| year | type | hospital | metric_number | metric_name | numerator | numerator_annotation_code | denominator | denominator_annotation_code | achievement_value | achievement_rate | achievement_rate_annotation_code | baseline_rate | baseline_rate_annotation_code | target_rate | allocation |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| DY14 | DPH | Alameda Health System | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 2553 | 0 | 21543 | 0 | 1 | 0.1185 | 0 | 0.1144 | 0 | None | 536188.355 |
| DY14 | DPH | Alameda Health System | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 15759 | 0 | 21543 | 0 | 1 | 0.7315 | 0 | 0.1144 | 0 | None | 536188.355 |
| DY14 | DPH | Alameda Health System | 1.1.3.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 1456 | 0 | 4686 | 0 | 0 | 0.3107 | 0 | 0.2936 | 0 | 0 | 1072376.71 |
| DY14 | DPH | Alameda Health System | 1.1.5.f | Screening for Clinical Depression and follow-up | 13879 | 0 | 17366 | 0 | 1 | 0.7992 | 0 | 0.7059 | 0 | 0 | 1072376.71 |
| DY14 | DPH | Alameda Health System | 1.1.6.t | Tobacco Assessment and Counseling | 15943 | 0 | 16032 | 0 | 1 | 0.9944 | 0 | 0.9948 | 0 | 0 | 1072376.71 |
| DY14 | DPH | Alameda Health System | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Follow-up | 154 | 0 | 492 | 0 | 1 | 0.313 | 0 | 0.271676301 | 0 | 0.2841 | 357458.9033 |
| DY14 | DPH | Alameda Health System | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Remission | 15 | 0 | 492 | 0 | 0 | 0.0305 | 0 | None | 1 | 0.0366 | 357458.9033 |
| DY14 | DPH | Alameda Health System | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Response | 45 | 0 | 492 | 0 | 1 | 0.0915 | 0 | None | 1 | 0.062 | 357458.9033 |
| DY14 | DPH | Alameda Health System | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 15759 | 0 | 21543 | 0 | 1 | 0.7315 | 0 | 0.1144 | 0 | None | 536188.355 |
| DY14 | DPH | Alameda Health System | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 2553 | 0 | 21543 | 0 | 1 | 0.1185 | 0 | 0.1144 | 0 | None | 536188.355 |
| DY14 | DPH | Alameda Health System | 1.2.10 | REAL and/or SO/GI disparity reduction | 444 | 0 | 1226 | 0 | 0 | 0.3622 | 0 | 0.354 | 0 | 0 | 1072376.7 |
| DY14 | DPH | Alameda Health System | 1.2.11 | REAL data completeness | 27529 | 0 | 27535 | 0 | 1 | 0.9998 | 0 | 0.9999 | 0 | 0 | 1072376.7 |
| DY14 | DPH | Alameda Health System | 1.2.12.f | Screening for Clinical Depression and follow-up | 13879 | 0 | 17366 | 0 | 1 | 0.7992 | 0 | 0.7059 | 0 | 0 | 1072376.7 |
| DY14 | DPH | Alameda Health System | 1.2.13 | SO/GI data completeness | 18224 | 0 | 19778 | 0 | 1 | 0.9214 | 0 | 0.6973 | 0 | 0 | 1072376.7 |
| DY14 | DPH | Alameda Health System | 1.2.14.t | Tobacco Assessment and Counseling | 15943 | 0 | 16032 | 0 | 1 | 0.9944 | 0 | 0.9948 | 0 | 0 | 1072376.7 |
| DY14 | DPH | Alameda Health System | 1.2.2 | CG-CAHPS: Provider Rating | 1952 | 0 | 2672 | 0 | 0 | 0.7305 | 0 | 0.7589 | 0 | 0 | 1072376.71 |
| DY14 | DPH | Alameda Health System | 1.2.3.c | Colorectal Cancer Screening | 6572 | 0 | 9796 | 0 | 1 | 0.6709 | 0 | 0.6435 | 0 | 0 | 1072376.71 |
| DY14 | DPH | Alameda Health System | 1.2.4.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 1456 | 0 | 4686 | 0 | 0 | 0.3107 | 0 | 0.2936 | 0 | 0 | 1072376.71 |
| DY14 | DPH | Alameda Health System | 1.2.5.b | Controlling Blood Pressure | 4676 | 0 | 5917 | 0 | 1 | 0.7903 | 0 | 0.7525 | 0 | 0 | 1072376.71 |
| DY14 | DPH | Alameda Health System | 1.2.7.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 528 | 0 | 569 | 0 | 1 | 0.9279 | 0 | 0.9537 | 0 | 0 | 1072376.7 |
| DY14 | DPH | Alameda Health System | 1.2.8 | Prevention Quality Overall Composite #90 | 374 | 0 | 43075 | 0 | 0 | 0.0087 | 0 | 0.0082 | 0 | 0 | 1072376.7 |
| DY14 | DPH | Alameda Health System | 1.3.1 | Closing the referral loop: receipt of specialist report (CMS50v3) | 9269 | 0 | 9533 | 0 | 1 | 0.9723 | 0 | 0.9123 | 0 | 0 | 1072376.7 |
| DY14 | DPH | Alameda Health System | 1.3.2 | DHCS All-Cause Readmissions | 211 | 0 | 1416 | 0 | 0 | 0.149 | 0 | 0.1227 | 0 | 0 | 1072376.7 |
| DY14 | DPH | Alameda Health System | 1.3.3 | Influenza Immunization | 3718 | 0 | 4777 | 0 | 1 | 0.7783 | 0 | 0.727 | 0 | 0 | 1072376.7 |
| DY14 | DPH | Alameda Health System | 1.3.5 | Request for Specialty Care Expertise Turnaround Time | 26664 | 0 | 26766 | 0 | 1 | 0.9962 | 0 | 0.9535 | 0 | 0 | 1072376.7 |
| DY14 | DPH | Alameda Health System | 1.3.6 | Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters | 1288 | 0 | 27374 | 0 | 0 | 0.0471 | 0 | 0.0429 | 0 | 0 | 1072376.7 |
| DY14 | DPH | Alameda Health System | 1.3.7 | Tobacco Assessment and Counseling | 4291 | 0 | 4303 | 0 | 1 | 0.9972 | 0 | 0.9928 | 0 | 0 | 1072376.7 |
| DY14 | DPH | Alameda Health System | 1.5.1.b | Controlling Blood Pressure | 4676 | 0 | 5917 | 0 | 1 | 0.7903 | 0 | 0.7525 | 0 | 0 | 1072376.7 |
| DY14 | DPH | Alameda Health System | 1.5.2.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 528 | 0 | 569 | 0 | 1 | 0.9279 | 0 | 0.9537 | 0 | 0 | 1072376.7 |
| DY14 | DPH | Alameda Health System | 1.5.3 | PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 10248 | 0 | 11304 | 0 | 1 | 0.9066 | 0 | 0.84 | 0 | 0 | 1072376.7 |
| DY14 | DPH | Alameda Health System | 1.5.4.t | Tobacco Assessment and Counseling | 15943 | 0 | 16032 | 0 | 1 | 0.9944 | 0 | 0.9948 | 0 | 0 | 1072376.7 |
| DY14 | DPH | Alameda Health System | 2.1.1 | Baby Friendly Hospital designation: BFUSA Designation Yes | Yes | 0 | BFUSA Cert? | 0 | 1 | 0 | 0 | None | 0 | None | 1103015.96 |
| DY14 | DPH | Alameda Health System | 2.1.2 | Exclusive Breast Milk Feeding (PC-05) | 150 | 0 | 193 | 0 | 1 | 0.7772 | 0 | 0.7518 | 0 | 0 | 1103015.96 |
| DY14 | DPH | Alameda Health System | 2.1.3 | OB Hemorrhage: Massive Transfusion | None | 1 | 838 | 0 | 1 | None | 1 | None | 1 | 0 | 1103015.96 |
| DY14 | DPH | Alameda Health System | 2.1.4 | OB Hemorrhage: Total Products Transfused | 23 | 0 | 838 | 0 | 1 | 0.0274 | 0 | 0.0433 | 0 | 0 | 1103015.96 |
| DY14 | DPH | Alameda Health System | 2.1.5 | PC-02 Cesarean Section | 43 | 0 | 286 | 0 | 1 | 0.1503 | 0 | 0.1661 | 0 | 0 | 1103015.96 |
| DY14 | DPH | Alameda Health System | 2.1.6 | Prenatal and Postpartum Care: Prenatal Care | 859 | 0 | 912 | 0 | 1 | 0.9419 | 0 | 0.874601488 | 0 | 0.8788 | 551507.975 |
| DY14 | DPH | Alameda Health System | 2.1.6 | Prenatal and Postpartum Care: Postpartum Care | 674 | 0 | 912 | 0 | 1 | 0.739 | 0 | 0.650371945 | 0 | 0.659 | 551507.975 |
| DY14 | DPH | Alameda Health System | 2.1.7 | Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage | 13 | 0 | 83 | 0 | 1 | 0.1566 | 0 | 0.2427 | 0 | 0 | 1103015.95 |
| DY14 | DPH | Alameda Health System | 2.1.8 | Unexpected Newborn Complications (UNC) | 33 | 0 | 680 | 0 | 1 | 0.0485 | 0 | 0.0671 | 0 | 0 | 1103015.95 |
| DY14 | DPH | Alameda Health System | 2.1.9 | OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes | Yes | 0 | 10 Debriefs? | 0 | n/a | 0 | 0 | None | 0 | None | 367671.9833 |
| DY14 | DPH | Alameda Health System | 2.1.9 | OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) |
16 | 0 | 16 | 0 | 1 | 1 | 0 | 1 | 0 | None | 367671.9833 |
| DY14 | DPH | Alameda Health System | 2.1.9 | OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes | Yes | 0 | 3 Safety Drills? | 0 | n/a | 0 | 0 | None | 0 | None | 367671.9833 |
| DY14 | DPH | Alameda Health System | 2.2.1 | DHCS All-Cause Readmissions | 218 | 0 | 1519 | 0 | 0 | 0.1435 | 0 | 0.1177 | 0 | 0 | 1103015.95 |
| DY14 | DPH | Alameda Health System | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 4580 | 0 | 10000 | 0 | 0 | 0.458 | 0 | 0.46 | 0 | 0 | 1103015.95 |
| DY14 | DPH | Alameda Health System | 2.2.3 | Medication Reconciliation 30 days | 1230 | 0 | 1331 | 0 | 1 | 0.9241 | 0 | 0.9204 | 0 | 0 | 1103015.95 |
| DY14 | DPH | Alameda Health System | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 2393 | 0 | 3047 | 0 | 1 | 0.7854 | 0 | 0.5983 | 0 | 0 | 1103015.95 |
| DY14 | DPH | Alameda Health System | 2.2.5 | Timely Transmission of Transition Record | 1822 | 0 | 2509 | 0 | 1 | 0.7262 | 0 | 0.5737 | 0 | 0 | 1103015.95 |
| DY14 | DPH | Alameda Health System | 2.3.2 | Medication Reconciliation 30 days | 1165 | 0 | 1259 | 0 | 1 | 0.9253 | 0 | 0.9196 | 0 | 0 | 1103015.95 |
| DY14 | DPH | Alameda Health System | 2.3.4 | Timely Transmission of Transition Record | 1561 | 0 | 2169 | 0 | 1 | 0.7197 | 0 | 0.1508 | 0 | 0 | 1103015.95 |
| DY14 | DPH | Alameda Health System | 2.6.1 | Alcohol and Drug Misuse (SBIRT): Brief screening only | 1837 | 0 | 2286 | 0 | 1 | 0.8036 | 0 | 0.5791 | 0 | None | 551507.975 |
| DY14 | DPH | Alameda Health System | 2.6.1 | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 329 | 0 | 2286 | 0 | 1 | 0.1439 | 0 | 0.2062 | 0 | None | 551507.975 |
| DY14 | 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 | 83 | 0 | 109 | 0 | 1 | 0.7615 | 0 | 0.5714 | 0 | 0 | 1103015.95 |
| DY14 | DPH | Alameda Health System | 2.6.3 | Patients with chronic pain on long term opioid therapy checked in PDMPs | 102 | 0 | 109 | 0 | 1 | 0.9358 | 0 | 0.7669 | 0 | 0 | 1103015.95 |
| DY14 | DPH | Alameda Health System | 2.6.4 | Screening for Clinical Depression and follow-up | 1497 | 0 | 1811 | 0 | 1 | 0.8266 | 0 | 0.7657 | 0 | 0 | 1103015.95 |
| DY14 | DPH | Alameda Health System | 2.6.5 | Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy | 2259 | 0 | 2292 | 0 | 1 | 0.9856 | 0 | 0.9833 | 0 | 0 | 1103015.95 |
| DY14 | DPH | Alameda Health System | 3.1.1 | Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis | 60 | 0 | 90 | 0 | 1 | 0.6667 | 0 | 0.7662 | 0 | 0 | 1447708.5 |
| DY14 | DPH | Alameda Health System | 3.1.3 | National Healthcare Safety Network (NHSN) Antimicrobial Use Measure | 26484 | 0 | 126791 | 0 | 1 | 0.2089 | 0 | 0.2645 | 0 | 0 | 1447708.5 |
| DY14 | DPH | Alameda Health System | 3.1.4 | Peri-operative Prophylactic Antibiotics Administered after Surgical Closure | 103 | 0 | 411 | 0 | 1 | 0.2506 | 0 | 0.2994 | 0 | 0 | 1447708.5 |
| DY14 | DPH | Alameda Health System | 3.1.5 | Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR | 8650 | 0 | 10000 | 0 | 0 | 0.865 | 0 | 0.605 | 0 | 0.7 | 1447708.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 2.1.1 | Baby Friendly Hospital designation: BFUSA Designation Yes | Yes | 0 | BFUSA Cert? | 0 | 1 | 0 | 0 | None | 0 | None | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 2.1.2 | Exclusive Breast Milk Feeding (PC-05) | 162 | 0 | 306 | 0 | 0 | 0.5294 | 0 | 0.5759 | 0 | 0 | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 2.1.3 | OB Hemorrhage: Massive Transfusion | None | 1 | 1650 | 0 | 1 | None | 1 | None | 1 | 0 | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 2.1.4 | OB Hemorrhage: Total Products Transfused | 46 | 0 | 1650 | 0 | 1 | 0.0279 | 0 | 0.035 | 0 | 0 | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 2.1.5 | PC-02 Cesarean Section | 134 | 0 | 465 | 0 | 0 | 0.2882 | 0 | 0.2849 | 0 | 0 | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 2.1.6 | Prenatal and Postpartum Care: Prenatal Care | None | 1 | 239 | 0 | 0 | None | 1 | 0.111111111 | 0 | 0.7766 | 335531.25 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 2.1.6 | Prenatal and Postpartum Care: Postpartum Care | 171 | 0 | 239 | 0 | 1 | 0.7155 | 0 | 0.526570048 | 0 | 0.5959 | 335531.25 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 2.1.7 | Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage | 13 | 0 | 72 | 0 | 1 | 0.1806 | 0 | 0.3333 | 0 | 0 | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 2.1.8 | Unexpected Newborn Complications (UNC) | 21 | 0 | 1315 | 0 | 1 | 0.016 | 0 | 0.0112 | 0 | 0 | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 2.1.9 | OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) |
16 | 0 | 16 | 0 | 1 | 1 | 0 | 1 | 0 | None | 223687.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 2.1.9 | OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes | Yes | 0 | 3 Safety Drills? | 0 | n/a | 0 | 0 | None | 0 | None | 223687.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 2.1.9 | OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes | Yes | 0 | 10 Debriefs? | 0 | n/a | 0 | 0 | None | 0 | None | 223687.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 2.2.1 | DHCS All-Cause Readmissions | 247 | 0 | 5362 | 0 | 1 | 0.0461 | 0 | 0.0755 | 0 | 0 | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 1265 | 0 | 2910 | 0 | 0 | 0.4347 | 0 | 0.4423 | 0 | 0 | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 2.2.3 | Medication Reconciliation 30 days | 31 | 0 | 31 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 3505 | 0 | 3897 | 0 | 1 | 0.8994 | 0 | 0.8558 | 0 | 0 | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 2.2.5 | Timely Transmission of Transition Record | 722 | 0 | 4817 | 0 | 0 | 0.1499 | 0 | 0.1098 | 0 | 0 | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 2.3.2 | Medication Reconciliation 30 days | 31 | 0 | 31 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 2.3.4 | Timely Transmission of Transition Record | 722 | 0 | 4817 | 0 | 0 | 0.1499 | 0 | 0.1098 | 0 | 0 | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 2.7.1 | Advance Care Plan | 79 | 0 | 614 | 0 | 0 | 0.1287 | 0 | 0.3977 | 0 | 0 | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 2.7.3 | MWM #8: Treatment Preferences (documentation) Inpatient | 22 | 0 | 134 | 0 | 0 | 0.1642 | 0 | 0.9953 | 0 | 0 | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 2.7.4 | MWM #8: Treatment Preferences (documentation) Outpatient | 31 | 0 | 31 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 2.7.5 | Palliative Care Service Offered at Time of Diagnosis of Advanced Illness | 26 | 0 | 128 | 0 | 1 | 0.2031 | 0 | 0.375 | 0 | 0 | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 2.7.6 | Proportion Admitted to Hospice for Less Than 3 Days | None | 1 | 46 | 0 | 1 | None | 1 | None | 1 | 0 | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 3.1.1 | Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis | 397 | 0 | 421 | 0 | 1 | 0.943 | 0 | 0.7469 | 0 | 0 | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 3.1.3 | National Healthcare Safety Network (NHSN) Antimicrobial Use Measure | 20325 | 0 | 78089 | 0 | 1 | 0.2603 | 0 | 0.3286 | 0 | 0 | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 3.1.4 | Peri-operative Prophylactic Antibiotics Administered after Surgical Closure | 70 | 0 | 362 | 0 | 1 | 0.1934 | 0 | 0.4156 | 0 | 0 | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 3.1.5 | Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR | 5880 | 0 | 10000 | 0 | 1 | 0.588 | 0 | 0.98 | 0 | 0.952 | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 3.2.1 | Dont Do Imaging for Uncomplicated Headaches (Choosing Wisely) | 130 | 0 | 465 | 0 | 0 | 0.2796 | 0 | 0.2046 | 0 | 0 | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 3.2.2 | Appropriate Emergency Department Utilization of CT for Pulmonary Embolism | 125 | 0 | 293 | 0 | 1 | 0.4266 | 0 | 0.3351 | 0 | 0 | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 3.2.3 | Use of Imaging Studies for Low Back Pain | 2755 | 0 | 3164 | 0 | 1 | 0.8707 | 0 | 0.7779 | 0 | 0 | 671062.5 |
| DY14 | 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 | 237 | 0 | 260 | 0 | 1 | 0.9115 | 0 | 0.650485437 | 0 | None | 335531.25 |
| DY14 | 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 | 23 | 0 | 260 | 0 | 1 | 0.0885 | 0 | 0.495145631 | 0 | None | 335531.25 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 3.4.1 | ePBM-01 Pre-op Anemia Screening, Selected Elective Surgical Patients | 109 | 0 | 383 | 0 | 0 | 0.2846 | 0 | 0.3898 | 0 | 0 | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 3.4.3 | ePBM-03 Pre-op Type and Crossmatch, Type and Screen, Selected elective Surgical Patients | 102 | 0 | 381 | 0 | 0 | 0.2677 | 0 | 0.5452 | 0 | 0 | 671062.5 |
| DY14 | DMPH | Antelope Valley Hospital, Lancaster | 3.4.4 | ePBM-04 Initial Transfusion Threshold | 598 | 0 | 598 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 671062.5 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | None | 1 | 377 | 0 | 1 | None | 1 | 0.0216 | 0 | None | 745338.485 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | None | 1 | 377 | 0 | 0 | None | 1 | 0.0216 | 0 | None | 745338.485 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.1.3.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 2013 | 0 | 6164 | 0 | 0 | 0.3266 | 0 | 0.2722 | 0 | 0 | 1490676.97 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.1.5.f | Screening for Clinical Depression and follow-up | 7428 | 0 | 8350 | 0 | 1 | 0.8896 | 0 | 0.8172 | 0 | 0 | 1490676.97 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.1.6.t | Tobacco Assessment and Counseling | 12299 | 0 | 12510 | 0 | 1 | 0.9831 | 0 | 0.9966 | 0 | 0 | 1490676.97 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Follow-up | 22 | 0 | 72 | 0 | 1 | 0.3056 | 0 | None | 1 | 0.0921 | 496892.32 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Remission | None | 1 | 72 | 0 | 0 | None | 1 | None | 1 | 0.0151 | 496892.32 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Response | None | 1 | 72 | 0 | 0 | None | 1 | None | 1 | 0.0431 | 496892.32 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | None | 1 | 377 | 0 | 1 | None | 1 | 0.0216 | 0 | None | 745338.48 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | None | 1 | 377 | 0 | 0 | None | 1 | 0.0216 | 0 | None | 745338.48 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.2.10 | REAL and/or SO/GI disparity reduction | 1327 | 0 | 2609 | 0 | 0 | 0.5086 | 0 | 0.5722 | 0 | 0 | 1490676.96 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.2.11 | REAL data completeness | 17699 | 0 | 20295 | 0 | 1 | 0.8721 | 0 | 0.8506 | 0 | 0 | 1490676.96 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.2.12.f | Screening for Clinical Depression and follow-up | 7428 | 0 | 8350 | 0 | 1 | 0.8896 | 0 | 0.8177 | 0 | 0 | 1490676.96 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.2.13 | SO/GI data completeness | 14921 | 0 | 15006 | 0 | 1 | 0.9943 | 0 | 0.9985 | 0 | 0 | 1490676.96 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.2.14.t | Tobacco Assessment and Counseling | 12299 | 0 | 12510 | 0 | 1 | 0.9831 | 0 | 0.9966 | 0 | 0 | 1490676.96 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.2.2 | CG-CAHPS: Provider Rating | 1390 | 0 | 1681 | 0 | 0 | 0.8269 | 0 | 0.8525 | 0 | 0 | 1490676.96 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.2.3.c | Colorectal Cancer Screening | 218 | 0 | 370 | 0 | 1 | 0.5892 | 0 | 0.5812 | 0 | 0 | 1490676.96 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.2.4.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 2013 | 0 | 6164 | 0 | 0 | 0.3266 | 0 | 0.2722 | 0 | 0 | 1490676.96 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.2.5.b | Controlling Blood Pressure | 4727 | 0 | 7236 | 0 | 0 | 0.6533 | 0 | 0.6799 | 0 | 0 | 1490676.96 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.2.7.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 437 | 0 | 512 | 0 | 1 | 0.8535 | 0 | 0.81 | 0 | 0 | 1490676.96 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.2.8 | Prevention Quality Overall Composite #90 | 956 | 0 | 7977 | 0 | 0 | 0.1198 | 0 | 0.0129 | 0 | 0 | 1490676.96 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.3.1 | Closing the referral loop: receipt of specialist report (CMS50v3) | 22855 | 0 | 33373 | 0 | 1 | 0.6848 | 0 | 0.6152 | 0 | 0 | 1490676.96 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.3.2 | DHCS All-Cause Readmissions | 149 | 0 | 1152 | 0 | 1 | 0.1293 | 0 | 0.1577 | 0 | 0 | 1490676.96 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.3.3 | Influenza Immunization | 1166 | 0 | 1650 | 0 | 1 | 0.7067 | 0 | 0.6168 | 0 | 0 | 1490676.96 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.3.5 | Request for Specialty Care Expertise Turnaround Time | 20842 | 0 | 33373 | 0 | 0 | 0.6245 | 0 | 0.6587 | 0 | 0 | 1490676.96 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.3.6 | Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters | 2855 | 0 | 33373 | 0 | 1 | 0.0855 | 0 | 0.0079 | 0 | 0 | 1490676.96 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.3.7 | Tobacco Assessment and Counseling | 408 | 0 | 409 | 0 | 1 | 0.9976 | 0 | 0.9407 | 0 | 0 | 1490676.96 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.7.1 | BMI Screening and Follow-up | 250 | 0 | 366 | 0 | 0 | 0.6831 | 0 | 0.878 | 0 | 0 | 1490676.96 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.7.2 | Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met) Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 8) |
8 | 0 | 8 | 0 | 1 | 1 | 0 | None | 0 | None | 1490676.96 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.7.3 | Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI | 368 | 0 | 377 | 0 | 1 | 0.9761 | 0 | 1 | 0 | 0.875 | 496892.32 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.7.3 | Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition | 301 | 0 | 377 | 0 | 0 | 0.7984 | 0 | 1 | 0 | 0.8253 | 496892.32 |
| DY14 | DPH | Arrowhead Regional Medical Center | 1.7.3 | Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity | 295 | 0 | 377 | 0 | 0 | 0.7825 | 0 | 0.997067449 | 0 | 0.754 | 496892.32 |
| DY14 | DPH | Arrowhead Regional Medical Center | 2.1.1 | Baby Friendly Hospital designation: BFUSA Designation Yes | Yes | 0 | BFUSA Cert? | 0 | 1 | 0 | 0 | None | 0 | None | 1476479.96 |
| DY14 | DPH | Arrowhead Regional Medical Center | 2.1.2 | Exclusive Breast Milk Feeding (PC-05) | 328 | 0 | 454 | 0 | 1 | 0.7225 | 0 | 0.5872 | 0 | 0 | 1476479.96 |
| DY14 | DPH | Arrowhead Regional Medical Center | 2.1.3 | OB Hemorrhage: Massive Transfusion | None | 1 | 626 | 0 | 1 | None | 1 | None | 1 | 0 | 1476479.96 |
| DY14 | DPH | Arrowhead Regional Medical Center | 2.1.4 | OB Hemorrhage: Total Products Transfused | 53 | 0 | 626 | 0 | 1 | 0.0847 | 0 | 0.048 | 0 | 0 | 1476479.96 |
| DY14 | DPH | Arrowhead Regional Medical Center | 2.1.5 | PC-02 Cesarean Section | 32 | 0 | 163 | 0 | 1 | 0.1963 | 0 | 0.2571 | 0 | 0 | 1476479.96 |
| DY14 | DPH | Arrowhead Regional Medical Center | 2.1.6 | Prenatal and Postpartum Care: Postpartum Care | 161 | 0 | 236 | 0 | 1 | 0.6822 | 0 | 0.757575758 | 0 | 0.6055 | 738239.975 |
| DY14 | DPH | Arrowhead Regional Medical Center | 2.1.6 | Prenatal and Postpartum Care: Prenatal Care | 65 | 0 | 236 | 0 | 0 | 0.2754 | 0 | 0.590909091 | 0 | 0.7766 | 738239.975 |
| DY14 | DPH | Arrowhead Regional Medical Center | 2.1.7 | Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage | 19 | 0 | 45 | 0 | 1 | 0.4222 | 0 | 0.359 | 0 | 0 | 1476479.95 |
| DY14 | DPH | Arrowhead Regional Medical Center | 2.1.8 | Unexpected Newborn Complications (UNC) | 15 | 0 | 512 | 0 | 1 | 0.0293 | 0 | 0.0279 | 0 | 0 | 1476479.95 |
| DY14 | DPH | Arrowhead Regional Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) |
16 | 0 | 16 | 0 | 1 | 1 | 0 | 1 | 0 | None | 492159.9833 |
| DY14 | DPH | Arrowhead Regional Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes | Yes | 0 | 3 Safety Drills? | 0 | n/a | 0 | 0 | None | 0 | None | 492159.9833 |
| DY14 | DPH | Arrowhead Regional Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes | Yes | 0 | 10 Debriefs? | 0 | n/a | 0 | 0 | None | 0 | None | 492159.9833 |
| DY14 | DPH | Arrowhead Regional Medical Center | 2.2.1 | DHCS All-Cause Readmissions | 337 | 0 | 2663 | 0 | 1 | 0.1265 | 0 | 0.1437 | 0 | 0 | 1476479.95 |
| DY14 | DPH | Arrowhead Regional Medical Center | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 657 | 0 | 1354 | 0 | 0 | 0.4852 | 0 | 0.4939 | 0 | 0 | 1476479.95 |
| DY14 | DPH | Arrowhead Regional Medical Center | 2.2.3 | Medication Reconciliation 30 days | 273 | 0 | 377 | 0 | 0 | 0.7241 | 0 | 0.9618 | 0 | 0 | 1476479.95 |
| DY14 | DPH | Arrowhead Regional Medical Center | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 354 | 0 | 359 | 0 | 1 | 0.9861 | 0 | 0.9501 | 0 | 0 | 1476479.95 |
| DY14 | DPH | Arrowhead Regional Medical Center | 2.2.5 | Timely Transmission of Transition Record | 3000 | 0 | 3221 | 0 | 1 | 0.9314 | 0 | 0.9273 | 0 | 0 | 1476479.95 |
| DY14 | DPH | Arrowhead Regional Medical Center | 2.3.2 | Medication Reconciliation 30 days | 256 | 0 | 277 | 0 | 0 | 0.9242 | 0 | 0.9708 | 0 | 0 | 1476479.95 |
| DY14 | DPH | Arrowhead Regional Medical Center | 2.3.4 | Timely Transmission of Transition Record | 602 | 0 | 629 | 0 | 1 | 0.9571 | 0 | 0.9167 | 0 | 0 | 1476479.95 |
| DY14 | DPH | Arrowhead Regional Medical Center | 2.6.1 | Alcohol and Drug Misuse (SBIRT): Brief screening only | None | 1 | 377 | 0 | 1 | None | 1 | 0.0134 | 0 | None | 738239.975 |
| DY14 | DPH | Arrowhead Regional Medical Center | 2.6.1 | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | None | 1 | 377 | 0 | 0.5 | None | 1 | 0.0134 | 0 | None | 738239.975 |
| DY14 | 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 | 31 | 0 | 69 | 0 | 1 | 0.4493 | 0 | 0.2482 | 0 | 0 | 1476479.95 |
| DY14 | DPH | Arrowhead Regional Medical Center | 2.6.3 | Patients with chronic pain on long term opioid therapy checked in PDMPs | 64 | 0 | 69 | 0 | 1 | 0.9275 | 0 | 0.1475 | 0 | 0 | 1476479.95 |
| DY14 | DPH | Arrowhead Regional Medical Center | 2.6.4 | Screening for Clinical Depression and follow-up | 1475 | 0 | 1913 | 0 | 0 | 0.771 | 0 | 0.8271 | 0 | 0 | 1476479.95 |
| DY14 | DPH | Arrowhead Regional Medical Center | 2.6.5 | Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy | 1693 | 0 | 1913 | 0 | 1 | 0.885 | 0 | 0.851 | 0 | 0 | 1476479.95 |
| DY14 | DPH | Arrowhead Regional Medical Center | 3.1.1 | Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis | 50 | 0 | 133 | 0 | 0 | 0.3759 | 0 | 0.4878 | 0 | 0 | 1937880 |
| DY14 | DPH | Arrowhead Regional Medical Center | 3.1.3 | National Healthcare Safety Network (NHSN) Antimicrobial Use Measure | 289 | 0 | 2908 | 0 | 1 | 0.0994 | 0 | 0.1001 | 0 | 0 | 1937880 |
| DY14 | DPH | Arrowhead Regional Medical Center | 3.1.4 | Peri-operative Prophylactic Antibiotics Administered after Surgical Closure | 329 | 0 | 3878 | 0 | 1 | 0.0848 | 0 | 0.6784 | 0 | 0 | 1937880 |
| DY14 | DPH | Arrowhead Regional Medical Center | 3.1.5 | Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0.252 | 0 | 0.7 | 1937880 |
| DY14 | DMPH | Bear Valley Community Hospital, Big Bear Lake | 2.6.1 | Alcohol and Drug Misuse (SBIRT): Brief screening only | 776 | 0 | 1366 | 0 | 1 | 0.5681 | 0 | 0.105 | 0 | None | 135000 |
| DY14 | DMPH | Bear Valley Community Hospital, Big Bear Lake | 2.6.1 | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 422 | 0 | 1366 | 0 | 1 | 0.3089 | 0 | 0.105 | 0 | None | 135000 |
| DY14 | 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 | 130 | 0 | 134 | 0 | 1 | 0.9701 | 0 | 0.8137 | 0 | 0 | 270000 |
| DY14 | DMPH | Bear Valley Community Hospital, Big Bear Lake | 2.6.3 | Patients with chronic pain on long term opioid therapy checked in PDMPs | 134 | 0 | 134 | 0 | 1 | 1 | 0 | 0.9216 | 0 | 0 | 270000 |
| DY14 | DMPH | Bear Valley Community Hospital, Big Bear Lake | 2.6.4 | Screening for Clinical Depression and follow-up | 853 | 0 | 880 | 0 | 1 | 0.9693 | 0 | 0.6197 | 0 | 0 | 270000 |
