13	DPH	San Francisco General Hospital	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	0	0	0	0	0	see specification	0	None	None	None	311054.545
DY13	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	0	0	0	0	0	see specification	0	None	None	None	311054.545
DY13	DPH	San Francisco General Hospital	2.2.1	DHCS All-Cause Readmissions	432	0	2993	0	0	0.1443	0	0.1446	0	0.143	1244218.18
DY13	DPH	San Francisco General Hospital	2.2.2	H-CAHPS: Care Transition Metrics (3)	641	0	1228	0	1	0.522	0	0.512	0	0.5218	1244218.18
DY13	DPH	San Francisco General Hospital	2.2.3	Medication Reconciliation – 30 days	3190	0	3995	0	1	0.7985	0	0.769	0	0.7911	1244218.18
DY13	DPH	San Francisco General Hospital	2.2.4	Reconciled Medication List Received by Discharged Patients	3105	0	3155	0	1	0.9842	0	0.9515	0	0.9554	1244218.18
DY13	DPH	San Francisco General Hospital	2.2.5	Timely Transmission of Transition Record	3710	0	4794	0	1	0.7739	0	0.6678	0	0.7	1244218.18
DY13	DPH	San Francisco General Hospital	2.3.2	Medication Reconciliation – 30 days	920	0	1110	0	1	0.8288	0	0.8058	0	0.8242	1244218.18
DY13	DPH	San Francisco General Hospital	2.3.3	Prevention Quality Overall Composite #90	368	0	806	0	1	0.4566	0	0.2385	0	0	1244218.18
DY13	DPH	San Francisco General Hospital	2.3.4	Timely Transmission of Transition Record	1169	0	1341	0	1	0.8717	0	0.7417	0	0.7665	1244218.18
DY13	DPH	San Francisco General Hospital	2.6.1	Alcohol and Drug Misuse (SBIRT)	69	0	4308	0	1	0.016	0	None	1	0	1244218.18
DY13	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	850	0	1475	0	1	0.5763	0	0.4662	0	0	1244218.18
DY13	DPH	San Francisco General Hospital	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	1213	0	1475	0	1	0.8224	0	0.6187	0	0	1244218.18
DY13	DPH	San Francisco General Hospital	2.6.4	Screening for Clinical Depression and follow-up	1323	0	2660	0	1	0.4974	0	0.3478	0	0.3976	1244218.18
DY13	DPH	San Francisco General Hospital	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	4093	0	4425	0	1	0.925	0	0.9402	0	0	1244218.18
DY13	DPH	San Francisco General Hospital	3.3.1	Adherence to Medications: Rate 1	97	0	136	0	1	0.713235294	0	None	4	None	1140533.335
DY13	DPH	San Francisco General Hospital	3.3.1	Adherence to Medications: Rate 2	162	0	240	0	N/A	0.675	0	None	4	None	1140533.335
DY13	DPH	San Francisco General Hospital	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 1	41	0	126	0	1	0.325396825	0	None	4	None	1140533.335
DY13	DPH	San Francisco General Hospital	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 2	41	0	157	0	N/A	0.261146497	0	None	4	None	1140533.335
DY13	DPH	San Francisco General Hospital	3.3.4	Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 1	554	0	643	0	1	0.861586314	0	0.5131	0	None	1140533.33
DY13	DPH	San Francisco General Hospital	3.3.4	Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 2	888	0	1125	0	N/A	0.789333333	0	0.5131	0	None	1140533.33
DY13	DMPH	San Gorgonio Memorial Hospital, Banning	1.7.1	BMI Screening and Follow-up	68	0	142	0	0	0.4789	0	0.4865	0	0.5269	291666.67
DY13	DMPH	San Gorgonio Memorial Hospital, Banning	1.7.2	Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Please specify which critera have been met in the textbox below. No	0	0	0	0	N/A	N/A - see narrative	0	N/A	0	None	145833.335
DY13	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 5)	3	0	8	0	1	see specification	0	N/A	0	None	145833.335
DY13	DMPH	San Gorgonio Memorial Hospital, Banning	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI	72	0	103	0	1	0.699029126	0	0	0	0.545	97222.22333
DY13	DMPH	San Gorgonio Memorial Hospital, Banning	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition	72	0	103	0	1	0.699029126	0	0	0	0.5184	97222.22333
DY13	DMPH	San Gorgonio Memorial Hospital, Banning	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity	70	0	103	0	1	0.67961165	0	0	0	0.4509	97222.22333
DY13	DMPH	San Gorgonio Memorial Hospital, Banning	2.2.1	DHCS All-Cause Readmissions	57	0	604	0	1	0.0944	0	0.6849	0	0.1745	291666.67
DY13	DMPH	San Gorgonio Memorial Hospital, Banning	2.2.2	H-CAHPS: Care Transition Metrics (3)	5951	0	10000	0	1	0.5951	0	0.4248	0	0.48	291666.67
DY13	DMPH	San Gorgonio Memorial Hospital, Banning	2.2.3	Medication Reconciliation – 30 days	58	0	58	0	1	1	0	0.4884	0	0.5386	291666.67
DY13	DMPH	San Gorgonio Memorial Hospital, Banning	2.2.4	Reconciled Medication List Received by Discharged Patients	58	0	58	0	1	1	0	0.907	0	0.9153	291666.67
DY13	DMPH	San Gorgonio Memorial Hospital, Banning	2.2.5	Timely Transmission of Transition Record	58	0	58	0	1	1	0	None	1	0.2037	291666.67
DY13	DMPH	San Gorgonio Memorial Hospital, Banning	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	48	0	55	0	1	0.8727	0	0.4342	0	0.387	291666.66
DY13	DMPH	San Gorgonio Memorial Hospital, Banning	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	6360	0	13338	0	1	0.4768	0	0.4412	0	0	291666.66
DY13	DMPH	San Gorgonio Memorial Hospital, Banning	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	None	1	107	0	1	None	1	0.6879	0	0	291666.66
DY13	DMPH	San Gorgonio Memorial Hospital, Banning	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR No	8400	0	10000	0	1	0.84	0	None	None	None	291666.66
DY13	DPH	San Joaquin General Hospital	1.1.1.a	Alcohol and Drug Misuse (SBIRT)	372	0	15620	0	1	0.0238	0	0.003	0	0	691962.07
DY13	DPH	San Joaquin General Hospital	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	94	0	323	0	1	0.291	0	0.2221	0	0.2936	691962.07
DY13	DPH	San Joaquin General Hospital	1.1.5.f	Screening for Clinical Depression and follow-up	269	0	377	0	1	0.7135	0	0.8727	0	0.7397	691962.07
DY13	DPH	San Joaquin General Hospital	1.1.6.t	Tobacco Assessment and Counseling	337	0	377	0	1	0.8939	0	0.8579	0	0.8683	691962.07
DY13	DPH	San Joaquin General Hospital	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	94	0	908	0	1	0.103524229	0	None	None	None	230654.0233
DY13	DPH	San Joaquin General Hospital	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	18	0	908	0	1	0.019823789	0	None	None	None	230654.0233
DY13	DPH	San Joaquin General Hospital	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	38	0	908	0	1	0.04185022	0	None	None	None	230654.0233
DY13	DPH	San Joaquin General Hospital	1.2.1.a	Alcohol and Drug Misuse (SBIRT)	372	0	15620	0	1	0.0238	0	0.003	0	0	691962.07
DY13	DPH	San Joaquin General Hospital	1.2.10	REAL and/or SO/GI disparity reduction	150	0	249	0	1	0.6024	0	None	None	0.5908	691962.07
DY13	DPH	San Joaquin General Hospital	1.2.11	REAL data completeness	13337	0	21589	0	1	0.6178	0	0.6318	0	None	691962.07
DY13	DPH	San Joaquin General Hospital	1.2.12.f	Screening for Clinical Depression and follow-up	269	0	377	0	1	0.7135	0	0.8727	0	0.7397	691962.07
DY13	DPH	San Joaquin General Hospital	1.2.13	SO/GI data completeness	6230	0	21589	0	1	0.2886	0	0	0	None	691962.07
DY13	DPH	San Joaquin General Hospital	1.2.14.t	Tobacco Assessment and Counseling	337	0	377	0	1	0.8939	0	0.8579	0	0.8683	691962.07
DY13	DPH	San Joaquin General Hospital	1.2.2	CG-CAHPS: Provider Rating	7021	0	10000	0	1	0.7021	0	0.708	0	0.6201	691962.07
DY13	DPH	San Joaquin General Hospital	1.2.3.c	Colorectal Cancer Screening	139	0	370	0	0	0.3757	0	0.4595	0	0.4194	691962.07
DY13	DPH	San Joaquin General Hospital	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	94	0	323	0	1	0.291	0	0.2221	0	0.2936	691962.07
DY13	DPH	San Joaquin General Hospital	1.2.5.b	Controlling Blood Pressure	288	0	411	0	1	0.7007	0	0.6649	0	0.5852	691962.07
DY13	DPH	San Joaquin General Hospital	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	598	0	772	0	1	0.7746	0	0.8692	0	0.742	691962.07
DY13	DPH	San Joaquin General Hospital	1.2.8	Prevention Quality Overall Composite #90	409	0	26711	0	1	0.0153	0	0.0292	0	0	691962.07
DY13	DPH	San Joaquin General Hospital	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	209	0	357	0	0	0.5854	0	0.7616	0	0.6725	691962.07
DY13	DPH	San Joaquin General Hospital	1.3.2	DHCS All-Cause Readmissions	81	0	679	0	1	0.1193	0	0.1318	0	0.1381	691962.07
DY13	DPH	San Joaquin General Hospital	1.3.3	Influenza Immunization	169	0	323	0	1	0.5232	0	0.3812	0	0.4071	691962.07
DY13	DPH	San Joaquin General Hospital	1.3.4	Post Procedure ED Visits	42	0	3981	0	1	0.0106	0	0.0134	0	0	691962.07
DY13	DPH	San Joaquin General Hospital	1.3.5	Request for Specialty Care Expertise Turnaround Time	130	0	341	0	1	0.3812	0	0.4324	0	0	691962.07
DY13	DPH	San Joaquin General Hospital	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	None	1	370	0	1	None	1	None	1	0	691962.07
DY13	DPH	San Joaquin General Hospital	1.3.7	Tobacco Assessment and Counseling	335	0	342	0	1	0.9795	0	0.9474	0	0.9489	691962.07
DY13	DPH	San Joaquin General Hospital	1.6.1	BIRADS to Biopsy	24	0	51	0	1	0.4706	0	0.2333	0	0	691962.07
DY13	DPH	San Joaquin General Hospital	1.6.2	Breast Cancer Screening	178	0	351	0	0	0.5071	0	0.5897	0	0.5269	691962.07
DY13	DPH	San Joaquin General Hospital	1.6.3	Cervical Cancer Screening	136	0	377	0	0	0.3607	0	0.4784	0	0.4379	691962.06
DY13	DPH	San Joaquin General Hospital	1.6.4.c	Colorectal Cancer Screening	139	0	370	0	0	0.3757	0	0.4595	0	0.4194	691962.06
DY13	DPH	San Joaquin General Hospital	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	20	0	52	0	1	0.3846	0	0.5	0	0	691962.06
DY13	DPH	San Joaquin General Hospital	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	None	0	None	None	None	364852.725
DY13	DPH	San Joaquin General Hospital	2.1.1	Baby Friendly Hospital designation: Development Phase Complete No	No	0	Development Phase?	0	0	see specification	0	None	None	None	364852.725
DY13	DPH	San Joaquin General Hospital	2.1.2	Exclusive Breast Milk Feeding (PC-05)	257	0	392	0	0	0.6556	0	0.7117	0	0.7184	729705.45
DY13	DPH	San Joaquin General Hospital	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	538	0	1	None	1	None	1	0	729705.45
DY13	DPH	San Joaquin General Hospital	2.1.4	OB Hemorrhage: Total Products Transfused	65	0	538	0	1	0.1208	0	0.0984	0	0	729705.45
DY13	DPH	San Joaquin General Hospital	2.1.5	PC-02 Cesarean Section	23	0	103	0	1	0.2233	0	0.32	0	0.2743	729705.45
DY13	DPH	San Joaquin General Hospital	2.1.6	Prenatal and Postpartum Care: Prenatal Care	324	0	479	0	0	0.676409186	0	0.7504	0	0.6706	364852.725
DY13	DPH	San Joaquin General Hospital	2.1.6	Prenatal and Postpartum Care: Postpartum Care	280	0	479	0	1	0.584551148	0	0.6173	0	0.5506	364852.725
DY13	DPH	San Joaquin General Hospital	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	17	0	32	0	1	0.5313	0	0.4909	0	0	729705.45
DY13	DPH	San Joaquin General Hospital	2.1.8	Unexpected Newborn Complications (UNC)	15	0	399	0	1	0.0376	0	0.0489	0	0	729705.45
DY13	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	see specification	0	None	None	None	182426.3625
DY13	DPH	San Joaquin General Hospital	2.1.9	OB Hemorrhage Safety Bundle: Please specify which elements have been completed in the textbox below No	0	0	0	0	0	see specification	0	None	None	None	182426.3625
DY13	DPH	San Joaquin General Hospital	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	0	0	0	0	0	see specification	0	None	None	None	182426.3625
DY13	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	0	0	0	0	0	see specification	0	None	None	None	182426.3625
DY13	DPH	San Joaquin General Hospital	2.2.1	DHCS All-Cause Readmissions	107	0	1030	0	1	0.1039	0	0.0942	0	0.129	729705.45
DY13	DPH	San Joaquin General Hospital	2.2.2	H-CAHPS: Care Transition Metrics (3)	4510	0	10000	0	0	0.451	0	0.4961	0	0.5075	729705.45
DY13	DPH	San Joaquin General Hospital	2.2.3	Medication Reconciliation – 30 days	209	0	323	0	1	0.6471	0	0.4396	0	0.4946	729705.45
DY13	DPH	San Joaquin General Hospital	2.2.4	Reconciled Medication List Received by Discharged Patients	259	0	341	0	1	0.7595	0	0.7214	0	0.7483	729705.46
DY13	DPH	San Joaquin General Hospital	2.2.5	Timely Transmission of Transition Record	94	0	341	0	1	0.2757	0	None	1	0.1069	729705.46
DY13	DPH	San Joaquin General Hospital	2.3.2	Medication Reconciliation – 30 days	191	0	249	0	1	0.7671	0	0.1619	0	0.2447	729705.46
DY13	DPH	San Joaquin General Hospital	2.3.3	Prevention Quality Overall Composite #90	649	0	7785	0	1	0.0834	0	0.0601	0	0	729705.46
DY13	DPH	San Joaquin General Hospital	2.3.4	Timely Transmission of Transition Record	93	0	323	0	1	0.2879	0	None	1	0.1026	729705.46
DY13	DPH	San Joaquin General Hospital	2.7.1	Advance Care Plan	86	0	323	0	1	0.2663	0	0.0352	0	0.1307	729705.46