| DY14 | DMPH | Bear Valley Community Hospital, Big Bear Lake | 2.6.5 | Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy | 134 | 0 | 134 | 0 | 1 | 1 | 0 | 0.9608 | 0 | 0 | 270000 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 28831 | 0 | 50291 | 0 | 1 | 0.5733 | 0 | 0.1517 | 0 | None | 604811.27 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 8273 | 0 | 50291 | 0 | 1 | 0.1645 | 0 | 0.1517 | 0 | None | 604811.27 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.1.3.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 2153 | 0 | 8483 | 0 | 1 | 0.2538 | 0 | 0.2531 | 0 | 0 | 1209622.54 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.1.5.f | Screening for Clinical Depression and follow-up | 20150 | 0 | 27505 | 0 | 1 | 0.7326 | 0 | 0.5853 | 0 | 0 | 1209622.54 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.1.6.t | Tobacco Assessment and Counseling | 38438 | 0 | 39418 | 0 | 1 | 0.9751 | 0 | 0.9755 | 0 | 0 | 1209622.54 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Follow-up | 302 | 0 | 1582 | 0 | 1 | 0.1909 | 0 | 0.150141643 | 0 | 0.1747 | 403207.5133 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Remission | 48 | 0 | 1582 | 0 | 1 | 0.0303 | 0 | 0.019830028 | 0 | 0.0232 | 403207.5133 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Response | 92 | 0 | 1582 | 0 | 1 | 0.0582 | 0 | 0.043437205 | 0 | 0.049 | 403207.5133 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 8273 | 0 | 50291 | 0 | 1 | 0.1645 | 0 | 0.1517 | 0 | None | 604811.27 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 28831 | 0 | 50291 | 0 | 1 | 0.5733 | 0 | 0.1517 | 0 | None | 604811.27 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.2.10 | REAL and/or SO/GI disparity reduction | 1510 | 0 | 2113 | 0 | 1 | 0.7146 | 0 | 0.685 | 0 | 0 | 1209622.54 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.2.11 | REAL data completeness | 59044 | 0 | 59324 | 0 | 1 | 0.9953 | 0 | 0.993 | 0 | 0 | 1209622.54 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.2.12.f | Screening for Clinical Depression and follow-up | 20150 | 0 | 27505 | 0 | 1 | 0.7326 | 0 | 0.5853 | 0 | 0 | 1209622.54 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.2.13 | SO/GI data completeness | 41715 | 0 | 41771 | 0 | 1 | 0.9987 | 0 | 0.9956 | 0 | 0 | 1209622.54 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.2.14.t | Tobacco Assessment and Counseling | 38438 | 0 | 39418 | 0 | 1 | 0.9751 | 0 | 0.9755 | 0 | 0 | 1209622.53 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.2.2 | CG-CAHPS: Provider Rating | 8753 | 0 | 11140 | 0 | 1 | 0.7857 | 0 | 0.7573 | 0 | 0 | 1209622.54 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.2.3.c | Colorectal Cancer Screening | 12692 | 0 | 18757 | 0 | 1 | 0.6767 | 0 | 0.6744 | 0 | 0 | 1209622.54 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.2.4.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 2153 | 0 | 8483 | 0 | 1 | 0.2538 | 0 | 0.2531 | 0 | 0 | 1209622.54 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.2.5.b | Controlling Blood Pressure | 7793 | 0 | 10131 | 0 | 1 | 0.7692 | 0 | 0.763 | 0 | 0 | 1209622.54 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.2.7.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 1346 | 0 | 1417 | 0 | 1 | 0.9499 | 0 | 0.9451 | 0 | 0 | 1209622.54 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.2.8 | Prevention Quality Overall Composite #90 | 512 | 0 | 63453 | 0 | 1 | 0.0081 | 0 | 0.0084 | 0 | 0 | 1209622.54 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.3.1 | Closing the referral loop: receipt of specialist report (CMS50v3) | 22790 | 0 | 22790 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 1209622.53 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.3.2 | DHCS All-Cause Readmissions | 83 | 0 | 1264 | 0 | 1 | 0.0657 | 0 | 0.0733 | 0 | 0 | 1209622.53 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.3.3 | Influenza Immunization | 19443 | 0 | 22197 | 0 | 1 | 0.8759 | 0 | 0.6408 | 0 | 0 | 1209622.53 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.3.5 | Request for Specialty Care Expertise Turnaround Time | 45000 | 0 | 55938 | 0 | 1 | 0.8045 | 0 | 0.7689 | 0 | 0 | 1209622.53 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.3.6 | Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters | 911 | 0 | 32281 | 0 | 1 | 0.0282 | 0 | 0.0054 | 0 | 0 | 1209622.53 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.3.7 | Tobacco Assessment and Counseling | 15751 | 0 | 16029 | 0 | 1 | 0.9827 | 0 | 0.9804 | 0 | 0 | 1209622.53 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.6.1 | BIRADS to Biopsy | 55 | 0 | 61 | 0 | 1 | 0.9016 | 0 | 0.9104 | 0 | 0 | 1209622.53 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.6.2 | Breast Cancer Screening | 10022 | 0 | 12777 | 0 | 1 | 0.7844 | 0 | 0.753 | 0 | 0 | 1209622.53 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.6.3 | Cervical Cancer Screening | 17177 | 0 | 25784 | 0 | 1 | 0.6662 | 0 | 0.6328 | 0 | 0 | 1209622.53 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.6.4.c | Colorectal Cancer Screening | 12692 | 0 | 18757 | 0 | 1 | 0.6767 | 0 | 0.6744 | 0 | 0 | 1209622.53 |
| DY14 | DPH | Contra Costa Regional Medical Center | 1.6.5 | Receipt of appropriate follow-up for abnormal CRC screening | 168 | 0 | 266 | 0 | 1 | 0.6316 | 0 | 0.564 | 0 | 0 | 1209622.53 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.1.1 | Baby Friendly Hospital designation: BFUSA Designation No | No | 0 | BFUSA Cert? | 0 | See other 2.1.1 row for AV | 0 | 0 | None | 0 | None | 967697.97 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.1.1 | Baby Friendly Hospital designation: [Numerator] Dissemination Elements Completed (If your system as more than one hospital, please enter the sum of all elements completed) [Denominator] Dissemination Elements Required (if your system has more than one hospital, multiply the number of hospitals by 11) |
11 | 0 | None | 4 | 1 | None | 4 | None | 0 | None | 0 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.1.2 | Exclusive Breast Milk Feeding (PC-05) | 1075 | 0 | 1438 | 0 | 1 | 0.7476 | 0 | 0.7435 | 0 | 0 | 967697.97 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.1.3 | OB Hemorrhage: Massive Transfusion | None | 1 | 1579 | 0 | 1 | None | 1 | None | 1 | 0 | 967697.97 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.1.4 | OB Hemorrhage: Total Products Transfused | 78 | 0 | 1579 | 0 | 1 | 0.0494 | 0 | 0.0344 | 0 | 0 | 967697.97 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.1.5 | PC-02 Cesarean Section | 92 | 0 | 492 | 0 | 1 | 0.187 | 0 | 0.2101 | 0 | 0 | 967697.97 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.1.6 | Prenatal and Postpartum Care: Prenatal Care | 1161 | 0 | 1249 | 0 | 1 | 0.9295 | 0 | 0.945753034 | 0 | 0.9167 | 483848.985 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.1.6 | Prenatal and Postpartum Care: Postpartum Care | 1065 | 0 | 1249 | 0 | 1 | 0.8527 | 0 | 0.839400428 | 0 | 0.7367 | 483848.985 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.1.7 | Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage | 46 | 0 | 210 | 0 | 1 | 0.219 | 0 | 0.162 | 0 | 0 | 967697.97 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.1.8 | Unexpected Newborn Complications (UNC) | 49 | 0 | 1335 | 0 | 1 | 0.0367 | 0 | 0.0374 | 0 | 0 | 967697.97 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes | Yes | 0 | 3 Safety Drills? | 0 | n/a | 0 | 0 | None | 0 | None | 322565.99 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes | Yes | 0 | 10 Debriefs? | 0 | n/a | 0 | 0 | None | 0 | None | 322565.99 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) |
16 | 0 | 16 | 0 | 1 | 1 | 0 | 1 | 0 | None | 322565.99 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.2.1 | DHCS All-Cause Readmissions | 86 | 0 | 1341 | 0 | 1 | 0.0641 | 0 | 0.0716 | 0 | 0 | 967697.97 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 302 | 0 | 547 | 0 | 1 | 0.5521 | 0 | 0.5171 | 0 | 0 | 967697.97 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.2.3 | Medication Reconciliation 30 days | 2899 | 0 | 2909 | 0 | 1 | 0.9966 | 0 | 0.9931 | 0 | 0 | 967697.97 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 4533 | 0 | 4551 | 0 | 1 | 0.996 | 0 | 0.9834 | 0 | 0 | 967697.96 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.2.5 | Timely Transmission of Transition Record | 3159 | 0 | 3850 | 0 | 1 | 0.8205 | 0 | 0.6411 | 0 | 0 | 967697.96 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.3.2 | Medication Reconciliation 30 days | 1240 | 0 | 1248 | 0 | 1 | 0.9936 | 0 | 0.9884 | 0 | 0 | 967697.96 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.3.4 | Timely Transmission of Transition Record | 1394 | 0 | 1647 | 0 | 1 | 0.8464 | 0 | 0.669 | 0 | 0 | 967697.96 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.4.1 | Adolescent Well-Care Visit | 77 | 0 | 95 | 0 | 1 | 0.8105 | 0 | 0.8462 | 0 | 0 | 967697.96 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.4.2 | Developmental Screening in the First Three Years of Life | 44 | 0 | 74 | 0 | 1 | 0.5946 | 0 | 0.48 | 0 | 0 | 967697.96 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.4.3 | Documentation of Current Medications in the Medical Record (0-18 yo) | 636 | 0 | 636 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 967697.96 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.4.4 | Screening for Clinical Depression and follow-up | 33 | 0 | 44 | 0 | 1 | 0.75 | 0 | 0.68 | 0 | 0 | 967697.96 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.4.5 | Tobacco Assessment and Counseling (13 yo and older) | 93 | 0 | 93 | 0 | 1 | 1 | 0 | 0.956 | 0 | 0 | 967697.96 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.4.7 | Well Child Visits - Third, Fourth, Fifth, and Sixth Years of life | 30 | 0 | 35 | 0 | 1 | 0.8571 | 0 | 0.9487 | 0 | 0 | 967697.96 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.4.8 | Comprehensive Medical Evaluation Following Foster Youth Placement in Foster Care | 41 | 0 | 65 | 0 | 1 | 0.6308 | 0 | 0.4746 | 0 | 0 | 967697.96 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.6.1 | Alcohol and Drug Misuse (SBIRT): Brief screening only | 4865 | 0 | 7382 | 0 | 1 | 0.659 | 0 | 0.1012 | 0 | None | 483848.98 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.6.1 | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 835 | 0 | 7382 | 0 | 1 | 0.1131 | 0 | 0.1012 | 0 | None | 483848.98 |
| DY14 | 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 | 169 | 0 | 199 | 0 | 1 | 0.8492 | 0 | 0.3199 | 0 | 0 | 967697.96 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.6.3 | Patients with chronic pain on long term opioid therapy checked in PDMPs | 199 | 0 | 199 | 0 | 1 | 1 | 0 | 0.6466 | 0 | 0 | 967697.96 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.6.4 | Screening for Clinical Depression and follow-up | 2737 | 0 | 3442 | 0 | 1 | 0.7952 | 0 | 0.663 | 0 | 0 | 967697.96 |
| DY14 | DPH | Contra Costa Regional Medical Center | 2.6.5 | Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy | 6625 | 0 | 8084 | 0 | 1 | 0.8195 | 0 | 0.7899 | 0 | 0 | 967697.96 |
| DY14 | DPH | Contra Costa Regional Medical Center | 3.2.1 | Dont Do Imaging for Uncomplicated Headaches (Choosing Wisely) | 481 | 0 | 4579 | 0 | 1 | 0.105 | 0 | 0.1192 | 0 | 0 | 1693471.5 |
| DY14 | DPH | Contra Costa Regional Medical Center | 3.2.2 | Appropriate Emergency Department Utilization of CT for Pulmonary Embolism | 258 | 0 | 274 | 0 | 1 | 0.9416 | 0 | 0.9108 | 0 | 0 | 1693471.5 |
| DY14 | DPH | Contra Costa Regional Medical Center | 3.2.3 | Use of Imaging Studies for Low Back Pain | 2623 | 0 | 3151 | 0 | 1 | 0.8324 | 0 | 0.8729 | 0 | 0 | 1693471.5 |
| DY14 | 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 | 1046 | 0 | 1755 | 0 | 1 | 0.596 | 0 | 0.078649922 | 0 | None | 846735.75 |
| DY14 | 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 | 709 | 0 | 1755 | 0 | 1 | 0.404 | 0 | 0.110518053 | 0 | None | 846735.75 |
| DY14 | DMPH | Eastern Plumas Health Care, Portol | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 593 | 0 | 910 | 0 | 1 | 0.6516 | 0 | 0.0529 | 0 | None | 135000 |
| DY14 | DMPH | Eastern Plumas Health Care, Portol | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 412 | 0 | 910 | 0 | 1 | 0.4527 | 0 | 0.0529 | 0 | None | 135000 |
| DY14 | DMPH | Eastern Plumas Health Care, Portol | 1.1.3.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 27 | 0 | 107 | 0 | 1 | 0.2523 | 0 | 0.2642 | 0 | 0 | 270000 |
| DY14 | DMPH | Eastern Plumas Health Care, Portol | 1.1.5.f | Screening for Clinical Depression and follow-up | 187 | 0 | 461 | 0 | 1 | 0.4056 | 0 | 0.1458 | 0 | 0 | 270000 |
| DY14 | DMPH | Eastern Plumas Health Care, Portol | 1.1.6.t | Tobacco Assessment and Counseling | 760 | 0 | 939 | 0 | 1 | 0.8094 | 0 | 0.7604 | 0 | 0 | 270000 |
| DY14 | DMPH | Eastern Plumas Health Care, Portol | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Follow-up | 44 | 0 | 54 | 0 | 1 | 0.8148 | 0 | 0.240740741 | 0 | 0.2562 | 90000 |
| DY14 | 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 | 1 | 0.022 | 90000 |
| DY14 | DMPH | Eastern Plumas Health Care, Portol | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Response | 13 | 0 | 54 | 0 | 1 | 0.2407 | 0 | None | 1 | 0.0433 | 90000 |
| DY14 | DMPH | El Camino Hospital, Mountain View | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 1735 | 0 | 2654 | 0 | 1 | 0.6537 | 0 | None | 1 | None | 162000 |
| DY14 | DMPH | El Camino Hospital, Mountain View | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 43 | 0 | 2654 | 0 | 1 | 0.0162 | 0 | None | 1 | None | 162000 |
| DY14 | DMPH | El Camino Hospital, Mountain View | 1.1.3.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 70 | 0 | 323 | 0 | 1 | 0.2167 | 0 | 0.1929 | 0 | 0 | 324000 |
| DY14 | DMPH | El Camino Hospital, Mountain View | 1.1.5.f | Screening for Clinical Depression and follow-up | 2042 | 0 | 2278 | 0 | 1 | 0.8964 | 0 | 0.9434 | 0 | 0 | 324000 |
| DY14 | DMPH | El Camino Hospital, Mountain View | 1.1.6.t | Tobacco Assessment and Counseling | 2086 | 0 | 2278 | 0 | 1 | 0.9157 | 0 | 0.8616 | 0 | 0 | 324000 |
| DY14 | DMPH | El Camino Hospital, Mountain View | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Follow-up | 203 | 0 | 312 | 0 | 1 | 0.6506 | 0 | 0.48440367 | 0 | 0.3956 | 108000 |
| DY14 | DMPH | El Camino Hospital, Mountain View | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Remission | 109 | 0 | 312 | 0 | 1 | 0.3494 | 0 | None | 1 | 0.0202 | 108000 |
| DY14 | DMPH | El Camino Hospital, Mountain View | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Response | 105 | 0 | 312 | 0 | 1 | 0.3365 | 0 | 0.025688073 | 0 | 0.0331 | 108000 |
| DY14 | DMPH | El Camino Hospital, Mountain View | 2.1.1 | Baby Friendly Hospital designation: BFUSA Designation No | No | 0 | BFUSA Cert? | 0 | See other 2.1.1 row for AV | 0 | 0 | None | 0 | None | 324000 |
| DY14 | DMPH | El Camino Hospital, Mountain View | 2.1.1 | Baby Friendly Hospital designation: [Numerator] Dissemination Elements Completed (If your system as more than one hospital, please enter the sum of all elements completed) [Denominator] Dissemination Elements Required (if your system has more than one hospital, multiply the number of hospitals by 11) |
0 | 0 | None | 4 | 0 | None | 4 | None | 0 | None | 0 |
| DY14 | DMPH | El Camino Hospital, Mountain View | 2.1.2 | Exclusive Breast Milk Feeding (PC-05) | 23 | 0 | 42 | 0 | 1 | 0.5476 | 0 | 0.4 | 0 | 0 | 324000 |
| DY14 | DMPH | El Camino Hospital, Mountain View | 2.1.3 | OB Hemorrhage: Massive Transfusion | 0 | 0 | 47 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 324000 |
| DY14 | DMPH | El Camino Hospital, Mountain View | 2.1.4 | OB Hemorrhage: Total Products Transfused | None | 1 | 47 | 0 | 1 | None | 1 | None | 1 | 0 | 324000 |
| DY14 | DMPH | El Camino Hospital, Mountain View | 2.1.5 | PC-02 Cesarean Section | None | 1 | None | 4 | 0 | None | 1 | None | 1 | 0 | 0 |
| DY14 | DMPH | El Camino Hospital, Mountain View | 2.1.6 | Prenatal and Postpartum Care: Postpartum Care | 70 | 0 | 82 | 0 | 1 | 0.8537 | 0 | 0.754716981 | 0 | 0.7367 | 162000 |
| DY14 | DMPH | El Camino Hospital, Mountain View | 2.1.6 | Prenatal and Postpartum Care: Prenatal Care | 55 | 0 | 82 | 0 | 0 | 0.6707 | 0 | 0.867924528 | 0 | 0.7766 | 162000 |
| DY14 | DMPH | El Camino Hospital, Mountain View | 2.1.7 | Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage | None | 1 | None | 1 | 0 | None | 1 | None | 1 | 0 | 0 |
| DY14 | DMPH | El Camino Hospital, Mountain View | 2.1.8 | Unexpected Newborn Complications (UNC) | None | 1 | 43 | 0 | 1 | None | 1 | 0 | 0 | 0 | 324000 |
| DY14 | 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 | 1 | 0 | 1 | 0 | None | 108000 |
| DY14 | DMPH | El Camino Hospital, Mountain View | 2.1.9 | OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes | Yes | 0 | 10 Debriefs? | 0 | n/a | 0 | 0 | None | 0 | None | 108000 |
| DY14 | DMPH | El Camino Hospital, Mountain View | 2.1.9 | OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes | Yes | 0 | 3 Safety Drills? | 0 | n/a | 0 | 0 | None | 0 | None | 108000 |
| DY14 | DMPH | El Camino Hospital, Mountain View | 3.4.1 | ePBM-01 Pre-op Anemia Screening, Selected Elective Surgical Patients | None | 1 | None | 4 | 0 | None | 1 | None | 1 | 0 | 0 |
| DY14 | DMPH | El Camino Hospital, Mountain View | 3.4.3 | ePBM-03 Pre-op Type and Crossmatch, Type and Screen, Selected elective Surgical Patients | None | 1 | None | 4 | 0 | None | 1 | None | 4 | 0 | 0 |
| DY14 | DMPH | El Camino Hospital, Mountain View | 3.4.4 | ePBM-04 Initial Transfusion Threshold | 101 | 0 | 101 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 324000 |
| DY14 | DMPH | El Centro Regional Medical Center, El Centro | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 668 | 0 | 9620 | 0 | 1 | 0.0694 | 0 | 0.0631 | 0 | None | 214578.95 |
| DY14 | DMPH | El Centro Regional Medical Center, El Centro | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 6258 | 0 | 9620 | 0 | 1 | 0.6505 | 0 | 0.0631 | 0 | None | 214578.95 |
| DY14 | DMPH | El Centro Regional Medical Center, El Centro | 1.2.10 | REAL and/or SO/GI disparity reduction | 496 | 0 | 808 | 0 | 1 | 0.6139 | 0 | 0.1654 | 0 | 0 | 429157.9 |
| DY14 | DMPH | El Centro Regional Medical Center, El Centro | 1.2.11 | REAL data completeness | 6599 | 0 | 8413 | 0 | 1 | 0.7844 | 0 | 0.9706 | 0 | 0 | 429157.9 |
| DY14 | DMPH | El Centro Regional Medical Center, El Centro | 1.2.12.f | Screening for Clinical Depression and follow-up | 3778 | 0 | 5039 | 0 | 1 | 0.7498 | 0 | 0.6125 | 0 | 0 | 429157.89 |
| DY14 | DMPH | El Centro Regional Medical Center, El Centro | 1.2.13 | SO/GI data completeness | 6067 | 0 | 8413 | 0 | 1 | 0.7211 | 0 | 0.4934 | 0 | 0 | 429157.89 |
| DY14 | DMPH | El Centro Regional Medical Center, El Centro | 1.2.14.t | Tobacco Assessment and Counseling | 6762 | 0 | 8413 | 0 | 1 | 0.8038 | 0 | 0.7803 | 0 | 0 | 429157.89 |
| DY14 | DMPH | El Centro Regional Medical Center, El Centro | 1.2.2 | CG-CAHPS: Provider Rating | 1581 | 0 | 2155 | 0 | 1 | 0.7336 | 0 | 0.7149 | 0 | 0 | 429157.9 |
| DY14 | DMPH | El Centro Regional Medical Center, El Centro | 1.2.3.c | Colorectal Cancer Screening | 1088 | 0 | 2478 | 0 | 1 | 0.4391 | 0 | 0.3138 | 0 | 0 | 429157.9 |
| DY14 | DMPH | El Centro Regional Medical Center, El Centro | 1.2.4.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 310 | 0 | 1184 | 0 | 1 | 0.2618 | 0 | 0.2835 | 0 | 0 | 429157.9 |
| DY14 | DMPH | El Centro Regional Medical Center, El Centro | 1.2.5.b | Controlling Blood Pressure | 336 | 0 | 435 | 0 | 1 | 0.7724 | 0 | 0.8805 | 0 | 0 | 429157.9 |
| DY14 | DMPH | El Centro Regional Medical Center, El Centro | 1.2.7.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 178 | 0 | 208 | 0 | 1 | 0.8558 | 0 | 0.8337 | 0 | 0 | 429157.9 |
| DY14 | DMPH | El Centro Regional Medical Center, El Centro | 1.2.8 | Prevention Quality Overall Composite #90 | 379 | 0 | 9369 | 0 | 0 | 0.0405 | 0 | 0.0344 | 0 | 0 | 429157.9 |
| DY14 | DMPH | El Centro Regional Medical Center, El Centro | 1.7.1 | BMI Screening and Follow-up | 4458 | 0 | 8093 | 0 | 1 | 0.5508 | 0 | 0.1011 | 0 | 0 | 429157.89 |
| DY14 | DMPH | El Centro Regional Medical Center, El Centro | 1.7.2 | Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met) Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 8) |
7 | 0 | 8 | 0 | 0.75 | 0.75 | 0 | None | 0 | None | 429157.89 |
| DY14 | 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 | 3017 | 0 | 3057 | 0 | 1 | 0.9869 | 0 | 0.999137931 | 0 | 0.875 | 143052.63 |
| DY14 | 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 | 1794 | 0 | 3057 | 0 | 1 | 0.5868 | 0 | 0.2875 | 0 | 0.5856 | 143052.63 |
| DY14 | 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 | 1794 | 0 | 3057 | 0 | 1 | 0.5868 | 0 | 0.275862069 | 0 | 0.4906 | 143052.63 |
| DY14 | DMPH | El Centro Regional Medical Center, El Centro | 3.2.1 | Dont Do Imaging for Uncomplicated Headaches (Choosing Wisely) | 247 | 0 | 1278 | 0 | 1 | 0.1933 | 0 | 0.282 | 0 | 0 | 429157.89 |
| DY14 | DMPH | El Centro Regional Medical Center, El Centro | 3.2.2 | Appropriate Emergency Department Utilization of CT for Pulmonary Embolism | 199 | 0 | 239 | 0 | 1 | 0.8326 | 0 | 0.6781 | 0 | 0 | 429157.89 |
| DY14 | DMPH | El Centro Regional Medical Center, El Centro | 3.2.3 | Use of Imaging Studies for Low Back Pain | 388 | 0 | 536 | 0 | 1 | 0.7239 | 0 | 0.6681 | 0 | 0 | 429157.89 |
| DY14 | 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 | 130 | 0 | 365 | 0 | 1 | 0.3562 | 0 | 0.231666667 | 0 | None | 214578.945 |
| DY14 | 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 | 235 | 0 | 365 | 0 | 1 | 0.6438 | 0 | 0.188333333 | 0 | None | 214578.945 |
| DY14 | DMPH | Hazel Hawkins Memorial Hospital, Hollister | 2.3.2 | Medication Reconciliation 30 days | 29 | 0 | 32 | 0 | 1 | 0.9063 | 0 | 0.6522 | 0 | 0 | 1179000 |
| DY14 | DMPH | Hazel Hawkins Memorial Hospital, Hollister | 2.3.4 | Timely Transmission of Transition Record | 32 | 0 | 32 | 0 | 1 | 1 | 0 | 0.9348 | 0 | 0 | 1179000 |
| DY14 | DMPH | Healdsburg District Hospital, Healdsburg | 1.5.1.b | Controlling Blood Pressure | 46 | 0 | 61 | 0 | 1 | 0.7541 | 0 | 0.7176 | 0 | 0 | 339000 |
| DY14 | DMPH | Healdsburg District Hospital, Healdsburg | 1.5.2.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 45 | 0 | 48 | 0 | 1 | 0.9375 | 0 | None | 4 | 0 | 0 |
| DY14 | DMPH | Healdsburg District Hospital, Healdsburg | 1.5.3 | PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 12 | 0 | 71 | 0 | 0 | 0.169 | 0 | 0.2148 | 0 | 0 | 339000 |
| DY14 | DMPH | Healdsburg District Hospital, Healdsburg | 1.5.4.t | Tobacco Assessment and Counseling | 186 | 0 | 188 | 0 | 1 | 0.9894 | 0 | 0.2298 | 0 | 0 | 339000 |
| DY14 | DMPH | Healdsburg District Hospital, Healdsburg | 1.6.1 | BIRADS to Biopsy | None | 1 | None | 1 | 0 | None | 1 | None | 1 | 0 | 0 |
| DY14 | DMPH | Healdsburg District Hospital, Healdsburg | 1.6.2 | Breast Cancer Screening | 151 | 0 | 184 | 0 | 1 | 0.8207 | 0 | 0.2647 | 0 | 0 | 339000 |
| DY14 | DMPH | Healdsburg District Hospital, Healdsburg | 1.6.3 | Cervical Cancer Screening | 154 | 0 | 242 | 0 | 1 | 0.6364 | 0 | 0.2053 | 0 | 0 | 339000 |
| DY14 | DMPH | Healdsburg District Hospital, Healdsburg | 1.6.4.c | Colorectal Cancer Screening | 119 | 0 | 170 | 0 | 1 | 0.7 | 0 | 0.1977 | 0 | 0 | 339000 |
| DY14 | DMPH | Healdsburg District Hospital, Healdsburg | 1.6.5 | Receipt of appropriate follow-up for abnormal CRC screening | 0 | 0 | 0 | 0 | 0 | 0 | 0 | None | 1 | 0 | 0 |
| DY14 | DMPH | Jerold Phelps Community Hospital, Garberville | 1.5.1.b | Controlling Blood Pressure | 35 | 0 | 54 | 0 | 1 | 0.6481 | 0 | 0.6047 | 0 | 0 | 450000 |
| DY14 | DMPH | Jerold Phelps Community Hospital, Garberville | 1.5.2.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | None | 1 | None | 1 | 0 | None | 1 | None | 1 | 0 | 0 |
| DY14 | DMPH | Jerold Phelps Community Hospital, Garberville | 1.5.3 | PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 237 | 0 | 283 | 0 | 0 | 0.8375 | 0 | 0.9444 | 0 | 0 | 450000 |
| DY14 | DMPH | Jerold Phelps Community Hospital, Garberville | 1.5.4.t | Tobacco Assessment and Counseling | 183 | 0 | 195 | 0 | 1 | 0.9385 | 0 | 0.92 | 0 | 0 | 450000 |
| DY14 | DMPH | John C. Fremont Healthcare District, Mariposa | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 749 | 0 | 795 | 0 | 1 | 0.9421 | 0 | 0.0554 | 0 | None | 56250 |
| DY14 | DMPH | John C. Fremont Healthcare District, Mariposa | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 23 | 0 | 795 | 0 | 0 | 0.0289 | 0 | 0.0554 | 0 | None | 56250 |
| DY14 | DMPH | John C. Fremont Healthcare District, Mariposa | 1.2.10 | REAL and/or SO/GI disparity reduction | 12 | 0 | 73 | 0 | 1 | 0.1644 | 0 | 0.5435 | 0 | 0 | 112500 |
| DY14 | DMPH | John C. Fremont Healthcare District, Mariposa | 1.2.11 | REAL data completeness | 893 | 0 | 909 | 0 | 1 | 0.9824 | 0 | 0.4519 | 0 | 0 | 112500 |
| DY14 | DMPH | John C. Fremont Healthcare District, Mariposa | 1.2.12.f | Screening for Clinical Depression and follow-up | 366 | 0 | 726 | 0 | 1 | 0.5041 | 0 | 0.0845 | 0 | 0 | 112500 |
| DY14 | DMPH | John C. Fremont Healthcare District, Mariposa | 1.2.13 | SO/GI data completeness | 683 | 0 | 726 | 0 | 1 | 0.9408 | 0 | 0.4823 | 0 | 0 | 112500 |
| DY14 | DMPH | John C. Fremont Healthcare District, Mariposa | 1.2.14.t | Tobacco Assessment and Counseling | 590 | 0 | 726 | 0 | 1 | 0.8127 | 0 | 0.5658 | 0 | 0 | 112500 |
| DY14 | DMPH | John C. Fremont Healthcare District, Mariposa | 1.2.2 | CG-CAHPS: Provider Rating | 379 | 0 | 466 | 0 | 1 | 0.8133 | 0 | 0.3629 | 0 | 0 | 112500 |
| DY14 | DMPH | John C. Fremont Healthcare District, Mariposa | 1.2.3.c | Colorectal Cancer Screening | 178 | 0 | 422 | 0 | 1 | 0.4218 | 0 | 0.1758 | 0 | 0 | 112500 |
| DY14 | DMPH | John C. Fremont Healthcare District, Mariposa | 1.2.4.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 29 | 0 | 136 | 0 | 1 | 0.2132 | 0 | 0.5241 | 0 | 0 | 112500 |
| DY14 | DMPH | John C. Fremont Healthcare District, Mariposa | 1.2.5.b | Controlling Blood Pressure | 237 | 0 | 308 | 0 | 1 | 0.7695 | 0 | 0.3892 | 0 | 0 | 112500 |
| DY14 | DMPH | John C. Fremont Healthcare District, Mariposa | 1.2.7.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 56 | 0 | 68 | 0 | 1 | 0.8235 | 0 | 0.488 | 0 | 0 | 112500 |
| DY14 | DMPH | John C. Fremont Healthcare District, Mariposa | 1.2.8 | Prevention Quality Overall Composite #90 | 53 | 0 | 726 | 0 | 0 | 0.073 | 0 | 0.057 | 0 | 0 | 112500 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 178 | 0 | 434 | 0 | 1 | 0.4101 | 0 | 0.0673 | 0 | None | 373973.685 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 80 | 0 | 434 | 0 | 1 | 0.1843 | 0 | 0.0673 | 0 | None | 373973.685 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 1.2.10 | REAL and/or SO/GI disparity reduction | 197 | 0 | 259 | 0 | 1 | 0.7606 | 0 | 0.5983 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 1.2.11 | REAL data completeness | 11598 | 0 | 11598 | 0 | 1 | 1 | 0 | 0.6803 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 1.2.12.f | Screening for Clinical Depression and follow-up | 283 | 0 | 377 | 0 | 1 | 0.7507 | 0 | 0.4473 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 1.2.13 | SO/GI data completeness | 2975 | 0 | 6722 | 0 | 1 | 0.4426 | 0 | 0.3549 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 1.2.14.t | Tobacco Assessment and Counseling | 396 | 0 | 431 | 0 | 1 | 0.9188 | 0 | 0.8963 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 1.2.2 | CG-CAHPS: Provider Rating | 1141 | 0 | 1458 | 0 | 1 | 0.7826 | 0 | 0.7381 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 1.2.3.c | Colorectal Cancer Screening | 139 | 0 | 401 | 0 | 1 | 0.3466 | 0 | 0.2689 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 1.2.4.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 139 | 0 | 383 | 0 | 1 | 0.3629 | 0 | 0.4763 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 1.2.5.b | Controlling Blood Pressure | 281 | 0 | 411 | 0 | 1 | 0.6837 | 0 | 0.6599 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 1.2.7.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 156 | 0 | 170 | 0 | 1 | 0.9176 | 0 | 0.8842 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 1.2.8 | Prevention Quality Overall Composite #90 | 243 | 0 | 21407 | 0 | 0 | 0.0114 | 0 | 0.0303 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 1.3.1 | Closing the referral loop: receipt of specialist report (CMS50v3) | 133 | 0 | 393 | 0 | 0 | 0.3384 | 0 | 0.4006 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 1.3.2 | DHCS All-Cause Readmissions | 197 | 0 | 1008 | 0 | 0 | 0.1954 | 0 | 0.1728 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 1.3.3 | Influenza Immunization | 127 | 0 | 369 | 0 | 1 | 0.3442 | 0 | 0.1541 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 1.3.5 | Request for Specialty Care Expertise Turnaround Time | 4740 | 0 | 5622 | 0 | 1 | 0.8431 | 0 | 0.2452 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 1.3.6 | Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters | 226 | 0 | 6855 | 0 | 0 | 0.033 | 0 | 0.017 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 1.3.7 | Tobacco Assessment and Counseling | 376 | 0 | 402 | 0 | 1 | 0.9353 | 0 | 0.8676 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 1.5.1.b | Controlling Blood Pressure | 281 | 0 | 411 | 0 | 1 | 0.6837 | 0 | 0.6599 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 1.5.2.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 156 | 0 | 170 | 0 | 1 | 0.9176 | 0 | 0.8842 | 0 | 0 | 747947.37 |