DY13	DPH	San Joaquin General Hospital	2.7.2	Ambulatory Palliative Care Team Established: Ambulatory Palliative Care Team Established? Yes	Yes	0	Team Established?	0	1	None	0	None	None	None	729705.46
DY13	DPH	San Joaquin General Hospital	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	73	0	99	0	1	0.7374	0	0.6667	0	0.678	729705.46
DY13	DPH	San Joaquin General Hospital	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	38	0	42	0	1	0.9048	0	0.9333	0	0	729705.46
DY13	DPH	San Joaquin General Hospital	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	39	0	283	0	1	0.1378	0	0.0861	0	0	729705.46
DY13	DPH	San Joaquin General Hospital	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	None	1	None	4	0	None	1	None	1	0.25	0
DY13	DPH	San Joaquin General Hospital	3.2.1	Imaging for Routine Headaches (Choosing Wisely)	45	0	260	0	0	0.1731	0	0.1269	0	0.1464	1003345
DY13	DPH	San Joaquin General Hospital	3.2.2	Appropriate Emergency Department Utilization of CT for Pulmonary Embolism	93	0	101	0	1	0.9208	0	0.595	0	0.6026	1003345
DY13	DPH	San Joaquin General Hospital	3.2.3	Use of Imaging Studies for Low Back Pain	856	0	945	0	1	0.9058	0	0.8951	0	0.8141	1003345
DY13	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	44	0	1085	0	1	0.040552995	0	None	None	None	501672.5
DY13	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: Inappropriate Score	157	0	1036	0	1	0.151544402	0	None	None	None	501672.5
DY13	DPH	San Mateo Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT)	422	0	23960	0	1	0.0176	0	0.0231	0	0	747125
DY13	DPH	San Mateo Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1082	0	4339	0	1	0.2494	0	0.2608	0	0.2936	747125
DY13	DPH	San Mateo Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	4798	0	19965	0	1	0.2403	0	0.0265	0	0.1814	747125
DY13	DPH	San Mateo Medical Center	1.1.6.t	Tobacco Assessment and Counseling	17774	0	18435	0	1	0.9641	0	0.9606	0	0.9607	747125
DY13	DPH	San Mateo Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	16	0	None	4	1	None	4	None	None	None	0
DY13	DPH	San Mateo Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	16	0	None	4	0	None	4	None	None	None	0
DY13	DPH	San Mateo Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	16	0	None	4	1	None	4	None	None	None	0
DY13	DPH	San Mateo Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT)	422	0	23960	0	1	0.0176	0	0.0231	0	0	747125
DY13	DPH	San Mateo Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	187	0	279	0	1	0.6703	0	None	None	0.6837	747125
DY13	DPH	San Mateo Medical Center	1.2.11	REAL data completeness	32279	0	32965	0	1	0.9792	0	0.9965	0	None	747125
DY13	DPH	San Mateo Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	4798	0	19965	0	1	0.2403	0	0.0265	0	0.1814	747125
DY13	DPH	San Mateo Medical Center	1.2.13	SO/GI data completeness	16604	0	21512	0	1	0.7718	0	0	0	None	747125
DY13	DPH	San Mateo Medical Center	1.2.14.t	Tobacco Assessment and Counseling	17774	0	18435	0	1	0.9641	0	0.9606	0	0.9607	747125
DY13	DPH	San Mateo Medical Center	1.2.2	CG-CAHPS: Provider Rating	1358	0	1694	0	1	0.8017	0	0.824	0	0.7148	747125
DY13	DPH	San Mateo Medical Center	1.2.3.c	Colorectal Cancer Screening	5253	0	8404	0	1	0.6251	0	0.5956	0	0.6018	747125
DY13	DPH	San Mateo Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1082	0	4339	0	1	0.2494	0	0.2608	0	0.2936	747125
DY13	DPH	San Mateo Medical Center	1.2.5.b	Controlling Blood Pressure	4424	0	6002	0	1	0.7371	0	0.7263	0	0.7041	747125
DY13	DPH	San Mateo Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	780	0	826	0	1	0.9443	0	0.8613	0	0.8646	747125
DY13	DPH	San Mateo Medical Center	1.2.8	Prevention Quality Overall Composite #90	236	0	21208	0	1	0.0111	0	0.0042	0	0	747125
DY13	DPH	San Mateo Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	13077	0	13077	0	1	1	0	1	0	0.832	747125
DY13	DPH	San Mateo Medical Center	1.3.2	DHCS All-Cause Readmissions	29	0	385	0	1	0.0753	0	0.0936	0	0.129	747125
DY13	DPH	San Mateo Medical Center	1.3.3	Influenza Immunization	8878	0	13104	0	1	0.6775	0	0.6104	0	0.6134	747125
DY13	DPH	San Mateo Medical Center	1.3.4	Post Procedure ED Visits	319	0	12849	0	1	0.0248	0	0.0253	0	0	747125
DY13	DPH	San Mateo Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	3173	0	29361	0	1	0.1081	0	0.0752	0	0	747125
DY13	DPH	San Mateo Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	None	1	33681	0	1	None	1	0	0	0	747125
DY13	DPH	San Mateo Medical Center	1.3.7	Tobacco Assessment and Counseling	5982	0	6154	0	1	0.9721	0	0.9643	0	0.9619	747125
DY13	DPH	San Mateo Medical Center	1.6.1	BIRADS to Biopsy	65	0	153	0	1	0.4248	0	0.4473	0	0	747125
DY13	DPH	San Mateo Medical Center	1.6.2	Breast Cancer Screening	4116	0	5508	0	1	0.7473	0	0.7354	0	0.7144	747125
DY13	DPH	San Mateo Medical Center	1.6.3	Cervical Cancer Screening	6490	0	10926	0	1	0.594	0	0.5696	0	0.5825	747125
DY13	DPH	San Mateo Medical Center	1.6.4.c	Colorectal Cancer Screening	5253	0	8404	0	1	0.6251	0	0.5956	0	0.6018	747125
DY13	DPH	San Mateo Medical Center	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	189	0	2691	0	1	0.0702	0	0.0843	0	0	747125
DY13	DPH	San Mateo Medical Center	2.2.1	DHCS All-Cause Readmissions	34	0	434	0	1	0.0783	0	0.0865	0	0.129	1287353.84
DY13	DPH	San Mateo Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	4767	0	10000	0	0	0.4767	0	0.52	0	0.529	1287353.84
DY13	DPH	San Mateo Medical Center	2.2.3	Medication Reconciliation – 30 days	538	0	833	0	1	0.6459	0	0	0	0.099	1287353.84
DY13	DPH	San Mateo Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	898	0	925	0	1	0.9708	0	0.9394	0	0.9445	1287353.84
DY13	DPH	San Mateo Medical Center	2.2.5	Timely Transmission of Transition Record	2221	0	2228	0	1	0.9969	0	0.9946	0	0.99	1287353.84
DY13	DPH	San Mateo Medical Center	2.3.2	Medication Reconciliation – 30 days	63	0	110	0	1	0.5727	0	0	0	0.099	1287353.85
DY13	DPH	San Mateo Medical Center	2.3.3	Prevention Quality Overall Composite #90	29	0	95	0	1	0.3053	0	0.0541	0	0	1287353.85
DY13	DPH	San Mateo Medical Center	2.3.4	Timely Transmission of Transition Record	234	0	234	0	1	1	0	0.9952	0	0.99	1287353.85
DY13	DPH	San Mateo Medical Center	2.4.1	Adolescent Well-Care Visit	33	0	39	0	1	0.8462	0	None	4	0.6604	1287353.85
DY13	DPH	San Mateo Medical Center	2.4.2	Developmental Screening in the First Three Years of Life	None	1	None	4	0	None	1	None	1	0.3975	0
DY13	DPH	San Mateo Medical Center	2.4.3	Documentation of Current Medications in the Medical Record (0-18 yo)	154	0	209	0	1	0.7368	0	0.8065	0	0	1287353.85
DY13	DPH	San Mateo Medical Center	2.4.4	Screening for Clinical Depression and follow-up	None	1	None	4	0	None	1	None	1	0.2963	0
DY13	DPH	San Mateo Medical Center	2.4.5	Tobacco Assessment and Counseling (13 yo and older)	29	0	None	4	0	None	4	None	4	0.9462	0
DY13	DPH	San Mateo Medical Center	2.4.7	Well Child Visits - Third, Fourth, Fifth, and Sixth Years of life	None	1	None	4	0	None	1	None	1	0.8194	0
DY13	DPH	San Mateo Medical Center	2.4.8	Comprehensive Medical Evaluation Following Foster Youth Placement in Foster Care	None	1	None	4	0	None	1	None	None	0	0
DY13	DPH	San Mateo Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT)	None	1	346	0	1	None	1	None	1	0	1287353.85
DY13	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
DY13	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
DY13	DPH	San Mateo Medical Center	2.6.4	Screening for Clinical Depression and follow-up	86	0	312	0	1	0.2756	0	None	1	0.1814	1287353.85
DY13	DPH	San Mateo Medical Center	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	303	0	352	0	1	0.8608	0	0.875	0	0	1287353.85
DY13	DPH	San Mateo Medical Center	3.2.1	Imaging for Routine Headaches (Choosing Wisely)	195	0	1320	0	1	0.1477	0	0.1494	0	0.1491	1045975
DY13	DPH	San Mateo Medical Center	3.2.2	Appropriate Emergency Department Utilization of CT for Pulmonary Embolism	119	0	174	0	1	0.6839	0	None	1	0.1108	1045975
DY13	DPH	San Mateo Medical Center	3.2.3	Use of Imaging Studies for Low Back Pain	620	0	679	0	1	0.9131	0	0.8962	0	0.8141	1045975
DY13	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	231	0	1278	0	1	0.180751174	0	None	None	None	522987.5
DY13	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: Inappropriate Score	107	0	988	0	1	0.108299595	0	None	None	None	522987.5
DY13	DPH	Santa Clara Valley Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT)	1145	0	51435	0	1	0.0223	0	None	1	0	2220062.97
DY13	DPH	Santa Clara Valley Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	3151	0	11159	0	1	0.2824	0	0.2851	0	0.2936	2220062.97
DY13	DPH	Santa Clara Valley Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	15704	0	35237	0	1	0.4457	0	0.337	0	0.3878	2220062.97
DY13	DPH	Santa Clara Valley Medical Center	1.1.6.t	Tobacco Assessment and Counseling	30816	0	31198	0	1	0.9878	0	0.9317	0	0.9347	2220062.97
DY13	DPH	Santa Clara Valley Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	657	0	1536	0	1	0.427734375	0	None	None	None	740020.99
DY13	DPH	Santa Clara Valley Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	86	0	1536	0	1	0.055989583	0	None	None	None	740020.99
DY13	DPH	Santa Clara Valley Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	158	0	1536	0	1	0.102864583	0	None	None	None	740020.99
DY13	DPH	Santa Clara Valley Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT)	1145	0	51435	0	1	0.0223	0	None	1	0	2220062.97
DY13	DPH	Santa Clara Valley Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	1400	0	4415	0	0	0.3171	0	None	None	0.3146	2220062.96
DY13	DPH	Santa Clara Valley Medical Center	1.2.11	REAL data completeness	42790	0	60519	0	1	0.7071	0	0.4186	0	None	2220062.96
DY13	DPH	Santa Clara Valley Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	15704	0	35237	0	1	0.4457	0	0.337	0	0.3878	2220062.96
DY13	DPH	Santa Clara Valley Medical Center	1.2.13	SO/GI data completeness	18880	0	39281	0	1	0.4806	0	0	0	None	2220062.96
DY13	DPH	Santa Clara Valley Medical Center	1.2.14.t	Tobacco Assessment and Counseling	30816	0	31198	0	1	0.9878	0	0.9317	0	0.9347	2220062.96
DY13	DPH	Santa Clara Valley Medical Center	1.2.2	CG-CAHPS: Provider Rating	5113	0	6937	0	1	0.7371	0	0.7396	0	0.7148	2220062.97
DY13	DPH	Santa Clara Valley Medical Center	1.2.3.c	Colorectal Cancer Screening	15391	0	21656	0	1	0.7107	0	0.7069	0	0.6571	2220062.97
DY13	DPH	Santa Clara Valley Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	3151	0	11159	0	1	0.2824	0	0.2851	0	0.2936	2220062.96
DY13	DPH	Santa Clara Valley Medical Center	1.2.5.b	Controlling Blood Pressure	8379	0	12294	0	1	0.6816	0	0.6696	0	0.6731	2220062.96
DY13	DPH	Santa Clara Valley Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	1548	0	1634	0	1	0.9474	0	0.8935	0	0.8153	2220062.96
DY13	DPH	Santa Clara Valley Medical Center	1.2.8	Prevention Quality Overall Composite #90	810	0	65282	0	1	0.0124	0	0.0094	0	0	2220062.96
DY13	DPH	Santa Clara Valley Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	31658	0	32318	0	1	0.9796	0	0.1923	0	0.2563	2220062.96
DY13	DPH	Santa Clara Valley Medical Center	1.3.2	DHCS All-Cause Readmissions	265	0	1896	0	1	0.1398	0	0.1413	0	0.1401	2220062.96
DY13	DPH	Santa Clara Valley Medical Center	1.3.3	Influenza Immunization	13726	0	16136	0	1	0.8506	0	0.6867	0	0.64	2220062.96
DY13	DPH	Santa Clara Valley Medical Center	1.3.4	Post Procedure ED Visits	112	0	24640	0	1	0.0045	0	0.0099	0	0	2220062.96
DY13	DPH	Santa Clara Valley Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	46739	0	83790	0	1	0.5578	0	0.2887	0	0	2220062.96
DY13	DPH	Santa Clara Valley Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	3302	0	61056	0	1	0.0541	0	0.0291	0	0	2220062.96
DY13	DPH	Santa Clara Valley Medical Center	1.3.7	Tobacco Assessment and Counseling	21918	0	22117	0	1	0.991	0	0.9415	0	0.9435	2220062.96
DY13	DPH	Santa Clara Valley Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	15237	0	16659	0	1	0.914640735	0	0.9056	0	None	740020.9867
DY13	DPH	Santa Clara Valley Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	8971	0	9574	0	1	0.937016921	0	0.947	0	None	740020.9867
DY13	DPH	Santa Clara Valley Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	2895	0	6587	0	1	0.439502049	0	0.3782	0	None	740020.9867
DY13	DPH	Santa Clara Valley Medical Center	1.4.2	Annual Monitoring for Patients on Persistent Medications	17065	0	18493	0	1	0.9228	0	0.9014	0	0.9034	2220062.96
DY13	DPH	Santa Clara Valley Medical Center	1.4.3	INR Monitoring for Individuals on Warfarin	684	0	829	0	1	0.8251	0	0.7803	0	0.7813	2220062.96
DY13	DPH	Santa Clara Valley Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation No	No	0	BFUSA Cert?	0	0	see specification	0	None	None	None	999028.335
DY13	DPH	Santa Clara Valley Medical Center	2.1.1	Baby Friendly Hospital designation: Development Phase Complete Yes	Yes	0	Development Phase?	0	1	see specification	0	None	None	None	999028.335
DY13	DPH	Santa Clara Valley Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	1305	0	1991	0	1	0.6554	0	0.5554	0	0.5778	1998056.67
DY13	DPH	Santa Clara Valley Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	2220	0	1	None	1	None	1	0	1998056.67
DY13	DPH	Santa Clara Valley Medical Center	2.1.4	OB Hemorrhage: Total Products Transfused	81	0	2220	0	1	0.0365	0	0.0188	0	0	1998056.67
DY13	DPH	Santa Clara Valley Medical Center	2.1.5	PC-02 Cesarean Section	142	0	664	0	1	0.2139	0	0.2643	0	0.2599	1998056.67
DY13	DPH	Santa Clara Valley Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	289	0	335	0	1	0.862686567	0	0.8471	0	0.8534	999028.335
DY13	DPH	Santa Clara Valley Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	240	0	335	0	1	0.71641791	0	0.6818	0	0.6872	999028.335
DY13	DPH	Santa Clara Valley Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	1	223	0	1	None	1	0.0531	0	0	1998056.67
DY13	DPH	Santa Clara Valley Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	43	0	1886	0	1	0.0228	0	0.0362	0	0	1998056.67
DY13	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	1	see specification	0	None	None	None	499514.1675
DY13	DPH	Santa Clara Valley Medical Center	2.1.9	OB Hemorrhage Safety Bundle: Please specify which elements have been completed in the textbox below No	0	0	0	0	0	see specification	0	None	None	None	499514.1675
DY13	DPH	Santa Clara Valley Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	0	0	0	0	0	see specification	0	None	None	None	499514.1675
DY13	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) Yes	0	0	0	0	0	see specification	0	None	None	None	499514.1675
DY13	DPH	Santa Clara Valley Medical Center	2.2.1	DHCS All-Cause Readmissions	277	0	2063	0	1	0.1343	0	0.1358	0	0.1351	1998056.67
DY13	DPH	Santa Clara Valley Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	4112	0	10000	0	0	0.4112	0	0.3948	0	0.48	1998056.67
DY13	DPH	Santa Clara Valley Medical Center	2.2.3	Medication Reconciliation – 30 days	2826	0	4246	0	1	0.6656	0	0.5797	0	0.6207	1998056.67
DY13	DPH	Santa Clara Valley Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	7366	0	7714	0	0	0.9549	0	0.9584	0	0.9616	1998056.67
DY13	DPH	Santa Clara Valley Medical Center	2.2.5	Timely Transmission of Transition Record	2617	0	5870	0	1	0.4458	0	0.2199	0	0.2969	1998056.67
DY13	DPH	Santa Clara Valley Medical Center	2.3.2	Medication Reconciliation – 30 days	196	0	287	0	1	0.6829	0	0.588	0	0.6282	1998056.67
DY13	DPH	Santa Clara Valley Medical Center	2.3.3	Prevention Quality Overall Composite #90	69	0	965	0	1	0.0715	0	0.0559	0	0	1998056.67
DY13	DPH	Santa Clara Valley Medical Center	2.3.4	Timely Transmission of Transition Record	163	0	347	0	1	0.4697	0	0.2212	0	0.2981	1998056.66
DY13	DPH	Santa Clara Valley Medical Center	2.4.1	Adolescent Well-Care Visit	97	0	98	0	1	0.9898	0	0.8462	0	0.6604	1998056.66
DY13	DPH	Santa Clara Valley Medical Center	2.4.2	Developmental Screening in the First Three Years of Life	None	1	85	0	1	None	1	0	0	0.06	1998056.66
DY13	DPH	Santa Clara Valley Medical Center	2.4.3	Documentation of Current Medications in the Medical Record (0-18 yo)	852	0	1007	0	1	0.8461	0	0.8434	0	0	1998056.66
DY13	DPH	Santa Clara Valley Medical Center	2.4.4	Screening for Clinical Depression and follow-up	166	0	255	0	1	0.651	0	None	1	0.1814	1998056.66
DY13	DPH	Santa Clara Valley Medical Center	2.4.5	Tobacco Assessment and Counseling (13 yo and older)	22	0	None	4	0	None	4	0.8	0	0.8162	1998056.66
DY13	DPH	Santa Clara Valley Medical Center	2.4.7	Well Child Visits - Third, Fourth, Fifth, and Sixth Years of life	58	0	58	0	1	1	0	0.875	0	0.8297	1998056.66
DY13	DPH	Santa Clara Valley Medical Center	2.4.8	Comprehensive Medical Evaluation Following Foster Youth Placement in Foster Care	235	0	305	0	1	0.7705	0	None	None	0	1998056.66
DY13	DPH	Santa Clara Valley Medical Center	3.3.1	Adherence to Medications: Rate 1	110	0	235	0	1	0.468085106	0	0.3158	0	None	1998056.67
DY13	DPH	Santa Clara Valley Medical Center	3.3.1	Adherence to Medications: Rate 2	164	0	323	0	N/A	0.507739938	0	0.3158	0	None	1998056.67
DY13	DPH	Santa Clara Valley Medical Center	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 1	114	0	125	0	1	0.912	0	0.9833	0	None	1998056.665
DY13	DPH	Santa Clara Valley Medical Center	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 2	114	0	135	0	N/A	0.844444444	0	0.9833	0	None	1998056.665
DY13	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	2263	0	5607	0	1	0.40360264	0	0.4567	0	None	1998056.665
DY13	DPH	Santa Clara Valley Medical Center	3.3.4	Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 2	2870	0	7176	0	N/A	0.399944259	0	0.4567	0	None	1998056.665
DY13	DMPH	Seneca Healthcare District, Chester	2.2.1	DHCS All-Cause Readmissions	13	0	125	0	1	0.104	0	0.0803	0	0.129	300000
DY13	DMPH	Seneca Healthcare District, Chester	2.2.2	H-CAHPS: Care Transition Metrics (3)	4558	0	10000	0	0	0.4558	0	0.2581	0	0.48	300000
DY13	DMPH	Seneca Healthcare District, Chester	2.2.3	Medication Reconciliation – 30 days	59	0	59	0	1	1	0	0.6634	0	0.6961	300000
DY13	DMPH	Seneca Healthcare District, Chester	2.2.4	Reconciled Medication List Received by Discharged Patients	62	0	125	0	1	0.496	0	0.1972	0	0.2765	300000
DY13	DMPH	Seneca Healthcare District, Chester	2.2.5	Timely Transmission of Transition Record	101	0	103	0	1	0.9806	0	0.7113	0	0.7392	300000
DY13	DMPH	Sierra View District Hospital, Porterville	1.7.1	BMI Screening and Follow-up	2516	0	3431	0	1	0.7333	0	0.0991	0	0.4249	626666.67
DY13	DMPH	Sierra View District Hospital, Porterville	1.7.2	Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Please specify which critera have been met in the textbox below. No	0	0	0	0	N/A	N/A - see narrative	0	N/A	0	None	313333.335
DY13	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 5)	5	0	8	0	1	see specification	0	N/A	0	None	313333.335
DY13	DMPH	Sierra View District Hospital, Porterville	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI	721	0	729	0	1	0.989026063	0	0	0	0.545	208888.89
DY13	DMPH	Sierra View District Hospital, Porterville	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition	692	0	729	0	1	0.949245542	0	0	0	0.5184	208888.89
DY13	DMPH	Sierra View District Hospital, Porterville	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity	691	0	729	0	1	0.9478738	0	0	0	0.4509	208888.89
DY13	DMPH	Sierra View District Hospital, Porterville	2.2.1	DHCS All-Cause Readmissions	158	0	1494	0	1	0.1058	0	0.1622	0	0.1589	626666.67
DY13	DMPH	Sierra View District Hospital, Porterville	2.2.2	H-CAHPS: Care Transition Metrics (3)	4084	0	10000	0	0	0.4084	0	0.425	0	0.48	626666.67
DY13	DMPH	Sierra View District Hospital, Porterville	2.2.3	Medication Reconciliation – 30 days	379	0	394	0	1	0.9619	0	0	0	0.099	626666.67
DY13	DMPH	Sierra View District Hospital, Porterville	2.2.4	Reconciled Medication List Received by Discharged Patients	48	0	395	0	1	0.1215	0	0	0	0.099	626666.67
DY13	DMPH	Sierra View District Hospital, Porterville	2.2.5	Timely Transmission of Transition Record	390	0	3393	0	1	0.1149	0	0	0	0.099	626666.67
DY13	DMPH	Sierra View District Hospital, Porterville	2.3.2	Medication Reconciliation – 30 days	70	0	73	0	1	0.9589	0	0	0	0.099	626666.67
DY13	DMPH	Sierra View District Hospital, Porterville	2.3.3	Prevention Quality Overall Composite #90	87	0	501	0	1	0.1737	0	0.1929	0	0	626666.67
DY13	DMPH	Sierra View District Hospital, Porterville	2.3.4	Timely Transmission of Transition Record	115	0	384	0	1	0.2995	0	0	0	0.099	626666.66
DY13	DMPH	Sierra View District Hospital, Porterville	2.7.1	Advance Care Plan	None	1	None	4	0	None	1	None	1	0.2048	0
DY13	DMPH	Sierra View District Hospital, Porterville	2.7.2	Ambulatory Palliative Care Team Established: Ambulatory Palliative Care Team Established? Yes	Yes	0	Team Established?	0	1	None	0	None	None	None	626666.66
DY13	DMPH	Sierra View District Hospital, Porterville	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	191	0	215	0	1	0.8884	0	0.9792	0	0.78	626666.66
DY13	DMPH	Sierra View District Hospital, Porterville	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	12	0	None	4	0	None	4	0	0	0	0
DY13	DMPH	Sierra View District Hospital, Porterville	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	141	0	515	0	1	0.2738	0	0.0773	0	0	626666.66
DY13	DMPH	Sierra View District Hospital, Porterville	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	None	1	41	0	1	None	1	0.3824	0	0.25	626666.66
DY13	DMPH	Sonoma Valley Hospital, Sonoma	2.2.1	DHCS All-Cause Readmissions	12	0	107	0	1	0.1121	0	0.1867	0	0.1745	300000
DY13	DMPH	Sonoma Valley Hospital, Sonoma	2.2.2	H-CAHPS: Care Transition Metrics (3)	94	0	178	0	0.5	0.5281	0	0.5238	0	0.5324	300000
DY13	DMPH	Sonoma Valley Hospital, Sonoma	2.2.3	Medication Reconciliation – 30 days	23	0	96	0	1	0.2396	0	None	1	0.1116	300000
DY13	DMPH	Sonoma Valley Hospital, Sonoma	2.2.4	Reconciled Medication List Received by Discharged Patients	245	0	274	0	1	0.8942	0	0.229	0	0.3051	300000
DY13	DMPH	Sonoma Valley Hospital, Sonoma	2.2.5	Timely Transmission of Transition Record	44	0	250	0	1	0.176	0	None	1	0.1068	300000
DY13	DMPH	Sonoma West Medical Center, Sebastopol	2.2.1	DHCS All-Cause Readmissions	None	1	56	0	1	None	1	0.0972	0	0.129	300000
DY13	DMPH	Sonoma West Medical Center, Sebastopol	2.2.2	H-CAHPS: Care Transition Metrics (3)	52	0	100	0	1	0.52	0	0.45	0	0.48	300000
DY13	DMPH	Sonoma West Medical Center, Sebastopol	2.2.3	Medication Reconciliation – 30 days	34	0	34	0	1	1	0	0.8667	0	0.879	300000
DY13	DMPH	Sonoma West Medical Center, Sebastopol	2.2.4	Reconciled Medication List Received by Discharged Patients	51	0	59	0	1	0.8644	0	0.7778	0	0.799	300000
DY13	DMPH	Sonoma West Medical Center, Sebastopol	2.2.5	Timely Transmission of Transition Record	56	0	56	0	1	1	0	0.2986	0	0.3677	300000
DY13	DMPH	Southern Inyo Hospital, Lone Pine	1.2.1.a	Alcohol and Drug Misuse (SBIRT)	193	0	344	0	1	0.561	0	0	0	0	115384.61
DY13	DMPH	Southern Inyo Hospital, Lone Pine	1.2.10	REAL and/or SO/GI disparity reduction	0	0	0	0	0	0	0	None	None	None	115384.61
DY13	DMPH	Southern Inyo Hospital, Lone Pine	1.2.11	REAL data completeness	203	0	363	0	0.75	0.5592	0	0	0	0.6	115384.62
DY13	DMPH	Southern Inyo Hospital, Lone Pine	1.2.12.f	Screening for Clinical Depression and follow-up	11	0	335	0	0	0.0328	0	0	0	0.1814	115384.62
DY13	DMPH	Southern Inyo Hospital, Lone Pine	1.2.13	SO/GI data completeness	250	0	335	0	1	0.7463	0	0	0	0.1	115384.62
DY13	DMPH	Southern Inyo Hospital, Lone Pine	1.2.14.t	Tobacco Assessment and Counseling	304	0	335	0	1	0.9075	0	0	0	0.759	115384.62
DY13	DMPH	Southern Inyo Hospital, Lone Pine	1.2.2	CG-CAHPS: Provider Rating	0	0	344	0	0	0	0	0	0	0.6228	115384.61
DY13	DMPH	Southern Inyo Hospital, Lone Pine	1.2.3.c	Colorectal Cancer Screening	167	0	184	0	1	0.9076	0	None	1	0.2669	115384.61
DY13	DMPH	Southern Inyo Hospital, Lone Pine	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	1	47	0	1	None	1	None	1	0.2936	115384.61
DY13	DMPH	Southern Inyo Hospital, Lone Pine	1.2.5.b	Controlling Blood Pressure	43	0	94	0	0	0.4574	0	None	1	0.4687	115384.61
DY13	DMPH	Southern Inyo Hospital, Lone Pine	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	0	0	None	4	0	None	4	0	0	0.7022	0
DY13	DMPH	Southern Inyo Hospital, Lone Pine	1.2.8	Prevention Quality Overall Composite #90	0	0	0	0	0	0	0	0	0	0	0
DY13	DMPH	Southern Inyo Hospital, Lone Pine	1.6.1	BIRADS to Biopsy	0	0	0	0	0	0	0	None	1	0	0
DY13	DMPH	Southern Inyo Hospital, Lone Pine	1.6.2	Breast Cancer Screening	58	0	91	0	1	0.6374	0	0.2931	0	0.5228	115384.62
DY13	DMPH	Southern Inyo Hospital, Lone Pine	1.6.3	Cervical Cancer Screening	42	0	63	0	1	0.6667	0	0	0	0.4834	115384.62
DY13	DMPH	Southern Inyo Hospital, Lone Pine	1.6.4.c	Colorectal Cancer Screening	167	0	184	0	1	0.9076	0	None	1	0.2669	115384.62
DY13	DMPH	Southern Inyo Hospital, Lone Pine	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	None	1	None	4	0	None	1	None	1	0	0
DY13	DMPH	Tahoe Forest Hospital District, Truckee	1.5.1.b	Controlling Blood Pressure	116	0	154	0	1	0.7532	0	0.7358	0	0.7041	188888.89
DY13	DMPH	Tahoe Forest Hospital District, Truckee	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	31	0	38	0	1	0.8158	0	None	4	0.7022	188888.89