| DY14 | 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 | 310 | 0 | 384 | 0 | 1 | 0.8073 | 0 | 0.7802 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 1.5.4.t | Tobacco Assessment and Counseling | 396 | 0 | 431 | 0 | 1 | 0.9188 | 0 | 0.8963 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 2.2.1 | DHCS All-Cause Readmissions | 754 | 0 | 3970 | 0 | 0 | 0.1899 | 0 | 0.1867 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 4878 | 0 | 10000 | 0 | 0 | 0.4878 | 0 | 0.488 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 2.2.3 | Medication Reconciliation 30 days | 300 | 0 | 371 | 0 | 0 | 0.8086 | 0 | 0.835 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 152 | 0 | 432 | 0 | 1 | 0.3519 | 0 | 0.1178 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 2.2.5 | Timely Transmission of Transition Record | 37 | 0 | 424 | 0 | 0 | 0.0873 | 0 | None | 1 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 2.3.2 | Medication Reconciliation 30 days | 164 | 0 | 181 | 0 | 1 | 0.9061 | 0 | 0.8167 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 2.3.4 | Timely Transmission of Transition Record | 69 | 0 | 345 | 0 | 1 | 0.2 | 0 | None | 1 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 2.6.1 | Alcohol and Drug Misuse (SBIRT): Brief screening only | 328 | 0 | 556 | 0 | 1 | 0.5899 | 0 | 0.4797 | 0 | None | 373973.685 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 2.6.1 | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 199 | 0 | 556 | 0 | 1 | 0.3579 | 0 | 0.4797 | 0 | None | 373973.685 |
| DY14 | 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 | 155 | 0 | 245 | 0 | 1 | 0.6327 | 0 | 0.2748 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 2.6.3 | Patients with chronic pain on long term opioid therapy checked in PDMPs | 201 | 0 | 245 | 0 | 1 | 0.8204 | 0 | 0.3153 | 0 | 0 | 747947.37 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 2.6.4 | Screening for Clinical Depression and follow-up | 328 | 0 | 373 | 0 | 1 | 0.8794 | 0 | 0.7246 | 0 | 0 | 747947.36 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 2.6.5 | Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy | 535 | 0 | 663 | 0 | 1 | 0.8069 | 0 | 0.3468 | 0 | 0 | 747947.36 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 2.7.1 | Advance Care Plan | 204 | 0 | 369 | 0 | 1 | 0.5528 | 0 | 0.1848 | 0 | 0 | 747947.36 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 2.7.3 | MWM #8: Treatment Preferences (documentation) Inpatient | 232 | 0 | 235 | 0 | 1 | 0.9872 | 0 | 0.9245 | 0 | 0 | 747947.36 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 2.7.4 | MWM #8: Treatment Preferences (documentation) Outpatient | None | 1 | None | 1 | 0 | None | 1 | None | 4 | 0 | 0 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 2.7.5 | Palliative Care Service Offered at Time of Diagnosis of Advanced Illness | 160 | 0 | 1171 | 0 | 1 | 0.1366 | 0 | 0.3935 | 0 | 0 | 747947.36 |
| DY14 | DMPH | Kaweah Delta Health Care District, Visalia | 2.7.6 | Proportion Admitted to Hospice for Less Than 3 Days | 13 | 0 | 61 | 0 | 0 | 0.2131 | 0 | 0.217 | 0 | 0 | 747947.36 |
| DY14 | DPH | Kern Medical Center | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 5267 | 0 | 10748 | 0 | 1 | 0.49 | 0 | 0.5703 | 0 | None | 548778.465 |
| DY14 | DPH | Kern Medical Center | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 5267 | 0 | 10748 | 0 | 1 | 0.49 | 0 | 0.5703 | 0 | None | 548778.465 |
| DY14 | DPH | Kern Medical Center | 1.1.3.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 649 | 0 | 2361 | 0 | 1 | 0.2749 | 0 | 0.2744 | 0 | 0 | 1097556.93 |
| DY14 | DPH | Kern Medical Center | 1.1.5.f | Screening for Clinical Depression and follow-up | 4463 | 0 | 6617 | 0 | 1 | 0.6745 | 0 | 0.5536 | 0 | 0 | 1097556.93 |
| DY14 | DPH | Kern Medical Center | 1.1.6.t | Tobacco Assessment and Counseling | 7684 | 0 | 7900 | 0 | 1 | 0.9727 | 0 | 0.9563 | 0 | 0 | 1097556.93 |
| DY14 | DPH | Kern Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Remission | 22 | 0 | 290 | 0 | 1 | 0.0759 | 0 | 0.204545455 | 0 | 0.0492 | 365852.31 |
| DY14 | DPH | Kern Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Follow-up | 80 | 0 | 290 | 0 | 1 | 0.2759 | 0 | 0.048701299 | 0 | 0.2236 | 365852.31 |
| DY14 | DPH | Kern Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Response | 34 | 0 | 290 | 0 | 1 | 0.1172 | 0 | 0.077922078 | 0 | 0.0801 | 365852.31 |
| DY14 | DPH | Kern Medical Center | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 5267 | 0 | 10748 | 0 | 1 | 0.49 | 0 | 0.5703 | 0 | None | 548778.465 |
| DY14 | DPH | Kern Medical Center | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 5267 | 0 | 10748 | 0 | 1 | 0.49 | 0 | 0.5703 | 0 | None | 548778.465 |
| DY14 | DPH | Kern Medical Center | 1.2.10 | REAL and/or SO/GI disparity reduction | 121 | 0 | 138 | 0 | 1 | 0.8768 | 0 | 0.8365 | 0 | 0 | 1097556.92 |
| DY14 | DPH | Kern Medical Center | 1.2.11 | REAL data completeness | 11992 | 0 | 14840 | 0 | 1 | 0.8081 | 0 | 0.5804 | 0 | 0 | 1097556.92 |
| DY14 | DPH | Kern Medical Center | 1.2.12.f | Screening for Clinical Depression and follow-up | 4463 | 0 | 6617 | 0 | 1 | 0.6745 | 0 | 0.5536 | 0 | 0 | 1097556.92 |
| DY14 | DPH | Kern Medical Center | 1.2.13 | SO/GI data completeness | 3461 | 0 | 8266 | 0 | 1 | 0.4187 | 0 | 0.2742 | 0 | 0 | 1097556.92 |
| DY14 | DPH | Kern Medical Center | 1.2.14.t | Tobacco Assessment and Counseling | 7684 | 0 | 7900 | 0 | 1 | 0.9727 | 0 | 0.9563 | 0 | 0 | 1097556.92 |
| DY14 | DPH | Kern Medical Center | 1.2.2 | CG-CAHPS: Provider Rating | 180 | 0 | 243 | 0 | 1 | 0.7407 | 0 | 0.725 | 0 | 0 | 1097556.93 |
| DY14 | DPH | Kern Medical Center | 1.2.3.c | Colorectal Cancer Screening | 2437 | 0 | 3612 | 0 | 1 | 0.6747 | 0 | 0.6689 | 0 | 0 | 1097556.93 |
| DY14 | DPH | Kern Medical Center | 1.2.4.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 649 | 0 | 2361 | 0 | 1 | 0.2749 | 0 | 0.2744 | 0 | 0 | 1097556.92 |
| DY14 | DPH | Kern Medical Center | 1.2.5.b | Controlling Blood Pressure | 2304 | 0 | 2990 | 0 | 1 | 0.7706 | 0 | 0.6878 | 0 | 0 | 1097556.92 |
| DY14 | DPH | Kern Medical Center | 1.2.7.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 436 | 0 | 493 | 0 | 1 | 0.8844 | 0 | 0.8344 | 0 | 0 | 1097556.92 |
| DY14 | DPH | Kern Medical Center | 1.2.8 | Prevention Quality Overall Composite #90 | 43 | 0 | 12094 | 0 | 1 | 0.0036 | 0 | 0.0101 | 0 | 0 | 1097556.92 |
| DY14 | DPH | Kern Medical Center | 1.3.1 | Closing the referral loop: receipt of specialist report (CMS50v3) | 17814 | 0 | 17814 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 1097556.92 |
| DY14 | DPH | Kern Medical Center | 1.3.2 | DHCS All-Cause Readmissions | 30 | 0 | 289 | 0 | 1 | 0.1038 | 0 | 0.0766 | 0 | 0 | 1097556.92 |
| DY14 | DPH | Kern Medical Center | 1.3.3 | Influenza Immunization | 2039 | 0 | 2856 | 0 | 1 | 0.7139 | 0 | 0.5887 | 0 | 0 | 1097556.92 |
| DY14 | DPH | Kern Medical Center | 1.3.5 | Request for Specialty Care Expertise Turnaround Time | 35127 | 0 | 97670 | 0 | 1 | 0.3596 | 0 | 0.1422 | 0 | 0 | 1097556.92 |
| DY14 | DPH | Kern Medical Center | 1.3.6 | Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters | 4980 | 0 | 85425 | 0 | 1 | 0.0583 | 0 | 0.0002 | 0 | 0 | 1097556.92 |
| DY14 | DPH | Kern Medical Center | 1.3.7 | Tobacco Assessment and Counseling | 3986 | 0 | 4069 | 0 | 1 | 0.9796 | 0 | 0.966 | 0 | 0 | 1097556.92 |
| DY14 | DPH | Kern Medical Center | 1.4.1 | Abnormal Results Follow-Up: Abnormal Potassium Follow-up | 9476 | 0 | 10142 | 0 | 1 | 0.9343 | 0 | 0.871805112 | 0 | 0.8746 | 365852.3067 |
| DY14 | DPH | Kern Medical Center | 1.4.1 | Abnormal Results Follow-Up: Abnormal INR Follow-up | 940 | 0 | 1101 | 0 | 1 | 0.8538 | 0 | 0.381578947 | 0 | 0.4334 | 365852.3067 |
| DY14 | DPH | Kern Medical Center | 1.4.1 | Abnormal Results Follow-Up: Abnormal BIRADS Follow-up | 701 | 0 | 1344 | 0 | 1 | 0.5216 | 0 | 0.425925926 | 0 | 0.4733 | 365852.3067 |
| DY14 | DPH | Kern Medical Center | 1.4.2 | Annual Monitoring for Patients on Persistent Medications | 4183 | 0 | 4623 | 0 | 1 | 0.9048 | 0 | 0.8942 | 0 | 0 | 1097556.92 |
| DY14 | DPH | Kern Medical Center | 1.4.3 | INR Monitoring for Individuals on Warfarin | 87 | 0 | 91 | 0 | 1 | 0.956 | 0 | 0.8539 | 0 | 0 | 1097556.92 |
| DY14 | DPH | Kern Medical Center | 2.1.1 | Baby Friendly Hospital designation: BFUSA Designation Yes | Yes | 0 | BFUSA Cert? | 0 | 1 | 0 | 0 | None | 0 | None | 1141459.2 |
| DY14 | DPH | Kern Medical Center | 2.1.2 | Exclusive Breast Milk Feeding (PC-05) | 522 | 0 | 759 | 0 | 1 | 0.6877 | 0 | 0.5252 | 0 | 0 | 1141459.2 |
| DY14 | DPH | Kern Medical Center | 2.1.3 | OB Hemorrhage: Massive Transfusion | None | 1 | 1005 | 0 | 1 | None | 1 | None | 1 | 0 | 1141459.2 |
| DY14 | DPH | Kern Medical Center | 2.1.4 | OB Hemorrhage: Total Products Transfused | 95 | 0 | 1005 | 0 | 1 | 0.0945 | 0 | 0.1216 | 0 | 0 | 1141459.2 |
| DY14 | DPH | Kern Medical Center | 2.1.5 | PC-02 Cesarean Section | 42 | 0 | 194 | 0 | 1 | 0.2165 | 0 | 0.179 | 0 | 0 | 1141459.2 |
| DY14 | DPH | Kern Medical Center | 2.1.6 | Prenatal and Postpartum Care: Prenatal Care | 760 | 0 | 841 | 0 | 1 | 0.9037 | 0 | 0.748979592 | 0 | 0.7766 | 570729.6 |
| DY14 | DPH | Kern Medical Center | 2.1.6 | Prenatal and Postpartum Care: Postpartum Care | 573 | 0 | 841 | 0 | 1 | 0.6813 | 0 | 0.656122449 | 0 | 0.6642 | 570729.6 |
| DY14 | DPH | Kern Medical Center | 2.1.7 | Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage | 44 | 0 | 112 | 0 | 1 | 0.3929 | 0 | 0.4513 | 0 | 0 | 1141459.2 |
| DY14 | DPH | Kern Medical Center | 2.1.8 | Unexpected Newborn Complications (UNC) | 35 | 0 | 740 | 0 | 1 | 0.0473 | 0 | 0.0419 | 0 | 0 | 1141459.2 |
| DY14 | DPH | Kern Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) |
16 | 0 | 16 | 0 | 1 | 1 | 0 | 1 | 0 | None | 380486.4 |
| DY14 | DPH | Kern Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes | Yes | 0 | 3 Safety Drills? | 0 | n/a | 0 | 0 | None | 0 | None | 380486.4 |
| DY14 | DPH | Kern Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes | Yes | 0 | 10 Debriefs? | 0 | n/a | 0 | 0 | None | 0 | None | 380486.4 |
| DY14 | DPH | Kern Medical Center | 2.2.1 | DHCS All-Cause Readmissions | 28 | 0 | 299 | 0 | 1 | 0.0936 | 0 | 0.0987 | 0 | 0 | 1141459.2 |
| DY14 | DPH | Kern Medical Center | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 5370 | 0 | 10000 | 0 | 1 | 0.537 | 0 | 0.5233 | 0 | 0 | 1141459.2 |
| DY14 | DPH | Kern Medical Center | 2.2.3 | Medication Reconciliation 30 days | 377 | 0 | 610 | 0 | 1 | 0.618 | 0 | 0.4331 | 0 | 0 | 1141459.2 |
| DY14 | DPH | Kern Medical Center | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 1238 | 0 | 1531 | 0 | 1 | 0.8086 | 0 | 0.7731 | 0 | 0 | 1141459.2 |
| DY14 | DPH | Kern Medical Center | 2.2.5 | Timely Transmission of Transition Record | 938 | 0 | 1090 | 0 | 1 | 0.8606 | 0 | 0.7959 | 0 | 0 | 1141459.2 |
| DY14 | DPH | Kern Medical Center | 2.3.2 | Medication Reconciliation 30 days | 87 | 0 | 139 | 0 | 1 | 0.6259 | 0 | 0.4947 | 0 | 0 | 1141459.2 |
| DY14 | DPH | Kern Medical Center | 2.3.4 | Timely Transmission of Transition Record | 216 | 0 | 219 | 0 | 1 | 0.9863 | 0 | 0.977 | 0 | 0 | 1141459.2 |
| DY14 | DPH | Kern Medical Center | 2.5.1 | Alcohol and Drug Misuse (SBIRT): Brief screening only | 185 | 0 | 306 | 0 | 1 | 0.6046 | 0 | 0.6269 | 0 | None | 570729.6 |
| DY14 | DPH | Kern Medical Center | 2.5.1 | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 185 | 0 | 306 | 0 | 1 | 0.6046 | 0 | 0.6269 | 0 | None | 570729.6 |
| DY14 | DPH | Kern Medical Center | 2.5.2 | Controlling Blood Pressure | 57 | 0 | 71 | 0 | 1 | 0.8028 | 0 | 0.7222 | 0 | 0 | 1141459.2 |
| DY14 | DPH | Kern Medical Center | 2.5.4 | Screening for Clinical Depression and follow-up | 155 | 0 | 222 | 0 | 1 | 0.6982 | 0 | 0.5567 | 0 | 0 | 1141459.2 |
| DY14 | DPH | Kern Medical Center | 2.5.5 | Tobacco Assessment and Counseling | 245 | 0 | 253 | 0 | 1 | 0.9684 | 0 | 0.9552 | 0 | 0 | 1141459.2 |
| DY14 | DPH | Kern Medical Center | 3.2.1 | Dont Do Imaging for Uncomplicated Headaches (Choosing Wisely) | 244 | 0 | 1456 | 0 | 1 | 0.1676 | 0 | 0.0798 | 0 | 0 | 1426824 |
| DY14 | DPH | Kern Medical Center | 3.2.2 | Appropriate Emergency Department Utilization of CT for Pulmonary Embolism | 211 | 0 | 211 | 0 | 1 | 1 | 0 | 1 | 0 | 1 | 1426824 |
| DY14 | DPH | Kern Medical Center | 3.2.3 | Use of Imaging Studies for Low Back Pain | 994 | 0 | 1151 | 0 | 1 | 0.8636 | 0 | 0.9949 | 0 | 0 | 1426824 |
| DY14 | 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 | 738 | 0 | 856 | 0 | 1 | 0.8621 | 0 | 0.323022312 | 0 | None | 713412 |
| DY14 | 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 | 118 | 0 | 856 | 0 | 1 | 0.1379 | 0 | None | 1 | None | 713412 |
| DY14 | DMPH | Kern Valley Healthcare District, Lake Isabella | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 408 | 0 | 845 | 0 | 1 | 0.4828 | 0 | 0.5067 | 0 | None | 135000 |
| DY14 | DMPH | Kern Valley Healthcare District, Lake Isabella | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 327 | 0 | 845 | 0 | 1 | 0.387 | 0 | 0.5067 | 0 | None | 135000 |
| DY14 | DMPH | Kern Valley Healthcare District, Lake Isabella | 1.1.3.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 31 | 0 | 103 | 0 | 1 | 0.301 | 0 | 0.3514 | 0 | 0 | 270000 |
| DY14 | DMPH | Kern Valley Healthcare District, Lake Isabella | 1.1.5.f | Screening for Clinical Depression and follow-up | 382 | 0 | 471 | 0 | 1 | 0.811 | 0 | 0.4638 | 0 | 0 | 270000 |
| DY14 | DMPH | Kern Valley Healthcare District, Lake Isabella | 1.1.6.t | Tobacco Assessment and Counseling | 756 | 0 | 793 | 0 | 1 | 0.9533 | 0 | 0.8611 | 0 | 0 | 270000 |
| DY14 | DMPH | Kern Valley Healthcare District, Lake Isabella | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Follow-up | 53 | 0 | 76 | 0 | 1 | 0.6974 | 0 | 0.461538462 | 0 | 0.3956 | 90000 |
| DY14 | DMPH | Kern Valley Healthcare District, Lake Isabella | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Remission | None | 1 | 76 | 0 | 1 | None | 1 | None | 1 | 0.0539 | 90000 |
| DY14 | DMPH | Kern Valley Healthcare District, Lake Isabella | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Response | None | 1 | 76 | 0 | 1 | None | 1 | None | 1 | 0.0998 | 90000 |
| DY14 | DMPH | Lompoc Valley Medical Center, Lompoc | 1.3.1 | Closing the referral loop: receipt of specialist report (CMS50v3) | 654 | 0 | 984 | 0 | 1 | 0.6646 | 0 | 0.5941 | 0 | 0 | 320625 |
| DY14 | DMPH | Lompoc Valley Medical Center, Lompoc | 1.3.2 | DHCS All-Cause Readmissions | None | 1 | 246 | 0 | 1 | None | 1 | None | 1 | 0 | 320625 |
| DY14 | DMPH | Lompoc Valley Medical Center, Lompoc | 1.3.3 | Influenza Immunization | 215 | 0 | 466 | 0 | 1 | 0.4614 | 0 | 0.4083 | 0 | 0 | 320625 |
| DY14 | DMPH | Lompoc Valley Medical Center, Lompoc | 1.3.5 | Request for Specialty Care Expertise Turnaround Time | 644 | 0 | 954 | 0 | 1 | 0.6751 | 0 | 0.5351 | 0 | 0 | 320625 |
| DY14 | DMPH | Lompoc Valley Medical Center, Lompoc | 1.3.6 | Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters | 112 | 0 | 995 | 0 | 0 | 0.1126 | 0 | 0.2235 | 0 | 0 | 320625 |
| DY14 | DMPH | Lompoc Valley Medical Center, Lompoc | 1.3.7 | Tobacco Assessment and Counseling | 319 | 0 | 359 | 0 | 1 | 0.8886 | 0 | 0.8506 | 0 | 0 | 320625 |
| DY14 | DMPH | Lompoc Valley Medical Center, Lompoc | 1.5.1.b | Controlling Blood Pressure | 133 | 0 | 174 | 0 | 1 | 0.7644 | 0 | 0.7521 | 0 | 0 | 320625 |
| DY14 | DMPH | Lompoc Valley Medical Center, Lompoc | 1.5.2.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 12 | 0 | None | 4 | 0 | None | 4 | None | 1 | 0 | 0 |
| DY14 | DMPH | Lompoc Valley Medical Center, Lompoc | 1.5.3 | PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 445 | 0 | 739 | 0 | 1 | 0.6022 | 0 | 0.5568 | 0 | 0 | 320625 |
| DY14 | DMPH | Lompoc Valley Medical Center, Lompoc | 1.5.4.t | Tobacco Assessment and Counseling | 258 | 0 | 276 | 0 | 1 | 0.9348 | 0 | 0.9182 | 0 | 0 | 320625 |
| DY14 | DMPH | Lompoc Valley Medical Center, Lompoc | 1.7.1 | BMI Screening and Follow-up | 478 | 0 | 502 | 0 | 1 | 0.9522 | 0 | 0.665 | 0 | 0 | 320625 |
| DY14 | DMPH | Lompoc Valley Medical Center, Lompoc | 1.7.2 | Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met) Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 8) |
6 | 0 | 8 | 0 | 0.75 | 0.75 | 0 | None | 0 | None | 320625 |
| DY14 | DMPH | Lompoc Valley Medical Center, Lompoc | 1.7.3 | Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI | 151 | 0 | 152 | 0 | 1 | 0.9934 | 0 | 0.797752809 | 0 | 0.8055 | 106875 |
| DY14 | DMPH | Lompoc Valley Medical Center, Lompoc | 1.7.3 | Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition | 132 | 0 | 152 | 0 | 1 | 0.8684 | 0 | 0.629213483 | 0 | 0.6488 | 106875 |
| DY14 | DMPH | Lompoc Valley Medical Center, Lompoc | 1.7.3 | Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity | 132 | 0 | 152 | 0 | 1 | 0.8684 | 0 | 0.561797753 | 0 | 0.581 | 106875 |
| DY14 | DMPH | Lompoc Valley Medical Center, Lompoc | 2.2.1 | DHCS All-Cause Readmissions | 29 | 0 | 492 | 0 | 1 | 0.0589 | 0 | 0.1057 | 0 | 0 | 320625 |
| DY14 | DMPH | Lompoc Valley Medical Center, Lompoc | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 321 | 0 | 765 | 0 | 0 | 0.4196 | 0 | 0.4523 | 0 | 0 | 320625 |
| DY14 | DMPH | Lompoc Valley Medical Center, Lompoc | 2.2.3 | Medication Reconciliation 30 days | 23 | 0 | None | 4 | 0 | None | 4 | 1 | 0 | 0 | 0 |
| DY14 | DMPH | Lompoc Valley Medical Center, Lompoc | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 598 | 0 | 774 | 0 | 1 | 0.7726 | 0 | 0.7086 | 0 | 0 | 320625 |
| DY14 | DMPH | Lompoc Valley Medical Center, Lompoc | 2.2.5 | Timely Transmission of Transition Record | 567 | 0 | 804 | 0 | 1 | 0.7052 | 0 | 0.5848 | 0 | 0 | 320625 |
| DY14 | DPH | Los Angeles County Health System | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 48 | 0 | 377 | 0 | 1 | 0.1273 | 0 | 0.1008 | 0 | None | 2960851.825 |
| DY14 | DPH | Los Angeles County Health System | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 326 | 0 | 377 | 0 | 1 | 0.8647 | 0 | 0.1008 | 0 | None | 2960851.825 |
| DY14 | DPH | Los Angeles County Health System | 1.1.3.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 10180 | 0 | 35974 | 0 | 1 | 0.283 | 0 | 0.2581 | 0 | 0 | 5921703.65 |
| DY14 | DPH | Los Angeles County Health System | 1.1.5.f | Screening for Clinical Depression and follow-up | 83475 | 0 | 96970 | 0 | 1 | 0.8608 | 0 | 0.8355 | 0 | 0 | 5921703.65 |
| DY14 | DPH | Los Angeles County Health System | 1.1.6.t | Tobacco Assessment and Counseling | 101303 | 0 | 107165 | 0 | 1 | 0.9453 | 0 | 0.9061 | 0 | 0 | 5921703.65 |
| DY14 | DPH | Los Angeles County Health System | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Response | 202 | 0 | 1935 | 0 | 1 | 0.1044 | 0 | 0.228945217 | 0 | 0.0644 | 1973901.217 |
| DY14 | DPH | Los Angeles County Health System | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Follow-up | 571 | 0 | 1935 | 0 | 1 | 0.2951 | 0 | 0.036794767 | 0 | 0.2456 | 1973901.217 |
| DY14 | DPH | Los Angeles County Health System | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Remission | 130 | 0 | 1935 | 0 | 1 | 0.0672 | 0 | 0.06050695 | 0 | 0.0385 | 1973901.217 |
| DY14 | DPH | Los Angeles County Health System | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 326 | 0 | 377 | 0 | 1 | 0.8647 | 0 | 0.1008 | 0 | None | 2960851.825 |
| DY14 | DPH | Los Angeles County Health System | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 48 | 0 | 377 | 0 | 1 | 0.1273 | 0 | 0.1008 | 0 | None | 2960851.825 |
| DY14 | DPH | Los Angeles County Health System | 1.2.10 | REAL and/or SO/GI disparity reduction | 5416 | 0 | 7921 | 0 | 1 | 0.6838 | 0 | 0.6369 | 0 | 0 | 5921703.65 |
| DY14 | DPH | Los Angeles County Health System | 1.2.11 | REAL data completeness | 133773 | 0 | 133973 | 0 | 1 | 0.9985 | 0 | 0.9828 | 0 | 0 | 5921703.65 |
| DY14 | DPH | Los Angeles County Health System | 1.2.12.f | Screening for Clinical Depression and follow-up | 83475 | 0 | 96970 | 0 | 1 | 0.8608 | 0 | 0.8355 | 0 | 0 | 5921703.65 |
| DY14 | DPH | Los Angeles County Health System | 1.2.13 | SO/GI data completeness | 96137 | 0 | 111217 | 0 | 1 | 0.8644 | 0 | 0.6653 | 0 | 0 | 5921703.65 |
| DY14 | DPH | Los Angeles County Health System | 1.2.14.t | Tobacco Assessment and Counseling | 101303 | 0 | 107165 | 0 | 1 | 0.9453 | 0 | 0.9061 | 0 | 0 | 5921703.65 |
| DY14 | DPH | Los Angeles County Health System | 1.2.2 | CG-CAHPS: Provider Rating | 5804 | 0 | 7548 | 0 | 1 | 0.7689 | 0 | 0.7547 | 0 | 0 | 5921703.65 |
| DY14 | DPH | Los Angeles County Health System | 1.2.3.c | Colorectal Cancer Screening | 47895 | 0 | 63480 | 0 | 1 | 0.7545 | 0 | 0.715 | 0 | 0 | 5921703.65 |
| DY14 | DPH | Los Angeles County Health System | 1.2.4.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 10180 | 0 | 35974 | 0 | 1 | 0.283 | 0 | 0.2575 | 0 | 0 | 5921703.65 |
| DY14 | DPH | Los Angeles County Health System | 1.2.5.b | Controlling Blood Pressure | 32069 | 0 | 43118 | 0 | 1 | 0.7437 | 0 | 0.7253 | 0 | 0 | 5921703.65 |
| DY14 | DPH | Los Angeles County Health System | 1.2.7.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 4971 | 0 | 5532 | 0 | 1 | 0.8986 | 0 | 0.8773 | 0 | 0 | 5921703.65 |
| DY14 | DPH | Los Angeles County Health System | 1.2.8 | Prevention Quality Overall Composite #90 | 1822 | 0 | 219181 | 0 | 0 | 0.0083 | 0 | 0.0076 | 0 | 0 | 5921703.65 |
| DY14 | DPH | Los Angeles County Health System | 1.3.1 | Closing the referral loop: receipt of specialist report (CMS50v3) | 83847 | 0 | 97562 | 0 | 1 | 0.8594 | 0 | 0.796 | 0 | 0 | 5921703.65 |
| DY14 | DPH | Los Angeles County Health System | 1.3.2 | DHCS All-Cause Readmissions | 1261 | 0 | 8389 | 0 | 0 | 0.1503 | 0 | 0.1364 | 0 | 0 | 5921703.65 |
| DY14 | DPH | Los Angeles County Health System | 1.3.3 | Influenza Immunization | 26992 | 0 | 35406 | 0 | 1 | 0.7624 | 0 | 0.6708 | 0 | 0 | 5921703.65 |
| DY14 | DPH | Los Angeles County Health System | 1.3.5 | Request for Specialty Care Expertise Turnaround Time | 148854 | 0 | 176546 | 0 | 1 | 0.8431 | 0 | 0.8061 | 0 | 0 | 5921703.65 |
| DY14 | DPH | Los Angeles County Health System | 1.3.6 | Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters | 45544 | 0 | 182005 | 0 | 1 | 0.2502 | 0 | 0.2514 | 0 | 0 | 5921703.65 |
| DY14 | DPH | Los Angeles County Health System | 1.3.7 | Tobacco Assessment and Counseling | 47190 | 0 | 49862 | 0 | 1 | 0.9464 | 0 | 0.9386 | 0 | 0 | 5921703.65 |
| DY14 | DPH | Los Angeles County Health System | 1.4.1 | Abnormal Results Follow-Up: Abnormal BIRADS Follow-up | 15081 | 0 | 23359 | 0 | 1 | 0.6456 | 0 | 0.952225028 | 0 | 0.6336 | 1973901.217 |
| DY14 | DPH | Los Angeles County Health System | 1.4.1 | Abnormal Results Follow-Up: Abnormal INR Follow-up | 32757 | 0 | 34761 | 0 | 1 | 0.9423 | 0 | 0.944395808 | 0 | 0.9 | 1973901.217 |
| DY14 | DPH | Los Angeles County Health System | 1.4.1 | Abnormal Results Follow-Up: Abnormal Potassium Follow-up | 79523 | 0 | 83570 | 0 | 1 | 0.9516 | 0 | 0.604008397 | 0 | 0.9 | 1973901.217 |
| DY14 | DPH | Los Angeles County Health System | 1.4.2 | Annual Monitoring for Patients on Persistent Medications | 38232 | 0 | 40064 | 0 | 1 | 0.9543 | 0 | 0.937 | 0 | 0 | 5921703.64 |
| DY14 | DPH | Los Angeles County Health System | 1.4.3 | INR Monitoring for Individuals on Warfarin | 1589 | 0 | 1737 | 0 | 1 | 0.9148 | 0 | 0.9063 | 0 | 0 | 5921703.64 |
| DY14 | DPH | Los Angeles County Health System | 1.6.1 | BIRADS to Biopsy | 426 | 0 | 780 | 0 | 1 | 0.5462 | 0 | 0.4188 | 0 | 0 | 5921703.64 |
| DY14 | DPH | Los Angeles County Health System | 1.6.2 | Breast Cancer Screening | 34799 | 0 | 45910 | 0 | 1 | 0.758 | 0 | 0.7101 | 0 | 0 | 5921703.64 |
| DY14 | DPH | Los Angeles County Health System | 1.6.3 | Cervical Cancer Screening | 43504 | 0 | 80295 | 0 | 1 | 0.5418 | 0 | 0.5176 | 0 | 0 | 5921703.64 |
| DY14 | DPH | Los Angeles County Health System | 1.6.4.c | Colorectal Cancer Screening | 47895 | 0 | 63480 | 0 | 1 | 0.7545 | 0 | 0.715 | 0 | 0 | 5921703.64 |
| DY14 | DPH | Los Angeles County Health System | 1.6.5 | Receipt of appropriate follow-up for abnormal CRC screening | 614 | 0 | 1246 | 0 | 1 | 0.4928 | 0 | 0.38 | 0 | 0 | 5921703.64 |
| DY14 | DPH | Los Angeles County Health System | 1.7.1 | BMI Screening and Follow-up | 105838 | 0 | 117769 | 0 | 1 | 0.8987 | 0 | 0.881 | 0 | 0 | 5921703.64 |
| DY14 | DPH | Los Angeles County Health System | 1.7.2 | Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met) Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 8) |
40 | 0 | 40 | 0 | 1 | 1 | 0 | None | 0 | None | 5921703.64 |
| DY14 | DPH | Los Angeles County Health System | 1.7.3 | Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI | 17522 | 0 | 18336 | 0 | 1 | 0.9556 | 0 | 0.943608401 | 0 | 0.875 | 1973901.213 |
| DY14 | DPH | Los Angeles County Health System | 1.7.3 | Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition | 14983 | 0 | 18336 | 0 | 1 | 0.8171 | 0 | 0.801664737 | 0 | 0.8041 | 1973901.213 |
| DY14 | DPH | Los Angeles County Health System | 1.7.3 | Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity | 14761 | 0 | 18336 | 0 | 1 | 0.805 | 0 | 0.762747368 | 0 | 0.754 | 1973901.213 |
| DY14 | DPH | Los Angeles County Health System | 2.1.1 | Baby Friendly Hospital designation: BFUSA Designation Yes | Yes | 0 | BFUSA Cert? | 0 | 1 | 0 | 0 | None | 0 | None | 6442813.28 |
| DY14 | DPH | Los Angeles County Health System | 2.1.2 | Exclusive Breast Milk Feeding (PC-05) | 871 | 0 | 1326 | 0 | 1 | 0.6569 | 0 | 0.6158 | 0 | 0 | 6442813.28 |
| DY14 | DPH | Los Angeles County Health System | 2.1.3 | OB Hemorrhage: Massive Transfusion | None | 1 | 2033 | 0 | 1 | None | 1 | None | 1 | 0 | 6442813.28 |
| DY14 | DPH | Los Angeles County Health System | 2.1.4 | OB Hemorrhage: Total Products Transfused | 252 | 0 | 2033 | 0 | 1 | 0.124 | 0 | 0.1123 | 0 | 0 | 6442813.28 |
| DY14 | DPH | Los Angeles County Health System | 2.1.5 | PC-02 Cesarean Section | 149 | 0 | 690 | 0 | 1 | 0.2159 | 0 | 0.208 | 0 | 0 | 6442813.28 |
| DY14 | DPH | Los Angeles County Health System | 2.1.6 | Prenatal and Postpartum Care: Prenatal Care | 1701 | 0 | 1809 | 0 | 1 | 0.9403 | 0 | 0.879955947 | 0 | 0.8837 | 3221406.64 |
| DY14 | DPH | Los Angeles County Health System | 2.1.6 | Prenatal and Postpartum Care: Postpartum Care | 1239 | 0 | 1809 | 0 | 1 | 0.6849 | 0 | 0.67345815 | 0 | 0.6798 | 3221406.64 |
| DY14 | DPH | Los Angeles County Health System | 2.1.7 | Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage | 120 | 0 | 327 | 0 | 1 | 0.367 | 0 | 0.3344 | 0 | 0 | 6442813.28 |
| DY14 | DPH | Los Angeles County Health System | 2.1.8 | Unexpected Newborn Complications (UNC) | 119 | 0 | 1356 | 0 | 1 | 0.0878 | 0 | 0.0794 | 0 | 0 | 6442813.28 |
| DY14 | DPH | Los Angeles County Health System | 2.1.9 | OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes | Yes | 0 | 10 Debriefs? | 0 | n/a | 0 | 0 | None | 0 | None | 2147604.427 |
| DY14 | DPH | Los Angeles County Health System | 2.1.9 | OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) |
48 | 0 | 48 | 0 | 1 | 1 | 0 | 1 | 0 | None | 2147604.427 |
| DY14 | DPH | Los Angeles County Health System | 2.1.9 | OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes | Yes | 0 | 3 Safety Drills? | 0 | n/a | 0 | 0 | None | 0 | None | 2147604.427 |
| DY14 | DPH | Los Angeles County Health System | 2.2.1 | DHCS All-Cause Readmissions | 1354 | 0 | 9151 | 0 | 0 | 0.148 | 0 | 0.1353 | 0 | 0 | 6442813.28 |
| DY14 | DPH | Los Angeles County Health System | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 4594 | 0 | 8016 | 0 | 0 | 0.5731 | 0 | 0.5719 | 0 | 0 | 6442813.28 |
| DY14 | DPH | Los Angeles County Health System | 2.2.3 | Medication Reconciliation 30 days | 8939 | 0 | 10465 | 0 | 1 | 0.8542 | 0 | 0.6254 | 0 | 0 | 6442813.28 |
| DY14 | DPH | Los Angeles County Health System | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 365 | 0 | 377 | 0 | 1 | 0.9682 | 0 | 0.8175 | 0 | 0 | 6442813.28 |
| DY14 | DPH | Los Angeles County Health System | 2.2.5 | Timely Transmission of Transition Record | 6996 | 0 | 9794 | 0 | 1 | 0.7143 | 0 | 0.647 | 0 | 0 | 6442813.28 |
| DY14 | DPH | Los Angeles County Health System | 2.3.2 | Medication Reconciliation 30 days | 6412 | 0 | 7393 | 0 | 1 | 0.8673 | 0 | 0.6556 | 0 | 0 | 6442813.28 |
| DY14 | DPH | Los Angeles County Health System | 2.3.4 | Timely Transmission of Transition Record | 4880 | 0 | 6361 | 0 | 1 | 0.7672 | 0 | 0.6663 | 0 | 0 | 6442813.28 |
| DY14 | DPH | Los Angeles County Health System | 2.5.1 | Alcohol and Drug Misuse (SBIRT): Brief screening only | 193 | 0 | 218 | 0 | 1 | 0.8853 | 0 | 0.1872 | 0 | None | 3221406.64 |
| DY14 | DPH | Los Angeles County Health System | 2.5.1 | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 40 | 0 | 218 | 0 | 1 | 0.1835 | 0 | 0.1872 | 0 | None | 3221406.64 |
| DY14 | DPH | Los Angeles County Health System | 2.5.2 | Controlling Blood Pressure | 39 | 0 | 58 | 0 | 1 | 0.6724 | 0 | 0.5678 | 0 | 0 | 6442813.28 |
| DY14 | DPH | Los Angeles County Health System | 2.5.4 | Screening for Clinical Depression and follow-up | 207 | 0 | 355 | 0 | 0 | 0.5831 | 0 | 0.695 | 0 | 0 | 6442813.28 |
| DY14 | DPH | Los Angeles County Health System | 2.5.5 | Tobacco Assessment and Counseling | 310 | 0 | 352 | 0 | 1 | 0.8807 | 0 | 0.668 | 0 | 0 | 6442813.28 |
| DY14 | DPH | Los Angeles County Health System | 2.7.1 | Advance Care Plan | 16068 | 0 | 16341 | 0 | 1 | 0.9833 | 0 | 0.9926 | 0 | 0 | 6442813.28 |