DY13	DMPH	Tahoe Forest Hospital District, Truckee	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	234	0	388	0	1	0.6031	0	0.1027	0	0.28	188888.89
DY13	DMPH	Tahoe Forest Hospital District, Truckee	1.5.4.t	Tobacco Assessment and Counseling	526	0	555	0	1	0.9477	0	0.9455	0	0.9471	188888.89
DY13	DMPH	Tahoe Forest Hospital District, Truckee	2.6.1	Alcohol and Drug Misuse (SBIRT)	28	0	480	0	1	0.0583	0	0.0252	0	0	188888.89
DY13	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	32	0	116	0	1	0.2759	0	None	1	0	188888.89
DY13	DMPH	Tahoe Forest Hospital District, Truckee	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	33	0	116	0	1	0.2845	0	None	1	0	188888.89
DY13	DMPH	Tahoe Forest Hospital District, Truckee	2.6.4	Screening for Clinical Depression and follow-up	40	0	124	0	1	0.3226	0	None	1	0.1814	188888.89
DY13	DMPH	Tahoe Forest Hospital District, Truckee	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	167	0	195	0	1	0.8564	0	0.7634	0	0	188888.88
DY13	DMPH	Tri-City Medical Center, Oceanside	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	0	0	0	0	None	None	0	None	None	None	41740.5406
DY13	DMPH	Tri-City Medical Center, Oceanside	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	0	0	0	0	None	None	0	None	None	None	41740.5406
DY13	DMPH	Tri-City Medical Center, Oceanside	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	0	0	0	0	None	None	0	None	None	None	41740.5406
DY13	DMPH	Tri-City Medical Center, Oceanside	1.4.2	Annual Monitoring for Patients on Persistent Medications	0	0	0	0	None	None	0	None	None	None	0
DY13	DMPH	Tri-City Medical Center, Oceanside	1.4.3	INR Monitoring for Individuals on Warfarin	0	0	0	0	None	None	0	None	None	None	0
DY13	DMPH	Tri-City Medical Center, Oceanside	1.5.1.b	Controlling Blood Pressure	1560	0	2704	0	1	0.5769	0	0	0	0.4687	424994.59
DY13	DMPH	Tri-City Medical Center, Oceanside	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	57	0	57	0	1	1	0	1	0	0.9173	424994.59
DY13	DMPH	Tri-City Medical Center, Oceanside	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	1592	0	4393	0	1	0.3624	0	0.2524	0	0.2872	424994.59
DY13	DMPH	Tri-City Medical Center, Oceanside	1.5.4.t	Tobacco Assessment and Counseling	47	0	58	0	1	0.8103	0	None	1	0.759	424994.59
DY13	DMPH	Tri-City Medical Center, Oceanside	1.7.1	BMI Screening and Follow-up	858	0	1391	0	1	0.6168	0	0.4217	0	0.4686	424994.59
DY13	DMPH	Tri-City Medical Center, Oceanside	1.7.2	Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Please specify which critera have been met in the textbox below. No	0	0	0	0	N/A	N/A - see narrative	0	N/A	0	None	212497.295
DY13	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 5)	5	0	8	0	1	see specification	0	N/A	0	None	212497.295
DY13	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	0.545	0
DY13	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	0.5184	0
DY13	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	0.4509	0
DY13	DMPH	Tri-City Medical Center, Oceanside	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	None	0	None	None	None	212497.295
DY13	DMPH	Tri-City Medical Center, Oceanside	2.1.1	Baby Friendly Hospital designation: Development Phase Complete Yes	Yes	0	Development Phase?	0	1	see specification	0	None	None	None	212497.295
DY13	DMPH	Tri-City Medical Center, Oceanside	2.1.2	Exclusive Breast Milk Feeding (PC-05)	453	0	813	0	0	0.5572	0	0.5821	0	0.6018	424994.59
DY13	DMPH	Tri-City Medical Center, Oceanside	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	1616	0	1	None	1	0	0	0	424994.59
DY13	DMPH	Tri-City Medical Center, Oceanside	2.1.4	OB Hemorrhage: Total Products Transfused	50	0	1616	0	1	0.0309	0	0.0268	0	0	424994.59
DY13	DMPH	Tri-City Medical Center, Oceanside	2.1.5	PC-02 Cesarean Section	108	0	493	0	1	0.2191	0	0.203	0	0.22	424994.59
DY13	DMPH	Tri-City Medical Center, Oceanside	2.1.6	Prenatal and Postpartum Care: Prenatal Care	0	0	1455	0	0	0	0	0	0	0.7421	212497.295
DY13	DMPH	Tri-City Medical Center, Oceanside	2.1.6	Prenatal and Postpartum Care: Postpartum Care	0	0	1455	0	0	0	0	0	0	0.5547	212497.295
DY13	DMPH	Tri-City Medical Center, Oceanside	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	31	0	106	0	1	0.2925	0	0.3226	0	0	424994.59
DY13	DMPH	Tri-City Medical Center, Oceanside	2.1.8	Unexpected Newborn Complications (UNC)	109	0	1373	0	1	0.0794	0	0.0803	0	0	424994.59
DY13	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)	16	0	16	0	1	see specification	0	None	None	None	106248.65
DY13	DMPH	Tri-City Medical Center, Oceanside	2.1.9	OB Hemorrhage Safety Bundle: Please specify which elements have been completed in the textbox below No	0	0	0	0	0	see specification	0	None	None	None	106248.65
DY13	DMPH	Tri-City Medical Center, Oceanside	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter No	0	0	0	0	0	see specification	0	None	None	None	106248.65
DY13	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) Yes	0	0	0	0	0	see specification	0	None	None	None	106248.65
DY13	DMPH	Tri-City Medical Center, Oceanside	2.2.1	DHCS All-Cause Readmissions	175	0	3923	0	1	0.0446	0	0.0545	0	0.129	424994.6
DY13	DMPH	Tri-City Medical Center, Oceanside	2.2.2	H-CAHPS: Care Transition Metrics (3)	190	0	394	0	0	0.4822	0	0.5142	0	0.5238	424994.6
DY13	DMPH	Tri-City Medical Center, Oceanside	2.2.3	Medication Reconciliation – 30 days	0	0	0	0	0	0	0	0	0	0.099	0
DY13	DMPH	Tri-City Medical Center, Oceanside	2.2.4	Reconciled Medication List Received by Discharged Patients	14131	0	14604	0	1	0.9676	0	0.9199	0	0.9269	424994.6
DY13	DMPH	Tri-City Medical Center, Oceanside	2.2.5	Timely Transmission of Transition Record	15335	0	15666	0	1	0.9789	0	0.9631	0	0.9658	424994.6
DY13	DMPH	Tri-City Medical Center, Oceanside	2.3.2	Medication Reconciliation – 30 days	0	0	0	0	0	0	0	0	0	0.099	0
DY13	DMPH	Tri-City Medical Center, Oceanside	2.3.3	Prevention Quality Overall Composite #90	325	0	1570	0	1	0.207	0	0.1319	0	0	424994.6
DY13	DMPH	Tri-City Medical Center, Oceanside	2.3.4	Timely Transmission of Transition Record	681	0	1620	0	1	0.4204	0	0.2776	0	0.3488	424994.6
DY13	DMPH	Tri-City Medical Center, Oceanside	2.7.1	Advance Care Plan	0	0	0	0	None	None	0	None	None	None	189729.73
DY13	DMPH	Tri-City Medical Center, Oceanside	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	0	0	0	0	None	None	0	None	None	None	0
DY13	DMPH	Tri-City Medical Center, Oceanside	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	0	0	0	0	None	None	0	None	1	0	0
DY13	DMPH	Tri-City Medical Center, Oceanside	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	0	0	0	0	None	None	0	None	None	0	189729.73
DY13	DMPH	Tri-City Medical Center, Oceanside	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	0	0	0	0	None	None	0	None	1	None	0
DY13	DMPH	Tri-City Medical Center, Oceanside	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	57	0	67	0	1	0.8507	0	0.5588	0	0.387	424994.6
DY13	DMPH	Tri-City Medical Center, Oceanside	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	14602	0	25380	0	1	0.5753	0	0.5801	0	0	424994.6
DY13	DMPH	Tri-City Medical Center, Oceanside	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	1526	0	2025	0	1	0.7536	0	0.6896	0	0	424994.6
DY13	DMPH	Tri-City Medical Center, Oceanside	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR No	8992	0	10000	0	0	0.8992	0	None	None	None	424994.6
DY13	DMPH	Trinity Hospital, Weaverville	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	753	0	771	0	1	0.976653696	0	0.8364	0	None	100000
DY13	DMPH	Trinity Hospital, Weaverville	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	179	0	179	0	1	1	0	0.8448	0	None	100000
DY13	DMPH	Trinity Hospital, Weaverville	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	135	0	136	0	1	0.992647059	0	0.375	0	None	100000
DY13	DMPH	Trinity Hospital, Weaverville	1.4.2	Annual Monitoring for Patients on Persistent Medications	294	0	353	0	0	0.8329	0	0.7756	0	0.8563	300000
DY13	DMPH	Trinity Hospital, Weaverville	1.4.3	INR Monitoring for Individuals on Warfarin	18	0	None	4	0	None	4	0.8103	0	0.79	0
DY13	DMPH	Trinity Hospital, Weaverville	1.6.1	BIRADS to Biopsy	None	1	None	1	0	None	1	0	0	0	0
DY13	DMPH	Trinity Hospital, Weaverville	1.6.2	Breast Cancer Screening	81	0	328	0	0	0.247	0	0.1493	0	0.5228	300000
DY13	DMPH	Trinity Hospital, Weaverville	1.6.3	Cervical Cancer Screening	231	0	689	0	0	0.3353	0	0.3892	0	0.4834	300000
DY13	DMPH	Trinity Hospital, Weaverville	1.6.4.c	Colorectal Cancer Screening	167	0	598	0	0.75	0.2793	0	0.2408	0	0.2824	300000
DY13	DMPH	Trinity Hospital, Weaverville	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	0	0	0	0	0	0	0	0	0	0	0
DY13	DPH	UC Davis Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT)	15	0	65173	0	1	0.0002	0	0	0	0	1043450
DY13	DPH	UC Davis Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1402	0	6839	0	1	0.205	0	0.2001	0	0.2936	1043450
DY13	DPH	UC Davis Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	20988	0	39251	0	1	0.5347	0	0.0393	0	0.1814	1043450
DY13	DPH	UC Davis Medical Center	1.1.6.t	Tobacco Assessment and Counseling	56814	0	58065	0	1	0.9785	0	0.9652	0	0.9619	1043450
DY13	DPH	UC Davis Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	204	0	1022	0	1	0.199608611	0	None	None	None	347816.6667
DY13	DPH	UC Davis Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	76	0	1022	0	1	0.074363992	0	None	None	None	347816.6667
DY13	DPH	UC Davis Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	99	0	1022	0	1	0.096868885	0	None	None	None	347816.6667
DY13	DPH	UC Davis Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT)	15	0	65173	0	1	0.0002	0	0	0	0	1043450
DY13	DPH	UC Davis Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	205	0	758	0	1	0.2704	0	None	None	0	1043450
DY13	DPH	UC Davis Medical Center	1.2.11	REAL data completeness	57521	0	72577	0	1	0.7926	0	0.984	0	None	1043450
DY13	DPH	UC Davis Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	20988	0	39251	0	1	0.5347	0	0.0393	0	0.1814	1043450
DY13	DPH	UC Davis Medical Center	1.2.13	SO/GI data completeness	19094	0	61396	0	1	0.311	0	0.0387	0	None	1043450
DY13	DPH	UC Davis Medical Center	1.2.14.t	Tobacco Assessment and Counseling	56814	0	58065	0	1	0.9785	0	0.9652	0	0.9619	1043450
DY13	DPH	UC Davis Medical Center	1.2.2	CG-CAHPS: Provider Rating	29349	0	34254	0	1	0.8568	0	0.8496	0	0.7148	1043450
DY13	DPH	UC Davis Medical Center	1.2.3.c	Colorectal Cancer Screening	22565	0	29789	0	1	0.7575	0	0.7249	0	0.6571	1043450
DY13	DPH	UC Davis Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1402	0	6839	0	1	0.205	0	0.2001	0	0.2936	1043450
DY13	DPH	UC Davis Medical Center	1.2.5.b	Controlling Blood Pressure	18894	0	23300	0	1	0.8109	0	0.7995	0	0.7041	1043450
DY13	DPH	UC Davis Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	2330	0	2527	0	1	0.922	0	0.9687	0	0.9095	1043450
DY13	DPH	UC Davis Medical Center	1.2.8	Prevention Quality Overall Composite #90	661	0	61074	0	1	0.0108	0	0.007	0	0	1043450
DY13	DPH	UC Davis Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	62602	0	82987	0	0.5	0.7544	0	0.7486	0	0.7569	1043450
DY13	DPH	UC Davis Medical Center	1.3.2	DHCS All-Cause Readmissions	497	0	3824	0	0	0.13	0	0.1275	0	0.129	1043450
DY13	DPH	UC Davis Medical Center	1.3.3	Influenza Immunization	18799	0	23013	0	1	0.8169	0	0.7049	0	0.64	1043450
DY13	DPH	UC Davis Medical Center	1.3.4	Post Procedure ED Visits	746	0	83787	0	1	0.0089	0	0.0099	0	0	1043450
DY13	DPH	UC Davis Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	81081	0	111798	0	1	0.7252	0	0.6878	0	0	1043450
DY13	DPH	UC Davis Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	1591	0	119086	0	1	0.0134	0	0.0138	0	0	1043450
DY13	DPH	UC Davis Medical Center	1.3.7	Tobacco Assessment and Counseling	23350	0	23670	0	1	0.9865	0	0.9802	0	0.9619	1043450
DY13	DPH	UC Davis Medical Center	1.5.1.b	Controlling Blood Pressure	18894	0	23300	0	1	0.8109	0	0.7995	0	0.7041	1043450
DY13	DPH	UC Davis Medical Center	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	2330	0	2527	0	1	0.922	0	0.9687	0	0.9095	1043450
DY13	DPH	UC Davis Medical Center	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	29732	0	35988	0	1	0.8262	0	0.8402	0	0.6	1043450
DY13	DPH	UC Davis Medical Center	1.5.4.t	Tobacco Assessment and Counseling	56814	0	58065	0	1	0.9785	0	0.9652	0	0.9619	1043450
DY13	DPH	UC Davis Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation No	No	0	BFUSA Cert?	0	0	see specification	0	None	None	None	531210.91
DY13	DPH	UC Davis Medical Center	2.1.1	Baby Friendly Hospital designation: Development Phase Complete Yes	Yes	0	Development Phase?	0	1	see specification	0	None	None	None	531210.91
DY13	DPH	UC Davis Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	261	0	391	0	1	0.6675	0	0.5914	0	0.6102	1062421.82
DY13	DPH	UC Davis Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	1290	0	1	None	1	None	1	0	1062421.82
DY13	DPH	UC Davis Medical Center	2.1.4	OB Hemorrhage: Total Products Transfused	123	0	1290	0	1	0.0953	0	0.0853	0	0	1062421.82
DY13	DPH	UC Davis Medical Center	2.1.5	PC-02 Cesarean Section	119	0	473	0	0	0.2516	0	0.2484	0	0.2456	1062421.82
DY13	DPH	UC Davis Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	685	0	863	0	0	0.793742758	0	0.8559	0	0.8613	531210.91
DY13	DPH	UC Davis Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	410	0	863	0	0	0.475086906	0	0.4785	0	0.5547	531210.91
DY13	DPH	UC Davis Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	21	0	190	0	1	0.1105	0	None	1	0	1062421.82
DY13	DPH	UC Davis Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	36	0	1006	0	1	0.0358	0	0.0501	0	0	1062421.82
DY13	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	see specification	0	None	None	None	265605.455
DY13	DPH	UC Davis Medical Center	2.1.9	OB Hemorrhage Safety Bundle: Please specify which elements have been completed in the textbox below No	0	0	0	0	0	see specification	0	None	None	None	265605.455
DY13	DPH	UC Davis Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	0	0	0	0	0	see specification	0	None	None	None	265605.455
DY13	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	0	0	0	0	0	see specification	0	None	None	None	265605.455
DY13	DPH	UC Davis Medical Center	2.2.1	DHCS All-Cause Readmissions	507	0	3971	0	1	0.1277	0	0.1237	0	0.129	1062421.82
DY13	DPH	UC Davis Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	2901	0	5152	0	1	0.5631	0	0.5559	0	0.5613	1062421.82
DY13	DPH	UC Davis Medical Center	2.2.3	Medication Reconciliation – 30 days	4682	0	4973	0	0.5	0.9415	0	0.9386	0	0.9437	1062421.82
DY13	DPH	UC Davis Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	7093	0	7153	0	1	0.9916	0	0.9622	0	0.965	1062421.82
DY13	DPH	UC Davis Medical Center	2.2.5	Timely Transmission of Transition Record	6231	0	6531	0	1	0.9541	0	0.9461	0	0.9505	1062421.82
DY13	DPH	UC Davis Medical Center	2.3.2	Medication Reconciliation – 30 days	1482	0	1539	0	0	0.963	0	0.9626	0	0.9653	1062421.82
DY13	DPH	UC Davis Medical Center	2.3.3	Prevention Quality Overall Composite #90	422	0	1171	0	1	0.3604	0	0.2209	0	0	1062421.82
DY13	DPH	UC Davis Medical Center	2.3.4	Timely Transmission of Transition Record	2011	0	2109	0	1	0.9535	0	0.93	0	0.936	1062421.82
DY13	DPH	UC Davis Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT)	14	0	6395	0	1	0.0022	0	0	0	0	1062421.82
DY13	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	1568	0	3164	0	1	0.4956	0	0.2437	0	0	1062421.81
DY13	DPH	UC Davis Medical Center	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	2453	0	3164	0	1	0.7753	0	0.1821	0	0	1062421.81
DY13	DPH	UC Davis Medical Center	2.6.4	Screening for Clinical Depression and follow-up	1688	0	2927	0	1	0.5767	0	0.0713	0	0.1814	1062421.81
DY13	DPH	UC Davis Medical Center	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	5527	0	6404	0	1	0.8631	0	0.882	0	0	1062421.81
DY13	DPH	UC Davis Medical Center	3.2.1	Imaging for Routine Headaches (Choosing Wisely)	621	0	4015	0	1	0.1547	0	0.1658	0	0.1639	1460830
DY13	DPH	UC Davis Medical Center	3.2.2	Appropriate Emergency Department Utilization of CT for Pulmonary Embolism	1025	0	1102	0	1	0.9301	0	0.8408	0	0.6707	1460830
DY13	DPH	UC Davis Medical Center	3.2.3	Use of Imaging Studies for Low Back Pain	1217	0	1384	0	1	0.8793	0	0.9028	0	0.8141	1460830
DY13	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	1615	0	11674	0	1	0.138341614	0	None	None	None	730415
DY13	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: Inappropriate Score	1380	0	11674	0	1	0.11821141	0	None	None	None	730415
DY13	DPH	UC Irvine Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT)	1478	0	16706	0	1	0.0885	0	0.1155	0	0	674566.67
DY13	DPH	UC Irvine Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	907	0	3199	0	1	0.2835	0	0.317	0	0.3147	674566.67
DY13	DPH	UC Irvine Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	10575	0	14161	0	1	0.7468	0	0.1818	0	0.2482	674566.67
DY13	DPH	UC Irvine Medical Center	1.1.6.t	Tobacco Assessment and Counseling	15102	0	15448	0	1	0.9776	0	0.9667	0	0.9619	674566.67
DY13	DPH	UC Irvine Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	12	0	94	0	1	0.127659574	0	None	None	None	224855.5567
DY13	DPH	UC Irvine Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	1	94	0	1	None	1	None	None	None	224855.5567
DY13	DPH	UC Irvine Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	1	94	0	1	None	1	None	None	None	224855.5567
DY13	DPH	UC Irvine Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT)	1478	0	16706	0	1	0.0885	0	0.1155	0	0	674566.67
DY13	DPH	UC Irvine Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	1314	0	2527	0	1	0.52	0	None	None	0.4781	674566.67
DY13	DPH	UC Irvine Medical Center	1.2.11	REAL data completeness	13320	0	20024	0	1	0.6652	0	0.0299	0	None	674566.67
DY13	DPH	UC Irvine Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	10575	0	14161	0	1	0.7468	0	0.1816	0	0.248	674566.67
DY13	DPH	UC Irvine Medical Center	1.2.13	SO/GI data completeness	7047	0	15839	0	1	0.4449	0	0.069	0	None	674566.67
DY13	DPH	UC Irvine Medical Center	1.2.14.t	Tobacco Assessment and Counseling	15104	0	15448	0	1	0.9777	0	0.967	0	0.9619	674566.67
DY13	DPH	UC Irvine Medical Center	1.2.2	CG-CAHPS: Provider Rating	1329	0	1581	0	1	0.8406	0	0.8321	0	0.7148	674566.67
DY13	DPH	UC Irvine Medical Center	1.2.3.c	Colorectal Cancer Screening	4028	0	6439	0	1	0.6256	0	0.5672	0	0.5762	674566.67
DY13	DPH	UC Irvine Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	907	0	3199	0	1	0.2835	0	0.317	0	0.3147	674566.67
DY13	DPH	UC Irvine Medical Center	1.2.5.b	Controlling Blood Pressure	1953	0	2846	0	1	0.6862	0	0.6534	0	0.6585	674566.67
DY13	DPH	UC Irvine Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	913	0	1063	0	1	0.8589	0	0.8348	0	0.8431	674566.67
DY13	DPH	UC Irvine Medical Center	1.2.8	Prevention Quality Overall Composite #90	194	0	16309	0	1	0.0119	0	0.0646	0	0	674566.67
DY13	DPH	UC Irvine Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	6101	0	6368	0	1	0.9581	0	0.9263	0	0.832	674566.67
DY13	DPH	UC Irvine Medical Center	1.3.2	DHCS All-Cause Readmissions	168	0	1509	0	1	0.1113	0	0.1771	0	0.1745	674566.66
DY13	DPH	UC Irvine Medical Center	1.3.3	Influenza Immunization	5917	0	8632	0	1	0.6855	0	0.4353	0	0.4558	674566.66
DY13	DPH	UC Irvine Medical Center	1.3.4	Post Procedure ED Visits	968	0	23554	0	1	0.0411	0	0.0655	0	0	674566.66
DY13	DPH	UC Irvine Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	11	0	4860	0	1	0.0023	0	0.2801	0	0	674566.66
DY13	DPH	UC Irvine Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	25	0	9837	0	1	0.0025	0	0.002	0	0	674566.66
DY13	DPH	UC Irvine Medical Center	1.3.7	Tobacco Assessment and Counseling	8783	0	8895	0	1	0.9874	0	0.9707	0	0.9619	674566.66
DY13	DPH	UC Irvine Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	1388	0	1435	0	1	0.967247387	0	0.9486	0	None	224855.5533
DY13	DPH	UC Irvine Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	470	0	487	0	1	0.965092402	0	0.642	0	None	224855.5533
DY13	DPH	UC Irvine Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	551	0	937	0	1	0.588046958	0	0.6619	0	None	224855.5533
DY13	DPH	UC Irvine Medical Center	1.4.2	Annual Monitoring for Patients on Persistent Medications	4967	0	5506	0	1	0.9021	0	0.8896	0	0.8928	674566.66
DY13	DPH	UC Irvine Medical Center	1.4.3	INR Monitoring for Individuals on Warfarin	594	0	688	0	1	0.8634	0	0.3336	0	0.3792	674566.66
DY13	DPH	UC Irvine Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	None	0	None	None	None	331150.91
DY13	DPH	UC Irvine Medical Center	2.1.1	Baby Friendly Hospital designation: Development Phase Complete Yes	Yes	0	Development Phase?	0	1	see specification	0	None	None	None	331150.91
DY13	DPH	UC Irvine Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	143	0	247	0	0	0.5789	0	0.6172	0	0.6334	662301.82
DY13	DPH	UC Irvine Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	12	0	1425	0	1	0.0084	0	0.0089	0	0	662301.82
DY13	DPH	UC Irvine Medical Center	2.1.4	OB Hemorrhage: Total Products Transfused	235	0	1425	0	1	0.1649	0	0.1609	0	0	662301.82
DY13	DPH	UC Irvine Medical Center	2.1.5	PC-02 Cesarean Section	91	0	444	0	1	0.205	0	0.2438	0	0.2414	662301.82
DY13	DPH	UC Irvine Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	367	0	424	0	1	0.865566038	0	0.4088	0	0.7421	331150.91
DY13	DPH	UC Irvine Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	299	0	424	0	1	0.705188679	0	0.5657	0	0.5827	331150.91
DY13	DPH	UC Irvine Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	43	0	196	0	1	0.2194	0	0.2153	0	0	662301.82
DY13	DPH	UC Irvine Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	25	0	985	0	1	0.0254	0	0.0164	0	0	662301.82
DY13	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	see specification	0	None	None	None	165575.455
DY13	DPH	UC Irvine Medical Center	2.1.9	OB Hemorrhage Safety Bundle: Please specify which elements have been completed in the textbox below No	0	0	0	0	0	see specification	0	None	None	None	165575.455
DY13	DPH	UC Irvine Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	0	0	0	0	0	see specification	0	None	None	None	165575.455
DY13	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	0	0	0	0	0	see specification	0	None	None	None	165575.455
DY13	DPH	UC Irvine Medical Center	2.2.1	DHCS All-Cause Readmissions	174	0	1625	0	1	0.1071	0	0.1645	0	0.161	662301.82
DY13	DPH	UC Irvine Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	3622	0	6579	0	0	0.5505	0	0.9426	0	0.61	662301.82
DY13	DPH	UC Irvine Medical Center	2.2.3	Medication Reconciliation – 30 days	1415	0	1753	0	0	0.8072	0	0.8699	0	0.8819	662301.82
DY13	DPH	UC Irvine Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	3011	0	3455	0	1	0.8715	0	0.5999	0	0.6389	662301.82
DY13	DPH	UC Irvine Medical Center	2.2.5	Timely Transmission of Transition Record	1362	0	1662	0	0	0.8195	0	0.987	0	0.9873	662301.82
DY13	DPH	UC Irvine Medical Center	2.3.2	Medication Reconciliation – 30 days	1176	0	1465	0	0	0.8027	0	0.8824	0	0.8932	662301.82
DY13	DPH	UC Irvine Medical Center	2.3.3	Prevention Quality Overall Composite #90	177	0	13039	0	1	0.0136	0	0.0734	0	0	662301.82
DY13	DPH	UC Irvine Medical Center	2.3.4	Timely Transmission of Transition Record	1208	0	1423	0	0	0.8489	0	0.987	0	0.9873	662301.82
DY13	DPH	UC Irvine Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT)	108	0	622	0	1	0.1736	0	None	1	0	662301.82
DY13	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	63	0	652	0	1	0.0966	0	None	1	0	662301.81
DY13	DPH	UC Irvine Medical Center	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	56	0	652	0	1	0.0859	0	0.1494	0	0	662301.81
DY13	DPH	UC Irvine Medical Center	2.6.4	Screening for Clinical Depression and follow-up	538	0	573	0	1	0.9389	0	0.1364	0	0.2073	662301.81
DY13	DPH	UC Irvine Medical Center	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	436	0	659	0	1	0.6616	0	0.8864	0	0	662301.81
DY13	DPH	UC Irvine Medical Center	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	22	0	43	0	1	0.5116	0	0.411	0	0.387	910665
DY13	DPH	UC Irvine Medical Center	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	30497	0	136288	0	1	0.2238	0	0.2509	0	0	910665
DY13	DPH	UC Irvine Medical Center	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	777	0	3475	0	1	0.2236	0	0.3402	0	0	910665
DY13	DPH	UC Irvine Medical Center	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR No	3510	0	10000	0	1	0.351	0	None	None	None	910665
DY13	DPH	UC Los Angeles Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT)	479	0	121579	0	1	0.0039	0	0.0143	0	0	483725.93
DY13	DPH	UC Los Angeles Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	281	0	2246	0	1	0.1251	0	0.1398	0	0.2936	483725.93
DY13	DPH	UC Los Angeles Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	17612	0	88755	0	0	0.1984	0	0.1914	0	0.2568	483725.93
DY13	DPH	UC Los Angeles Medical Center	1.1.6.t	Tobacco Assessment and Counseling	111073	0	115642	0	0	0.9605	0	0.9643	0	0.9619	483725.93