| DY14 | DPH | Los Angeles County Health System | 2.7.3 | MWM #8: Treatment Preferences (documentation) Inpatient | 123 | 0 | 135 | 0 | 1 | 0.9111 | 0 | 0.8154 | 0 | 0 | 6442813.28 |
| DY14 | DPH | Los Angeles County Health System | 2.7.4 | MWM #8: Treatment Preferences (documentation) Outpatient | 44 | 0 | 46 | 0 | 1 | 0.9565 | 0 | 0.9231 | 0 | 0 | 6442813.28 |
| DY14 | DPH | Los Angeles County Health System | 2.7.5 | Palliative Care Service Offered at Time of Diagnosis of Advanced Illness | 153 | 0 | 4716 | 0 | 1 | 0.0324 | 0 | 0.3567 | 0 | 0 | 6442813.28 |
| DY14 | DPH | Los Angeles County Health System | 2.7.6 | Proportion Admitted to Hospice for Less Than 3 Days | None | 1 | 56 | 0 | 1 | None | 1 | 0.1121 | 0 | 0 | 6442813.28 |
| DY14 | DPH | Los Angeles County Health System | 3.1.1 | Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis | 188 | 0 | 339 | 0 | 1 | 0.5546 | 0 | 0.5126 | 0 | 0 | 5752512 |
| DY14 | DPH | Los Angeles County Health System | 3.1.3 | National Healthcare Safety Network (NHSN) Antimicrobial Use Measure | 49743 | 0 | 598224 | 0 | 1 | 0.0832 | 0 | 0.1038 | 0 | 0 | 5752512 |
| DY14 | DPH | Los Angeles County Health System | 3.1.4 | Peri-operative Prophylactic Antibiotics Administered after Surgical Closure | 65 | 0 | 377 | 0 | 1 | 0.1724 | 0 | 0.2069 | 0 | 0 | 5752512 |
| DY14 | DPH | Los Angeles County Health System | 3.1.5 | Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR | 4980 | 0 | 10000 | 0 | 1 | 0.498 | 0 | 0.7142 | 0 | 0.7128 | 5752512 |
| DY14 | DPH | Los Angeles County Health System | 3.3.1 | Adherence to Medications: Rate 1 | 163 | 0 | 196 | 0 | 1 | 0.8316 | 0 | 0.797752809 | 0 | 0.7619 | 5752512 |
| DY14 | DPH | Los Angeles County Health System | 3.3.1 | Adherence to Medications: Rate 2 | 296 | 0 | 329 | 0 | n/a | 0.8997 | 0 | 0.746575342 | 0 | None | 0 |
| DY14 | DPH | Los Angeles County Health System | 3.3.3 | High-Cost Pharmaceuticals Ordering Protocols: Rate 1 | 139 | 0 | 171 | 0 | 1 | 0.8129 | 0 | 0.213592233 | 0 | 0.25 | 5752512 |
| DY14 | DPH | Los Angeles County Health System | 3.3.3 | High-Cost Pharmaceuticals Ordering Protocols: Rate 2 | 246 | 0 | 278 | 0 | n/a | 0.8849 | 0 | 0.12716763 | 0 | None | 0 |
| DY14 | 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 | 1501 | 0 | 2648 | 0 | 1 | 0.5668 | 0 | 0.376363636 | 0 | None | 5752512 |
| DY14 | 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 | 2437 | 0 | 4387 | 0 | n/a | 0.5555 | 0 | 0.334673367 | 0 | None | 0 |
| DY14 | DMPH | Mammoth Hospital, Mammoth Lakes | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 60 | 0 | 350 | 0 | 1 | 0.1714 | 0 | 0.2082 | 0 | None | 104400 |
| DY14 | DMPH | Mammoth Hospital, Mammoth Lakes | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 60 | 0 | 350 | 0 | 1 | 0.1714 | 0 | 0.2082 | 0 | None | 104400 |
| DY14 | DMPH | Mammoth Hospital, Mammoth Lakes | 1.1.3.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 23 | 0 | 84 | 0 | 1 | 0.2738 | 0 | 0.2241 | 0 | 0 | 208800 |
| DY14 | DMPH | Mammoth Hospital, Mammoth Lakes | 1.1.5.f | Screening for Clinical Depression and follow-up | 161 | 0 | 324 | 0 | 1 | 0.4969 | 0 | 0.2821 | 0 | 0 | 208800 |
| DY14 | DMPH | Mammoth Hospital, Mammoth Lakes | 1.1.6.t | Tobacco Assessment and Counseling | 272 | 0 | 323 | 0 | 1 | 0.8421 | 0 | 0.78 | 0 | 0 | 208800 |
| DY14 | DMPH | Mammoth Hospital, Mammoth Lakes | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Follow-up | 28 | 0 | 54 | 0 | 1 | 0.5185 | 0 | 0.349206349 | 0 | 0.3538 | 69600 |
| DY14 | DMPH | Mammoth Hospital, Mammoth Lakes | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Response | None | 1 | 54 | 0 | 1 | None | 1 | None | 1 | 0.0998 | 69600 |
| DY14 | DMPH | Mammoth Hospital, Mammoth Lakes | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Remission | None | 1 | 54 | 0 | 1 | None | 1 | 0.174603175 | 0 | 0.0539 | 69600 |
| DY14 | DMPH | Mammoth Hospital, Mammoth Lakes | 2.6.1 | Alcohol and Drug Misuse (SBIRT): Brief screening only | 36 | 0 | 79 | 0 | 1 | 0.4557 | 0 | 0.6765 | 0 | None | 104400 |
| DY14 | DMPH | Mammoth Hospital, Mammoth Lakes | 2.6.1 | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 40 | 0 | 79 | 0 | 1 | 0.5063 | 0 | 0.6765 | 0 | None | 104400 |
| DY14 | 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 | 31 | 0 | 32 | 0 | 1 | 0.9688 | 0 | None | 1 | 0 | 208800 |
| DY14 | DMPH | Mammoth Hospital, Mammoth Lakes | 2.6.3 | Patients with chronic pain on long term opioid therapy checked in PDMPs | 31 | 0 | 32 | 0 | 1 | 0.9688 | 0 | 0.5758 | 0 | 0 | 208800 |
| DY14 | DMPH | Mammoth Hospital, Mammoth Lakes | 2.6.4 | Screening for Clinical Depression and follow-up | 32 | 0 | 36 | 0 | 1 | 0.8889 | 0 | 0.7317 | 0 | 0 | 208800 |
| DY14 | DMPH | Mammoth Hospital, Mammoth Lakes | 2.6.5 | Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy | 79 | 0 | 79 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 208800 |
| DY14 | DMPH | Marin General Hospital, Greenbrae | 2.3.2 | Medication Reconciliation 30 days | 279 | 0 | 342 | 0 | 1 | 0.8158 | 0 | 0.7359 | 0 | 0 | 439200 |
| DY14 | DMPH | Marin General Hospital, Greenbrae | 2.3.4 | Timely Transmission of Transition Record | 197 | 0 | 323 | 0 | 1 | 0.6099 | 0 | 0.1061 | 0 | 0 | 439200 |
| DY14 | DMPH | Marin General Hospital, Greenbrae | 2.7.1 | Advance Care Plan | 349 | 0 | 366 | 0 | 1 | 0.9536 | 0 | 0.8662 | 0 | 0 | 439200 |
| DY14 | DMPH | Marin General Hospital, Greenbrae | 2.7.3 | MWM #8: Treatment Preferences (documentation) Inpatient | 135 | 0 | 135 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 439200 |
| DY14 | DMPH | Marin General Hospital, Greenbrae | 2.7.4 | MWM #8: Treatment Preferences (documentation) Outpatient | 12 | 0 | None | 4 | 0 | None | 4 | None | 1 | 0 | 0 |
| DY14 | DMPH | Marin General Hospital, Greenbrae | 2.7.5 | Palliative Care Service Offered at Time of Diagnosis of Advanced Illness | 70 | 0 | 283 | 0 | 1 | 0.2473 | 0 | 0.1803 | 0 | 0 | 439200 |
| DY14 | DMPH | Marin General Hospital, Greenbrae | 2.7.6 | Proportion Admitted to Hospice for Less Than 3 Days | None | 1 | 61 | 0 | 1 | None | 1 | None | 4 | 0 | 0 |
| DY14 | DMPH | Mayers Memorial Hospital District, Fall River Mills | 1.7.1 | BMI Screening and Follow-up | None | 1 | None | 1 | 0 | None | 1 | None | 1 | 0 | 0 |
| DY14 | DMPH | Mayers Memorial Hospital District, Fall River Mills | 1.7.2 | Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met) Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 8) |
8 | 0 | 8 | 0 | 1 | 1 | 0 | None | 0 | None | 1350000 |
| DY14 | DMPH | Mayers Memorial Hospital District, Fall River Mills | 1.7.3 | Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0.6019 | 0 |
| DY14 | DMPH | Mayers Memorial Hospital District, Fall River Mills | 1.7.3 | Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0.5856 | 0 |
| DY14 | DMPH | Mayers Memorial Hospital District, Fall River Mills | 1.7.3 | Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0.4906 | 0 |
| DY14 | DMPH | Mendocino Coast District Hospital, Fort Bragg | 1.6.1 | BIRADS to Biopsy | None | 1 | None | 1 | 0 | None | 1 | None | 1 | 0 | 0 |
| DY14 | DMPH | Mendocino Coast District Hospital, Fort Bragg | 1.6.2 | Breast Cancer Screening | 291 | 0 | 462 | 0 | 1 | 0.6299 | 0 | 0.5429 | 0 | 0 | 450000 |
| DY14 | DMPH | Mendocino Coast District Hospital, Fort Bragg | 1.6.3 | Cervical Cancer Screening | 404 | 0 | 884 | 0 | 0 | 0.457 | 0 | 0.211 | 0 | 0 | 450000 |
| DY14 | DMPH | Mendocino Coast District Hospital, Fort Bragg | 1.6.4.c | Colorectal Cancer Screening | 546 | 0 | 1024 | 0 | 1 | 0.5332 | 0 | 0.4239 | 0 | 0 | 450000 |
| DY14 | DMPH | Mendocino Coast District Hospital, Fort Bragg | 1.6.5 | Receipt of appropriate follow-up for abnormal CRC screening | None | 1 | None | 1 | 0 | None | 1 | None | 1 | 0 | 0 |
| DY14 | DMPH | Modoc Medical Center, Alturas | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 429 | 0 | 621 | 0 | 1 | 0.6908 | 0 | 0.0158 | 0 | None | 67500 |
| DY14 | DMPH | Modoc Medical Center, Alturas | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | None | 1 | 621 | 0 | 0 | None | 1 | 0.0158 | 0 | None | 67500 |
| DY14 | DMPH | Modoc Medical Center, Alturas | 1.2.10 | REAL and/or SO/GI disparity reduction | 11 | 0 | None | 4 | 0 | None | 4 | None | 1 | 0 | 0 |
| DY14 | DMPH | Modoc Medical Center, Alturas | 1.2.11 | REAL data completeness | 786 | 0 | 788 | 0 | 1 | 0.9975 | 0 | 0.9943 | 0 | 0 | 135000 |
| DY14 | DMPH | Modoc Medical Center, Alturas | 1.2.12.f | Screening for Clinical Depression and follow-up | 481 | 0 | 535 | 0 | 1 | 0.8991 | 0 | 0.6855 | 0 | 0 | 135000 |
| DY14 | DMPH | Modoc Medical Center, Alturas | 1.2.13 | SO/GI data completeness | 218 | 0 | 535 | 0 | 1 | 0.4075 | 0 | 1 | 0 | 0 | 135000 |
| DY14 | DMPH | Modoc Medical Center, Alturas | 1.2.14.t | Tobacco Assessment and Counseling | 532 | 0 | 535 | 0 | 1 | 0.9944 | 0 | 0.9687 | 0 | 0 | 135000 |
| DY14 | DMPH | Modoc Medical Center, Alturas | 1.2.2 | CG-CAHPS: Provider Rating | 156 | 0 | 207 | 0 | 0 | 0.7536 | 0 | 0.8289 | 0 | 0 | 135000 |
| DY14 | DMPH | Modoc Medical Center, Alturas | 1.2.3.c | Colorectal Cancer Screening | 94 | 0 | 237 | 0 | 0 | 0.3966 | 0 | 0.3961 | 0 | 0 | 135000 |
| DY14 | DMPH | Modoc Medical Center, Alturas | 1.2.4.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 18 | 0 | 76 | 0 | 1 | 0.2368 | 0 | 0.6579 | 0 | 0 | 135000 |
| DY14 | DMPH | Modoc Medical Center, Alturas | 1.2.5.b | Controlling Blood Pressure | 118 | 0 | 195 | 0 | 1 | 0.6051 | 0 | 0.5399 | 0 | 0 | 135000 |
| DY14 | DMPH | Modoc Medical Center, Alturas | 1.2.7.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 14 | 0 | None | 4 | 0 | None | 4 | None | 4 | 0 | 0 |
| DY14 | DMPH | Modoc Medical Center, Alturas | 1.2.8 | Prevention Quality Overall Composite #90 | 11 | 0 | 535 | 0 | 0 | 0.0206 | 0 | 0.0179 | 0 | 0 | 135000 |
| DY14 | DPH | Natividad Medical Center | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 769 | 0 | 6702 | 0 | 1 | 0.1147 | 0 | 0.0857 | 0 | None | 264996.67 |
| DY14 | DPH | Natividad Medical Center | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 5417 | 0 | 6702 | 0 | 1 | 0.8083 | 0 | 0.0857 | 0 | None | 264996.67 |
| DY14 | DPH | Natividad Medical Center | 1.1.3.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 335 | 0 | 1007 | 0 | 1 | 0.3327 | 0 | 0.3633 | 0 | 0 | 529993.34 |
| DY14 | DPH | Natividad Medical Center | 1.1.5.f | Screening for Clinical Depression and follow-up | 3008 | 0 | 3913 | 0 | 1 | 0.7687 | 0 | 0.725 | 0 | 0 | 529993.34 |
| DY14 | DPH | Natividad Medical Center | 1.1.6.t | Tobacco Assessment and Counseling | 4833 | 0 | 4871 | 0 | 1 | 0.9922 | 0 | 0.9676 | 0 | 0 | 529993.34 |
| DY14 | DPH | Natividad Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Follow-up | 25 | 0 | 95 | 0 | 1 | 0.2632 | 0 | 0.193548387 | 0 | 0.2137 | 176664.4467 |
| DY14 | DPH | Natividad Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Remission | None | 1 | 95 | 0 | 1 | None | 1 | None | 1 | 0.0151 | 176664.4467 |
| DY14 | DPH | Natividad Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Response | None | 1 | 95 | 0 | 1 | None | 1 | None | 1 | 0.0487 | 176664.4467 |
| DY14 | DPH | Natividad Medical Center | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 769 | 0 | 6702 | 0 | 1 | 0.1147 | 0 | 0.0857 | 0 | None | 264996.67 |
| DY14 | DPH | Natividad Medical Center | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 5417 | 0 | 6702 | 0 | 1 | 0.8083 | 0 | 0.0857 | 0 | None | 264996.67 |
| DY14 | DPH | Natividad Medical Center | 1.2.10 | REAL and/or SO/GI disparity reduction | 483 | 0 | 706 | 0 | 1 | 0.6841 | 0 | 0.657 | 0 | 0 | 529993.33 |
| DY14 | DPH | Natividad Medical Center | 1.2.11 | REAL data completeness | 8228 | 0 | 9310 | 0 | 1 | 0.8838 | 0 | 0.8873 | 0 | 0 | 529993.33 |
| DY14 | DPH | Natividad Medical Center | 1.2.12.f | Screening for Clinical Depression and follow-up | 3008 | 0 | 3913 | 0 | 1 | 0.7687 | 0 | 0.725 | 0 | 0 | 529993.33 |
| DY14 | DPH | Natividad Medical Center | 1.2.13 | SO/GI data completeness | 6030 | 0 | 6305 | 0 | 1 | 0.9564 | 0 | 0.9188 | 0 | 0 | 529993.33 |
| DY14 | DPH | Natividad Medical Center | 1.2.14.t | Tobacco Assessment and Counseling | 4833 | 0 | 4871 | 0 | 1 | 0.9922 | 0 | 0.9676 | 0 | 0 | 529993.33 |
| DY14 | DPH | Natividad Medical Center | 1.2.2 | CG-CAHPS: Provider Rating | 7425 | 0 | 10000 | 0 | 0 | 0.7425 | 0 | 0.7587 | 0 | 0 | 529993.34 |
| DY14 | DPH | Natividad Medical Center | 1.2.3.c | Colorectal Cancer Screening | 1159 | 0 | 1618 | 0 | 1 | 0.7163 | 0 | 0.6887 | 0 | 0 | 529993.34 |
| DY14 | DPH | Natividad Medical Center | 1.2.4.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 335 | 0 | 1007 | 0 | 1 | 0.3327 | 0 | 0.3633 | 0 | 0 | 529993.34 |
| DY14 | DPH | Natividad Medical Center | 1.2.5.b | Controlling Blood Pressure | 1166 | 0 | 1584 | 0 | 1 | 0.7361 | 0 | 0.7288 | 0 | 0 | 529993.33 |
| DY14 | DPH | Natividad Medical Center | 1.2.7.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 158 | 0 | 172 | 0 | 1 | 0.9186 | 0 | 0.9138 | 0 | 0 | 529993.33 |
| DY14 | DPH | Natividad Medical Center | 1.2.8 | Prevention Quality Overall Composite #90 | 64 | 0 | 7160 | 0 | 1 | 0.0089 | 0 | 0.0095 | 0 | 0 | 529993.33 |
| DY14 | DPH | Natividad Medical Center | 1.3.1 | Closing the referral loop: receipt of specialist report (CMS50v3) | 4797 | 0 | 5139 | 0 | 1 | 0.9335 | 0 | 0.9366 | 0 | 0 | 529993.33 |
| DY14 | DPH | Natividad Medical Center | 1.3.2 | DHCS All-Cause Readmissions | 14 | 0 | 146 | 0 | 1 | 0.0959 | 0 | 0.1481 | 0 | 0 | 529993.33 |
| DY14 | DPH | Natividad Medical Center | 1.3.3 | Influenza Immunization | 653 | 0 | 930 | 0 | 1 | 0.7022 | 0 | 0.6156 | 0 | 0 | 529993.33 |
| DY14 | DPH | Natividad Medical Center | 1.3.5 | Request for Specialty Care Expertise Turnaround Time | 6439 | 0 | 11457 | 0 | 1 | 0.562 | 0 | 0.2401 | 0 | 0 | 529993.33 |
| DY14 | DPH | Natividad Medical Center | 1.3.6 | Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters | 12 | 0 | 11504 | 0 | 0 | 0.001 | 0 | 0.0045 | 0 | 0 | 529993.33 |
| DY14 | DPH | Natividad Medical Center | 1.3.7 | Tobacco Assessment and Counseling | 1293 | 0 | 1296 | 0 | 1 | 0.9977 | 0 | 0.9772 | 0 | 0 | 529993.33 |
| DY14 | DPH | Natividad Medical Center | 1.5.1.b | Controlling Blood Pressure | 1166 | 0 | 1584 | 0 | 1 | 0.7361 | 0 | 0.7288 | 0 | 0 | 529993.33 |
| DY14 | DPH | Natividad Medical Center | 1.5.2.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 158 | 0 | 172 | 0 | 1 | 0.9186 | 0 | 0.9138 | 0 | 0 | 529993.33 |
| DY14 | DPH | Natividad Medical Center | 1.5.3 | PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 3604 | 0 | 3906 | 0 | 1 | 0.9227 | 0 | 0.8952 | 0 | 0 | 529993.33 |
| DY14 | DPH | Natividad Medical Center | 1.5.4.t | Tobacco Assessment and Counseling | 4833 | 0 | 4871 | 0 | 1 | 0.9922 | 0 | 0.9676 | 0 | 0 | 529993.33 |
| DY14 | DPH | Natividad Medical Center | 2.1.1 | Baby Friendly Hospital designation: BFUSA Designation Yes | Yes | 0 | BFUSA Cert? | 0 | 1 | 0 | 0 | None | 0 | None | 545136 |
| DY14 | DPH | Natividad Medical Center | 2.1.2 | Exclusive Breast Milk Feeding (PC-05) | 297 | 0 | 604 | 0 | 0 | 0.4917 | 0 | 0.4753 | 0 | 0 | 545136 |
| DY14 | DPH | Natividad Medical Center | 2.1.3 | OB Hemorrhage: Massive Transfusion | 0 | 0 | 680 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 545136 |
| DY14 | DPH | Natividad Medical Center | 2.1.4 | OB Hemorrhage: Total Products Transfused | 27 | 0 | 680 | 0 | 1 | 0.0397 | 0 | None | 1 | 0 | 545136 |
| DY14 | DPH | Natividad Medical Center | 2.1.5 | PC-02 Cesarean Section | 28 | 0 | 139 | 0 | 1 | 0.2014 | 0 | 0.2319 | 0 | 0 | 545136 |
| DY14 | DPH | Natividad Medical Center | 2.1.6 | Prenatal and Postpartum Care: Prenatal Care | 466 | 0 | 480 | 0 | 1 | 0.9708 | 0 | 0.98568873 | 0 | 0.9167 | 272568 |
| DY14 | DPH | Natividad Medical Center | 2.1.6 | Prenatal and Postpartum Care: Postpartum Care | 410 | 0 | 480 | 0 | 1 | 0.8542 | 0 | 0.82647585 | 0 | 0.7367 | 272568 |
| DY14 | DPH | Natividad Medical Center | 2.1.7 | Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage | 17 | 0 | 109 | 0 | 1 | 0.156 | 0 | None | 1 | 0 | 545136 |
| DY14 | DPH | Natividad Medical Center | 2.1.8 | Unexpected Newborn Complications (UNC) | 30 | 0 | 561 | 0 | 1 | 0.0535 | 0 | 0.0443 | 0 | 0 | 545136 |
| DY14 | 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 | 1 | 0 | 1 | 0 | None | 181712 |
| DY14 | DPH | Natividad Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes | Yes | 0 | 3 Safety Drills? | 0 | n/a | 0 | 0 | None | 0 | None | 181712 |
| DY14 | DPH | Natividad Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes | Yes | 0 | 10 Debriefs? | 0 | n/a | 0 | 0 | None | 0 | None | 181712 |
| DY14 | DPH | Natividad Medical Center | 2.2.1 | DHCS All-Cause Readmissions | 23 | 0 | 256 | 0 | 1 | 0.0898 | 0 | 0.0945 | 0 | 0 | 545136 |
| DY14 | DPH | Natividad Medical Center | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 4462 | 0 | 10000 | 0 | 1 | 0.4462 | 0 | 0.3841 | 0 | 0 | 545136 |
| DY14 | DPH | Natividad Medical Center | 2.2.3 | Medication Reconciliation 30 days | 279 | 0 | 317 | 0 | 1 | 0.8801 | 0 | 0.8338 | 0 | 0 | 545136 |
| DY14 | DPH | Natividad Medical Center | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 431 | 0 | 436 | 0 | 1 | 0.9885 | 0 | 0.9829 | 0 | 0 | 545136 |
| DY14 | DPH | Natividad Medical Center | 2.2.5 | Timely Transmission of Transition Record | 425 | 0 | 432 | 0 | 1 | 0.9838 | 0 | 0.9849 | 0 | 0 | 545136 |
| DY14 | DPH | Natividad Medical Center | 2.3.2 | Medication Reconciliation 30 days | 47 | 0 | 49 | 0 | 1 | 0.9592 | 0 | 0.9583 | 0 | 0 | 545136 |
| DY14 | DPH | Natividad Medical Center | 2.3.4 | Timely Transmission of Transition Record | 69 | 0 | 70 | 0 | 1 | 0.9857 | 0 | 0.9756 | 0 | 0 | 545136 |
| DY14 | DPH | Natividad Medical Center | 2.6.1 | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 29 | 0 | 299 | 0 | 1 | 0.097 | 0 | 0.0645 | 0 | None | 272568 |
| DY14 | DPH | Natividad Medical Center | 2.6.1 | Alcohol and Drug Misuse (SBIRT): Brief screening only | 266 | 0 | 299 | 0 | 1 | 0.8896 | 0 | 0.0645 | 0 | None | 272568 |
| DY14 | 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 | 68 | 0 | 143 | 0 | 1 | 0.4755 | 0 | 0.354 | 0 | 0 | 545136 |
| DY14 | DPH | Natividad Medical Center | 2.6.3 | Patients with chronic pain on long term opioid therapy checked in PDMPs | 82 | 0 | 143 | 0 | 1 | 0.5734 | 0 | 0.5 | 0 | 0 | 545136 |
| DY14 | DPH | Natividad Medical Center | 2.6.4 | Screening for Clinical Depression and follow-up | 94 | 0 | 115 | 0 | 1 | 0.8174 | 0 | 0.7455 | 0 | 0 | 545136 |
| DY14 | DPH | Natividad Medical Center | 2.6.5 | Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy | 297 | 0 | 315 | 0 | 1 | 0.9429 | 0 | 0.9161 | 0 | 0 | 545136 |
| DY14 | DPH | Natividad Medical Center | 3.4.1 | ePBM-01 Pre-op Anemia Screening, Selected Elective Surgical Patients | 46 | 0 | 97 | 0 | 1 | 0.4742 | 0 | 0.4412 | 0 | 0 | 953988 |
| DY14 | DPH | Natividad Medical Center | 3.4.3 | ePBM-03 Pre-op Type and Crossmatch, Type and Screen, Selected elective Surgical Patients | 55 | 0 | 66 | 0 | 1 | 0.8333 | 0 | 0.7755 | 0 | 0 | 953988 |
| DY14 | DPH | Natividad Medical Center | 3.4.4 | ePBM-04 Initial Transfusion Threshold | 194 | 0 | 194 | 0 | 1 | 1 | 0 | 0.9947 | 0 | 0 | 953988 |
| DY14 | DMPH | Northern Inyo Hospital, Bishop | 3.1.1 | Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis | None | 1 | None | 1 | 0 | None | 1 | None | 1 | 0 | 0 |
| DY14 | DMPH | Northern Inyo Hospital, Bishop | 3.1.3 | National Healthcare Safety Network (NHSN) Antimicrobial Use Measure | 80 | 0 | 181 | 0 | 0 | 0.442 | 0 | 0.1007 | 0 | 0 | 3564000 |
| DY14 | DMPH | Northern Inyo Hospital, Bishop | 3.1.4 | Peri-operative Prophylactic Antibiotics Administered after Surgical Closure | None | 1 | None | 4 | 0 | None | 1 | None | 1 | 0 | 0 |
| DY14 | DMPH | Northern Inyo Hospital, Bishop | 3.1.5 | Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0.7 | 0 |
| DY14 | DMPH | Oak Valley Hospital District, Oakdale | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 1918 | 0 | 4276 | 0 | 1 | 0.4486 | 0 | 0.3049 | 0 | None | 106800 |
| DY14 | DMPH | Oak Valley Hospital District, Oakdale | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 591 | 0 | 4276 | 0 | 1 | 0.1382 | 0 | 0.3049 | 0 | None | 106800 |
| DY14 | DMPH | Oak Valley Hospital District, Oakdale | 1.2.10 | REAL and/or SO/GI disparity reduction | 128 | 0 | 392 | 0 | 1 | 0.3265 | 0 | 0.6271 | 0 | 0 | 213600 |
| DY14 | DMPH | Oak Valley Hospital District, Oakdale | 1.2.11 | REAL data completeness | 4414 | 0 | 4447 | 0 | 1 | 0.9926 | 0 | 0.9899 | 0 | 0 | 213600 |
| DY14 | DMPH | Oak Valley Hospital District, Oakdale | 1.2.12.f | Screening for Clinical Depression and follow-up | 2330 | 0 | 3620 | 0 | 1 | 0.6436 | 0 | 0.5178 | 0 | 0 | 213600 |
| DY14 | DMPH | Oak Valley Hospital District, Oakdale | 1.2.13 | SO/GI data completeness | 3314 | 0 | 3620 | 0 | 1 | 0.9155 | 0 | 0.8986 | 0 | 0 | 213600 |
| DY14 | DMPH | Oak Valley Hospital District, Oakdale | 1.2.14.t | Tobacco Assessment and Counseling | 2701 | 0 | 2916 | 0 | 1 | 0.9263 | 0 | 0.895 | 0 | 0 | 213600 |
| DY14 | DMPH | Oak Valley Hospital District, Oakdale | 1.2.2 | CG-CAHPS: Provider Rating | 2985 | 0 | 3282 | 0 | 1 | 0.9095 | 0 | 0.7373 | 0 | 0 | 213600 |
| DY14 | DMPH | Oak Valley Hospital District, Oakdale | 1.2.3.c | Colorectal Cancer Screening | 634 | 0 | 1187 | 0 | 1 | 0.5341 | 0 | 0.4029 | 0 | 0 | 213600 |
| DY14 | DMPH | Oak Valley Hospital District, Oakdale | 1.2.4.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 198 | 0 | 694 | 0 | 1 | 0.2853 | 0 | 0.3054 | 0 | 0 | 213600 |
| DY14 | DMPH | Oak Valley Hospital District, Oakdale | 1.2.5.b | Controlling Blood Pressure | 422 | 0 | 633 | 0 | 1 | 0.6667 | 0 | 0.6061 | 0 | 0 | 213600 |
| DY14 | DMPH | Oak Valley Hospital District, Oakdale | 1.2.7.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 138 | 0 | 162 | 0 | 1 | 0.8519 | 0 | 0.7262 | 0 | 0 | 213600 |
| DY14 | DMPH | Oak Valley Hospital District, Oakdale | 1.2.8 | Prevention Quality Overall Composite #90 | 86 | 0 | 3529 | 0 | 0 | 0.0244 | 0 | 0.0213 | 0 | 0 | 213600 |
| DY14 | DMPH | Oak Valley Hospital District, Oakdale | 1.4.1 | Abnormal Results Follow-Up: Abnormal BIRADS Follow-up | 1878 | 0 | 1956 | 0 | 1 | 0.9601 | 0 | 0.885476879 | 0 | 0.9 | 71200 |
| DY14 | DMPH | Oak Valley Hospital District, Oakdale | 1.4.1 | Abnormal Results Follow-Up: Abnormal Potassium Follow-up | 2295 | 0 | 2516 | 0 | 1 | 0.9122 | 0 | 0.638461538 | 0 | 0.887 | 71200 |
| DY14 | DMPH | Oak Valley Hospital District, Oakdale | 1.4.1 | Abnormal Results Follow-Up: Abnormal INR Follow-up | 40 | 0 | 41 | 0 | 1 | 0.9756 | 0 | 0.971858321 | 0 | 0.6647 | 71200 |
| DY14 | DMPH | Oak Valley Hospital District, Oakdale | 1.4.2 | Annual Monitoring for Patients on Persistent Medications | 1081 | 0 | 1213 | 0 | 1 | 0.8912 | 0 | 0.7807 | 0 | 0 | 213600 |
| DY14 | DMPH | Oak Valley Hospital District, Oakdale | 1.4.3 | INR Monitoring for Individuals on Warfarin | None | 1 | None | 4 | 0 | None | 1 | None | 4 | 0 | 213600 |
| DY14 | DMPH | Palo Verde Hospital, Blythe | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 202 | 0 | 261 | 0 | 1 | 0.7739 | 0 | 0.1094 | 0 | None | 131250 |
| DY14 | DMPH | Palo Verde Hospital, Blythe | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 33 | 0 | 261 | 0 | 1 | 0.1264 | 0 | 0.1094 | 0 | None | 131250 |
| DY14 | DMPH | Palo Verde Hospital, Blythe | 1.1.3.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 131 | 0 | 498 | 0 | 1 | 0.2631 | 0 | 0.1404 | 0 | 0 | 262500 |
| DY14 | DMPH | Palo Verde Hospital, Blythe | 1.1.5.f | Screening for Clinical Depression and follow-up | 43 | 0 | 109 | 0 | 1 | 0.3945 | 0 | 0.1856 | 0 | 0 | 262500 |
| DY14 | DMPH | Palo Verde Hospital, Blythe | 1.1.6.t | Tobacco Assessment and Counseling | 631 | 0 | 679 | 0 | 1 | 0.9293 | 0 | 0.8894 | 0 | 0 | 262500 |
| DY14 | DMPH | Palo Verde Hospital, Blythe | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Follow-up | 17 | 0 | 81 | 0 | 1 | 0.2099 | 0 | 0.164948454 | 0 | 0.188 | 87500 |
| DY14 | DMPH | Palo Verde Hospital, Blythe | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Remission | 11 | 0 | 81 | 0 | 1 | 0.1358 | 0 | 0.113402062 | 0 | 0.0539 | 87500 |
| DY14 | DMPH | Palo Verde Hospital, Blythe | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Response | 11 | 0 | 81 | 0 | 1 | 0.1358 | 0 | 0.113402062 | 0 | 0.0998 | 87500 |
| DY14 | DMPH | Palo Verde Hospital, Blythe | 2.2.1 | DHCS All-Cause Readmissions | 38 | 0 | 272 | 0 | 0 | 0.1397 | 0 | 0.1417 | 0 | 0 | 262500 |
| DY14 | DMPH | Palo Verde Hospital, Blythe | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 156 | 0 | 307 | 0 | 0 | 0.5081 | 0 | 0.4968 | 0 | 0 | 262500 |
| DY14 | DMPH | Palo Verde Hospital, Blythe | 2.2.3 | Medication Reconciliation 30 days | 239 | 0 | 620 | 0 | 1 | 0.3855 | 0 | 0.1795 | 0 | 0 | 262500 |
| DY14 | DMPH | Palo Verde Hospital, Blythe | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 189 | 0 | 591 | 0 | 1 | 0.3198 | 0 | 0.193 | 0 | 0 | 262500 |
| DY14 | DMPH | Palo Verde Hospital, Blythe | 2.2.5 | Timely Transmission of Transition Record | 169 | 0 | 533 | 0 | 1 | 0.3171 | 0 | 0.145 | 0 | 0 | 262500 |
| DY14 | DMPH | Palo Verde Hospital, Blythe | 2.3.2 | Medication Reconciliation 30 days | 221 | 0 | 486 | 0 | 1 | 0.4547 | 0 | 0.1557 | 0 | 0 | 262500 |
| DY14 | DMPH | Palo Verde Hospital, Blythe | 2.3.4 | Timely Transmission of Transition Record | 94 | 0 | 166 | 0 | 1 | 0.5663 | 0 | 0.4128 | 0 | 0 | 262500 |
| DY14 | DMPH | Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) | 1.7.1 | BMI Screening and Follow-up | 102 | 0 | 202 | 0 | 1 | 0.505 | 0 | 0.449 | 0 | 0 | 757500 |
| DY14 | DMPH | Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) | 1.7.2 | Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met) Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 8) |
16 | 0 | 16 | 0 | 1 | 1 | 0 | None | 0 | None | 757500 |
| DY14 | 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 | 342 | 0 | 348 | 0 | 1 | 0.9828 | 0 | None | 1 | 0.875 | 0 |
| DY14 | 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 | 331 | 0 | 348 | 0 | 1 | 0.9511 | 0 | None | 1 | 0.8253 | 0 |
| DY14 | 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 | 331 | 0 | 348 | 0 | 1 | 0.9511 | 0 | None | 1 | 0.754 | 0 |
| DY14 | DMPH | Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) | 2.2.1 | DHCS All-Cause Readmissions | 52 | 0 | 393 | 0 | 1 | 0.1323 | 0 | 0.1399 | 0 | 0 | 757500 |
| DY14 | DMPH | Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 5623 | 0 | 10000 | 0 | 1 | 0.5623 | 0 | 0.5507 | 0 | 0 | 757500 |
| DY14 | DMPH | Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) | 2.2.3 | Medication Reconciliation 30 days | 572 | 0 | 611 | 0 | 1 | 0.9362 | 0 | 0.8724 | 0 | 0 | 757500 |
| DY14 | DMPH | Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 5423 | 0 | 5462 | 0 | 1 | 0.9929 | 0 | 0.9946 | 0 | 0 | 757500 |
| DY14 | DMPH | Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) | 2.2.5 | Timely Transmission of Transition Record | 1509 | 0 | 3233 | 0 | 1 | 0.4667 | 0 | 0.0073 | 0 | 0 | 757500 |
| DY14 | DMPH | Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) | 2.3.2 | Medication Reconciliation 30 days | 675 | 0 | 711 | 0 | 1 | 0.9494 | 0 | 0.904 | 0 | 0 | 757500 |
| DY14 | DMPH | Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) | 2.3.4 | Timely Transmission of Transition Record | 1492 | 0 | 3116 | 0 | 1 | 0.4788 | 0 | 0.0087 | 0 | 0 | 757500 |
| DY14 | DMPH | Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) | 2.7.1 | Advance Care Plan | 275 | 0 | 275 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 757500 |
| DY14 | DMPH | Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) | 2.7.3 | MWM #8: Treatment Preferences (documentation) Inpatient | 188 | 0 | 188 | 0 | 1 | 1 | 0 | 0.9851 | 0 | 0 | 757500 |
| DY14 | DMPH | Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) | 2.7.4 | MWM #8: Treatment Preferences (documentation) Outpatient | 32 | 0 | 32 | 0 | 1 | 1 | 0 | None | 4 | 0 | 0 |
| DY14 | DMPH | Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) | 2.7.5 | Palliative Care Service Offered at Time of Diagnosis of Advanced Illness | 197 | 0 | 1130 | 0 | 1 | 0.1743 | 0 | 0.0442 | 0 | 0 | 757500 |
| DY14 | DMPH | Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) | 2.7.6 | Proportion Admitted to Hospice for Less Than 3 Days | 13 | 0 | 58 | 0 | 1 | 0.2241 | 0 | 0.3415 | 0 | 0 | 757500 |
| DY14 | DMPH | Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) | 3.1.1 | Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis | 104 | 0 | 116 | 0 | 1 | 0.8966 | 0 | 0.9865 | 0 | 0 | 757500 |
| DY14 | DMPH | Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) | 3.1.3 | National Healthcare Safety Network (NHSN) Antimicrobial Use Measure | 27579 | 0 | 175325 | 0 | 1 | 0.1573 | 0 | 0.1643 | 0 | 0 | 757500 |
| DY14 | DMPH | Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) | 3.1.4 | Peri-operative Prophylactic Antibiotics Administered after Surgical Closure | 1976 | 0 | 4048 | 0 | 1 | 0.4881 | 0 | 0.7003 | 0 | 0 | 757500 |
| DY14 | DMPH | Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) | 3.1.5 | Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR | 5311 | 0 | 10000 | 0 | 1 | 0.5311 | 0 | 0.642 | 0 | 0.7 | 757500 |
| DY14 | DMPH | Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) | 3.2.1 | Dont Do Imaging for Uncomplicated Headaches (Choosing Wisely) | 522 | 0 | 2237 | 0 | 1 | 0.2333 | 0 | 0.5477 | 0 | 0 | 757500 |
| DY14 | DMPH | Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) | 3.2.2 | Appropriate Emergency Department Utilization of CT for Pulmonary Embolism | 1200 | 0 | 1341 | 0 | 1 | 0.8949 | 0 | 0.5801 | 0 | 0 | 757500 |
| DY14 | DMPH | Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) | 3.2.3 | Use of Imaging Studies for Low Back Pain | 2920 | 0 | 3790 | 0 | 1 | 0.7704 | 0 | 0.7569 | 0 | 0 | 757500 |
| DY14 | 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 | 1250 | 0 | 3056 | 0 | 0.75 | 0.409 | 0 | 0.0304045 | 0 | None | 378750 |
| DY14 | 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 | 1806 | 0 | 3056 | 0 | 0 | 0.591 | 0 | 0.293999464 | 0 | None | 378750 |
| DY14 | DMPH | Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) | 3.3.1 | Adherence to Medications: Rate 1 | 87 | 0 | 175 | 0 | 1 | 0.4971 | 0 | 0.318181818 | 0 | 0.3837 | 757500 |
| DY14 | DMPH | Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) | 3.3.1 | Adherence to Medications: Rate 2 | 102 | 0 | 197 | 0 | n/a | 0.5178 | 0 | 0.326315789 | 0 | None | 0 |
| DY14 | DMPH | Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) | 3.3.3 | High-Cost Pharmaceuticals Ordering Protocols: Rate 1 | 49 | 0 | 66 | 0 | 1 | 0.7424 | 0 | None | 1 | 0.25 | 757500 |
| DY14 | DMPH | Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) | 3.3.3 | High-Cost Pharmaceuticals Ordering Protocols: Rate 2 | 56 | 0 | 78 | 0 | n/a | 0.7179 | 0 | None | 1 | None | 0 |
| DY14 | 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 | 1070 | 0 | 1537 | 0 | 1 | 0.6962 | 0 | 0.710632571 | 0 | None | 757500 |
| DY14 | 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 | 1194 | 0 | 1723 | 0 | n/a | 0.693 | 0 | 0.71334214 | 0 | None | 0 |
| DY14 | DMPH | Pioneers Memorial Healthcare District, Brawley | 1.4.1 | Abnormal Results Follow-Up: Abnormal Potassium Follow-up | 1018 | 0 | 1083 | 0 | 1 | 0.94 | 0 | 0.93442623 | 0 | 0.9 | 142153.8467 |
| DY14 | DMPH | Pioneers Memorial Healthcare District, Brawley | 1.4.1 | Abnormal Results Follow-Up: Abnormal INR Follow-up | 45 | 0 | 52 | 0 | 0 | 0.8654 | 0 | 0.908045977 | 0 | 0.9 | 142153.8467 |
| DY14 | DMPH | Pioneers Memorial Healthcare District, Brawley | 1.4.1 | Abnormal Results Follow-Up: Abnormal BIRADS Follow-up | 147 | 0 | 235 | 0 | 0 | 0.6255 | 0 | 0.648648649 | 0 | 0.6737 | 142153.8467 |
| DY14 | DMPH | Pioneers Memorial Healthcare District, Brawley | 1.4.2 | Annual Monitoring for Patients on Persistent Medications | 962 | 0 | 1089 | 0 | 1 | 0.8834 | 0 | 0.8601 | 0 | 0 | 426461.54 |
| DY14 | DMPH | Pioneers Memorial Healthcare District, Brawley | 1.4.3 | INR Monitoring for Individuals on Warfarin | None | 1 | None | 1 | 0 | None | 1 | None | 1 | 0 | 0 |
| DY14 | DMPH | Pioneers Memorial Healthcare District, Brawley | 1.6.1 | BIRADS to Biopsy | 0 | 0 | None | 1 | 0 | None | 1 | None | 1 | 0 | 0 |
| DY14 | DMPH | Pioneers Memorial Healthcare District, Brawley | 1.6.2 | Breast Cancer Screening | 383 | 0 | 488 | 0 | 1 | 0.7848 | 0 | 0.6769 | 0 | 0 | 426461.54 |
| DY14 | DMPH | Pioneers Memorial Healthcare District, Brawley | 1.6.3 | Cervical Cancer Screening | 673 | 0 | 1168 | 0 | 1 | 0.5762 | 0 | 0.5488 | 0 | 0 | 426461.54 |
| DY14 | DMPH | Pioneers Memorial Healthcare District, Brawley | 1.6.4.c | Colorectal Cancer Screening | 320 | 0 | 873 | 0 | 1 | 0.3666 | 0 | 0.3228 | 0 | 0 | 426461.54 |
| DY14 | DMPH | Pioneers Memorial Healthcare District, Brawley | 1.6.5 | Receipt of appropriate follow-up for abnormal CRC screening | 0 | 0 | None | 1 | 0 | None | 1 | 0 | 0 | 0 | 0 |
| DY14 | DMPH | Pioneers Memorial Healthcare District, Brawley | 2.2.1 | DHCS All-Cause Readmissions | 22 | 0 | 227 | 0 | 1 | 0.0969 | 0 | 0.1167 | 0 | 0 | 426461.54 |
| DY14 | DMPH | Pioneers Memorial Healthcare District, Brawley | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 59 | 0 | 100 | 0 | 1 | 0.59 | 0 | 0.52 | 0 | 0 | 426461.54 |
| DY14 | DMPH | Pioneers Memorial Healthcare District, Brawley | 2.2.3 | Medication Reconciliation 30 days | 25 | 0 | 187 | 0 | 0 | 0.1337 | 0 | 0.104 | 0 | 0 | 426461.54 |
| DY14 | DMPH | Pioneers Memorial Healthcare District, Brawley | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 451 | 0 | 733 | 0 | 0 | 0.6153 | 0 | 0.6185 | 0 | 0 | 426461.54 |
| DY14 | DMPH | Pioneers Memorial Healthcare District, Brawley | 2.2.5 | Timely Transmission of Transition Record | 130 | 0 | 512 | 0 | 1 | 0.2539 | 0 | 0.0587 | 0 | 0 | 426461.54 |
| DY14 | DMPH | Pioneers Memorial Healthcare District, Brawley | 3.1.1 | Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis | 17 | 0 | 36 | 0 | 1 | 0.4722 | 0 | None | 1 | 0 | 0 |
| DY14 | DMPH | Pioneers Memorial Healthcare District, Brawley | 3.1.3 | National Healthcare Safety Network (NHSN) Antimicrobial Use Measure | 6187 | 0 | 28500 | 0 | 1 | 0.2171 | 0 | 0.2431 | 0 | 0 | 426461.54 |
| DY14 | DMPH | Pioneers Memorial Healthcare District, Brawley | 3.1.4 | Peri-operative Prophylactic Antibiotics Administered after Surgical Closure | 317 | 0 | 4422 | 0 | 1 | 0.0717 | 0 | 0.1041 | 0 | 0 | 426461.53 |
| DY14 | DMPH | Pioneers Memorial Healthcare District, Brawley | 3.1.5 | Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR | 10610 | 0 | 10000 | 0 | 0 | 1.061 | 0 | 0.854 | 0 | 0.8386 | 426461.53 |
| DY14 | DMPH | Plumas District Hospital, Quincy | 2.6.1 | Alcohol and Drug Misuse (SBIRT): Brief screening only | 290 | 0 | 395 | 0 | 1 | 0.7342 | 0 | 0.078 | 0 | None | 135000 |
| DY14 | DMPH | Plumas District Hospital, Quincy | 2.6.1 | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 74 | 0 | 395 | 0 | 1 | 0.1873 | 0 | 0.078 | 0 | None | 135000 |
| DY14 | 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 | 131 | 0 | 189 | 0 | 1 | 0.6931 | 0 | 0.2749 | 0 | 0 | 270000 |
| DY14 | DMPH | Plumas District Hospital, Quincy | 2.6.3 | Patients with chronic pain on long term opioid therapy checked in PDMPs | 148 | 0 | 189 | 0 | 1 | 0.7831 | 0 | 0.3318 | 0 | 0 | 270000 |
| DY14 | DMPH | Plumas District Hospital, Quincy | 2.6.4 | Screening for Clinical Depression and follow-up | 125 | 0 | 270 | 0 | 1 | 0.463 | 0 | 0.1881 | 0 | 0 | 270000 |
| DY14 | DMPH | Plumas District Hospital, Quincy | 2.6.5 | Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy | 379 | 0 | 396 | 0 | 1 | 0.9571 | 0 | 0.9638 | 0 | 0 | 270000 |
| DY14 | DPH | Riverside University Health System | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 30634 | 0 | 38584 | 0 | 1 | 0.794 | 0 | 0.0012 | 0 | None | 556325.02 |
| DY14 | DPH | Riverside University Health System | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 1884 | 0 | 38584 | 0 | 1 | 0.0488 | 0 | 0.0012 | 0 | None | 556325.02 |
| DY14 | DPH | Riverside University Health System | 1.1.3.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 116 | 0 | 400 | 0 | 1 | 0.29 | 0 | 0.2833 | 0 | 0 | 1112650.04 |
| DY14 | DPH | Riverside University Health System | 1.1.5.f | Screening for Clinical Depression and follow-up | 26008 | 0 | 27469 | 0 | 1 | 0.9468 | 0 | 0.9111 | 0 | 0 | 1112650.04 |
| DY14 | DPH | Riverside University Health System | 1.1.6.t | Tobacco Assessment and Counseling | 30249 | 0 | 31574 | 0 | 1 | 0.958 | 0 | 0.9495 | 0 | 0 | 1112650.04 |
| DY14 | DPH | Riverside University Health System | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Response | 28 | 0 | 527 | 0 | 0 | 0.0531 | 0 | 0.247030879 | 0 | 0.0571 | 370883.3467 |
| DY14 | DPH | Riverside University Health System | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Follow-up | 148 | 0 | 527 | 0 | 1 | 0.2808 | 0 | None | 1 | 0.2619 | 370883.3467 |
| DY14 | DPH | Riverside University Health System | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Remission | 12 | 0 | 527 | 0 | 1 | 0.0228 | 0 | 0.052256532 | 0 | 0.0225 | 370883.3467 |
| DY14 | DPH | Riverside University Health System | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 30634 | 0 | 38584 | 0 | 1 | 0.794 | 0 | 0.0012 | 0 | None | 556325.02 |
| DY14 | DPH | Riverside University Health System | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 1884 | 0 | 38584 | 0 | 1 | 0.0488 | 0 | 0.0012 | 0 | None | 556325.02 |
| DY14 | DPH | Riverside University Health System | 1.2.10 | REAL and/or SO/GI disparity reduction | 15 | 0 | 43 | 0 | 0 | 0.3488 | 0 | 0.3 | 0 | 0 | 1112650.04 |
| DY14 | DPH | Riverside University Health System | 1.2.11 | REAL data completeness | 38103 | 0 | 38219 | 0 | 1 | 0.997 | 0 | 0.9856 | 0 | 0 | 1112650.04 |
| DY14 | DPH | Riverside University Health System | 1.2.12.f | Screening for Clinical Depression and follow-up | 26008 | 0 | 27469 | 0 | 1 | 0.9468 | 0 | 0.9111 | 0 | 0 | 1112650.04 |
| DY14 | DPH | Riverside University Health System | 1.2.13 | SO/GI data completeness | 27886 | 0 | 35804 | 0 | 1 | 0.7789 | 0 | 0.5454 | 0 | 0 | 1112650.04 |
| DY14 | DPH | Riverside University Health System | 1.2.14.t | Tobacco Assessment and Counseling | 30249 | 0 | 31574 | 0 | 1 | 0.958 | 0 | 0.9495 | 0 | 0 | 1112650.04 |
| DY14 | DPH | Riverside University Health System | 1.2.2 | CG-CAHPS: Provider Rating | 713 | 0 | 900 | 0 | 1 | 0.7922 | 0 | 0.7578 | 0 | 0 | 1112650.04 |
| DY14 | DPH | Riverside University Health System | 1.2.3.c | Colorectal Cancer Screening | 8247 | 0 | 14547 | 0 | 1 | 0.5669 | 0 | 0.5282 | 0 | 0 | 1112650.04 |
| DY14 | DPH | Riverside University Health System | 1.2.4.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 116 | 0 | 400 | 0 | 1 | 0.29 | 0 | 0.2833 | 0 | 0 | 1112650.04 |
| DY14 | DPH | Riverside University Health System | 1.2.5.b | Controlling Blood Pressure | 4758 | 0 | 6596 | 0 | 1 | 0.7213 | 0 | 0.716 | 0 | 0 | 1112650.04 |
| DY14 | DPH | Riverside University Health System | 1.2.7.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 265 | 0 | 300 | 0 | 1 | 0.8833 | 0 | 0.8725 | 0 | 0 | 1112650.04 |
| DY14 | DPH | Riverside University Health System | 1.2.8 | Prevention Quality Overall Composite #90 | 251 | 0 | 58727 | 0 | 1 | 0.0043 | 0 | 0.0041 | 0 | 0 | 1112650.04 |
| DY14 | DPH | Riverside University Health System | 1.3.1 | Closing the referral loop: receipt of specialist report (CMS50v3) | 7840 | 0 | 8596 | 0 | 1 | 0.9121 | 0 | 0.8413 | 0 | 0 | 1112650.04 |
| DY14 | DPH | Riverside University Health System | 1.3.2 | DHCS All-Cause Readmissions | 62 | 0 | 604 | 0 | 1 | 0.1026 | 0 | 0.124 | 0 | 0 | 1112650.04 |
| DY14 | DPH | Riverside University Health System | 1.3.3 | Influenza Immunization | 3477 | 0 | 5296 | 0 | 1 | 0.6565 | 0 | 0.5079 | 0 | 0 | 1112650.03 |
| DY14 | DPH | Riverside University Health System | 1.3.5 | Request for Specialty Care Expertise Turnaround Time | 8964 | 0 | 13041 | 0 | 1 | 0.6874 | 0 | 0.1769 | 0 | 0 | 1112650.03 |
| DY14 | DPH | Riverside University Health System | 1.3.6 | Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters | 1097 | 0 | 14852 | 0 | 0 | 0.0739 | 0 | 0.1222 | 0 | 0 | 1112650.03 |
| DY14 | DPH | Riverside University Health System | 1.3.7 | Tobacco Assessment and Counseling | 5310 | 0 | 5468 | 0 | 1 | 0.9711 | 0 | 0.9591 | 0 | 0 | 1112650.03 |
| DY14 | DPH | Riverside University Health System | 1.5.1.b | Controlling Blood Pressure | 4758 | 0 | 6596 | 0 | 1 | 0.7213 | 0 | 0.716 | 0 | 0 | 1112650.03 |
| DY14 | DPH | Riverside University Health System | 1.5.2.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 265 | 0 | 300 | 0 | 1 | 0.8833 | 0 | 0.8725 | 0 | 0 | 1112650.03 |
| DY14 | DPH | Riverside University Health System | 1.5.3 | PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 11859 | 0 | 21900 | 0 | 1 | 0.5415 | 0 | 0.4817 | 0 | 0 | 1112650.03 |
| DY14 | DPH | Riverside University Health System | 1.5.4.t | Tobacco Assessment and Counseling | 30249 | 0 | 31574 | 0 | 1 | 0.958 | 0 | 0.9495 | 0 | 0 | 1112650.03 |
| DY14 | DPH | Riverside University Health System | 2.1.1 | Baby Friendly Hospital designation: BFUSA Designation Yes | Yes | 0 | BFUSA Cert? | 0 | 1 | 0 | 0 | None | 0 | None | 1144439.96 |
| DY14 | DPH | Riverside University Health System | 2.1.2 | Exclusive Breast Milk Feeding (PC-05) | 191 | 0 | 230 | 0 | 1 | 0.8304 | 0 | 0.7577 | 0 | 0 | 1144439.96 |
| DY14 | DPH | Riverside University Health System | 2.1.3 | OB Hemorrhage: Massive Transfusion | 0 | 0 | 327 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 1144439.96 |
| DY14 | DPH | Riverside University Health System | 2.1.4 | OB Hemorrhage: Total Products Transfused | 11 | 0 | 327 | 0 | 1 | 0.0336 | 0 | 0.0327 | 0 | 0 | 1144439.96 |
| DY14 | DPH | Riverside University Health System | 2.1.5 | PC-02 Cesarean Section | 16 | 0 | 89 | 0 | 1 | 0.1798 | 0 | 0.2893 | 0 | 0 | 1144439.96 |
| DY14 | DPH | Riverside University Health System | 2.1.6 | Prenatal and Postpartum Care: Postpartum Care | 198 | 0 | 291 | 0 | 1 | 0.6804 | 0 | 0.744186047 | 0 | 0.6478 | 572219.975 |
| DY14 | DPH | Riverside University Health System | 2.1.6 | Prenatal and Postpartum Care: Prenatal Care | 231 | 0 | 291 | 0 | 1 | 0.7938 | 0 | 0.637873754 | 0 | 0.7766 | 572219.975 |
| DY14 | DPH | Riverside University Health System | 2.1.7 | Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage | None | 1 | 34 | 0 | 1 | None | 1 | None | 1 | 0 | 1144439.95 |
| DY14 | DPH | Riverside University Health System | 2.1.8 | Unexpected Newborn Complications (UNC) | None | 1 | 256 | 0 | 1 | None | 1 | 0.0588 | 0 | 0 | 1144439.95 |
| DY14 | DPH | Riverside University Health System | 2.1.9 | OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes | Yes | 0 | 3 Safety Drills? | 0 | n/a | 0 | 0 | None | 0 | None | 381479.9833 |
| DY14 | 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 | 1 | 0 | 1 | 0 | None | 381479.9833 |
| DY14 | 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 | Yes | 0 | 10 Debriefs? | 0 | n/a | 0 | 0 | None | 0 | None | 381479.9833 |
| DY14 | DPH | Riverside University Health System | 2.2.1 | DHCS All-Cause Readmissions | 68 | 0 | 731 | 0 | 1 | 0.093 | 0 | 0.1161 | 0 | 0 | 1144439.95 |
| DY14 | DPH | Riverside University Health System | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 650 | 0 | 1260 | 0 | 1 | 0.5159 | 0 | 0.4557 | 0 | 0 | 1144439.95 |
| DY14 | DPH | Riverside University Health System | 2.2.3 | Medication Reconciliation 30 days | 1689 | 0 | 1788 | 0 | 1 | 0.9446 | 0 | 0.9552 | 0 | 0 | 1144439.95 |
| DY14 | DPH | Riverside University Health System | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 358 | 0 | 378 | 0 | 1 | 0.9471 | 0 | 0.92 | 0 | 0 | 1144439.95 |
| DY14 | DPH | Riverside University Health System | 2.2.5 | Timely Transmission of Transition Record | 3240 | 0 | 3319 | 0 | 1 | 0.9762 | 0 | 0.9594 | 0 | 0 | 1144439.95 |
| DY14 | DPH | Riverside University Health System | 2.3.2 | Medication Reconciliation 30 days | 181 | 0 | 186 | 0 | 1 | 0.9731 | 0 | 0.957 | 0 | 0 | 1144439.95 |
| DY14 | DPH | Riverside University Health System | 2.3.4 | Timely Transmission of Transition Record | 447 | 0 | 454 | 0 | 1 | 0.9846 | 0 | 0.9649 | 0 | 0 | 1144439.95 |
| DY14 | DPH | Riverside University Health System | 2.6.1 | Alcohol and Drug Misuse (SBIRT): Brief screening only | 6718 | 0 | 7717 | 0 | 1 | 0.8705 | 0 | 0.0023 | 0 | None | 572219.975 |
| DY14 | DPH | Riverside University Health System | 2.6.1 | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 372 | 0 | 7717 | 0 | 1 | 0.0482 | 0 | 0.0023 | 0 | None | 572219.975 |
| DY14 | 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 | 85 | 0 | 270 | 0 | 1 | 0.3148 | 0 | 0.0131 | 0 | 0 | 1144439.95 |
| DY14 | DPH | Riverside University Health System | 2.6.3 | Patients with chronic pain on long term opioid therapy checked in PDMPs | 235 | 0 | 270 | 0 | 1 | 0.8704 | 0 | 0.0876 | 0 | 0 | 1144439.95 |
| DY14 | DPH | Riverside University Health System | 2.6.4 | Screening for Clinical Depression and follow-up | 4600 | 0 | 4720 | 0 | 1 | 0.9746 | 0 | 0.9134 | 0 | 0 | 1144439.95 |
| DY14 | DPH | Riverside University Health System | 2.6.5 | Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy | 7086 | 0 | 7742 | 0 | 1 | 0.9153 | 0 | 0.8316 | 0 | 0 | 1144439.95 |
| DY14 | DPH | Riverside University Health System | 3.3.1 | Adherence to Medications: Rate 1 | 2501 | 0 | 5056 | 0 | 0 | 0.4947 | 0 | 0.548888104 | 0 | 0.5654 | 2002770 |
| DY14 | DPH | Riverside University Health System | 3.3.1 | Adherence to Medications: Rate 2 | 2573 | 0 | 5130 | 0 | n/a | 0.5016 | 0 | 0.528215411 | 0 | None | 0 |
| DY14 | DPH | Riverside University Health System | 3.3.3 | High-Cost Pharmaceuticals Ordering Protocols: Rate 1 | 4756 | 0 | 7538 | 0 | 1 | 0.6309 | 0 | 0.525419217 | 0 | 0.4279 | 2002770 |
| DY14 | DPH | Riverside University Health System | 3.3.3 | High-Cost Pharmaceuticals Ordering Protocols: Rate 2 | 4756 | 0 | 7626 | 0 | n/a | 0.6237 | 0 | 0.375356532 | 0 | None | 0 |
| DY14 | DPH | Riverside University Health System | 3.3.4 | Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 1 | 13887 | 0 | 14344 | 0 | 1 | 0.9681 | 0 | 0.949003365 | 0 | None | 2002770 |
| DY14 | DPH | Riverside University Health System | 3.3.4 | Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 2 | 14130 | 0 | 14593 | 0 | n/a | 0.9683 | 0 | 0.951128982 | 0 | None | 0 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 1.4.1 | Abnormal Results Follow-Up: Abnormal Potassium Follow-up | 2343 | 0 | 2560 | 0 | 1 | 0.9152 | 0 | 0.888408304 | 0 | 0.8896 | 105310.3467 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 1.4.1 | Abnormal Results Follow-Up: Abnormal INR Follow-up | 1434 | 0 | 1482 | 0 | 1 | 0.9676 | 0 | 0.928499496 | 0 | 0.9 | 105310.3467 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 1.4.1 | Abnormal Results Follow-Up: Abnormal BIRADS Follow-up | 1408 | 0 | 1895 | 0 | 1 | 0.743 | 0 | 0.69412516 | 0 | 0.7147 | 105310.3467 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 1.4.2 | Annual Monitoring for Patients on Persistent Medications | 2677 | 0 | 2934 | 0 | 1 | 0.9124 | 0 | 0.8948 | 0 | 0 | 315931.04 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 1.4.3 | INR Monitoring for Individuals on Warfarin | 454 | 0 | 560 | 0 | 1 | 0.8107 | 0 | 0.7682 | 0 | 0 | 315931.04 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 1.5.1.b | Controlling Blood Pressure | 322 | 0 | 473 | 0 | 1 | 0.6808 | 0 | 0.6089 | 0 | 0 | 315931.04 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 1.5.2.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 1146 | 0 | 1390 | 0 | 1 | 0.8245 | 0 | 0.7623 | 0 | 0 | 315931.04 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 1.5.3 | PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 10938 | 0 | 12483 | 0 | 1 | 0.8762 | 0 | 0.8701 | 0 | 0 | 315931.04 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 1.5.4.t | Tobacco Assessment and Counseling | 12714 | 0 | 13174 | 0 | 1 | 0.9651 | 0 | 0.9613 | 0 | 0 | 315931.04 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 1.6.1 | BIRADS to Biopsy | 94 | 0 | 103 | 0 | 1 | 0.9126 | 0 | 0.8974 | 0 | 0 | 315931.04 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 1.6.2 | Breast Cancer Screening | 1329 | 0 | 2098 | 0 | 1 | 0.6335 | 0 | 0.6026 | 0 | 0 | 315931.04 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 1.6.3 | Cervical Cancer Screening | 2924 | 0 | 4669 | 0 | 1 | 0.6263 | 0 | 0.5618 | 0 | 0 | 315931.04 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 1.6.4.c | Colorectal Cancer Screening | 1920 | 0 | 3581 | 0 | 1 | 0.5362 | 0 | 0.4571 | 0 | 0 | 315931.04 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 1.6.5 | Receipt of appropriate follow-up for abnormal CRC screening | None | 1 | None | 1 | 0 | None | 1 | None | 1 | 0 | 0 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 2.2.1 | DHCS All-Cause Readmissions | 333 | 0 | 1831 | 0 | 0 | 0.1819 | 0 | 0.1796 | 0 | 0 | 315931.04 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 2404 | 0 | 4242 | 0 | 1 | 0.5667 | 0 | 0.5494 | 0 | 0 | 315931.04 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 2.2.3 | Medication Reconciliation 30 days | 764 | 0 | 882 | 0 | 1 | 0.8662 | 0 | 0.8484 | 0 | 0 | 315931.03 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 4400 | 0 | 4560 | 0 | 1 | 0.9649 | 0 | 0.885 | 0 | 0 | 315931.03 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 2.2.5 | Timely Transmission of Transition Record | 323 | 0 | 456 | 0 | 1 | 0.7083 | 0 | 0.1971 | 0 | 0 | 315931.03 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 2.3.2 | Medication Reconciliation 30 days | 607 | 0 | 781 | 0 | 1 | 0.7772 | 0 | 0.4537 | 0 | 0 | 315931.03 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 2.3.4 | Timely Transmission of Transition Record | 296 | 0 | 410 | 0 | 1 | 0.722 | 0 | 0.2613 | 0 | 0 | 315931.03 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 2.7.1 | Advance Care Plan | 1047 | 0 | 1047 | 0 | 1 | 1 | 0 | 0.6164 | 0 | 0 | 315931.03 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 2.7.3 | MWM #8: Treatment Preferences (documentation) Inpatient | 83 | 0 | 85 | 0 | 1 | 0.9765 | 0 | 0.9867 | 0 | 0 | 315931.03 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 2.7.4 | MWM #8: Treatment Preferences (documentation) Outpatient | 123 | 0 | 196 | 0 | 1 | 0.6276 | 0 | 0.3182 | 0 | 0 | 315931.03 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 2.7.5 | Palliative Care Service Offered at Time of Diagnosis of Advanced Illness | 134 | 0 | 1049 | 0 | 1 | 0.1277 | 0 | 0.228 | 0 | 0 | 315931.03 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 2.7.6 | Proportion Admitted to Hospice for Less Than 3 Days | None | 1 | 45 | 0 | 1 | None | 1 | None | 1 | 0 | 0 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 3.1.1 | Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis | 91 | 0 | 132 | 0 | 1 | 0.6894 | 0 | 0.7547 | 0 | 0 | 315931.03 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 3.1.3 | National Healthcare Safety Network (NHSN) Antimicrobial Use Measure | 4245 | 0 | 26149 | 0 | 1 | 0.1623 | 0 | 0.1756 | 0 | 0 | 315931.03 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 3.1.4 | Peri-operative Prophylactic Antibiotics Administered after Surgical Closure | 175 | 0 | 526 | 0 | 1 | 0.3327 | 0 | 0.5053 | 0 | 0 | 315931.03 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 3.1.5 | Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR | 6100 | 0 | 10000 | 0 | 1 | 0.61 | 0 | 1.17 | 0 | 1 | 315931.03 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 3.4.1 | ePBM-01 Pre-op Anemia Screening, Selected Elective Surgical Patients | 26 | 0 | 99 | 0 | 1 | 0.2626 | 0 | 0.1333 | 0 | 0 | 315931.03 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 3.4.3 | ePBM-03 Pre-op Type and Crossmatch, Type and Screen, Selected elective Surgical Patients | 44 | 0 | 98 | 0 | 0 | 0.449 | 0 | 0.4444 | 0 | 0 | 315931.03 |
| DY14 | DMPH | Salinas Valley Memorial Healthcare System | 3.4.4 | ePBM-04 Initial Transfusion Threshold | 243 | 0 | 243 | 0 | 1 | 1 | 0 | 0.9946 | 0 | 0 | 315931.03 |
| DY14 | DMPH | San Bernardino Mountains Community Hospital, Lake Arrowhead | 1.4.1 | Abnormal Results Follow-Up: Abnormal BIRADS Follow-up | 175 | 0 | 218 | 0 | 1 | 0.8028 | 0 | 0.918367347 | 0 | 0.7183 | 150000 |
| DY14 | DMPH | San Bernardino Mountains Community Hospital, Lake Arrowhead | 1.4.1 | Abnormal Results Follow-Up: Abnormal Potassium Follow-up | 656 | 0 | 689 | 0 | 1 | 0.9521 | 0 | 0.829268293 | 0 | 0.9 | 150000 |
| DY14 | DMPH | San Bernardino Mountains Community Hospital, Lake Arrowhead | 1.4.1 | Abnormal Results Follow-Up: Abnormal INR Follow-up | 58 | 0 | 66 | 0 | 1 | 0.8788 | 0 | 0.698113208 | 0 | 0.8364 | 150000 |
| DY14 | DMPH | San Bernardino Mountains Community Hospital, Lake Arrowhead | 1.4.2 | Annual Monitoring for Patients on Persistent Medications | 323 | 0 | 338 | 0 | 1 | 0.9556 | 0 | 0.9191 | 0 | 0 | 450000 |
| DY14 | DMPH | San Bernardino Mountains Community Hospital, Lake Arrowhead | 1.4.3 | INR Monitoring for Individuals on Warfarin | 67 | 0 | 79 | 0 | 1 | 0.8481 | 0 | 0.8 | 0 | 0 | 450000 |
| DY14 | DPH | San Francisco General Hospital | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 1649 | 0 | 37873 | 0 | 1 | 0.0435 | 0 | 0.0272 | 0 | None | 570266.69 |
| DY14 | DPH | San Francisco General Hospital | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 18929 | 0 | 37873 | 0 | 1 | 0.4998 | 0 | 0.0272 | 0 | None | 570266.69 |
| DY14 | DPH | San Francisco General Hospital | 1.1.3.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 1718 | 0 | 7023 | 0 | 1 | 0.2446 | 0 | 0.2358 | 0 | 0 | 1140533.37 |
| DY14 | DPH | San Francisco General Hospital | 1.1.5.f | Screening for Clinical Depression and follow-up | 17725 | 0 | 26626 | 0 | 1 | 0.6657 | 0 | 0.5273 | 0 | 0 | 1140533.37 |
| DY14 | DPH | San Francisco General Hospital | 1.1.6.t | Tobacco Assessment and Counseling | 30646 | 0 | 31365 | 0 | 1 | 0.9771 | 0 | 0.9691 | 0 | 0 | 1140533.37 |
| DY14 | DPH | San Francisco General Hospital | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Follow-up | 586 | 0 | 1760 | 0 | 1 | 0.333 | 0 | 0.256351039 | 0 | 0.2703 | 380177.79 |
| DY14 | DPH | San Francisco General Hospital | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Response | 168 | 0 | 1760 | 0 | 1 | 0.0955 | 0 | 0.030792918 | 0 | 0.0724 | 380177.79 |
| DY14 | DPH | San Francisco General Hospital | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Remission | 76 | 0 | 1760 | 0 | 1 | 0.0432 | 0 | 0.069284065 | 0 | 0.0331 | 380177.79 |
| DY14 | DPH | San Francisco General Hospital | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 18929 | 0 | 37873 | 0 | 1 | 0.4998 | 0 | 0.0272 | 0 | None | 570266.685 |
| DY14 | DPH | San Francisco General Hospital | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 1649 | 0 | 37873 | 0 | 1 | 0.0435 | 0 | 0.0272 | 0 | None | 570266.685 |
| DY14 | DPH | San Francisco General Hospital | 1.2.10 | REAL and/or SO/GI disparity reduction | 2031 | 0 | 2726 | 0 | 1 | 0.745 | 0 | 0.7169 | 0 | 0 | 1140533.37 |
| DY14 | DPH | San Francisco General Hospital | 1.2.11 | REAL data completeness | 32009 | 0 | 40728 | 0 | 1 | 0.7859 | 0 | 0.7593 | 0 | 0 | 1140533.37 |
| DY14 | DPH | San Francisco General Hospital | 1.2.12.f | Screening for Clinical Depression and follow-up | 17725 | 0 | 26626 | 0 | 1 | 0.6657 | 0 | 0.5273 | 0 | 0 | 1140533.37 |
| DY14 | DPH | San Francisco General Hospital | 1.2.13 | SO/GI data completeness | 19650 | 0 | 33776 | 0 | 1 | 0.5818 | 0 | 0.2506 | 0 | 0 | 1140533.37 |
| DY14 | DPH | San Francisco General Hospital | 1.2.14.t | Tobacco Assessment and Counseling | 30646 | 0 | 31365 | 0 | 1 | 0.9771 | 0 | 0.9691 | 0 | 0 | 1140533.37 |
| DY14 | DPH | San Francisco General Hospital | 1.2.2 | CG-CAHPS: Provider Rating | 1701 | 0 | 2195 | 0 | 1 | 0.7749 | 0 | 0.754 | 0 | 0 | 1140533.37 |
| DY14 | DPH | San Francisco General Hospital | 1.2.3.c | Colorectal Cancer Screening | 13382 | 0 | 20041 | 0 | 1 | 0.6677 | 0 | 0.6872 | 0 | 0 | 1140533.37 |
| DY14 | DPH | San Francisco General Hospital | 1.2.4.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 1718 | 0 | 7023 | 0 | 1 | 0.2446 | 0 | 0.2358 | 0 | 0 | 1140533.37 |
| DY14 | DPH | San Francisco General Hospital | 1.2.5.b | Controlling Blood Pressure | 10301 | 0 | 12726 | 0 | 1 | 0.8094 | 0 | 0.7866 | 0 | 0 | 1140533.37 |
| DY14 | DPH | San Francisco General Hospital | 1.2.7.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 2052 | 0 | 2209 | 0 | 1 | 0.9289 | 0 | 0.9225 | 0 | 0 | 1140533.37 |
| DY14 | DPH | San Francisco General Hospital | 1.2.8 | Prevention Quality Overall Composite #90 | 587 | 0 | 44704 | 0 | 0 | 0.0131 | 0 | 0.0136 | 0 | 0 | 1140533.37 |
| DY14 | DPH | San Francisco General Hospital | 1.3.1 | Closing the referral loop: receipt of specialist report (CMS50v3) | 107376 | 0 | 133005 | 0 | 1 | 0.8073 | 0 | 0.7306 | 0 | 0 | 1140533.37 |
| DY14 | DPH | San Francisco General Hospital | 1.3.2 | DHCS All-Cause Readmissions | 358 | 0 | 2449 | 0 | 1 | 0.1462 | 0 | 0.1521 | 0 | 0 | 1140533.37 |
| DY14 | DPH | San Francisco General Hospital | 1.3.3 | Influenza Immunization | 9687 | 0 | 10958 | 0 | 1 | 0.884 | 0 | 0.8515 | 0 | 0 | 1140533.37 |