DY13	DPH	UC Los Angeles Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	191	0	982	0	1	0.194501018	0	None	None	None	161241.9767
DY13	DPH	UC Los Angeles Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	45	0	982	0	1	0.045824847	0	None	None	None	161241.9767
DY13	DPH	UC Los Angeles Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	71	0	982	0	1	0.072301426	0	None	None	None	161241.9767
DY13	DPH	UC Los Angeles Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT)	479	0	121579	0	1	0.0039	0	0.0143	0	0	483725.93
DY13	DPH	UC Los Angeles Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	1690	0	2560	0	1	0.6602	0	None	None	0.6549	483725.93
DY13	DPH	UC Los Angeles Medical Center	1.2.11	REAL data completeness	30205	0	135735	0	0.5	0.2225	0	0	0	None	483725.93
DY13	DPH	UC Los Angeles Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	17612	0	88755	0	0	0.1984	0	0.1914	0	0.2568	483725.93
DY13	DPH	UC Los Angeles Medical Center	1.2.13	SO/GI data completeness	1646	0	116631	0	0	0.0141	0	0	0	None	483725.93
DY13	DPH	UC Los Angeles Medical Center	1.2.14.t	Tobacco Assessment and Counseling	111073	0	115642	0	0	0.9605	0	0.9643	0	0.9619	483725.92
DY13	DPH	UC Los Angeles Medical Center	1.2.2	CG-CAHPS: Provider Rating	383	0	455	0	1	0.8418	0	0.772	0	0.7148	483725.93
DY13	DPH	UC Los Angeles Medical Center	1.2.3.c	Colorectal Cancer Screening	29394	0	49227	0	1	0.5971	0	0.5684	0	0.5773	483725.93
DY13	DPH	UC Los Angeles Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	281	0	2246	0	1	0.1251	0	0.1398	0	0.2936	483725.93
DY13	DPH	UC Los Angeles Medical Center	1.2.5.b	Controlling Blood Pressure	18931	0	27039	0	0	0.7001	0	0.714	0	0.7041	483725.93
DY13	DPH	UC Los Angeles Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	1892	0	2498	0	0	0.7574	0	0.7877	0	0.7936	483725.93
DY13	DPH	UC Los Angeles Medical Center	1.2.8	Prevention Quality Overall Composite #90	744	0	116131	0	1	0.0064	0	0.006	0	0	483725.93
DY13	DPH	UC Los Angeles Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	28790	0	29116	0	1	0.9888	0	0.9871	0	0.832	483725.92
DY13	DPH	UC Los Angeles Medical Center	1.3.2	DHCS All-Cause Readmissions	745	0	5064	0	1	0.1471	0	0.177	0	0.1745	483725.92
DY13	DPH	UC Los Angeles Medical Center	1.3.3	Influenza Immunization	45683	0	76612	0	1	0.5963	0	0.4464	0	0.4658	483725.92
DY13	DPH	UC Los Angeles Medical Center	1.3.4	Post Procedure ED Visits	2215	0	247082	0	1	0.009	0	0.0141	0	0	483725.92
DY13	DPH	UC Los Angeles Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	14976	0	48195	0	1	0.3107	0	0.1158	0	0	483725.92
DY13	DPH	UC Los Angeles Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	955	0	6150	0	1	0.1553	0	0.0531	0	0	483725.92
DY13	DPH	UC Los Angeles Medical Center	1.3.7	Tobacco Assessment and Counseling	74867	0	77061	0	1	0.9715	0	0.9714	0	0.9619	483725.92
DY13	DPH	UC Los Angeles Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	69641	0	75708	0	1	0.919863158	0	0.9191	0	None	161241.9733
DY13	DPH	UC Los Angeles Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	18869	0	19874	0	1	0.949431418	0	0.9394	0	None	161241.9733
DY13	DPH	UC Los Angeles Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	9206	0	12800	0	1	0.71921875	0	0.7486	0	None	161241.9733
DY13	DPH	UC Los Angeles Medical Center	1.4.2	Annual Monitoring for Patients on Persistent Medications	33943	0	37972	0	0	0.8939	0	0.894	0	0.8967	483725.92
DY13	DPH	UC Los Angeles Medical Center	1.4.3	INR Monitoring for Individuals on Warfarin	989	0	1575	0	1	0.6279	0	0.6031	0	0.6218	483725.92
DY13	DPH	UC Los Angeles Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	None	0	None	None	None	227140.87
DY13	DPH	UC Los Angeles Medical Center	2.1.1	Baby Friendly Hospital designation: Development Phase Complete Yes	Yes	0	Development Phase?	0	1	see specification	0	None	None	None	227140.87
DY13	DPH	UC Los Angeles Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	300	0	399	0	1	0.7519	0	0.7311	0	0.7359	454281.74
DY13	DPH	UC Los Angeles Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	480	0	1	None	1	None	1	0	454281.74
DY13	DPH	UC Los Angeles Medical Center	2.1.4	OB Hemorrhage: Total Products Transfused	76	0	480	0	1	0.1583	0	0.0831	0	0	454281.74
DY13	DPH	UC Los Angeles Medical Center	2.1.5	PC-02 Cesarean Section	70	0	249	0	0	0.2811	0	0.25	0	0.247	454281.74
DY13	DPH	UC Los Angeles Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	1886	0	1923	0	1	0.98075923	0	0.9781	0	0.91	227140.87
DY13	DPH	UC Los Angeles Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	1500	0	1923	0	1	0.780031201	0	0.772	0	0.7361	227140.87
DY13	DPH	UC Los Angeles Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	12	0	43	0	1	0.2791	0	None	1	0	454281.74
DY13	DPH	UC Los Angeles Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	13	0	396	0	1	0.0328	0	0.0472	0	0	454281.74
DY13	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	see specification	0	None	None	None	113570.435
DY13	DPH	UC Los Angeles Medical Center	2.1.9	OB Hemorrhage Safety Bundle: Please specify which elements have been completed in the textbox below No	0	0	0	0	0	see specification	0	None	None	None	113570.435
DY13	DPH	UC Los Angeles Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	0	0	0	0	0	see specification	0	None	None	None	113570.435
DY13	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	0	0	0	0	0	see specification	0	None	None	None	113570.435
DY13	DPH	UC Los Angeles Medical Center	2.2.1	DHCS All-Cause Readmissions	713	0	4833	0	1	0.1475	0	0.1743	0	0.1698	454281.74
DY13	DPH	UC Los Angeles Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	6020	0	10000	0	1	0.602	0	0.5793	0	0.5824	454281.74
DY13	DPH	UC Los Angeles Medical Center	2.2.3	Medication Reconciliation – 30 days	6057	0	6065	0	1	0.9987	0	0.9675	0	0.9698	454281.74
DY13	DPH	UC Los Angeles Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	9939	0	10112	0	1	0.9829	0	0.9806	0	0.9815	454281.74
DY13	DPH	UC Los Angeles Medical Center	2.2.5	Timely Transmission of Transition Record	8089	0	8107	0	1	0.9978	0	0.9622	0	0.965	454281.74
DY13	DPH	UC Los Angeles Medical Center	2.3.2	Medication Reconciliation – 30 days	3471	0	3473	0	1	0.9994	0	0.9912	0	0.99	454281.74
DY13	DPH	UC Los Angeles Medical Center	2.3.3	Prevention Quality Overall Composite #90	612	0	19802	0	1	0.0309	0	0.0328	0	0	454281.74
DY13	DPH	UC Los Angeles Medical Center	2.3.4	Timely Transmission of Transition Record	4347	0	4354	0	1	0.9984	0	0.9743	0	0.9759	454281.74
DY13	DPH	UC Los Angeles Medical Center	2.7.1	Advance Care Plan	12048	0	34380	0	1	0.3504	0	0.2316	0	0.3074	454281.74
DY13	DPH	UC Los Angeles Medical Center	2.7.2	Ambulatory Palliative Care Team Established: Ambulatory Palliative Care Team Established? Yes	Yes	0	Team Established?	0	1	None	0	None	None	None	454281.74
DY13	DPH	UC Los Angeles Medical Center	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	372	0	391	0	1	0.9514	0	0.8182	0	0.78	454281.74
DY13	DPH	UC Los Angeles Medical Center	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	189	0	208	0	1	0.9087	0	0.8438	0	0	454281.74
DY13	DPH	UC Los Angeles Medical Center	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	29	0	319	0	1	0.0909	0	0.043	0	0	454281.73
DY13	DPH	UC Los Angeles Medical Center	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	13	0	80	0	1	0.1625	0	None	1	0.2093	454281.73
DY13	DPH	UC Los Angeles Medical Center	3.3.1	Adherence to Medications: Rate 1	149	0	211	0	1	0.706161137	0	0.69	0	None	435353.335
DY13	DPH	UC Los Angeles Medical Center	3.3.1	Adherence to Medications: Rate 2	771	0	926	0	N/A	0.832613391	0	0.69	0	None	435353.335
DY13	DPH	UC Los Angeles Medical Center	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 1	0	0	129	0	1	0	0	0	0	None	435353.335
DY13	DPH	UC Los Angeles Medical Center	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 2	0	0	672	0	N/A	0	0	0	0	None	435353.335
DY13	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	1850	0	1853	0	1	0.998381004	0	0.8769	0	None	435353.33
DY13	DPH	UC Los Angeles Medical Center	3.3.4	Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 2	7781	0	7794	0	N/A	0.99833205	0	0.8769	0	None	435353.33
DY13	DPH	UC San Diego Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT)	2991	0	39023	0	1	0.0766	0	None	1	0	625775
DY13	DPH	UC San Diego Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	653	0	3544	0	1	0.1843	0	0.1463	0	0.2936	625775
DY13	DPH	UC San Diego Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	12574	0	26713	0	1	0.4707	0	0.3576	0	0.4064	625775
DY13	DPH	UC San Diego Medical Center	1.1.6.t	Tobacco Assessment and Counseling	37423	0	38236	0	1	0.9787	0	0.9702	0	0.9619	625775
DY13	DPH	UC San Diego Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	394	0	1051	0	1	0.374881066	0	None	None	None	208591.6667
DY13	DPH	UC San Diego Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	51	0	1051	0	1	0.048525214	0	None	None	None	208591.6667
DY13	DPH	UC San Diego Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	115	0	1051	0	1	0.1094196	0	None	None	None	208591.6667
DY13	DPH	UC San Diego Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT)	2991	0	39023	0	1	0.0766	0	None	1	0	625775
DY13	DPH	UC San Diego Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	1409	0	1449	0	1	0.9724	0	None	None	0.948	625775
DY13	DPH	UC San Diego Medical Center	1.2.11	REAL data completeness	35873	0	38616	0	1	0.929	0	0.271	0	None	625775
DY13	DPH	UC San Diego Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	12574	0	26713	0	1	0.4707	0	0.3576	0	0.4064	625775
DY13	DPH	UC San Diego Medical Center	1.2.13	SO/GI data completeness	11268	0	37790	0	1	0.2982	0	0.0015	0	None	625775
DY13	DPH	UC San Diego Medical Center	1.2.14.t	Tobacco Assessment and Counseling	37423	0	38236	0	1	0.9787	0	0.9702	0	0.9619	625775
DY13	DPH	UC San Diego Medical Center	1.2.2	CG-CAHPS: Provider Rating	8793	0	9881	0	1	0.8899	0	0.8738	0	0.7148	625775
DY13	DPH	UC San Diego Medical Center	1.2.3.c	Colorectal Cancer Screening	15202	0	18898	0	1	0.8044	0	0.7846	0	0.6571	625775
DY13	DPH	UC San Diego Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	653	0	3544	0	1	0.1843	0	0.1463	0	0.2936	625775
DY13	DPH	UC San Diego Medical Center	1.2.5.b	Controlling Blood Pressure	6914	0	9262	0	1	0.7465	0	0.7434	0	0.7041	625775
DY13	DPH	UC San Diego Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	3528	0	3779	0	1	0.9336	0	0.827	0	0.8894	625775
DY13	DPH	UC San Diego Medical Center	1.2.8	Prevention Quality Overall Composite #90	287	0	41101	0	1	0.007	0	0.0239	0	0	625775
DY13	DPH	UC San Diego Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	45248	0	51271	0	1	0.8825	0	0.7228	0	0.7337	625775
DY13	DPH	UC San Diego Medical Center	1.3.2	DHCS All-Cause Readmissions	259	0	1721	0	1	0.1505	0	0.162	0	0.1587	625775
DY13	DPH	UC San Diego Medical Center	1.3.3	Influenza Immunization	12487	0	17767	0	1	0.7028	0	0.6955	0	0.64	625775
DY13	DPH	UC San Diego Medical Center	1.3.4	Post Procedure ED Visits	2414	0	133147	0	1	0.0181	0	0.0178	0	0	625775
DY13	DPH	UC San Diego Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	88798	0	192610	0	1	0.461	0	0.0057	0	0	625775
DY13	DPH	UC San Diego Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	2030	0	157936	0	1	0.0129	0	0.012	0	0	625775
DY13	DPH	UC San Diego Medical Center	1.3.7	Tobacco Assessment and Counseling	24651	0	24923	0	1	0.9891	0	0.976	0	0.9619	625775
DY13	DPH	UC San Diego Medical Center	1.5.1.b	Controlling Blood Pressure	6914	0	9262	0	1	0.7465	0	0.7434	0	0.7041	625775
DY13	DPH	UC San Diego Medical Center	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	3528	0	3779	0	1	0.9336	0	0.827	0	0.8894	625775
DY13	DPH	UC San Diego Medical Center	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	17571	0	21809	0	1	0.8057	0	0.4755	0	0.488	625775
DY13	DPH	UC San Diego Medical Center	1.5.4.t	Tobacco Assessment and Counseling	37423	0	38236	0	1	0.9787	0	0.9702	0	0.9619	625775
DY13	DPH	UC San Diego Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	None	0	None	None	None	304725.22
DY13	DPH	UC San Diego Medical Center	2.1.1	Baby Friendly Hospital designation: Development Phase Complete Yes	Yes	0	Development Phase?	0	1	see specification	0	None	None	None	304725.22
DY13	DPH	UC San Diego Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	1357	0	2032	0	1	0.6678	0	0.6417	0	0.6554	609450.44
DY13	DPH	UC San Diego Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	2695	0	1	None	1	None	1	0	609450.44