| DY14 | DPH | San Francisco General Hospital | 1.3.5 | Request for Specialty Care Expertise Turnaround Time | 40920 | 0 | 45212 | 0 | 1 | 0.9051 | 0 | 0.8885 | 0 | 0 | 1140533.37 |
| DY14 | DPH | San Francisco General Hospital | 1.3.6 | Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters | 13640 | 0 | 47278 | 0 | 1 | 0.2885 | 0 | 0.2816 | 0 | 0 | 1140533.37 |
| DY14 | DPH | San Francisco General Hospital | 1.3.7 | Tobacco Assessment and Counseling | 12933 | 0 | 13267 | 0 | 1 | 0.9748 | 0 | 0.9665 | 0 | 0 | 1140533.37 |
| DY14 | DPH | San Francisco General Hospital | 1.5.1.b | Controlling Blood Pressure | 10301 | 0 | 12726 | 0 | 1 | 0.8094 | 0 | 0.7866 | 0 | 0 | 1140533.37 |
| DY14 | DPH | San Francisco General Hospital | 1.5.2.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 2052 | 0 | 2209 | 0 | 1 | 0.9289 | 0 | 0.9225 | 0 | 0 | 1140533.37 |
| DY14 | DPH | San Francisco General Hospital | 1.5.3 | PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 18685 | 0 | 19653 | 0 | 1 | 0.9507 | 0 | 0.8582 | 0 | 0 | 1140533.37 |
| DY14 | DPH | San Francisco General Hospital | 1.5.4.t | Tobacco Assessment and Counseling | 30646 | 0 | 31365 | 0 | 1 | 0.9771 | 0 | 0.9691 | 0 | 0 | 1140533.37 |
| DY14 | DPH | San Francisco General Hospital | 2.1.1 | Baby Friendly Hospital designation: BFUSA Designation Yes | Yes | 0 | BFUSA Cert? | 0 | 1 | 0 | 0 | None | 0 | None | 1173119.96 |
| DY14 | DPH | San Francisco General Hospital | 2.1.2 | Exclusive Breast Milk Feeding (PC-05) | 644 | 0 | 777 | 0 | 1 | 0.8288 | 0 | 0.744 | 0 | 0 | 1173119.96 |
| DY14 | DPH | San Francisco General Hospital | 2.1.3 | OB Hemorrhage: Massive Transfusion | None | 1 | 952 | 0 | 1 | None | 1 | None | 1 | 0 | 1173119.96 |
| DY14 | DPH | San Francisco General Hospital | 2.1.4 | OB Hemorrhage: Total Products Transfused | 80 | 0 | 952 | 0 | 1 | 0.084 | 0 | 0.059 | 0 | 0 | 1173119.96 |
| DY14 | DPH | San Francisco General Hospital | 2.1.5 | PC-02 Cesarean Section | 45 | 0 | 315 | 0 | 1 | 0.1429 | 0 | 0.1591 | 0 | 0 | 1173119.96 |
| DY14 | DPH | San Francisco General Hospital | 2.1.6 | Prenatal and Postpartum Care: Prenatal Care | 693 | 0 | 742 | 0 | 1 | 0.934 | 0 | 0.913899139 | 0 | 0.9142 | 586559.975 |
| DY14 | DPH | San Francisco General Hospital | 2.1.6 | Prenatal and Postpartum Care: Postpartum Care | 547 | 0 | 742 | 0 | 1 | 0.7372 | 0 | 0.729397294 | 0 | 0.7301 | 586559.975 |
| DY14 | DPH | San Francisco General Hospital | 2.1.7 | Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage | 36 | 0 | 166 | 0 | 1 | 0.2169 | 0 | 0.1494 | 0 | 0 | 1173119.95 |
| DY14 | DPH | San Francisco General Hospital | 2.1.8 | Unexpected Newborn Complications (UNC) | 67 | 0 | 751 | 0 | 1 | 0.0892 | 0 | 0.1099 | 0 | 0 | 1173119.95 |
| DY14 | DPH | San Francisco General Hospital | 2.1.9 | OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes | Yes | 0 | 3 Safety Drills? | 0 | n/a | 0 | 0 | None | 0 | None | 391039.9833 |
| DY14 | DPH | San Francisco General Hospital | 2.1.9 | OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes | Yes | 0 | 10 Debriefs? | 0 | n/a | 0 | 0 | None | 0 | None | 391039.9833 |
| DY14 | DPH | San Francisco General Hospital | 2.1.9 | OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) |
16 | 0 | 16 | 0 | 1 | 1 | 0 | 1 | 0 | None | 391039.9833 |
| DY14 | DPH | San Francisco General Hospital | 2.2.1 | DHCS All-Cause Readmissions | 448 | 0 | 3046 | 0 | 0 | 0.1471 | 0 | 0.1443 | 0 | 0 | 1173119.95 |
| DY14 | DPH | San Francisco General Hospital | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 805 | 0 | 1554 | 0 | 0 | 0.518 | 0 | 0.522 | 0 | 0 | 1173119.95 |
| DY14 | DPH | San Francisco General Hospital | 2.2.3 | Medication Reconciliation 30 days | 3276 | 0 | 4013 | 0 | 1 | 0.8163 | 0 | 0.7985 | 0 | 0 | 1173119.95 |
| DY14 | DPH | San Francisco General Hospital | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 3144 | 0 | 3180 | 0 | 1 | 0.9887 | 0 | 0.9842 | 0 | 0 | 1173119.95 |
| DY14 | DPH | San Francisco General Hospital | 2.2.5 | Timely Transmission of Transition Record | 3964 | 0 | 4818 | 0 | 1 | 0.8227 | 0 | 0.7739 | 0 | 0 | 1173119.95 |
| DY14 | DPH | San Francisco General Hospital | 2.3.2 | Medication Reconciliation 30 days | 1105 | 0 | 1303 | 0 | 1 | 0.848 | 0 | 0.8288 | 0 | 0 | 1173119.95 |
| DY14 | DPH | San Francisco General Hospital | 2.3.4 | Timely Transmission of Transition Record | 1299 | 0 | 1440 | 0 | 1 | 0.9021 | 0 | 0.8717 | 0 | 0 | 1173119.95 |
| DY14 | DPH | San Francisco General Hospital | 2.6.1 | Alcohol and Drug Misuse (SBIRT): Brief screening only | 2572 | 0 | 4793 | 0 | 1 | 0.5366 | 0 | 0.016 | 0 | None | 586559.975 |
| DY14 | DPH | San Francisco General Hospital | 2.6.1 | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 157 | 0 | 4793 | 0 | 1 | 0.0328 | 0 | 0.016 | 0 | None | 586559.975 |
| DY14 | 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 | 950 | 0 | 1493 | 0 | 1 | 0.6363 | 0 | 0.5763 | 0 | 0 | 1173119.95 |
| DY14 | DPH | San Francisco General Hospital | 2.6.3 | Patients with chronic pain on long term opioid therapy checked in PDMPs | 1289 | 0 | 1493 | 0 | 1 | 0.8634 | 0 | 0.8224 | 0 | 0 | 1173119.95 |
| DY14 | DPH | San Francisco General Hospital | 2.6.4 | Screening for Clinical Depression and follow-up | 1870 | 0 | 2800 | 0 | 1 | 0.6679 | 0 | 0.4974 | 0 | 0 | 1173119.95 |
| DY14 | DPH | San Francisco General Hospital | 2.6.5 | Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy | 4526 | 0 | 4997 | 0 | 1 | 0.9057 | 0 | 0.925 | 0 | 0 | 1173119.95 |
| DY14 | DPH | San Francisco General Hospital | 3.3.1 | Adherence to Medications: Rate 1 | 111 | 0 | 162 | 0 | 0 | 0.6852 | 0 | 0.713235294 | 0 | 0.6975 | 2052960 |
| DY14 | DPH | San Francisco General Hospital | 3.3.1 | Adherence to Medications: Rate 2 | 368 | 0 | 496 | 0 | n/a | 0.7419 | 0 | 0.675 | 0 | None | 0 |
| DY14 | DPH | San Francisco General Hospital | 3.3.3 | High-Cost Pharmaceuticals Ordering Protocols: Rate 1 | 27 | 0 | 71 | 0 | 1 | 0.3803 | 0 | 0.325396825 | 0 | 0.325 | 2052960 |
| DY14 | DPH | San Francisco General Hospital | 3.3.3 | High-Cost Pharmaceuticals Ordering Protocols: Rate 2 | 65 | 0 | 272 | 0 | n/a | 0.239 | 0 | 0.261146497 | 0 | None | 0 |
| DY14 | DPH | San Francisco General Hospital | 3.3.4 | Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 1 | 693 | 0 | 957 | 0 | 1 | 0.7241 | 0 | 0.861586314 | 0 | None | 2052960 |
| DY14 | DPH | San Francisco General Hospital | 3.3.4 | Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 2 | 1616 | 0 | 2111 | 0 | n/a | 0.7655 | 0 | 0.789333333 | 0 | None | 0 |
| DY14 | DMPH | San Gorgonio Memorial Hospital, Banning | 1.7.1 | BMI Screening and Follow-up | 68 | 0 | 110 | 0 | 1 | 0.6182 | 0 | 0.4789 | 0 | 0 | 262500 |
| DY14 | DMPH | San Gorgonio Memorial Hospital, Banning | 1.7.2 | Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met) Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 8) |
8 | 0 | 8 | 0 | 1 | 1 | 0 | None | 0 | None | 262500 |
| DY14 | 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 | 92 | 0 | 1 | 0.7826 | 0 | 0.699029126 | 0 | 0.7166 | 87500 |
| DY14 | 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 | 92 | 0 | 1 | 0.7826 | 0 | 0.699029126 | 0 | 0.7116 | 87500 |
| DY14 | DMPH | San Gorgonio Memorial Hospital, Banning | 1.7.3 | Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity | 71 | 0 | 92 | 0 | 1 | 0.7717 | 0 | 0.67961165 | 0 | 0.687 | 87500 |
| DY14 | DMPH | San Gorgonio Memorial Hospital, Banning | 2.2.1 | DHCS All-Cause Readmissions | 75 | 0 | 549 | 0 | 0 | 0.1366 | 0 | 0.0944 | 0 | 0 | 262500 |
| DY14 | DMPH | San Gorgonio Memorial Hospital, Banning | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 5298 | 0 | 10000 | 0 | 0 | 0.5298 | 0 | 0.5951 | 0 | 0 | 262500 |
| DY14 | DMPH | San Gorgonio Memorial Hospital, Banning | 2.2.3 | Medication Reconciliation 30 days | 33 | 0 | 33 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 262500 |
| DY14 | DMPH | San Gorgonio Memorial Hospital, Banning | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 33 | 0 | 33 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 262500 |
| DY14 | DMPH | San Gorgonio Memorial Hospital, Banning | 2.2.5 | Timely Transmission of Transition Record | 33 | 0 | 33 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 262500 |
| DY14 | DMPH | San Gorgonio Memorial Hospital, Banning | 3.1.1 | Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis | 109 | 0 | 122 | 0 | 1 | 0.8934 | 0 | 0.8727 | 0 | 0 | 262500 |
| DY14 | DMPH | San Gorgonio Memorial Hospital, Banning | 3.1.3 | National Healthcare Safety Network (NHSN) Antimicrobial Use Measure | 5383 | 0 | 11979 | 0 | 0 | 0.4494 | 0 | 0.4768 | 0 | 0 | 262500 |
| DY14 | DMPH | San Gorgonio Memorial Hospital, Banning | 3.1.4 | Peri-operative Prophylactic Antibiotics Administered after Surgical Closure | 0 | 0 | 47 | 0 | 1 | 0 | 0 | None | 1 | 0 | 262500 |
| DY14 | DMPH | San Gorgonio Memorial Hospital, Banning | 3.1.5 | Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR | 0 | 0 | 10000 | 0 | 1 | 0 | 0 | 0.84 | 0 | 0.826 | 262500 |
| DY14 | DPH | San Joaquin General Hospital | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 8061 | 0 | 14733 | 0 | 1 | 0.5471 | 0 | 0.0238 | 0 | None | 322503.75 |
| DY14 | DPH | San Joaquin General Hospital | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 1192 | 0 | 14733 | 0 | 1 | 0.0809 | 0 | 0.0238 | 0 | None | 322503.75 |
| DY14 | DPH | San Joaquin General Hospital | 1.1.3.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 99 | 0 | 341 | 0 | 1 | 0.2903 | 0 | 0.291 | 0 | 0 | 645007.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.1.5.f | Screening for Clinical Depression and follow-up | 276 | 0 | 370 | 0 | 1 | 0.7459 | 0 | 0.7135 | 0 | 0 | 645007.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.1.6.t | Tobacco Assessment and Counseling | 372 | 0 | 377 | 0 | 1 | 0.9867 | 0 | 0.8939 | 0 | 0 | 645007.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Follow-up | 84 | 0 | 235 | 0 | 1 | 0.3574 | 0 | 0.103524229 | 0 | 0.1327 | 215002.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Remission | 25 | 0 | 235 | 0 | 1 | 0.1064 | 0 | 0.019823789 | 0 | 0.0232 | 215002.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Response | 34 | 0 | 235 | 0 | 1 | 0.1447 | 0 | 0.04185022 | 0 | 0.0477 | 215002.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 8061 | 0 | 14733 | 0 | 1 | 0.5471 | 0 | 0.0238 | 0 | None | 322503.75 |
| DY14 | DPH | San Joaquin General Hospital | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 1192 | 0 | 14733 | 0 | 1 | 0.0809 | 0 | 0.0238 | 0 | None | 322503.75 |
| DY14 | DPH | San Joaquin General Hospital | 1.2.10 | REAL and/or SO/GI disparity reduction | 142 | 0 | 260 | 0 | 0 | 0.5462 | 0 | 0.6024 | 0 | 0 | 645007.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.2.11 | REAL data completeness | 18029 | 0 | 18187 | 0 | 1 | 0.9913 | 0 | 0.6178 | 0 | 0 | 645007.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.2.12.f | Screening for Clinical Depression and follow-up | 276 | 0 | 370 | 0 | 1 | 0.7459 | 0 | 0.7135 | 0 | 0 | 645007.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.2.13 | SO/GI data completeness | 10279 | 0 | 13815 | 0 | 1 | 0.744 | 0 | 0.2886 | 0 | 0 | 645007.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.2.14.t | Tobacco Assessment and Counseling | 372 | 0 | 377 | 0 | 1 | 0.9867 | 0 | 0.8939 | 0 | 0 | 645007.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.2.2 | CG-CAHPS: Provider Rating | 7710 | 0 | 10000 | 0 | 1 | 0.771 | 0 | 0.7021 | 0 | 0 | 645007.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.2.3.c | Colorectal Cancer Screening | 179 | 0 | 357 | 0 | 1 | 0.5014 | 0 | 0.3757 | 0 | 0 | 645007.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.2.4.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 99 | 0 | 341 | 0 | 1 | 0.2903 | 0 | 0.291 | 0 | 0 | 645007.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.2.5.b | Controlling Blood Pressure | 233 | 0 | 357 | 0 | 0 | 0.6527 | 0 | 0.7007 | 0 | 0 | 645007.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.2.7.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 668 | 0 | 753 | 0 | 1 | 0.8871 | 0 | 0.7746 | 0 | 0 | 645007.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.2.8 | Prevention Quality Overall Composite #90 | 162 | 0 | 20811 | 0 | 1 | 0.0078 | 0 | 0.0153 | 0 | 0 | 645007.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.3.1 | Closing the referral loop: receipt of specialist report (CMS50v3) | 175 | 0 | 323 | 0 | 0 | 0.5418 | 0 | 0.5854 | 0 | 0 | 645007.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.3.2 | DHCS All-Cause Readmissions | 74 | 0 | 586 | 0 | 0 | 0.1263 | 0 | 0.1193 | 0 | 0 | 645007.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.3.3 | Influenza Immunization | 248 | 0 | 341 | 0 | 1 | 0.7273 | 0 | 0.5232 | 0 | 0 | 645007.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.3.5 | Request for Specialty Care Expertise Turnaround Time | 105 | 0 | 121 | 0 | 1 | 0.8678 | 0 | 0.3812 | 0 | 0 | 645007.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.3.6 | Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters | 62 | 0 | 370 | 0 | 1 | 0.1676 | 0 | None | 1 | 0 | 645007.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.3.7 | Tobacco Assessment and Counseling | 329 | 0 | 341 | 0 | 0 | 0.9648 | 0 | 0.9795 | 0 | 0 | 645007.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.6.1 | BIRADS to Biopsy | 26 | 0 | 43 | 0 | 1 | 0.6047 | 0 | 0.4706 | 0 | 0 | 645007.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.6.2 | Breast Cancer Screening | 242 | 0 | 351 | 0 | 1 | 0.6895 | 0 | 0.5071 | 0 | 0 | 645007.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.6.3 | Cervical Cancer Screening | 178 | 0 | 370 | 0 | 0 | 0.4811 | 0 | 0.3607 | 0 | 0 | 645007.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.6.4.c | Colorectal Cancer Screening | 179 | 0 | 357 | 0 | 1 | 0.5014 | 0 | 0.3757 | 0 | 0 | 645007.5 |
| DY14 | DPH | San Joaquin General Hospital | 1.6.5 | Receipt of appropriate follow-up for abnormal CRC screening | None | 1 | None | 1 | 0 | None | 1 | 0.3846 | 0 | 0 | 645007.5 |
| DY14 | DPH | San Joaquin General Hospital | 2.1.1 | Baby Friendly Hospital designation: BFUSA Designation Yes | Yes | 0 | BFUSA Cert? | 0 | 1 | 0 | 0 | None | 0 | None | 722408.4 |
| DY14 | DPH | San Joaquin General Hospital | 2.1.2 | Exclusive Breast Milk Feeding (PC-05) | 234 | 0 | 329 | 0 | 1 | 0.7112 | 0 | 0.6556 | 0 | 0 | 722408.4 |
| DY14 | DPH | San Joaquin General Hospital | 2.1.3 | OB Hemorrhage: Massive Transfusion | 0 | 0 | 944 | 0 | 1 | 0 | 0 | None | 1 | 0 | 722408.4 |
| DY14 | DPH | San Joaquin General Hospital | 2.1.4 | OB Hemorrhage: Total Products Transfused | 45 | 0 | 944 | 0 | 1 | 0.0477 | 0 | 0.1208 | 0 | 0 | 722408.4 |
| DY14 | DPH | San Joaquin General Hospital | 2.1.5 | PC-02 Cesarean Section | 52 | 0 | 241 | 0 | 1 | 0.2158 | 0 | 0.2233 | 0 | 0 | 722408.4 |
| DY14 | DPH | San Joaquin General Hospital | 2.1.6 | Prenatal and Postpartum Care: Prenatal Care | 81 | 0 | 135 | 0 | 0 | 0.6 | 0 | 0.676409186 | 0 | 0.7766 | 361204.2 |
| DY14 | DPH | San Joaquin General Hospital | 2.1.6 | Prenatal and Postpartum Care: Postpartum Care | 67 | 0 | 135 | 0 | 0 | 0.4963 | 0 | 0.584551148 | 0 | 0.5998 | 361204.2 |
| DY14 | DPH | San Joaquin General Hospital | 2.1.7 | Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage | 25 | 0 | 69 | 0 | 1 | 0.3623 | 0 | 0.5313 | 0 | 0 | 722408.4 |
| DY14 | DPH | San Joaquin General Hospital | 2.1.8 | Unexpected Newborn Complications (UNC) | 25 | 0 | 715 | 0 | 1 | 0.035 | 0 | 0.0376 | 0 | 0 | 722408.4 |
| DY14 | DPH | San Joaquin General Hospital | 2.1.9 | OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes | Yes | 0 | 3 Safety Drills? | 0 | n/a | 0 | 0 | None | 0 | None | 240802.8 |
| DY14 | DPH | San Joaquin General Hospital | 2.1.9 | OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) |
16 | 0 | 16 | 0 | 1 | 1 | 0 | 1 | 0 | None | 240802.8 |
| DY14 | DPH | San Joaquin General Hospital | 2.1.9 | OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes | Yes | 0 | 10 Debriefs? | 0 | n/a | 0 | 0 | None | 0 | None | 240802.8 |
| DY14 | DPH | San Joaquin General Hospital | 2.2.1 | DHCS All-Cause Readmissions | 92 | 0 | 860 | 0 | 1 | 0.107 | 0 | 0.1039 | 0 | 0 | 722408.4 |
| DY14 | DPH | San Joaquin General Hospital | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 3820 | 0 | 10000 | 0 | 0 | 0.382 | 0 | 0.451 | 0 | 0 | 722408.4 |
| DY14 | DPH | San Joaquin General Hospital | 2.2.3 | Medication Reconciliation 30 days | 149 | 0 | 177 | 0 | 1 | 0.8418 | 0 | 0.6471 | 0 | 0 | 722408.4 |
| DY14 | DPH | San Joaquin General Hospital | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 319 | 0 | 341 | 0 | 1 | 0.9355 | 0 | 0.7595 | 0 | 0 | 722408.4 |
| DY14 | DPH | San Joaquin General Hospital | 2.2.5 | Timely Transmission of Transition Record | 266 | 0 | 341 | 0 | 1 | 0.7801 | 0 | 0.2757 | 0 | 0 | 722408.4 |
| DY14 | DPH | San Joaquin General Hospital | 2.3.2 | Medication Reconciliation 30 days | 98 | 0 | 109 | 0 | 1 | 0.8991 | 0 | 0.7671 | 0 | 0 | 722408.4 |
| DY14 | DPH | San Joaquin General Hospital | 2.3.4 | Timely Transmission of Transition Record | 260 | 0 | 341 | 0 | 1 | 0.7625 | 0 | 0.2879 | 0 | 0 | 722408.4 |
| DY14 | DPH | San Joaquin General Hospital | 2.7.1 | Advance Care Plan | 107 | 0 | 323 | 0 | 1 | 0.3313 | 0 | 0.2663 | 0 | 0 | 722408.4 |
| DY14 | DPH | San Joaquin General Hospital | 2.7.3 | MWM #8: Treatment Preferences (documentation) Inpatient | 95 | 0 | 121 | 0 | 1 | 0.7851 | 0 | 0.7374 | 0 | 0 | 722408.4 |
| DY14 | DPH | San Joaquin General Hospital | 2.7.4 | MWM #8: Treatment Preferences (documentation) Outpatient | 55 | 0 | 59 | 0 | 1 | 0.9322 | 0 | 0.9048 | 0 | 0 | 722408.4 |
| DY14 | DPH | San Joaquin General Hospital | 2.7.5 | Palliative Care Service Offered at Time of Diagnosis of Advanced Illness | 40 | 0 | 109 | 0 | 1 | 0.367 | 0 | 0.1378 | 0 | 0 | 722408.4 |
| DY14 | 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 | 0 |
| DY14 | DPH | San Joaquin General Hospital | 3.2.1 | Dont Do Imaging for Uncomplicated Headaches (Choosing Wisely) | 17 | 0 | 184 | 0 | 1 | 0.0924 | 0 | 0.1731 | 0 | 0 | 903010.5 |
| DY14 | DPH | San Joaquin General Hospital | 3.2.2 | Appropriate Emergency Department Utilization of CT for Pulmonary Embolism | 135 | 0 | 167 | 0 | 0 | 0.8084 | 0 | 0.9208 | 0 | 0 | 903010.5 |
| DY14 | DPH | San Joaquin General Hospital | 3.2.3 | Use of Imaging Studies for Low Back Pain | 755 | 0 | 873 | 0 | 1 | 0.8648 | 0 | 0.9058 | 0 | 0 | 903010.5 |
| DY14 | 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 | 394 | 0 | 577 | 0 | 1 | 0.6828 | 0 | 0.040552995 | 0 | None | 451505.25 |
| DY14 | 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 | 183 | 0 | 577 | 0 | 1 | 0.3172 | 0 | 0.151544402 | 0 | None | 451505.25 |
| DY14 | DPH | San Mateo Medical Center | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 317 | 0 | 23396 | 0 | 1 | 0.0135 | 0 | 0.0176 | 0 | None | 348658.335 |
| DY14 | DPH | San Mateo Medical Center | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 1046 | 0 | 23396 | 0 | 1 | 0.0447 | 0 | 0.0176 | 0 | None | 348658.335 |
| DY14 | DPH | San Mateo Medical Center | 1.1.3.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 991 | 0 | 4187 | 0 | 1 | 0.2367 | 0 | 0.2494 | 0 | 0 | 697316.67 |
| DY14 | DPH | San Mateo Medical Center | 1.1.5.f | Screening for Clinical Depression and follow-up | 6583 | 0 | 16582 | 0 | 1 | 0.397 | 0 | 0.2403 | 0 | 0 | 697316.67 |
| DY14 | DPH | San Mateo Medical Center | 1.1.6.t | Tobacco Assessment and Counseling | 17314 | 0 | 17940 | 0 | 1 | 0.9651 | 0 | 0.9641 | 0 | 0 | 697316.67 |
| DY14 | DPH | San Mateo Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Follow-up | 177 | 0 | 549 | 0 | 0 | 0.3224 | 0 | None | 4 | 0.3956 | 0 |
| DY14 | DPH | San Mateo Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Remission | 38 | 0 | 549 | 0 | 1 | 0.0692 | 0 | None | 4 | 0.0539 | 0 |
| DY14 | DPH | San Mateo Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Response | 58 | 0 | 549 | 0 | 1 | 0.1056 | 0 | None | 4 | 0.0998 | 0 |
| DY14 | DPH | San Mateo Medical Center | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 317 | 0 | 23396 | 0 | 1 | 0.0135 | 0 | 0.0176 | 0 | None | 348658.335 |
| DY14 | DPH | San Mateo Medical Center | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 1046 | 0 | 23396 | 0 | 1 | 0.0447 | 0 | 0.0176 | 0 | None | 348658.335 |
| DY14 | DPH | San Mateo Medical Center | 1.2.10 | REAL and/or SO/GI disparity reduction | 193 | 0 | 267 | 0 | 1 | 0.7228 | 0 | 0.6703 | 0 | 0 | 697316.67 |
| DY14 | DPH | San Mateo Medical Center | 1.2.11 | REAL data completeness | 30299 | 0 | 31859 | 0 | 1 | 0.951 | 0 | 0.9792 | 0 | 0 | 697316.67 |
| DY14 | DPH | San Mateo Medical Center | 1.2.12.f | Screening for Clinical Depression and follow-up | 6583 | 0 | 16582 | 0 | 1 | 0.397 | 0 | 0.2403 | 0 | 0 | 697316.67 |
| DY14 | DPH | San Mateo Medical Center | 1.2.13 | SO/GI data completeness | 18034 | 0 | 20785 | 0 | 1 | 0.8676 | 0 | 0.7718 | 0 | 0 | 697316.67 |
| DY14 | DPH | San Mateo Medical Center | 1.2.14.t | Tobacco Assessment and Counseling | 17314 | 0 | 17940 | 0 | 1 | 0.9651 | 0 | 0.9641 | 0 | 0 | 697316.67 |
| DY14 | DPH | San Mateo Medical Center | 1.2.2 | CG-CAHPS: Provider Rating | 310 | 0 | 396 | 0 | 0 | 0.7828 | 0 | 0.8017 | 0 | 0 | 697316.67 |
| DY14 | DPH | San Mateo Medical Center | 1.2.3.c | Colorectal Cancer Screening | 5169 | 0 | 8136 | 0 | 1 | 0.6353 | 0 | 0.6251 | 0 | 0 | 697316.67 |
| DY14 | DPH | San Mateo Medical Center | 1.2.4.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 991 | 0 | 4187 | 0 | 1 | 0.2367 | 0 | 0.2494 | 0 | 0 | 697316.67 |
| DY14 | DPH | San Mateo Medical Center | 1.2.5.b | Controlling Blood Pressure | 4451 | 0 | 5628 | 0 | 1 | 0.7909 | 0 | 0.7371 | 0 | 0 | 697316.67 |
| DY14 | DPH | San Mateo Medical Center | 1.2.7.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 778 | 0 | 817 | 0 | 1 | 0.9523 | 0 | 0.9443 | 0 | 0 | 697316.67 |
| DY14 | DPH | San Mateo Medical Center | 1.2.8 | Prevention Quality Overall Composite #90 | 219 | 0 | 20547 | 0 | 0 | 0.0107 | 0 | 0.0111 | 0 | 0 | 697316.67 |
| DY14 | DPH | San Mateo Medical Center | 1.3.1 | Closing the referral loop: receipt of specialist report (CMS50v3) | 14066 | 0 | 14066 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 697316.67 |
| DY14 | DPH | San Mateo Medical Center | 1.3.2 | DHCS All-Cause Readmissions | 29 | 0 | 374 | 0 | 1 | 0.0775 | 0 | 0.0753 | 0 | 0 | 697316.67 |
| DY14 | DPH | San Mateo Medical Center | 1.3.3 | Influenza Immunization | 8055 | 0 | 11303 | 0 | 1 | 0.7126 | 0 | 0.6775 | 0 | 0 | 697316.66 |
| DY14 | DPH | San Mateo Medical Center | 1.3.5 | Request for Specialty Care Expertise Turnaround Time | 6726 | 0 | 26888 | 0 | 1 | 0.2501 | 0 | 0.1081 | 0 | 0 | 697316.66 |
| DY14 | DPH | San Mateo Medical Center | 1.3.6 | Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters | 394 | 0 | 32470 | 0 | 0 | 0.0121 | 0 | None | 1 | 0 | 697316.66 |
| DY14 | DPH | San Mateo Medical Center | 1.3.7 | Tobacco Assessment and Counseling | 5928 | 0 | 6096 | 0 | 1 | 0.9724 | 0 | 0.9721 | 0 | 0 | 697316.66 |
| DY14 | DPH | San Mateo Medical Center | 1.6.1 | BIRADS to Biopsy | 92 | 0 | 176 | 0 | 1 | 0.5227 | 0 | 0.4248 | 0 | 0 | 697316.66 |
| DY14 | DPH | San Mateo Medical Center | 1.6.2 | Breast Cancer Screening | 4217 | 0 | 5444 | 0 | 1 | 0.7746 | 0 | 0.7473 | 0 | 0 | 697316.66 |
| DY14 | DPH | San Mateo Medical Center | 1.6.3 | Cervical Cancer Screening | 6229 | 0 | 9691 | 0 | 1 | 0.6428 | 0 | 0.594 | 0 | 0 | 697316.66 |
| DY14 | DPH | San Mateo Medical Center | 1.6.4.c | Colorectal Cancer Screening | 5169 | 0 | 8136 | 0 | 1 | 0.6353 | 0 | 0.6251 | 0 | 0 | 697316.66 |
| DY14 | DPH | San Mateo Medical Center | 1.6.5 | Receipt of appropriate follow-up for abnormal CRC screening | 171 | 0 | 459 | 0 | 1 | 0.3725 | 0 | 0.0702 | 0 | 0 | 697316.66 |
| DY14 | DPH | San Mateo Medical Center | 2.2.1 | DHCS All-Cause Readmissions | 33 | 0 | 427 | 0 | 1 | 0.0773 | 0 | 0.0783 | 0 | 0 | 1255170 |
| DY14 | DPH | San Mateo Medical Center | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 5290 | 0 | 10000 | 0 | 1 | 0.529 | 0 | 0.4767 | 0 | 0 | 1255170 |
| DY14 | DPH | San Mateo Medical Center | 2.2.3 | Medication Reconciliation 30 days | 522 | 0 | 769 | 0 | 1 | 0.6788 | 0 | 0.6459 | 0 | 0 | 1255170 |
| DY14 | DPH | San Mateo Medical Center | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 856 | 0 | 876 | 0 | 1 | 0.9772 | 0 | 0.9708 | 0 | 0 | 1255170 |
| DY14 | DPH | San Mateo Medical Center | 2.2.5 | Timely Transmission of Transition Record | 1976 | 0 | 1990 | 0 | 1 | 0.993 | 0 | 0.9969 | 0 | 0 | 1255170 |
| DY14 | DPH | San Mateo Medical Center | 2.3.2 | Medication Reconciliation 30 days | 69 | 0 | 110 | 0 | 1 | 0.6273 | 0 | 0.5727 | 0 | 0 | 1255170 |
| DY14 | DPH | San Mateo Medical Center | 2.3.4 | Timely Transmission of Transition Record | 272 | 0 | 272 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 1255170 |
| DY14 | DPH | San Mateo Medical Center | 2.4.1 | Adolescent Well-Care Visit | 23 | 0 | 33 | 0 | 1 | 0.697 | 0 | 0.8462 | 0 | 0 | 1255170 |
| DY14 | DPH | San Mateo Medical Center | 2.4.2 | Developmental Screening in the First Three Years of Life | None | 1 | None | 1 | 0 | None | 1 | None | 1 | 0 | 0 |
| DY14 | DPH | San Mateo Medical Center | 2.4.3 | Documentation of Current Medications in the Medical Record (0-18 yo) | 191 | 0 | 247 | 0 | 1 | 0.7733 | 0 | 0.7368 | 0 | 0 | 1255170 |
| DY14 | DPH | San Mateo Medical Center | 2.4.4 | Screening for Clinical Depression and follow-up | 13 | 0 | None | 4 | 0 | None | 4 | None | 1 | 0 | 0 |
| DY14 | DPH | San Mateo Medical Center | 2.4.5 | Tobacco Assessment and Counseling (13 yo and older) | 20 | 0 | None | 4 | 0 | None | 4 | None | 4 | 0 | 0 |
| DY14 | DPH | San Mateo Medical Center | 2.4.7 | Well Child Visits - Third, Fourth, Fifth, and Sixth Years of life | 12 | 0 | None | 4 | 0 | None | 4 | None | 1 | 0 | 0 |
| DY14 | 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 | 1 | 0 | 0 |
| DY14 | DPH | San Mateo Medical Center | 2.6.1 | Alcohol and Drug Misuse (SBIRT): Brief screening only | 44 | 0 | 366 | 0 | 1 | 0.1202 | 0 | None | 1 | None | 627585 |
| DY14 | DPH | San Mateo Medical Center | 2.6.1 | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 59 | 0 | 366 | 0 | 1 | 0.1612 | 0 | None | 1 | None | 627585 |
| DY14 | 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 |
| DY14 | 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 |
| DY14 | DPH | San Mateo Medical Center | 2.6.4 | Screening for Clinical Depression and follow-up | 105 | 0 | 220 | 0 | 1 | 0.4773 | 0 | 0.2756 | 0 | 0 | 1255170 |
| DY14 | DPH | San Mateo Medical Center | 2.6.5 | Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy | 331 | 0 | 375 | 0 | 1 | 0.8827 | 0 | 0.8608 | 0 | 0 | 1255170 |
| DY14 | DPH | San Mateo Medical Center | 3.2.1 | Dont Do Imaging for Uncomplicated Headaches (Choosing Wisely) | 170 | 0 | 1190 | 0 | 1 | 0.1429 | 0 | 0.1477 | 0 | 0 | 941377.5 |
| DY14 | DPH | San Mateo Medical Center | 3.2.2 | Appropriate Emergency Department Utilization of CT for Pulmonary Embolism | 127 | 0 | 134 | 0 | 1 | 0.9478 | 0 | 0.6839 | 0 | 0 | 941377.5 |
| DY14 | DPH | San Mateo Medical Center | 3.2.3 | Use of Imaging Studies for Low Back Pain | 253 | 0 | 288 | 0 | 1 | 0.8785 | 0 | 0.9131 | 0 | 0 | 941377.5 |
| DY14 | 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 | 184 | 0 | 262 | 0 | 1 | 0.7023 | 0 | 0.180751174 | 0 | None | 470688.75 |