DY13	DPH	UC San Diego Medical Center	2.1.4	OB Hemorrhage: Total Products Transfused	343	0	2695	0	1	0.1273	0	0.022	0	0	609450.44
DY13	DPH	UC San Diego Medical Center	2.1.5	PC-02 Cesarean Section	204	0	1039	0	1	0.1963	0	0.2374	0	0.2357	609450.44
DY13	DPH	UC San Diego Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	1795	0	1803	0	1	0.995562951	0	0.99	0	0.91	304725.22
DY13	DPH	UC San Diego Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	1365	0	1803	0	1	0.757071547	0	0.7383	0	0.7361	304725.22
DY13	DPH	UC San Diego Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	65	0	207	0	1	0.314	0	0.2264	0	0	609450.44
DY13	DPH	UC San Diego Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	132	0	1858	0	1	0.071	0	0.0889	0	0	609450.44
DY13	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	see specification	0	None	None	None	152362.61
DY13	DPH	UC San Diego Medical Center	2.1.9	OB Hemorrhage Safety Bundle: Please specify which elements have been completed in the textbox below No	0	0	0	0	0	see specification	0	None	None	None	152362.61
DY13	DPH	UC San Diego Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter No	0	0	0	0	0	see specification	0	None	None	None	152362.61
DY13	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) No	0	0	0	0	0	see specification	0	None	None	None	152362.61
DY13	DPH	UC San Diego Medical Center	2.2.1	DHCS All-Cause Readmissions	260	0	1774	0	1	0.1466	0	0.1596	0	0.1565	609450.44
DY13	DPH	UC San Diego Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	6196	0	10000	0	1	0.6196	0	0.6053	0	0.6058	609450.44
DY13	DPH	UC San Diego Medical Center	2.2.3	Medication Reconciliation – 30 days	2403	0	3501	0	1	0.6864	0	0.6072	0	0.6455	609450.43
DY13	DPH	UC San Diego Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	3024	0	3037	0	1	0.9957	0	0.9906	0	0.99	609450.43
DY13	DPH	UC San Diego Medical Center	2.2.5	Timely Transmission of Transition Record	3695	0	4379	0	1	0.8438	0	0.8163	0	0.8337	609450.43
DY13	DPH	UC San Diego Medical Center	2.3.2	Medication Reconciliation – 30 days	140	0	184	0	1	0.7609	0	0.6933	0	0.723	609450.43
DY13	DPH	UC San Diego Medical Center	2.3.3	Prevention Quality Overall Composite #90	24	0	412	0	1	0.0583	0	0.1349	0	0	609450.43
DY13	DPH	UC San Diego Medical Center	2.3.4	Timely Transmission of Transition Record	203	0	234	0	1	0.8675	0	0.807	0	0.8253	609450.43
DY13	DPH	UC San Diego Medical Center	2.7.1	Advance Care Plan	7053	0	14670	0	1	0.4808	0	0.4112	0	0.4691	609450.43
DY13	DPH	UC San Diego Medical Center	2.7.2	Ambulatory Palliative Care Team Established: Ambulatory Palliative Care Team Established? Yes	Yes	0	Team Established?	0	1	None	0	None	None	None	609450.43
DY13	DPH	UC San Diego Medical Center	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	160	0	179	0	1	0.8939	0	0.7424	0	0.7462	609450.43
DY13	DPH	UC San Diego Medical Center	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	28	0	39	0	1	0.7179	0	0.697	0	0	609450.43
DY13	DPH	UC San Diego Medical Center	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	32	0	152	0	1	0.2105	0	0.118	0	0	609450.43
DY13	DPH	UC San Diego Medical Center	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	13	0	136	0	1	0.0956	0	0.1239	0	0.1115	609450.43
DY13	DPH	UC San Diego Medical Center	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	91	0	160	0	1	0.5688	0	0.6244	0	0.387	500620
DY13	DPH	UC San Diego Medical Center	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	59589	0	213384	0	1	0.2793	0	0.3366	0	0	500620
DY13	DPH	UC San Diego Medical Center	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	2659	0	5439	0	1	0.4889	0	0.6149	0	0	500620
DY13	DPH	UC San Diego Medical Center	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR No	9580	0	10000	0	1	0.958	0	None	None	None	500620
DY13	DPH	UC San Diego Medical Center	3.3.1	Adherence to Medications: Rate 1	508	0	786	0	1	0.646310433	0	0.6897	0	None	250310
DY13	DPH	UC San Diego Medical Center	3.3.1	Adherence to Medications: Rate 2	1380	0	2453	0	N/A	0.562576437	0	0.6897	0	None	250310
DY13	DPH	UC San Diego Medical Center	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 1	18	0	330	0	1	0.054545455	0	0	0	None	250310
DY13	DPH	UC San Diego Medical Center	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 2	43	0	1217	0	N/A	0.035332786	0	0	0	None	250310
DY13	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	7465	0	8533	0	1	0.874838861	0	0.7392	0	None	250310
DY13	DPH	UC San Diego Medical Center	3.3.4	Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 2	23471	0	26671	0	N/A	0.880019497	0	0.7392	0	None	250310
DY13	DPH	UC San Francisco Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT)	1106	0	33593	0	1	0.0329	0	0.0097	0	0	762420.69
DY13	DPH	UC San Francisco Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	473	0	2328	0	1	0.2032	0	0.1891	0	0.2936	762420.69
DY13	DPH	UC San Francisco Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	14459	0	26904	0	1	0.5374	0	0.0065	0	0.1814	762420.69
DY13	DPH	UC San Francisco Medical Center	1.1.6.t	Tobacco Assessment and Counseling	30533	0	31651	0	1	0.9647	0	0.9512	0	0.9523	762420.69
DY13	DPH	UC San Francisco Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	82	0	363	0	1	0.225895317	0	None	None	None	254140.23
DY13	DPH	UC San Francisco Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	1	363	0	1	None	1	None	None	None	254140.23
DY13	DPH	UC San Francisco Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	11	0	363	0	1	0.03030303	0	None	None	None	254140.23
DY13	DPH	UC San Francisco Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT)	1106	0	33593	0	1	0.0329	0	0.0097	0	0	762420.69
DY13	DPH	UC San Francisco Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	545	0	849	0	0	0.6419	0	None	None	0.655	762420.69
DY13	DPH	UC San Francisco Medical Center	1.2.11	REAL data completeness	41122	0	41131	0	1	0.9998	0	0.8571	0	None	762420.69
DY13	DPH	UC San Francisco Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	14459	0	26904	0	1	0.5374	0	0.0065	0	0.1814	762420.69
DY13	DPH	UC San Francisco Medical Center	1.2.13	SO/GI data completeness	126	0	31577	0	0	0.004	0	0.0004	0	None	762420.69
DY13	DPH	UC San Francisco Medical Center	1.2.14.t	Tobacco Assessment and Counseling	30533	0	31651	0	1	0.9647	0	0.9512	0	0.9523	762420.69
DY13	DPH	UC San Francisco Medical Center	1.2.2	CG-CAHPS: Provider Rating	8468	0	10091	0	1	0.8392	0	0.8356	0	0.7148	762420.69
DY13	DPH	UC San Francisco Medical Center	1.2.3.c	Colorectal Cancer Screening	10186	0	13266	0	1	0.7678	0	0.7618	0	0.6571	762420.69
DY13	DPH	UC San Francisco Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	473	0	2328	0	1	0.2032	0	0.1891	0	0.2936	762420.69
DY13	DPH	UC San Francisco Medical Center	1.2.5.b	Controlling Blood Pressure	4730	0	6378	0	1	0.7416	0	0.7345	0	0.7041	762420.69
DY13	DPH	UC San Francisco Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	1716	0	1873	0	1	0.9162	0	0.8512	0	0.8971	762420.69
DY13	DPH	UC San Francisco Medical Center	1.2.8	Prevention Quality Overall Composite #90	364	0	32811	0	1	0.0111	0	0.0085	0	0	762420.69
DY13	DPH	UC San Francisco Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	66510	0	73819	0	1	0.901	0	0.8088	0	0.8111	762420.69
DY13	DPH	UC San Francisco Medical Center	1.3.2	DHCS All-Cause Readmissions	240	0	1806	0	0	0.1329	0	0.1317	0	0.1314	762420.69
DY13	DPH	UC San Francisco Medical Center	1.3.3	Influenza Immunization	11811	0	13742	0	1	0.8595	0	0.6372	0	0.6375	762420.69
DY13	DPH	UC San Francisco Medical Center	1.3.4	Post Procedure ED Visits	449	0	70884	0	1	0.0063	0	0.0067	0	0	762420.69
DY13	DPH	UC San Francisco Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	160959	0	194783	0	1	0.8264	0	0.7673	0	0	762420.69
DY13	DPH	UC San Francisco Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	3868	0	194783	0	1	0.0199	0	0.0131	0	0	762420.69
DY13	DPH	UC San Francisco Medical Center	1.3.7	Tobacco Assessment and Counseling	14245	0	14527	0	1	0.9806	0	0.9754	0	0.9619	762420.69
DY13	DPH	UC San Francisco Medical Center	1.6.1	BIRADS to Biopsy	137	0	263	0	1	0.5209	0	0.6027	0	0	762420.69
DY13	DPH	UC San Francisco Medical Center	1.6.2	Breast Cancer Screening	5945	0	7524	0	1	0.7901	0	0.8114	0	0.7144	762420.69
DY13	DPH	UC San Francisco Medical Center	1.6.3	Cervical Cancer Screening	9192	0	12056	0	1	0.7624	0	0.7549	0	0.6983	762420.69
DY13	DPH	UC San Francisco Medical Center	1.6.4.c	Colorectal Cancer Screening	10186	0	13266	0	1	0.7678	0	0.7618	0	0.6571	762420.69
DY13	DPH	UC San Francisco Medical Center	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	19	0	47	0	1	0.4043	0	0.3611	0	0	762420.68
DY13	DPH	UC San Francisco Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation No	No	0	BFUSA Cert?	0	0	see specification	0	None	None	None	384525.22
DY13	DPH	UC San Francisco Medical Center	2.1.1	Baby Friendly Hospital designation: Development Phase Complete Yes	Yes	0	Development Phase?	0	1	see specification	0	None	None	None	384525.22
DY13	DPH	UC San Francisco Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	1423	0	1850	0	0	0.7692	0	0.7905	0	0.779	769050.44
DY13	DPH	UC San Francisco Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	2364	0	1	None	1	0.0075	0	0	769050.44
DY13	DPH	UC San Francisco Medical Center	2.1.4	OB Hemorrhage: Total Products Transfused	197	0	2364	0	1	0.0833	0	0.158	0	0	769050.44
DY13	DPH	UC San Francisco Medical Center	2.1.5	PC-02 Cesarean Section	263	0	1210	0	1	0.2174	0	0.1919	0	0.22	769050.44
DY13	DPH	UC San Francisco Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	2374	0	2442	0	1	0.972153972	0	0.9923	0	0.91	384525.22
DY13	DPH	UC San Francisco Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	1970	0	2442	0	1	0.806715807	0	0.7911	0	0.7361	384525.22
DY13	DPH	UC San Francisco Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	76	0	337	0	1	0.2255	0	0.2633	0	0	769050.44
DY13	DPH	UC San Francisco Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	78	0	1922	0	1	0.0406	0	0.0484	0	0	769050.44
DY13	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	see specification	0	None	None	None	192262.61
DY13	DPH	UC San Francisco Medical Center	2.1.9	OB Hemorrhage Safety Bundle: Please specify which elements have been completed in the textbox below No	0	0	0	0	0	see specification	0	None	None	None	192262.61
DY13	DPH	UC San Francisco Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	0	0	0	0	0	see specification	0	None	None	None	192262.61
DY13	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	0	0	0	0	0	see specification	0	None	None	None	192262.61
DY13	DPH	UC San Francisco Medical Center	2.2.1	DHCS All-Cause Readmissions	242	0	1874	0	1	0.1291	0	0.1304	0	0.1303	769050.44
DY13	DPH	UC San Francisco Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	7747	0	12117	0	1	0.6393	0	0.6156	0	0.61	769050.44
DY13	DPH	UC San Francisco Medical Center	2.2.3	Medication Reconciliation – 30 days	1577	0	1592	0	1	0.9906	0	0.895	0	0.9045	769050.43
DY13	DPH	UC San Francisco Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	3978	0	4010	0	1	0.992	0	0.9831	0	0.9838	769050.43
DY13	DPH	UC San Francisco Medical Center	2.2.5	Timely Transmission of Transition Record	4890	0	4986	0	1	0.9807	0	0.9378	0	0.943	769050.43
DY13	DPH	UC San Francisco Medical Center	2.3.2	Medication Reconciliation – 30 days	128	0	129	0	1	0.9922	0	0.9023	0	0.9111	769050.43
DY13	DPH	UC San Francisco Medical Center	2.3.3	Prevention Quality Overall Composite #90	36	0	90	0	1	0.4	0	0.5778	0	0	769050.43
DY13	DPH	UC San Francisco Medical Center	2.3.4	Timely Transmission of Transition Record	306	0	311	0	1	0.9839	0	0.9435	0	0.9482	769050.43
DY13	DPH	UC San Francisco Medical Center	2.7.1	Advance Care Plan	9091	0	9889	0	1	0.9193	0	0.8789	0	0.89	769050.43
DY13	DPH	UC San Francisco Medical Center	2.7.2	Ambulatory Palliative Care Team Established: Ambulatory Palliative Care Team Established? Yes	Yes	0	Team Established?	0	1	None	0	None	None	None	769050.43
DY13	DPH	UC San Francisco Medical Center	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	77	0	87	0	1	0.8851	0	0.8529	0	0.78	769050.43
DY13	DPH	UC San Francisco Medical Center	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	93	0	111	0	1	0.8378	0	0.8217	0	0	769050.43
DY13	DPH	UC San Francisco Medical Center	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	34	0	144	0	1	0.2361	0	0.1912	0	0	769050.43
DY13	DPH	UC San Francisco Medical Center	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	None	1	90	0	1	None	1	None	1	0.0459	769050.43