| DY14 | 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 | 78 | 0 | 262 | 0 | 1 | 0.2977 | 0 | 0.108299595 | 0 | None | 470688.75 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 4560 | 0 | 52156 | 0 | 1 | 0.0874 | 0 | 0.0223 | 0 | None | 1037452.52 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 26699 | 0 | 52156 | 0 | 1 | 0.5119 | 0 | 0.0223 | 0 | None | 1037452.52 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.1.3.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 2457 | 0 | 9749 | 0 | 1 | 0.252 | 0 | 0.2824 | 0 | 0 | 2074905.04 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.1.5.f | Screening for Clinical Depression and follow-up | 22193 | 0 | 35545 | 0 | 1 | 0.6244 | 0 | 0.4457 | 0 | 0 | 2074905.04 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.1.6.t | Tobacco Assessment and Counseling | 32096 | 0 | 32365 | 0 | 1 | 0.9917 | 0 | 0.9878 | 0 | 0 | 2074905.04 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Remission | 118 | 0 | 2269 | 0 | 0 | 0.052 | 0 | 0.427734375 | 0 | 0.0539 | 691635.0133 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Response | 238 | 0 | 2269 | 0 | 1 | 0.1049 | 0 | 0.055989583 | 0 | 0.0998 | 691635.0133 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Follow-up | 967 | 0 | 2269 | 0 | 1 | 0.4262 | 0 | 0.102864583 | 0 | 0.3956 | 691635.0133 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 26699 | 0 | 52156 | 0 | 1 | 0.5119 | 0 | 0.0223 | 0 | None | 1037452.52 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 4560 | 0 | 52156 | 0 | 1 | 0.0874 | 0 | 0.0223 | 0 | None | 1037452.52 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.2.10 | REAL and/or SO/GI disparity reduction | 1236 | 0 | 4160 | 0 | 1 | 0.2971 | 0 | 0.3171 | 0 | 0 | 2074905.04 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.2.11 | REAL data completeness | 46859 | 0 | 60636 | 0 | 1 | 0.7728 | 0 | 0.7071 | 0 | 0 | 2074905.04 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.2.12.f | Screening for Clinical Depression and follow-up | 22193 | 0 | 35545 | 0 | 1 | 0.6244 | 0 | 0.4457 | 0 | 0 | 2074905.04 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.2.13 | SO/GI data completeness | 35204 | 0 | 38781 | 0 | 1 | 0.9078 | 0 | 0.4806 | 0 | 0 | 2074905.04 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.2.14.t | Tobacco Assessment and Counseling | 32096 | 0 | 32365 | 0 | 1 | 0.9917 | 0 | 0.9878 | 0 | 0 | 2074905.04 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.2.2 | CG-CAHPS: Provider Rating | 7440 | 0 | 10000 | 0 | 0 | 0.744 | 0 | 0.7371 | 0 | 0 | 2074905.04 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.2.3.c | Colorectal Cancer Screening | 15529 | 0 | 21786 | 0 | 1 | 0.7128 | 0 | 0.7107 | 0 | 0 | 2074905.04 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.2.4.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 2457 | 0 | 9749 | 0 | 1 | 0.252 | 0 | 0.2824 | 0 | 0 | 2074905.04 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.2.5.b | Controlling Blood Pressure | 9171 | 0 | 13156 | 0 | 1 | 0.6971 | 0 | 0.6816 | 0 | 0 | 2074905.04 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.2.7.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 1565 | 0 | 1654 | 0 | 1 | 0.9462 | 0 | 0.9474 | 0 | 0 | 2074905.04 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.2.8 | Prevention Quality Overall Composite #90 | 772 | 0 | 66153 | 0 | 0 | 0.0117 | 0 | 0.0124 | 0 | 0 | 2074905.04 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.3.1 | Closing the referral loop: receipt of specialist report (CMS50v3) | 31889 | 0 | 32223 | 0 | 1 | 0.9896 | 0 | 0.9796 | 0 | 0 | 2074905.04 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.3.2 | DHCS All-Cause Readmissions | 248 | 0 | 1885 | 0 | 1 | 0.1316 | 0 | 0.1398 | 0 | 0 | 2074905.04 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.3.3 | Influenza Immunization | 13394 | 0 | 15646 | 0 | 1 | 0.8561 | 0 | 0.8506 | 0 | 0 | 2074905.04 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.3.5 | Request for Specialty Care Expertise Turnaround Time | 52981 | 0 | 73359 | 0 | 1 | 0.7222 | 0 | 0.5578 | 0 | 0 | 2074905.04 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.3.6 | Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters | 5451 | 0 | 49914 | 0 | 1 | 0.1092 | 0 | 0.0541 | 0 | 0 | 2074905.04 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.3.7 | Tobacco Assessment and Counseling | 22530 | 0 | 22663 | 0 | 1 | 0.9941 | 0 | 0.991 | 0 | 0 | 2074905.03 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.4.1 | Abnormal Results Follow-Up: Abnormal Potassium Follow-up | 16235 | 0 | 17717 | 0 | 1 | 0.9164 | 0 | 0.914640735 | 0 | 0.9 | 691635.01 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.4.1 | Abnormal Results Follow-Up: Abnormal INR Follow-up | 8666 | 0 | 9147 | 0 | 1 | 0.9474 | 0 | 0.937016921 | 0 | 0.9 | 691635.01 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.4.1 | Abnormal Results Follow-Up: Abnormal BIRADS Follow-up | 2936 | 0 | 5100 | 0 | 1 | 0.5757 | 0 | 0.439502049 | 0 | 0.4856 | 691635.01 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.4.2 | Annual Monitoring for Patients on Persistent Medications | 17707 | 0 | 19571 | 0 | 0 | 0.9048 | 0 | 0.9228 | 0 | 0 | 2074905.03 |
| DY14 | DPH | Santa Clara Valley Medical Center | 1.4.3 | INR Monitoring for Individuals on Warfarin | 645 | 0 | 744 | 0 | 1 | 0.8669 | 0 | 0.8251 | 0 | 0 | 2074905.03 |
| DY14 | DPH | Santa Clara Valley Medical Center | 2.1.1 | Baby Friendly Hospital designation: BFUSA Designation Yes | Yes | 0 | BFUSA Cert? | 0 | 1 | 0 | 0 | None | 0 | None | 1961728.32 |
| DY14 | DPH | Santa Clara Valley Medical Center | 2.1.2 | Exclusive Breast Milk Feeding (PC-05) | 1420 | 0 | 2043 | 0 | 1 | 0.6951 | 0 | 0.6554 | 0 | 0 | 1961728.32 |
| DY14 | DPH | Santa Clara Valley Medical Center | 2.1.3 | OB Hemorrhage: Massive Transfusion | None | 1 | 2267 | 0 | 1 | None | 1 | None | 1 | 0 | 1961728.32 |
| DY14 | DPH | Santa Clara Valley Medical Center | 2.1.4 | OB Hemorrhage: Total Products Transfused | 47 | 0 | 2267 | 0 | 1 | 0.0207 | 0 | 0.0365 | 0 | 0 | 1961728.32 |
| DY14 | DPH | Santa Clara Valley Medical Center | 2.1.5 | PC-02 Cesarean Section | 159 | 0 | 733 | 0 | 1 | 0.2169 | 0 | 0.2139 | 0 | 0 | 1961728.32 |
| DY14 | DPH | Santa Clara Valley Medical Center | 2.1.6 | Prenatal and Postpartum Care: Prenatal Care | 794 | 0 | 889 | 0 | 1 | 0.8931 | 0 | 0.862686567 | 0 | 0.8681 | 980864.16 |
| DY14 | DPH | Santa Clara Valley Medical Center | 2.1.6 | Prenatal and Postpartum Care: Postpartum Care | 644 | 0 | 889 | 0 | 1 | 0.7244 | 0 | 0.71641791 | 0 | 0.7184 | 980864.16 |
| DY14 | DPH | Santa Clara Valley Medical Center | 2.1.7 | Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage | 26 | 0 | 301 | 0 | 1 | 0.0864 | 0 | None | 1 | 0 | 1961728.32 |
| DY14 | DPH | Santa Clara Valley Medical Center | 2.1.8 | Unexpected Newborn Complications (UNC) | 46 | 0 | 1930 | 0 | 1 | 0.0238 | 0 | 0.0228 | 0 | 0 | 1961728.32 |
| DY14 | 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 | 1 | 0 | 1 | 0 | None | 653909.44 |
| DY14 | DPH | Santa Clara Valley Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes | Yes | 0 | 3 Safety Drills? | 0 | n/a | 0 | 0 | None | 0 | None | 653909.44 |
| DY14 | 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 | Yes | 0 | 10 Debriefs? | 0 | n/a | 0 | 0 | None | 0 | None | 653909.44 |
| DY14 | DPH | Santa Clara Valley Medical Center | 2.2.1 | DHCS All-Cause Readmissions | 270 | 0 | 2046 | 0 | 1 | 0.132 | 0 | 0.1343 | 0 | 0 | 1961728.32 |
| DY14 | DPH | Santa Clara Valley Medical Center | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 4810 | 0 | 10000 | 0 | 1 | 0.481 | 0 | 0.4112 | 0 | 0 | 1961728.32 |
| DY14 | DPH | Santa Clara Valley Medical Center | 2.2.3 | Medication Reconciliation 30 days | 3647 | 0 | 3649 | 0 | 1 | 0.9995 | 0 | 0.6656 | 0 | 0 | 1961728.32 |
| DY14 | DPH | Santa Clara Valley Medical Center | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 7113 | 0 | 7394 | 0 | 1 | 0.962 | 0 | 0.9549 | 0 | 0 | 1961728.32 |
| DY14 | DPH | Santa Clara Valley Medical Center | 2.2.5 | Timely Transmission of Transition Record | 3737 | 0 | 5610 | 0 | 1 | 0.6661 | 0 | 0.4458 | 0 | 0 | 1961728.32 |
| DY14 | DPH | Santa Clara Valley Medical Center | 2.3.2 | Medication Reconciliation 30 days | 180 | 0 | 180 | 0 | 1 | 1 | 0 | 0.6829 | 0 | 0 | 1961728.32 |
| DY14 | DPH | Santa Clara Valley Medical Center | 2.3.4 | Timely Transmission of Transition Record | 171 | 0 | 275 | 0 | 1 | 0.6218 | 0 | 0.4697 | 0 | 0 | 1961728.32 |
| DY14 | DPH | Santa Clara Valley Medical Center | 2.4.1 | Adolescent Well-Care Visit | 104 | 0 | 114 | 0 | 1 | 0.9123 | 0 | 0.9898 | 0 | 0 | 1961728.32 |
| DY14 | DPH | Santa Clara Valley Medical Center | 2.4.2 | Developmental Screening in the First Three Years of Life | 55 | 0 | 136 | 0 | 1 | 0.4044 | 0 | None | 1 | 0 | 1961728.32 |
| DY14 | DPH | Santa Clara Valley Medical Center | 2.4.3 | Documentation of Current Medications in the Medical Record (0-18 yo) | 1736 | 0 | 1971 | 0 | 1 | 0.8808 | 0 | 0.8461 | 0 | 0 | 1961728.31 |
| DY14 | DPH | Santa Clara Valley Medical Center | 2.4.4 | Screening for Clinical Depression and follow-up | 64 | 0 | 79 | 0 | 1 | 0.8101 | 0 | 0.651 | 0 | 0 | 1961728.31 |
| DY14 | DPH | Santa Clara Valley Medical Center | 2.4.5 | Tobacco Assessment and Counseling (13 yo and older) | 45 | 0 | 52 | 0 | 1 | 0.8654 | 0 | None | 4 | 0 | 0 |
| DY14 | DPH | Santa Clara Valley Medical Center | 2.4.7 | Well Child Visits - Third, Fourth, Fifth, and Sixth Years of life | 96 | 0 | 101 | 0 | 1 | 0.9505 | 0 | 1 | 0 | 0 | 1961728.31 |
| DY14 | DPH | Santa Clara Valley Medical Center | 2.4.8 | Comprehensive Medical Evaluation Following Foster Youth Placement in Foster Care | 223 | 0 | 262 | 0 | 1 | 0.8511 | 0 | 0.7705 | 0 | 0 | 1961728.31 |
| DY14 | DPH | Santa Clara Valley Medical Center | 3.3.1 | Adherence to Medications: Rate 1 | 89 | 0 | 90 | 0 | 1 | 0.9889 | 0 | 0.468085106 | 0 | 0.5469 | 3596502 |
| DY14 | DPH | Santa Clara Valley Medical Center | 3.3.1 | Adherence to Medications: Rate 2 | 137 | 0 | 166 | 0 | n/a | 0.8253 | 0 | 0.507739938 | 0 | None | 0 |
| DY14 | DPH | Santa Clara Valley Medical Center | 3.3.3 | High-Cost Pharmaceuticals Ordering Protocols: Rate 1 | 143 | 0 | 150 | 0 | 1 | 0.9533 | 0 | 0.912 | 0 | 0.85 | 3596502 |
| DY14 | DPH | Santa Clara Valley Medical Center | 3.3.3 | High-Cost Pharmaceuticals Ordering Protocols: Rate 2 | 155 | 0 | 196 | 0 | n/a | 0.7908 | 0 | 0.844444444 | 0 | None | 0 |
| DY14 | 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 | 2888 | 0 | 7920 | 0 | n/a | 0.3646 | 0 | 0.40360264 | 0 | None | 0 |
| DY14 | 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 | 2453 | 0 | 6653 | 0 | 1 | 0.3687 | 0 | 0.399944259 | 0 | None | 3596502 |
| DY14 | DMPH | Seneca Healthcare District, Chester | 2.2.1 | DHCS All-Cause Readmissions | None | 1 | 128 | 0 | 1 | None | 1 | 0.104 | 0 | 0 | 270000 |
| DY14 | DMPH | Seneca Healthcare District, Chester | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 3900 | 0 | 10000 | 0 | 0 | 0.39 | 0 | 0.4558 | 0 | 0 | 270000 |
| DY14 | DMPH | Seneca Healthcare District, Chester | 2.2.3 | Medication Reconciliation 30 days | 73 | 0 | 78 | 0 | 1 | 0.9359 | 0 | 1 | 0 | 0 | 270000 |
| DY14 | DMPH | Seneca Healthcare District, Chester | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 76 | 0 | 126 | 0 | 1 | 0.6032 | 0 | 0.496 | 0 | 0 | 270000 |
| DY14 | DMPH | Seneca Healthcare District, Chester | 2.2.5 | Timely Transmission of Transition Record | 100 | 0 | 101 | 0 | 1 | 0.9901 | 0 | 0.9806 | 0 | 0 | 270000 |
| DY14 | DMPH | Sierra View District Hospital, Porterville | 1.7.1 | BMI Screening and Follow-up | 3082 | 0 | 3378 | 0 | 1 | 0.9124 | 0 | 0.7333 | 0 | 0 | 705000 |
| DY14 | DMPH | Sierra View District Hospital, Porterville | 1.7.2 | Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met) Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 8) |
8 | 0 | 8 | 0 | 1 | 1 | 0 | None | 0 | None | 705000 |
| DY14 | DMPH | Sierra View District Hospital, Porterville | 1.7.3 | Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI | 674 | 0 | 682 | 0 | 1 | 0.9883 | 0 | 0.989026063 | 0 | 0.875 | 235000 |
| DY14 | DMPH | Sierra View District Hospital, Porterville | 1.7.3 | Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity | 662 | 0 | 682 | 0 | 1 | 0.9707 | 0 | 0.949245542 | 0 | 0.754 | 235000 |
| DY14 | DMPH | Sierra View District Hospital, Porterville | 1.7.3 | Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition | 662 | 0 | 682 | 0 | 1 | 0.9707 | 0 | 0.9478738 | 0 | 0.8253 | 235000 |
| DY14 | DMPH | Sierra View District Hospital, Porterville | 2.2.1 | DHCS All-Cause Readmissions | 224 | 0 | 1508 | 0 | 0 | 0.1485 | 0 | 0.1058 | 0 | 0 | 705000 |
| DY14 | DMPH | Sierra View District Hospital, Porterville | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 4110 | 0 | 10000 | 0 | 0 | 0.411 | 0 | 0.4084 | 0 | 0 | 705000 |
| DY14 | DMPH | Sierra View District Hospital, Porterville | 2.2.3 | Medication Reconciliation 30 days | 282 | 0 | 283 | 0 | 1 | 0.9965 | 0 | 0.9619 | 0 | 0 | 705000 |
| DY14 | DMPH | Sierra View District Hospital, Porterville | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 429 | 0 | 446 | 0 | 1 | 0.9619 | 0 | 0.1215 | 0 | 0 | 705000 |
| DY14 | DMPH | Sierra View District Hospital, Porterville | 2.2.5 | Timely Transmission of Transition Record | 1419 | 0 | 3610 | 0 | 1 | 0.3931 | 0 | 0.1149 | 0 | 0 | 705000 |
| DY14 | DMPH | Sierra View District Hospital, Porterville | 2.3.2 | Medication Reconciliation 30 days | 79 | 0 | 79 | 0 | 1 | 1 | 0 | 0.9589 | 0 | 0 | 705000 |
| DY14 | DMPH | Sierra View District Hospital, Porterville | 2.3.4 | Timely Transmission of Transition Record | 394 | 0 | 476 | 0 | 1 | 0.8277 | 0 | 0.2995 | 0 | 0 | 705000 |
| DY14 | DMPH | Sierra View District Hospital, Porterville | 2.7.1 | Advance Care Plan | 44 | 0 | 157 | 0 | 1 | 0.2803 | 0 | None | 1 | 0 | 0 |
| DY14 | DMPH | Sierra View District Hospital, Porterville | 2.7.3 | MWM #8: Treatment Preferences (documentation) Inpatient | 168 | 0 | 195 | 0 | 0 | 0.8615 | 0 | 0.8884 | 0 | 0 | 705000 |
| DY14 | DMPH | Sierra View District Hospital, Porterville | 2.7.4 | MWM #8: Treatment Preferences (documentation) Outpatient | 48 | 0 | 49 | 0 | 1 | 0.9796 | 0 | None | 4 | 0 | 0 |
| DY14 | DMPH | Sierra View District Hospital, Porterville | 2.7.5 | Palliative Care Service Offered at Time of Diagnosis of Advanced Illness | 145 | 0 | 457 | 0 | 1 | 0.3173 | 0 | 0.2738 | 0 | 0 | 705000 |
| DY14 | DMPH | Sierra View District Hospital, Porterville | 2.7.6 | Proportion Admitted to Hospice for Less Than 3 Days | None | 1 | 32 | 0 | 0 | None | 1 | None | 1 | 0 | 0 |
| DY14 | DMPH | Sonoma Valley Hospital, Sonoma | 2.2.1 | DHCS All-Cause Readmissions | 14 | 0 | 111 | 0 | 0 | 0.1261 | 0 | 0.1121 | 0 | 0 | 270000 |
| DY14 | DMPH | Sonoma Valley Hospital, Sonoma | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 5342 | 0 | 10000 | 0 | 0 | 0.5342 | 0 | 0.5281 | 0 | 0 | 270000 |
| DY14 | DMPH | Sonoma Valley Hospital, Sonoma | 2.2.3 | Medication Reconciliation 30 days | 29 | 0 | 127 | 0 | 0 | 0.2283 | 0 | 0.2396 | 0 | 0 | 270000 |
| DY14 | DMPH | Sonoma Valley Hospital, Sonoma | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 180 | 0 | 221 | 0 | 0 | 0.8145 | 0 | 0.8942 | 0 | 0 | 270000 |
| DY14 | DMPH | Sonoma Valley Hospital, Sonoma | 2.2.5 | Timely Transmission of Transition Record | 84 | 0 | 138 | 0 | 1 | 0.6087 | 0 | 0.176 | 0 | 0 | 270000 |
| DY14 | DMPH | Sonoma West Medical Center, Sebastopol | 2.2.1 | DHCS All-Cause Readmissions | None | 1 | 67 | 0 | 1 | None | 1 | None | 1 | 0 | 270000 |
| DY14 | DMPH | Sonoma West Medical Center, Sebastopol | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 153 | 0 | 305 | 0 | 0 | 0.5016 | 0 | 0.52 | 0 | 0 | 270000 |
| DY14 | DMPH | Sonoma West Medical Center, Sebastopol | 2.2.3 | Medication Reconciliation 30 days | 38 | 0 | 38 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 270000 |
| DY14 | DMPH | Sonoma West Medical Center, Sebastopol | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 64 | 0 | 67 | 0 | 1 | 0.9552 | 0 | 0.8644 | 0 | 0 | 270000 |
| DY14 | DMPH | Sonoma West Medical Center, Sebastopol | 2.2.5 | Timely Transmission of Transition Record | 67 | 0 | 67 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 270000 |
| DY14 | DMPH | Southern Inyo Hospital, Lone Pine | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 140 | 0 | 217 | 0 | 1 | 0.6452 | 0 | 0.561 | 0 | None | 61363.64 |
| DY14 | DMPH | Southern Inyo Hospital, Lone Pine | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 11 | 0 | 217 | 0 | 0 | 0.0507 | 0 | 0.561 | 0 | None | 61363.64 |
| DY14 | DMPH | Southern Inyo Hospital, Lone Pine | 1.2.10 | REAL and/or SO/GI disparity reduction | 0 | 0 | None | 1 | 0 | None | 1 | 0 | 0 | 0 | 0 |
| DY14 | DMPH | Southern Inyo Hospital, Lone Pine | 1.2.11 | REAL data completeness | 233 | 0 | 242 | 0 | 1 | 0.9628 | 0 | 0.5592 | 0 | 0 | 122727.27 |
| DY14 | DMPH | Southern Inyo Hospital, Lone Pine | 1.2.12.f | Screening for Clinical Depression and follow-up | 94 | 0 | 198 | 0 | 1 | 0.4747 | 0 | 0.0328 | 0 | 0 | 122727.27 |
| DY14 | DMPH | Southern Inyo Hospital, Lone Pine | 1.2.13 | SO/GI data completeness | 129 | 0 | 207 | 0 | 1 | 0.6232 | 0 | 0.7463 | 0 | 0 | 122727.27 |
| DY14 | DMPH | Southern Inyo Hospital, Lone Pine | 1.2.14.t | Tobacco Assessment and Counseling | 108 | 0 | 205 | 0 | 0 | 0.5268 | 0 | 0.9075 | 0 | 0 | 122727.27 |
| DY14 | DMPH | Southern Inyo Hospital, Lone Pine | 1.2.2 | CG-CAHPS: Provider Rating | 160 | 0 | 191 | 0 | 1 | 0.8377 | 0 | 0 | 0 | 0 | 122727.28 |
| DY14 | DMPH | Southern Inyo Hospital, Lone Pine | 1.2.3.c | Colorectal Cancer Screening | 31 | 0 | 85 | 0 | 0 | 0.3647 | 0 | 0.9076 | 0 | 0 | 122727.28 |
| DY14 | DMPH | Southern Inyo Hospital, Lone Pine | 1.2.4.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | None | 1 | None | 4 | 0 | None | 1 | None | 1 | 0 | 0 |
| DY14 | DMPH | Southern Inyo Hospital, Lone Pine | 1.2.5.b | Controlling Blood Pressure | 37 | 0 | 52 | 0 | 1 | 0.7115 | 0 | 0.4574 | 0 | 0 | 122727.27 |
| DY14 | DMPH | Southern Inyo Hospital, Lone Pine | 1.2.7.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 0 | 0 | 0 | 0 | 0 | 0 | 0 | None | 4 | 0 | 0 |
| DY14 | DMPH | Southern Inyo Hospital, Lone Pine | 1.2.8 | Prevention Quality Overall Composite #90 | None | 1 | 207 | 0 | 0 | None | 1 | 0 | 0 | 0 | 0 |
| DY14 | DMPH | Southern Inyo Hospital, Lone Pine | 1.6.1 | BIRADS to Biopsy | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| DY14 | DMPH | Southern Inyo Hospital, Lone Pine | 1.6.2 | Breast Cancer Screening | 17 | 0 | 46 | 0 | 0 | 0.3696 | 0 | 0.6374 | 0 | 0 | 0 |
| DY14 | DMPH | Southern Inyo Hospital, Lone Pine | 1.6.3 | Cervical Cancer Screening | 13 | 0 | 70 | 0 | 0 | 0.1857 | 0 | 0.6667 | 0 | 0 | 122727.27 |
| DY14 | DMPH | Southern Inyo Hospital, Lone Pine | 1.6.4.c | Colorectal Cancer Screening | 31 | 0 | 85 | 0 | 0 | 0.3647 | 0 | 0.9076 | 0 | 0 | 122727.27 |
| DY14 | DMPH | Southern Inyo Hospital, Lone Pine | 1.6.5 | Receipt of appropriate follow-up for abnormal CRC screening | 0 | 0 | None | 1 | 0 | None | 1 | None | 1 | 0 | 122727.27 |
| DY14 | DMPH | Tahoe Forest Hospital District, Truckee | 1.5.1.b | Controlling Blood Pressure | 91 | 0 | 136 | 0 | 0 | 0.6691 | 0 | 0.7532 | 0 | 0 | 150000 |
| DY14 | DMPH | Tahoe Forest Hospital District, Truckee | 1.5.2.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 39 | 0 | 46 | 0 | 1 | 0.8478 | 0 | 0.8158 | 0 | 0 | 150000 |
| DY14 | DMPH | Tahoe Forest Hospital District, Truckee | 1.5.3 | PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 349 | 0 | 548 | 0 | 1 | 0.6369 | 0 | 0.6031 | 0 | 0 | 150000 |
| DY14 | DMPH | Tahoe Forest Hospital District, Truckee | 1.5.4.t | Tobacco Assessment and Counseling | 691 | 0 | 727 | 0 | 1 | 0.9505 | 0 | 0.9477 | 0 | 0 | 150000 |
| DY14 | DMPH | Tahoe Forest Hospital District, Truckee | 2.6.1 | Alcohol and Drug Misuse (SBIRT): Brief screening only | 28 | 0 | 133 | 0 | 1 | 0.2105 | 0 | 0.0583 | 0 | None | 75000 |
| DY14 | DMPH | Tahoe Forest Hospital District, Truckee | 2.6.1 | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 18 | 0 | 133 | 0 | 1 | 0.1353 | 0 | 0.0583 | 0 | None | 75000 |
| DY14 | 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 | 33 | 0 | 94 | 0 | 1 | 0.3511 | 0 | 0.2759 | 0 | 0 | 150000 |
| DY14 | DMPH | Tahoe Forest Hospital District, Truckee | 2.6.3 | Patients with chronic pain on long term opioid therapy checked in PDMPs | 60 | 0 | 94 | 0 | 1 | 0.6383 | 0 | 0.2845 | 0 | 0 | 150000 |
| DY14 | DMPH | Tahoe Forest Hospital District, Truckee | 2.6.4 | Screening for Clinical Depression and follow-up | 48 | 0 | 118 | 0 | 1 | 0.4068 | 0 | 0.3226 | 0 | 0 | 150000 |
| DY14 | DMPH | Tahoe Forest Hospital District, Truckee | 2.6.5 | Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy | 180 | 0 | 203 | 0 | 1 | 0.8867 | 0 | 0.8564 | 0 | 0 | 150000 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 1.5.1.b | Controlling Blood Pressure | 1590 | 0 | 2981 | 0 | 0 | 0.5334 | 0 | 0.5769 | 0 | 0 | 394875 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 1.5.2.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 67 | 0 | 67 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 394875 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 1.5.3 | PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 1704 | 0 | 4920 | 0 | 0 | 0.3463 | 0 | 0.3624 | 0 | 0 | 394875 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 1.5.4.t | Tobacco Assessment and Counseling | 421 | 0 | 438 | 0 | 1 | 0.9612 | 0 | 0.8103 | 0 | 0 | 394875 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 1.7.1 | BMI Screening and Follow-up | 2050 | 0 | 2680 | 0 | 1 | 0.7649 | 0 | 0.6168 | 0 | 0 | 394875 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 1.7.2 | Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met) Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 8) |
8 | 0 | 8 | 0 | 1 | 1 | 0 | None | 0 | None | 394875 |
| DY14 | 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 | 0.6019 | 0 |
| DY14 | 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 | 0.5856 | 0 |
| DY14 | 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 | 0.4906 | 0 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 2.1.1 | Baby Friendly Hospital designation: BFUSA Designation No | No | 0 | BFUSA Cert? | 0 | See other 2.1.1 row for AV | 0 | 0 | None | 0 | None | 394875 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 2.1.1 | Baby Friendly Hospital designation: [Numerator] Dissemination Elements Completed (If your system as more than one hospital, please enter the sum of all elements completed) [Denominator] Dissemination Elements Required (if your system has more than one hospital, multiply the number of hospitals by 11) |
None | 1 | None | 4 | 0.75 | None | 1 | None | 0 | None | 0 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 2.1.2 | Exclusive Breast Milk Feeding (PC-05) | 738 | 0 | 1243 | 0 | 1 | 0.5937 | 0 | 0.5572 | 0 | 0 | 394875 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 2.1.3 | OB Hemorrhage: Massive Transfusion | None | 1 | 1578 | 0 | 1 | None | 1 | None | 1 | 0 | 394875 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 2.1.4 | OB Hemorrhage: Total Products Transfused | 71 | 0 | 1578 | 0 | 1 | 0.045 | 0 | 0.0309 | 0 | 0 | 394875 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 2.1.5 | PC-02 Cesarean Section | 99 | 0 | 455 | 0 | 1 | 0.2176 | 0 | 0.2191 | 0 | 0 | 394875 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 2.1.6 | Prenatal and Postpartum Care: Prenatal Care | 0 | 0 | 1578 | 0 | 0 | 0 | 0 | 0 | 0 | 0.7766 | 197437.5 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 2.1.6 | Prenatal and Postpartum Care: Postpartum Care | 0 | 0 | 1578 | 0 | 0 | 0 | 0 | 0 | 0 | 0.5959 | 197437.5 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 2.1.7 | Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage | 30 | 0 | 107 | 0 | 1 | 0.2804 | 0 | 0.2925 | 0 | 0 | 394875 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 2.1.8 | Unexpected Newborn Complications (UNC) | 86 | 0 | 1325 | 0 | 1 | 0.0649 | 0 | 0.0794 | 0 | 0 | 394875 |
| DY14 | 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 | 0.5 | 1 | 0 | 1 | 0 | None | 131625 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 2.1.9 | OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) No | No | 0 | 10 Debriefs? | 0 | n/a | 0 | 0 | None | 0 | None | 131625 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 2.1.9 | OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter No | No | 0 | 3 Safety Drills? | 0 | n/a | 0 | 0 | None | 0 | None | 131625 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 2.2.1 | DHCS All-Cause Readmissions | 166 | 0 | 3254 | 0 | 1 | 0.051 | 0 | 0.0446 | 0 | 0 | 394875 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 902 | 0 | 1841 | 0 | 0 | 0.49 | 0 | 0.4822 | 0 | 0 | 394875 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 2.2.3 | Medication Reconciliation 30 days | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 12534 | 0 | 12913 | 0 | 1 | 0.9706 | 0 | 0.9676 | 0 | 0 | 394875 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 2.2.5 | Timely Transmission of Transition Record | 14545 | 0 | 14847 | 0 | 1 | 0.9797 | 0 | 0.9789 | 0 | 0 | 394875 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 2.3.2 | Medication Reconciliation 30 days | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 2.3.4 | Timely Transmission of Transition Record | 608 | 0 | 1074 | 0 | 1 | 0.5661 | 0 | 0.4204 | 0 | 0 | 394875 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 3.1.1 | Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis | 44 | 0 | 54 | 0 | 1 | 0.8148 | 0 | 0.8507 | 0 | 0 | 394875 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 3.1.3 | National Healthcare Safety Network (NHSN) Antimicrobial Use Measure | 14852 | 0 | 48275 | 0 | 1 | 0.3077 | 0 | 0.5753 | 0 | 0 | 394875 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 3.1.4 | Peri-operative Prophylactic Antibiotics Administered after Surgical Closure | 84 | 0 | 1669 | 0 | 1 | 0.0503 | 0 | 0.7536 | 0 | 0 | 394875 |
| DY14 | DMPH | Tri-City Medical Center, Oceanside | 3.1.5 | Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR | 8202 | 0 | 10000 | 0 | 1 | 0.8202 | 0 | 0.8992 | 0 | 0.8793 | 394875 |
| DY14 | DMPH | Trinity Hospital, Weaverville | 1.4.1 | Abnormal Results Follow-Up: Abnormal INR Follow-up | 76 | 0 | 76 | 0 | 1 | 1 | 0 | 0.976653696 | 0 | 0.9 | 90000 |
| DY14 | DMPH | Trinity Hospital, Weaverville | 1.4.1 | Abnormal Results Follow-Up: Abnormal Potassium Follow-up | 495 | 0 | 516 | 0 | 1 | 0.9593 | 0 | 1 | 0 | 0.9 | 90000 |
| DY14 | DMPH | Trinity Hospital, Weaverville | 1.4.1 | Abnormal Results Follow-Up: Abnormal BIRADS Follow-up | 87 | 0 | 91 | 0 | 1 | 0.956 | 0 | 0.992647059 | 0 | 0.9 | 90000 |
| DY14 | DMPH | Trinity Hospital, Weaverville | 1.4.2 | Annual Monitoring for Patients on Persistent Medications | 195 | 0 | 210 | 0 | 1 | 0.9286 | 0 | 0.8329 | 0 | 0 | 270000 |
| DY14 | DMPH | Trinity Hospital, Weaverville | 1.4.3 | INR Monitoring for Individuals on Warfarin | None | 1 | None | 1 | 0 | None | 1 | None | 4 | 0 | 0 |
| DY14 | DMPH | Trinity Hospital, Weaverville | 1.6.1 | BIRADS to Biopsy | None | 1 | None | 1 | 0 | None | 1 | None | 1 | 0 | 0 |
| DY14 | DMPH | Trinity Hospital, Weaverville | 1.6.2 | Breast Cancer Screening | 70 | 0 | 190 | 0 | 0 | 0.3684 | 0 | 0.247 | 0 | 0 | 270000 |
| DY14 | DMPH | Trinity Hospital, Weaverville | 1.6.3 | Cervical Cancer Screening | 200 | 0 | 355 | 0 | 1 | 0.5634 | 0 | 0.3353 | 0 | 0 | 270000 |
| DY14 | DMPH | Trinity Hospital, Weaverville | 1.6.4.c | Colorectal Cancer Screening | 160 | 0 | 351 | 0 | 1 | 0.4558 | 0 | 0.2793 | 0 | 0 | 270000 |
| DY14 | DMPH | Trinity Hospital, Weaverville | 1.6.5 | Receipt of appropriate follow-up for abnormal CRC screening | None | 1 | None | 1 | 0 | None | 1 | 0 | 0 | 0 | 0 |
| DY14 | DPH | UC Davis Medical Center | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 954 | 0 | 60877 | 0 | 1 | 0.0157 | 0 | 0.0002 | 0 | None | 486943.335 |
| DY14 | DPH | UC Davis Medical Center | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 957 | 0 | 60877 | 0 | 1 | 0.0157 | 0 | 0.0002 | 0 | None | 486943.335 |
| DY14 | DPH | UC Davis Medical Center | 1.1.3.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 1303 | 0 | 6694 | 0 | 1 | 0.1947 | 0 | 0.205 | 0 | 0 | 973886.67 |
| DY14 | DPH | UC Davis Medical Center | 1.1.5.f | Screening for Clinical Depression and follow-up | 25796 | 0 | 37712 | 0 | 1 | 0.684 | 0 | 0.5347 | 0 | 0 | 973886.67 |
| DY14 | DPH | UC Davis Medical Center | 1.1.6.t | Tobacco Assessment and Counseling | 52455 | 0 | 53516 | 0 | 1 | 0.9802 | 0 | 0.9785 | 0 | 0 | 973886.67 |
| DY14 | DPH | UC Davis Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Follow-up | 310 | 0 | 1345 | 0 | 1 | 0.2305 | 0 | 0.199608611 | 0 | 0.2192 | 324628.89 |
| DY14 | DPH | UC Davis Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Remission | 60 | 0 | 1345 | 0 | 0 | 0.0446 | 0 | 0.074363992 | 0 | 0.0539 | 324628.89 |
| DY14 | DPH | UC Davis Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Response | 121 | 0 | 1345 | 0 | 0 | 0.09 | 0 | 0.096868885 | 0 | 0.0972 | 324628.89 |
| DY14 | DPH | UC Davis Medical Center | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 957 | 0 | 60877 | 0 | 1 | 0.0157 | 0 | 0.0002 | 0 | None | 486943.335 |
| DY14 | DPH | UC Davis Medical Center | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 954 | 0 | 60877 | 0 | 1 | 0.0157 | 0 | 0.0002 | 0 | None | 486943.335 |
| DY14 | DPH | UC Davis Medical Center | 1.2.10 | REAL and/or SO/GI disparity reduction | 187 | 0 | 771 | 0 | 1 | 0.2425 | 0 | 0.2704 | 0 | 0 | 973886.67 |