DY13	DPH	UC San Francisco Medical Center	3.3.1	Adherence to Medications: Rate 1	41	0	51	0	1	0.803921569	0	0.8532	0	None	1105510
DY13	DPH	UC San Francisco Medical Center	3.3.1	Adherence to Medications: Rate 2	130	0	155	0	N/A	0.838709677	0	0.8532	0	None	1105510
DY13	DPH	UC San Francisco Medical Center	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 1	None	1	None	4	0	None	1	None	1	None	0
DY13	DPH	UC San Francisco Medical Center	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 2	22	0	71	0	N/A	0.309859155	0	None	1	None	0
DY13	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	28	0	71	0	1	0.394366197	0	0.6557	0	None	1105510
DY13	DPH	UC San Francisco Medical Center	3.3.4	Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 2	121	0	255	0	N/A	0.474509804	0	0.6557	0	None	1105510
DY13	DPH	Ventura County Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT)	5267	0	48451	0	1	0.1087	0	0.0017	0	0	1684650
DY13	DPH	Ventura County Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1264	0	6271	0	1	0.2016	0	0.1934	0	0.2936	1684650
DY13	DPH	Ventura County Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	16942	0	34035	0	1	0.4978	0	0.3532	0	0.4024	1684650
DY13	DPH	Ventura County Medical Center	1.1.6.t	Tobacco Assessment and Counseling	34555	0	35499	0	1	0.9734	0	0.9338	0	0.9366	1684650
DY13	DPH	Ventura County Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	232	0	1156	0	1	0.200692042	0	None	None	None	561550
DY13	DPH	Ventura County Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	45	0	1156	0	1	0.038927336	0	None	None	None	561550
DY13	DPH	Ventura County Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	87	0	1156	0	1	0.075259516	0	None	None	None	561550
DY13	DPH	Ventura County Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT)	5267	0	48451	0	1	0.1087	0	0.0017	0	0	1684650
DY13	DPH	Ventura County Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	861	0	1345	0	1	0.6401	0	None	None	0.6341	1684650
DY13	DPH	Ventura County Medical Center	1.2.11	REAL data completeness	64005	0	64021	0	1	0.9998	0	0.9449	0	None	1684650
DY13	DPH	Ventura County Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	16942	0	34035	0	1	0.4978	0	0.3532	0	0.4024	1684650
DY13	DPH	Ventura County Medical Center	1.2.13	SO/GI data completeness	26217	0	37519	0	1	0.6988	0	0.2684	0	None	1684650
DY13	DPH	Ventura County Medical Center	1.2.14.t	Tobacco Assessment and Counseling	34555	0	35499	0	1	0.9734	0	0.9338	0	0.9366	1684650
DY13	DPH	Ventura County Medical Center	1.2.2	CG-CAHPS: Provider Rating	32074	0	40001	0	1	0.8018	0	0.805	0	0.7148	1684650
DY13	DPH	Ventura County Medical Center	1.2.3.c	Colorectal Cancer Screening	7987	0	15075	0	1	0.5298	0	0.4393	0	0.4611	1684650
DY13	DPH	Ventura County Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	1264	0	6271	0	1	0.2016	0	0.1934	0	0.2936	1684650
DY13	DPH	Ventura County Medical Center	1.2.5.b	Controlling Blood Pressure	9845	0	13913	0	1	0.7076	0	0.6523	0	0.6575	1684650
DY13	DPH	Ventura County Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	695	0	762	0	1	0.9121	0	0.8596	0	0.8856	1684650
DY13	DPH	Ventura County Medical Center	1.2.8	Prevention Quality Overall Composite #90	412	0	48516	0	1	0.0085	0	0.2395	0	0	1684650
DY13	DPH	Ventura County Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	7401	0	21314	0	1	0.3472	0	0.1696	0	0.2358	1684650
DY13	DPH	Ventura County Medical Center	1.3.2	DHCS All-Cause Readmissions	168	0	1272	0	0	0.1321	0	0.0899	0	0.129	1684650
DY13	DPH	Ventura County Medical Center	1.3.3	Influenza Immunization	7120	0	11068	0	1	0.6433	0	0.4656	0	0.483	1684650
DY13	DPH	Ventura County Medical Center	1.3.4	Post Procedure ED Visits	288	0	27875	0	1	0.0103	0	0.0118	0	0	1684650
DY13	DPH	Ventura County Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	15366	0	29149	0	1	0.5272	0	0.579	0	0	1684650
DY13	DPH	Ventura County Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	151	0	16217	0	1	0.0093	0	0.0011	0	0	1684650
DY13	DPH	Ventura County Medical Center	1.3.7	Tobacco Assessment and Counseling	17008	0	17286	0	1	0.9839	0	0.9586	0	0.9589	1684650
DY13	DPH	Ventura County Medical Center	1.5.1.b	Controlling Blood Pressure	9845	0	13913	0	1	0.7076	0	0.6523	0	0.6575	1684650
DY13	DPH	Ventura County Medical Center	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	695	0	762	0	1	0.9121	0	0.8596	0	0.8856	1684650
DY13	DPH	Ventura County Medical Center	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	17428	0	23965	0	1	0.7272	0	0.4722	0	0.485	1684650
DY13	DPH	Ventura County Medical Center	1.5.4.t	Tobacco Assessment and Counseling	34555	0	35499	0	1	0.9734	0	0.9338	0	0.9366	1684650
DY13	DPH	Ventura County Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	None	0	None	None	None	786170
DY13	DPH	Ventura County Medical Center	2.1.1	Baby Friendly Hospital designation: Development Phase Complete Yes	Yes	0	Development Phase?	0	1	see specification	0	None	None	None	786170
DY13	DPH	Ventura County Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	623	0	952	0	0	0.6544	0	0.8268	0	0.779	1572340
DY13	DPH	Ventura County Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	1157	0	1	None	1	None	1	0	1572340
DY13	DPH	Ventura County Medical Center	2.1.4	OB Hemorrhage: Total Products Transfused	21	0	1157	0	1	0.0182	0	0.0297	0	0	1572340
DY13	DPH	Ventura County Medical Center	2.1.5	PC-02 Cesarean Section	60	0	326	0	1	0.184	0	0.2454	0	0.2429	1572340
DY13	DPH	Ventura County Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	1279	0	1543	0	1	0.828904731	0	0.7889	0	0.801	786170
DY13	DPH	Ventura County Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	1144	0	1543	0	1	0.741412832	0	0.7433	0	0.7361	786170
DY13	DPH	Ventura County Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	13	0	89	0	1	0.1461	0	0.2113	0	0	1572340
DY13	DPH	Ventura County Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	37	0	968	0	1	0.0382	0	0.0532	0	0	1572340
DY13	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	see specification	0	None	None	None	393085
DY13	DPH	Ventura County Medical Center	2.1.9	OB Hemorrhage Safety Bundle: Please specify which elements have been completed in the textbox below No	0	0	0	0	0	see specification	0	None	None	None	393085
DY13	DPH	Ventura County Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	0	0	0	0	0	see specification	0	None	None	None	393085
DY13	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	0	0	0	0	0	see specification	0	None	None	None	393085
DY13	DPH	Ventura County Medical Center	2.2.1	DHCS All-Cause Readmissions	216	0	1558	0	0	0.1386	0	0.0915	0	0.129	1572340
DY13	DPH	Ventura County Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	651	0	1179	0	1	0.5522	0	0.5004	0	0.5114	1572340
DY13	DPH	Ventura County Medical Center	2.2.3	Medication Reconciliation – 30 days	2041	0	2427	0	1	0.841	0	0.7602	0	0.7832	1572340
DY13	DPH	Ventura County Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	3521	0	5965	0	1	0.5903	0	0.2066	0	0.2849	1572340
DY13	DPH	Ventura County Medical Center	2.2.5	Timely Transmission of Transition Record	1440	0	4810	0	1	0.2994	0	0.031	0	0.1269	1572340
DY13	DPH	Ventura County Medical Center	2.3.2	Medication Reconciliation – 30 days	301	0	347	0	1	0.8674	0	0.7305	0	0.7565	1572340
DY13	DPH	Ventura County Medical Center	2.3.3	Prevention Quality Overall Composite #90	156	0	1679	0	1	0.0929	0	0.1097	0	0	1572340
DY13	DPH	Ventura County Medical Center	2.3.4	Timely Transmission of Transition Record	247	0	637	0	0	0.3878	0	0.5016	0	0.5504	1572340
DY13	DPH	Ventura County Medical Center	2.4.1	Adolescent Well-Care Visit	77	0	112	0	1	0.6875	0	0.8	0	0.6604	1572340
DY13	DPH	Ventura County Medical Center	2.4.2	Developmental Screening in the First Three Years of Life	44	0	81	0	1	0.5432	0	0.3855	0	0.407	1572340
DY13	DPH	Ventura County Medical Center	2.4.3	Documentation of Current Medications in the Medical Record (0-18 yo)	798	0	1000	0	1	0.798	0	0.7106	0	0	1572340
DY13	DPH	Ventura County Medical Center	2.4.4	Screening for Clinical Depression and follow-up	31	0	67	0	1	0.4627	0	0.2941	0	0.3492	1572340
DY13	DPH	Ventura County Medical Center	2.4.5	Tobacco Assessment and Counseling (13 yo and older)	47	0	47	0	1	1	0	0.95	0	0.9512	1572340
DY13	DPH	Ventura County Medical Center	2.4.7	Well Child Visits - Third, Fourth, Fifth, and Sixth Years of life	62	0	71	0	1	0.8732	0	0.8871	0	0.8297	1572340
DY13	DPH	Ventura County Medical Center	2.4.8	Comprehensive Medical Evaluation Following Foster Youth Placement in Foster Care	62	0	80	0	1	0.775	0	None	None	0	1572340
DY13	DPH	Ventura County Medical Center	3.4.1	ePBM-01 Pre-op Anemia Screening, Selected Elective Surgical Patients	116	0	236	0	1	0.4915	0	0.3311	0	0.388	2358510
DY13	DPH	Ventura County Medical Center	3.4.2	ePBM-02 Pre-op Hemoglobin Level, Selected Elective Surgical Patients	11	0	None	4	0	None	4	0.9091	0	0	0
DY13	DPH	Ventura County Medical Center	3.4.3	ePBM-03 Pre-op Type and Crossmatch, Type and Screen, Selected elective Surgical Patients	305	0	345	0	1	0.8841	0	0.8808	0	0.8827	2358510
DY13	DPH	Ventura County Medical Center	3.4.4	ePBM-04 Initial Transfusion Threshold	404	0	406	0	1	0.9951	0	0.9931	0	0	2358510
DY13	DPH	Ventura County Medical Center	3.4.5	ePBM-05 Outcome of Patient Blood Management, Selected Elective Surgical Patients	None	1	116	0	1	None	1	0.11	0	0	2358510
DY13	DMPH	Washington Hospital Healthcare System, Fremont	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	Yes	0	BFUSA Cert?	0	1	None	0	None	None	None	254666.67
DY13	DMPH	Washington Hospital Healthcare System, Fremont	2.1.1	Baby Friendly Hospital designation: Development Phase Complete Yes	Yes	0	Development Phase?	0	1	see specification	0	None	None	None	254666.67
DY13	DMPH	Washington Hospital Healthcare System, Fremont	2.1.2	Exclusive Breast Milk Feeding (PC-05)	105	0	152	0	0	0.6908	0	0.7273	0	0.7325	509333.34
DY13	DMPH	Washington Hospital Healthcare System, Fremont	2.1.3	OB Hemorrhage: Massive Transfusion	None	1	188	0	1	None	1	0	0	0	509333.34
DY13	DMPH	Washington Hospital Healthcare System, Fremont	2.1.4	OB Hemorrhage: Total Products Transfused	None	1	188	0	1	None	1	None	1	0	509333.34
DY13	DMPH	Washington Hospital Healthcare System, Fremont	2.1.5	PC-02 Cesarean Section	12	0	71	0	1	0.169	0	None	1	0.2743	509333.34
DY13	DMPH	Washington Hospital Healthcare System, Fremont	2.1.6	Prenatal and Postpartum Care: Prenatal Care	566	0	607	0	1	0.932454695	0	0.9043	0	0.9049	254666.665
DY13	DMPH	Washington Hospital Healthcare System, Fremont	2.1.6	Prenatal and Postpartum Care: Postpartum Care	511	0	607	0	1	0.84184514	0	0.8239	0	0.7361	254666.665
DY13	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	509333.33
DY13	DMPH	Washington Hospital Healthcare System, Fremont	2.1.8	Unexpected Newborn Complications (UNC)	None	1	154	0	1	None	1	None	1	0	509333.33
DY13	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	see specification	0	None	None	None	127333.3325
DY13	DMPH	Washington Hospital Healthcare System, Fremont	2.1.9	OB Hemorrhage Safety Bundle: Please specify which elements have been completed in the textbox below No	0	0	0	0	0	see specification	0	None	None	None	127333.3325
DY13	DMPH	Washington Hospital Healthcare System, Fremont	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	0	0	0	0	0	see specification	0	None	None	None	127333.3325
DY13	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	0	0	0	0	0	see specification	0	None	None	None	127333.3325
DY13	DMPH	Washington Hospital Healthcare System, Fremont	2.7.1	Advance Care Plan	189	0	307	0	1	0.6156	0	0.5248	0	0.5713	509333.33
DY13	DMPH	Washington Hospital Healthcare System, Fremont	2.7.2	Ambulatory Palliative Care Team Established: Ambulatory Palliative Care Team Established? Yes	Yes	0	Team Established?	0	1	None	0	None	None	None	509333.33
DY13	DMPH	Washington Hospital Healthcare System, Fremont	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	29	0	30	0	1	0.9667	0	0.9355	0	0.78	509333.33
DY13	DMPH	Washington Hospital Healthcare System, Fremont	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	None	1	None	1	0	None	1	0	0	0	509333.33
DY13	DMPH	Washington Hospital Healthcare System, Fremont	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	93	0	719	0	1	0.1293	0	0.0834	0	0	509333.33
DY13	DMPH	Washington Hospital Healthcare System, Fremont	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	None	1	33	0	1	None	1	None	1	0.1154	509333.33