| DY14 | DPH | UC Davis Medical Center | 1.2.11 | REAL data completeness | 53261 | 0 | 67708 | 0 | 1 | 0.7866 | 0 | 0.7926 | 0 | 0 | 973886.67 |
| DY14 | DPH | UC Davis Medical Center | 1.2.12.f | Screening for Clinical Depression and follow-up | 25796 | 0 | 37712 | 0 | 1 | 0.684 | 0 | 0.5347 | 0 | 0 | 973886.67 |
| DY14 | DPH | UC Davis Medical Center | 1.2.13 | SO/GI data completeness | 51426 | 0 | 57437 | 0 | 1 | 0.8953 | 0 | 0.311 | 0 | 0 | 973886.67 |
| DY14 | DPH | UC Davis Medical Center | 1.2.14.t | Tobacco Assessment and Counseling | 52455 | 0 | 53516 | 0 | 1 | 0.9802 | 0 | 0.9785 | 0 | 0 | 973886.67 |
| DY14 | DPH | UC Davis Medical Center | 1.2.2 | CG-CAHPS: Provider Rating | 25360 | 0 | 29158 | 0 | 1 | 0.8697 | 0 | 0.8568 | 0 | 0 | 973886.67 |
| DY14 | DPH | UC Davis Medical Center | 1.2.3.c | Colorectal Cancer Screening | 22348 | 0 | 28911 | 0 | 1 | 0.773 | 0 | 0.7575 | 0 | 0 | 973886.67 |
| DY14 | DPH | UC Davis Medical Center | 1.2.4.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 1303 | 0 | 6694 | 0 | 1 | 0.1947 | 0 | 0.205 | 0 | 0 | 973886.67 |
| DY14 | DPH | UC Davis Medical Center | 1.2.5.b | Controlling Blood Pressure | 18710 | 0 | 22655 | 0 | 1 | 0.8259 | 0 | 0.8109 | 0 | 0 | 973886.67 |
| DY14 | DPH | UC Davis Medical Center | 1.2.7.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 2626 | 0 | 2907 | 0 | 0 | 0.9033 | 0 | 0.922 | 0 | 0 | 973886.67 |
| DY14 | DPH | UC Davis Medical Center | 1.2.8 | Prevention Quality Overall Composite #90 | 476 | 0 | 57228 | 0 | 1 | 0.0083 | 0 | 0.0108 | 0 | 0 | 973886.67 |
| DY14 | DPH | UC Davis Medical Center | 1.3.1 | Closing the referral loop: receipt of specialist report (CMS50v3) | 65025 | 0 | 82785 | 0 | 1 | 0.7855 | 0 | 0.7544 | 0 | 0 | 973886.67 |
| DY14 | DPH | UC Davis Medical Center | 1.3.2 | DHCS All-Cause Readmissions | 270 | 0 | 2150 | 0 | 1 | 0.1256 | 0 | 0.13 | 0 | 0 | 973886.66 |
| DY14 | DPH | UC Davis Medical Center | 1.3.3 | Influenza Immunization | 20656 | 0 | 26751 | 0 | 0 | 0.7722 | 0 | 0.8169 | 0 | 0 | 973886.66 |
| DY14 | DPH | UC Davis Medical Center | 1.3.5 | Request for Specialty Care Expertise Turnaround Time | 83712 | 0 | 113823 | 0 | 0 | 0.7355 | 0 | 0.7252 | 0 | 0 | 973886.66 |
| DY14 | DPH | UC Davis Medical Center | 1.3.6 | Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters | 2401 | 0 | 114436 | 0 | 0 | 0.021 | 0 | 0.0134 | 0 | 0 | 973886.66 |
| DY14 | DPH | UC Davis Medical Center | 1.3.7 | Tobacco Assessment and Counseling | 23916 | 0 | 24242 | 0 | 1 | 0.9866 | 0 | 0.9865 | 0 | 0 | 973886.66 |
| DY14 | DPH | UC Davis Medical Center | 1.5.1.b | Controlling Blood Pressure | 18710 | 0 | 22655 | 0 | 1 | 0.8259 | 0 | 0.8109 | 0 | 0 | 973886.66 |
| DY14 | DPH | UC Davis Medical Center | 1.5.2.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 2626 | 0 | 2907 | 0 | 0 | 0.9033 | 0 | 0.922 | 0 | 0 | 973886.66 |
| DY14 | DPH | UC Davis Medical Center | 1.5.3 | PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 27212 | 0 | 32431 | 0 | 1 | 0.8391 | 0 | 0.8262 | 0 | 0 | 973886.66 |
| DY14 | DPH | UC Davis Medical Center | 1.5.4.t | Tobacco Assessment and Counseling | 52455 | 0 | 53516 | 0 | 1 | 0.9802 | 0 | 0.9785 | 0 | 0 | 973886.66 |
| DY14 | DPH | UC Davis Medical Center | 2.1.1 | Baby Friendly Hospital designation: [Numerator] Dissemination Elements Completed (If your system as more than one hospital, please enter the sum of all elements completed) [Denominator] Dissemination Elements Required (if your system has more than one hospital, multiply the number of hospitals by 11) |
None | 1 | None | 4 | 0.5 | None | 1 | None | 0 | None | 0 |
| DY14 | DPH | UC Davis Medical Center | 2.1.1 | Baby Friendly Hospital designation: BFUSA Designation No | No | 0 | BFUSA Cert? | 0 | See other 2.1.1 row for AV | 0 | 0 | None | 0 | None | 1001712 |
| DY14 | DPH | UC Davis Medical Center | 2.1.2 | Exclusive Breast Milk Feeding (PC-05) | 151 | 0 | 224 | 0 | 1 | 0.6741 | 0 | 0.6675 | 0 | 0 | 1001712 |
| DY14 | DPH | UC Davis Medical Center | 2.1.3 | OB Hemorrhage: Massive Transfusion | None | 1 | 1081 | 0 | 1 | None | 1 | None | 1 | 0 | 1001712 |
| DY14 | DPH | UC Davis Medical Center | 2.1.4 | OB Hemorrhage: Total Products Transfused | 151 | 0 | 1081 | 0 | 1 | 0.1397 | 0 | 0.0953 | 0 | 0 | 1001712 |
| DY14 | DPH | UC Davis Medical Center | 2.1.5 | PC-02 Cesarean Section | 80 | 0 | 361 | 0 | 1 | 0.2216 | 0 | 0.2516 | 0 | 0 | 1001712 |
| DY14 | DPH | UC Davis Medical Center | 2.1.6 | Prenatal and Postpartum Care: Prenatal Care | 574 | 0 | 658 | 0 | 1 | 0.8723 | 0 | 0.793742758 | 0 | 0.806 | 500856 |
| DY14 | DPH | UC Davis Medical Center | 2.1.6 | Prenatal and Postpartum Care: Postpartum Care | 517 | 0 | 658 | 0 | 1 | 0.7857 | 0 | 0.475086906 | 0 | 0.5959 | 500856 |
| DY14 | DPH | UC Davis Medical Center | 2.1.7 | Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage | 40 | 0 | 180 | 0 | 1 | 0.2222 | 0 | 0.1105 | 0 | 0 | 1001712 |
| DY14 | DPH | UC Davis Medical Center | 2.1.8 | Unexpected Newborn Complications (UNC) | 35 | 0 | 833 | 0 | 1 | 0.042 | 0 | 0.0358 | 0 | 0 | 1001712 |
| DY14 | DPH | UC Davis Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes | Yes | 0 | 10 Debriefs? | 0 | n/a | 0 | 0 | None | 0 | None | 333904 |
| DY14 | DPH | UC Davis Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) |
16 | 0 | 16 | 0 | 1 | 1 | 0 | 1 | 0 | None | 333904 |
| DY14 | DPH | UC Davis Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes | Yes | 0 | 3 Safety Drills? | 0 | n/a | 0 | 0 | None | 0 | None | 333904 |
| DY14 | DPH | UC Davis Medical Center | 2.2.1 | DHCS All-Cause Readmissions | 287 | 0 | 2249 | 0 | 0 | 0.1276 | 0 | 0.1277 | 0 | 0 | 1001712 |
| DY14 | DPH | UC Davis Medical Center | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 2435 | 0 | 4250 | 0 | 1 | 0.5729 | 0 | 0.5631 | 0 | 0 | 1001712 |
| DY14 | DPH | UC Davis Medical Center | 2.2.3 | Medication Reconciliation 30 days | 3345 | 0 | 3489 | 0 | 1 | 0.9587 | 0 | 0.9415 | 0 | 0 | 1001712 |
| DY14 | DPH | UC Davis Medical Center | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 6678 | 0 | 6741 | 0 | 1 | 0.9907 | 0 | 0.9916 | 0 | 0 | 1001712 |
| DY14 | DPH | UC Davis Medical Center | 2.2.5 | Timely Transmission of Transition Record | 5381 | 0 | 5599 | 0 | 1 | 0.9611 | 0 | 0.9541 | 0 | 0 | 1001712 |
| DY14 | DPH | UC Davis Medical Center | 2.3.2 | Medication Reconciliation 30 days | 1236 | 0 | 1282 | 0 | 1 | 0.9641 | 0 | 0.963 | 0 | 0 | 1001712 |
| DY14 | DPH | UC Davis Medical Center | 2.3.4 | Timely Transmission of Transition Record | 1726 | 0 | 1787 | 0 | 1 | 0.9659 | 0 | 0.9535 | 0 | 0 | 1001712 |
| DY14 | DPH | UC Davis Medical Center | 2.6.1 | Alcohol and Drug Misuse (SBIRT): Brief screening only | 189 | 0 | 6017 | 0 | 1 | 0.0314 | 0 | 0.0022 | 0 | None | 500856 |
| DY14 | DPH | UC Davis Medical Center | 2.6.1 | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 220 | 0 | 6017 | 0 | 1 | 0.0366 | 0 | 0.0022 | 0 | None | 500856 |
| DY14 | 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 | 1934 | 0 | 2888 | 0 | 1 | 0.6697 | 0 | 0.4956 | 0 | 0 | 1001712 |
| DY14 | DPH | UC Davis Medical Center | 2.6.3 | Patients with chronic pain on long term opioid therapy checked in PDMPs | 2850 | 0 | 2888 | 0 | 1 | 0.9868 | 0 | 0.7753 | 0 | 0 | 1001712 |
| DY14 | DPH | UC Davis Medical Center | 2.6.4 | Screening for Clinical Depression and follow-up | 2136 | 0 | 2927 | 0 | 1 | 0.7298 | 0 | 0.5767 | 0 | 0 | 1001712 |
| DY14 | DPH | UC Davis Medical Center | 2.6.5 | Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy | 5266 | 0 | 6032 | 0 | 1 | 0.873 | 0 | 0.8631 | 0 | 0 | 1001712 |
| DY14 | DPH | UC Davis Medical Center | 3.2.1 | Dont Do Imaging for Uncomplicated Headaches (Choosing Wisely) | 1177 | 0 | 6798 | 0 | 1 | 0.1731 | 0 | 0.1547 | 0 | 0 | 1314747 |
| DY14 | DPH | UC Davis Medical Center | 3.2.2 | Appropriate Emergency Department Utilization of CT for Pulmonary Embolism | 1022 | 0 | 1043 | 0 | 1 | 0.9799 | 0 | 0.9301 | 0 | 0 | 1314747 |
| DY14 | DPH | UC Davis Medical Center | 3.2.3 | Use of Imaging Studies for Low Back Pain | 741 | 0 | 1063 | 0 | 1 | 0.6971 | 0 | 0.8793 | 0 | 0 | 1314747 |
| DY14 | 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 | 1625 | 0 | 3133 | 0 | 1 | 0.5187 | 0 | 0.138341614 | 0 | None | 657373.5 |
| DY14 | 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 | 1508 | 0 | 3133 | 0 | 1 | 0.4813 | 0 | 0.11821141 | 0 | None | 657373.5 |
| DY14 | DPH | UC Irvine Medical Center | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 353 | 0 | 16515 | 0 | 1 | 0.0214 | 0 | 0.0885 | 0 | None | 315230.195 |
| DY14 | DPH | UC Irvine Medical Center | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 3797 | 0 | 16515 | 0 | 1 | 0.2299 | 0 | 0.0885 | 0 | None | 315230.195 |
| DY14 | DPH | UC Irvine Medical Center | 1.1.3.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 801 | 0 | 3145 | 0 | 1 | 0.2547 | 0 | 0.2835 | 0 | 0 | 630460.39 |
| DY14 | DPH | UC Irvine Medical Center | 1.1.5.f | Screening for Clinical Depression and follow-up | 13219 | 0 | 15268 | 0 | 1 | 0.8658 | 0 | 0.7468 | 0 | 0 | 630460.39 |
| DY14 | DPH | UC Irvine Medical Center | 1.1.6.t | Tobacco Assessment and Counseling | 15214 | 0 | 15417 | 0 | 1 | 0.9868 | 0 | 0.9776 | 0 | 0 | 630460.39 |
| DY14 | DPH | UC Irvine Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Follow-up | 127 | 0 | 419 | 0 | 1 | 0.3031 | 0 | 0.127659574 | 0 | 0.1545 | 210153.4633 |
| DY14 | DPH | UC Irvine Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Remission | 36 | 0 | 419 | 0 | 1 | 0.0859 | 0 | None | 1 | 0.0246 | 210153.4633 |
| DY14 | DPH | UC Irvine Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Response | 56 | 0 | 419 | 0 | 1 | 0.1337 | 0 | None | 1 | 0.0292 | 210153.4633 |
| DY14 | DPH | UC Irvine Medical Center | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 353 | 0 | 16515 | 0 | 1 | 0.0214 | 0 | 0.0885 | 0 | None | 315230.195 |
| DY14 | DPH | UC Irvine Medical Center | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 3797 | 0 | 16515 | 0 | 1 | 0.2299 | 0 | 0.0885 | 0 | None | 315230.195 |
| DY14 | DPH | UC Irvine Medical Center | 1.2.10 | REAL and/or SO/GI disparity reduction | 1600 | 0 | 2570 | 0 | 1 | 0.6226 | 0 | 0.52 | 0 | 0 | 630460.38 |
| DY14 | DPH | UC Irvine Medical Center | 1.2.11 | REAL data completeness | 14312 | 0 | 19697 | 0 | 1 | 0.7266 | 0 | 0.6652 | 0 | 0 | 630460.38 |
| DY14 | DPH | UC Irvine Medical Center | 1.2.12.f | Screening for Clinical Depression and follow-up | 13219 | 0 | 15268 | 0 | 1 | 0.8658 | 0 | 0.7468 | 0 | 0 | 630460.38 |
| DY14 | DPH | UC Irvine Medical Center | 1.2.13 | SO/GI data completeness | 6976 | 0 | 15631 | 0 | 1 | 0.4463 | 0 | 0.4449 | 0 | 0 | 630460.38 |
| DY14 | DPH | UC Irvine Medical Center | 1.2.14.t | Tobacco Assessment and Counseling | 15214 | 0 | 15417 | 0 | 1 | 0.9868 | 0 | 0.9777 | 0 | 0 | 630460.38 |
| DY14 | DPH | UC Irvine Medical Center | 1.2.2 | CG-CAHPS: Provider Rating | 33441 | 0 | 38321 | 0 | 1 | 0.8727 | 0 | 0.8406 | 0 | 0 | 630460.39 |
| DY14 | DPH | UC Irvine Medical Center | 1.2.3.c | Colorectal Cancer Screening | 4696 | 0 | 6783 | 0 | 1 | 0.6923 | 0 | 0.6256 | 0 | 0 | 630460.39 |
| DY14 | DPH | UC Irvine Medical Center | 1.2.4.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 801 | 0 | 3145 | 0 | 1 | 0.2547 | 0 | 0.2835 | 0 | 0 | 630460.39 |
| DY14 | DPH | UC Irvine Medical Center | 1.2.5.b | Controlling Blood Pressure | 2135 | 0 | 3018 | 0 | 1 | 0.7074 | 0 | 0.6862 | 0 | 0 | 630460.39 |
| DY14 | DPH | UC Irvine Medical Center | 1.2.7.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 743 | 0 | 882 | 0 | 0 | 0.8424 | 0 | 0.8589 | 0 | 0 | 630460.39 |
| DY14 | DPH | UC Irvine Medical Center | 1.2.8 | Prevention Quality Overall Composite #90 | 231 | 0 | 15693 | 0 | 0 | 0.0147 | 0 | 0.0119 | 0 | 0 | 630460.39 |
| DY14 | DPH | UC Irvine Medical Center | 1.3.1 | Closing the referral loop: receipt of specialist report (CMS50v3) | 9857 | 0 | 16232 | 0 | 0 | 0.6073 | 0 | 0.9581 | 0 | 0 | 630460.38 |
| DY14 | DPH | UC Irvine Medical Center | 1.3.2 | DHCS All-Cause Readmissions | 194 | 0 | 1581 | 0 | 0 | 0.1227 | 0 | 0.1113 | 0 | 0 | 630460.38 |
| DY14 | DPH | UC Irvine Medical Center | 1.3.3 | Influenza Immunization | 6430 | 0 | 8198 | 0 | 1 | 0.7843 | 0 | 0.6855 | 0 | 0 | 630460.38 |
| DY14 | DPH | UC Irvine Medical Center | 1.3.5 | Request for Specialty Care Expertise Turnaround Time | 1349 | 0 | 46128 | 0 | 0 | 0.0292 | 0 | 0.0023 | 0 | 0 | 630460.38 |
| DY14 | DPH | UC Irvine Medical Center | 1.3.6 | Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters | 230 | 0 | 179544 | 0 | 0 | 0.0013 | 0 | 0.0025 | 0 | 0 | 630460.38 |
| DY14 | DPH | UC Irvine Medical Center | 1.3.7 | Tobacco Assessment and Counseling | 8589 | 0 | 8642 | 0 | 1 | 0.9939 | 0 | 0.9874 | 0 | 0 | 630460.38 |
| DY14 | DPH | UC Irvine Medical Center | 1.4.1 | Abnormal Results Follow-Up: Abnormal INR Follow-up | 2388 | 0 | 2422 | 0 | 1 | 0.986 | 0 | 0.967247387 | 0 | 0.9 | 210153.46 |
| DY14 | DPH | UC Irvine Medical Center | 1.4.1 | Abnormal Results Follow-Up: Abnormal BIRADS Follow-up | 898 | 0 | 1160 | 0 | 1 | 0.7741 | 0 | 0.965092402 | 0 | 0.6192 | 210153.46 |
| DY14 | DPH | UC Irvine Medical Center | 1.4.1 | Abnormal Results Follow-Up: Abnormal Potassium Follow-up | 2317 | 0 | 2456 | 0 | 1 | 0.9434 | 0 | 0.588046958 | 0 | 0.9 | 210153.46 |
| DY14 | DPH | UC Irvine Medical Center | 1.4.2 | Annual Monitoring for Patients on Persistent Medications | 6262 | 0 | 6819 | 0 | 1 | 0.9183 | 0 | 0.9021 | 0 | 0 | 630460.38 |
| DY14 | DPH | UC Irvine Medical Center | 1.4.3 | INR Monitoring for Individuals on Warfarin | 170 | 0 | 252 | 0 | 0 | 0.6746 | 0 | 0.8634 | 0 | 0 | 630460.38 |
| DY14 | DPH | UC Irvine Medical Center | 2.1.1 | Baby Friendly Hospital designation: BFUSA Designation Yes | Yes | 0 | BFUSA Cert? | 0 | 1 | 0 | 0 | None | 0 | None | 624456 |
| DY14 | DPH | UC Irvine Medical Center | 2.1.2 | Exclusive Breast Milk Feeding (PC-05) | 132 | 0 | 200 | 0 | 1 | 0.66 | 0 | 0.5789 | 0 | 0 | 624456 |
| DY14 | DPH | UC Irvine Medical Center | 2.1.3 | OB Hemorrhage: Massive Transfusion | 11 | 0 | 1460 | 0 | 1 | 0.0075 | 0 | 0.0084 | 0 | 0 | 624456 |
| DY14 | DPH | UC Irvine Medical Center | 2.1.4 | OB Hemorrhage: Total Products Transfused | 177 | 0 | 1460 | 0 | 1 | 0.1212 | 0 | 0.1649 | 0 | 0 | 624456 |
| DY14 | DPH | UC Irvine Medical Center | 2.1.5 | PC-02 Cesarean Section | 92 | 0 | 434 | 0 | 1 | 0.212 | 0 | 0.205 | 0 | 0 | 624456 |
| DY14 | DPH | UC Irvine Medical Center | 2.1.6 | Prenatal and Postpartum Care: Postpartum Care | 565 | 0 | 794 | 0 | 1 | 0.7116 | 0 | 0.865566038 | 0 | 0.7084 | 312228 |
| DY14 | DPH | UC Irvine Medical Center | 2.1.6 | Prenatal and Postpartum Care: Prenatal Care | 663 | 0 | 794 | 0 | 0 | 0.835 | 0 | 0.705188679 | 0 | 0.8707 | 312228 |
| DY14 | DPH | UC Irvine Medical Center | 2.1.7 | Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage | 57 | 0 | 199 | 0 | 1 | 0.2864 | 0 | 0.2194 | 0 | 0 | 624456 |
| DY14 | DPH | UC Irvine Medical Center | 2.1.8 | Unexpected Newborn Complications (UNC) | 35 | 0 | 949 | 0 | 1 | 0.0369 | 0 | 0.0254 | 0 | 0 | 624456 |
| DY14 | DPH | UC Irvine Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes | Yes | 0 | 3 Safety Drills? | 0 | n/a | 0 | 0 | None | 0 | None | 208152 |
| DY14 | DPH | UC Irvine Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) |
16 | 0 | 16 | 0 | 1 | 1 | 0 | 1 | 0 | None | 208152 |
| DY14 | DPH | UC Irvine Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes | Yes | 0 | 10 Debriefs? | 0 | n/a | 0 | 0 | None | 0 | None | 208152 |
| DY14 | DPH | UC Irvine Medical Center | 2.2.1 | DHCS All-Cause Readmissions | 208 | 0 | 1721 | 0 | 0 | 0.1209 | 0 | 0.1071 | 0 | 0 | 624456 |
| DY14 | DPH | UC Irvine Medical Center | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 5819 | 0 | 10000 | 0 | 1 | 0.5819 | 0 | 0.5505 | 0 | 0 | 624456 |
| DY14 | DPH | UC Irvine Medical Center | 2.2.3 | Medication Reconciliation 30 days | 1543 | 0 | 1713 | 0 | 1 | 0.9008 | 0 | 0.8072 | 0 | 0 | 624456 |
| DY14 | DPH | UC Irvine Medical Center | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 3191 | 0 | 3301 | 0 | 1 | 0.9667 | 0 | 0.8715 | 0 | 0 | 624456 |
| DY14 | DPH | UC Irvine Medical Center | 2.2.5 | Timely Transmission of Transition Record | 1553 | 0 | 1850 | 0 | 1 | 0.8395 | 0 | 0.8195 | 0 | 0 | 624456 |
| DY14 | DPH | UC Irvine Medical Center | 2.3.2 | Medication Reconciliation 30 days | 1210 | 0 | 1322 | 0 | 1 | 0.9153 | 0 | 0.8027 | 0 | 0 | 624456 |
| DY14 | DPH | UC Irvine Medical Center | 2.3.4 | Timely Transmission of Transition Record | 1311 | 0 | 1468 | 0 | 1 | 0.8931 | 0 | 0.8489 | 0 | 0 | 624456 |
| DY14 | DPH | UC Irvine Medical Center | 2.6.1 | Alcohol and Drug Misuse (SBIRT): Brief screening only | 29 | 0 | 1049 | 0 | 1 | 0.0276 | 0 | 0.1736 | 0 | None | 312228 |
| DY14 | DPH | UC Irvine Medical Center | 2.6.1 | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 483 | 0 | 1049 | 0 | 1 | 0.4604 | 0 | 0.1736 | 0 | None | 312228 |
| DY14 | 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 | 111 | 0 | 430 | 0 | 1 | 0.2581 | 0 | 0.0966 | 0 | 0 | 624456 |
| DY14 | DPH | UC Irvine Medical Center | 2.6.3 | Patients with chronic pain on long term opioid therapy checked in PDMPs | 359 | 0 | 430 | 0 | 1 | 0.8349 | 0 | 0.0859 | 0 | 0 | 624456 |
| DY14 | DPH | UC Irvine Medical Center | 2.6.4 | Screening for Clinical Depression and follow-up | 941 | 0 | 1034 | 0 | 1 | 0.9101 | 0 | 0.9389 | 0 | 0 | 624456 |
| DY14 | DPH | UC Irvine Medical Center | 2.6.5 | Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy | 930 | 0 | 1050 | 0 | 1 | 0.8857 | 0 | 0.6616 | 0 | 0 | 624456 |
| DY14 | DPH | UC Irvine Medical Center | 3.1.1 | Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis | 68 | 0 | 156 | 0 | 1 | 0.4359 | 0 | 0.5116 | 0 | 0 | 819598.5 |
| DY14 | DPH | UC Irvine Medical Center | 3.1.3 | National Healthcare Safety Network (NHSN) Antimicrobial Use Measure | 26458 | 0 | 136886 | 0 | 1 | 0.1933 | 0 | 0.2238 | 0 | 0 | 819598.5 |
| DY14 | DPH | UC Irvine Medical Center | 3.1.4 | Peri-operative Prophylactic Antibiotics Administered after Surgical Closure | 845 | 0 | 4917 | 0 | 1 | 0.1719 | 0 | 0.2236 | 0 | 0 | 819598.5 |
| DY14 | DPH | UC Irvine Medical Center | 3.1.5 | Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR | 4680 | 0 | 10000 | 0 | 1 | 0.468 | 0 | 0.351 | 0 | 0.7 | 819598.5 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 8908 | 0 | 127400 | 0 | 1 | 0.0699 | 0 | 0.0039 | 0 | None | 226048.85 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 7578 | 0 | 127400 | 0 | 1 | 0.0595 | 0 | 0.0039 | 0 | None | 226048.85 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.1.3.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 1187 | 0 | 9574 | 0 | 1 | 0.124 | 0 | 0.1251 | 0 | 0 | 452097.7 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.1.5.f | Screening for Clinical Depression and follow-up | 68625 | 0 | 97770 | 0 | 1 | 0.7019 | 0 | 0.1984 | 0 | 0 | 452097.7 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.1.6.t | Tobacco Assessment and Counseling | 116835 | 0 | 120717 | 0 | 1 | 0.9678 | 0 | 0.9605 | 0 | 0 | 452097.7 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Remission | 280 | 0 | 2638 | 0 | 1 | 0.1061 | 0 | 0.194501018 | 0 | 0.0466 | 150699.2333 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Follow-up | 936 | 0 | 2638 | 0 | 1 | 0.3548 | 0 | 0.045824847 | 0 | 0.2146 | 150699.2333 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Response | 403 | 0 | 2638 | 0 | 1 | 0.1528 | 0 | 0.072301426 | 0 | 0.0751 | 150699.2333 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 8908 | 0 | 127400 | 0 | 1 | 0.0699 | 0 | 0.0039 | 0 | None | 226048.85 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 7578 | 0 | 127400 | 0 | 1 | 0.0595 | 0 | 0.0039 | 0 | None | 226048.85 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.2.10 | REAL and/or SO/GI disparity reduction | 1883 | 0 | 2793 | 0 | 1 | 0.6742 | 0 | 0.6602 | 0 | 0 | 452097.69 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.2.11 | REAL data completeness | 35033 | 0 | 142045 | 0 | 0 | 0.2466 | 0 | 0.2225 | 0 | 0 | 452097.69 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.2.12.f | Screening for Clinical Depression and follow-up | 68625 | 0 | 97770 | 0 | 1 | 0.7019 | 0 | 0.1984 | 0 | 0 | 452097.69 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.2.13 | SO/GI data completeness | 7675 | 0 | 121596 | 0 | 0 | 0.0631 | 0 | 0.0141 | 0 | 0 | 452097.69 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.2.14.t | Tobacco Assessment and Counseling | 116835 | 0 | 120717 | 0 | 1 | 0.9678 | 0 | 0.9605 | 0 | 0 | 452097.69 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.2.2 | CG-CAHPS: Provider Rating | 369 | 0 | 466 | 0 | 0 | 0.7918 | 0 | 0.8418 | 0 | 0 | 452097.69 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.2.3.c | Colorectal Cancer Screening | 32240 | 0 | 51617 | 0 | 1 | 0.6246 | 0 | 0.5971 | 0 | 0 | 452097.69 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.2.4.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 1187 | 0 | 9574 | 0 | 1 | 0.124 | 0 | 0.1251 | 0 | 0 | 452097.69 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.2.5.b | Controlling Blood Pressure | 21232 | 0 | 29200 | 0 | 1 | 0.7271 | 0 | 0.7001 | 0 | 0 | 452097.69 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.2.7.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 6270 | 0 | 8417 | 0 | 0 | 0.7449 | 0 | 0.7574 | 0 | 0 | 452097.69 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.2.8 | Prevention Quality Overall Composite #90 | 694 | 0 | 121218 | 0 | 1 | 0.0057 | 0 | 0.0064 | 0 | 0 | 452097.69 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.3.1 | Closing the referral loop: receipt of specialist report (CMS50v3) | 25510 | 0 | 25510 | 0 | 1 | 1 | 0 | 0.9888 | 0 | 0 | 452097.69 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.3.2 | DHCS All-Cause Readmissions | 680 | 0 | 4658 | 0 | 0 | 0.146 | 0 | 0.1471 | 0 | 0 | 452097.69 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.3.3 | Influenza Immunization | 56338 | 0 | 85096 | 0 | 1 | 0.6621 | 0 | 0.5963 | 0 | 0 | 452097.69 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.3.5 | Request for Specialty Care Expertise Turnaround Time | 4031 | 0 | 7923 | 0 | 1 | 0.5088 | 0 | 0.3107 | 0 | 0 | 452097.69 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.3.6 | Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters | 1216 | 0 | 6197 | 0 | 1 | 0.1962 | 0 | 0.1553 | 0 | 0 | 452097.69 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.3.7 | Tobacco Assessment and Counseling | 53733 | 0 | 54793 | 0 | 1 | 0.9807 | 0 | 0.9715 | 0 | 0 | 452097.69 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.4.1 | Abnormal Results Follow-Up: Abnormal Potassium Follow-up | 78417 | 0 | 84528 | 0 | 1 | 0.9277 | 0 | 0.919863158 | 0 | 0.9 | 150699.23 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.4.1 | Abnormal Results Follow-Up: Abnormal BIRADS Follow-up | 9000 | 0 | 12614 | 0 | 0 | 0.7135 | 0 | 0.949431418 | 0 | 0.7373 | 150699.23 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.4.1 | Abnormal Results Follow-Up: Abnormal INR Follow-up | 19004 | 0 | 19924 | 0 | 1 | 0.9538 | 0 | 0.71921875 | 0 | 0.9 | 150699.23 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.4.2 | Annual Monitoring for Patients on Persistent Medications | 37507 | 0 | 40918 | 0 | 1 | 0.9166 | 0 | 0.8939 | 0 | 0 | 452097.69 |
| DY14 | DPH | UC Los Angeles Medical Center | 1.4.3 | INR Monitoring for Individuals on Warfarin | 839 | 0 | 1260 | 0 | 1 | 0.6659 | 0 | 0.6279 | 0 | 0 | 452097.69 |
| DY14 | DPH | UC Los Angeles Medical Center | 2.1.1 | Baby Friendly Hospital designation: BFUSA Designation Yes | Yes | 0 | BFUSA Cert? | 0 | 1 | 0 | 0 | None | 0 | None | 447792 |
| DY14 | DPH | UC Los Angeles Medical Center | 2.1.2 | Exclusive Breast Milk Feeding (PC-05) | 295 | 0 | 392 | 0 | 1 | 0.7526 | 0 | 0.7519 | 0 | 0 | 447792 |
| DY14 | DPH | UC Los Angeles Medical Center | 2.1.3 | OB Hemorrhage: Massive Transfusion | 0 | 0 | 478 | 0 | 1 | 0 | 0 | None | 1 | 0 | 447792 |
| DY14 | DPH | UC Los Angeles Medical Center | 2.1.4 | OB Hemorrhage: Total Products Transfused | None | 1 | 478 | 0 | 1 | None | 1 | 0.1583 | 0 | 0 | 447792 |
| DY14 | DPH | UC Los Angeles Medical Center | 2.1.5 | PC-02 Cesarean Section | 50 | 0 | 250 | 0 | 1 | 0.2 | 0 | 0.2811 | 0 | 0 | 447792 |
| DY14 | DPH | UC Los Angeles Medical Center | 2.1.6 | Prenatal and Postpartum Care: Prenatal Care | 1684 | 0 | 1746 | 0 | 1 | 0.9645 | 0 | 0.98075923 | 0 | 0.9167 | 223896 |
| DY14 | DPH | UC Los Angeles Medical Center | 2.1.6 | Prenatal and Postpartum Care: Postpartum Care | 1494 | 0 | 1746 | 0 | 1 | 0.8557 | 0 | 0.780031201 | 0 | 0.7367 | 223896 |
| DY14 | DPH | UC Los Angeles Medical Center | 2.1.7 | Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage | None | 1 | 59 | 0 | 1 | None | 1 | 0.2791 | 0 | 0 | 447792 |
| DY14 | DPH | UC Los Angeles Medical Center | 2.1.8 | Unexpected Newborn Complications (UNC) | 17 | 0 | 378 | 0 | 1 | 0.045 | 0 | 0.0328 | 0 | 0 | 447792 |
| DY14 | DPH | UC Los Angeles Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) |
32 | 0 | 32 | 0 | 1 | 1 | 0 | 1 | 0 | None | 149264 |
| DY14 | DPH | UC Los Angeles Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes | Yes | 0 | 3 Safety Drills? | 0 | n/a | 0 | 0 | None | 0 | None | 149264 |
| DY14 | DPH | UC Los Angeles Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes | Yes | 0 | 10 Debriefs? | 0 | n/a | 0 | 0 | None | 0 | None | 149264 |
| DY14 | DPH | UC Los Angeles Medical Center | 2.2.1 | DHCS All-Cause Readmissions | 698 | 0 | 4748 | 0 | 0 | 0.147 | 0 | 0.1475 | 0 | 0 | 447792 |
| DY14 | DPH | UC Los Angeles Medical Center | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 6230 | 0 | 10000 | 0 | 1 | 0.623 | 0 | 0.602 | 0 | 0 | 447792 |
| DY14 | DPH | UC Los Angeles Medical Center | 2.2.3 | Medication Reconciliation 30 days | 5988 | 0 | 5992 | 0 | 1 | 0.9993 | 0 | 0.9987 | 0 | 0 | 447792 |
| DY14 | DPH | UC Los Angeles Medical Center | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 9894 | 0 | 10092 | 0 | 1 | 0.9804 | 0 | 0.9829 | 0 | 0 | 447792 |
| DY14 | DPH | UC Los Angeles Medical Center | 2.2.5 | Timely Transmission of Transition Record | 8009 | 0 | 8024 | 0 | 1 | 0.9981 | 0 | 0.9978 | 0 | 0 | 447792 |
| DY14 | DPH | UC Los Angeles Medical Center | 2.3.2 | Medication Reconciliation 30 days | 3257 | 0 | 3259 | 0 | 1 | 0.9994 | 0 | 0.9994 | 0 | 0 | 447792 |
| DY14 | DPH | UC Los Angeles Medical Center | 2.3.4 | Timely Transmission of Transition Record | 4208 | 0 | 4283 | 0 | 1 | 0.9825 | 0 | 0.9984 | 0 | 0 | 447792 |
| DY14 | DPH | UC Los Angeles Medical Center | 2.7.1 | Advance Care Plan | 15236 | 0 | 36908 | 0 | 1 | 0.4128 | 0 | 0.3504 | 0 | 0 | 447792 |
| DY14 | DPH | UC Los Angeles Medical Center | 2.7.3 | MWM #8: Treatment Preferences (documentation) Inpatient | 482 | 0 | 499 | 0 | 1 | 0.9659 | 0 | 0.9514 | 0 | 0 | 447792 |
| DY14 | DPH | UC Los Angeles Medical Center | 2.7.4 | MWM #8: Treatment Preferences (documentation) Outpatient | 326 | 0 | 331 | 0 | 1 | 0.9849 | 0 | 0.9087 | 0 | 0 | 447792 |
| DY14 | DPH | UC Los Angeles Medical Center | 2.7.5 | Palliative Care Service Offered at Time of Diagnosis of Advanced Illness | 190 | 0 | 3056 | 0 | 1 | 0.0622 | 0 | 0.0909 | 0 | 0 | 447792 |
| DY14 | DPH | UC Los Angeles Medical Center | 2.7.6 | Proportion Admitted to Hospice for Less Than 3 Days | 23 | 0 | 166 | 0 | 1 | 0.1386 | 0 | 0.1625 | 0 | 0 | 447792 |
| DY14 | DPH | UC Los Angeles Medical Center | 3.3.1 | Adherence to Medications: Rate 2 | 597 | 0 | 746 | 0 | n/a | 0.8003 | 0 | 0.706161137 | 0 | None | 0 |
| DY14 | DPH | UC Los Angeles Medical Center | 3.3.1 | Adherence to Medications: Rate 1 | 430 | 0 | 540 | 0 | 0 | 0.7963 | 0 | 0.832613391 | 0 | 0.8393 | 783636 |
| DY14 | DPH | UC Los Angeles Medical Center | 3.3.3 | High-Cost Pharmaceuticals Ordering Protocols: Rate 2 | 21 | 0 | 978 | 0 | n/a | 0.0215 | 0 | 0 | 0 | None | 0 |
| DY14 | DPH | UC Los Angeles Medical Center | 3.3.3 | High-Cost Pharmaceuticals Ordering Protocols: Rate 1 | 20 | 0 | 725 | 0 | 0 | 0.0276 | 0 | 0 | 0 | 0.25 | 783636 |
| DY14 | 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 | 4073 | 0 | 4346 | 0 | 1 | 0.9372 | 0 | 0.998381004 | 0 | None | 783636 |
| DY14 | 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 | 5226 | 0 | 5640 | 0 | n/a | 0.9266 | 0 | 0.99833205 | 0 | None | 0 |
| DY14 | DPH | UC San Diego Medical Center | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 20358 | 0 | 39939 | 0 | 1 | 0.5097 | 0 | 0.0766 | 0 | None | 292028.335 |
| DY14 | DPH | UC San Diego Medical Center | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 5547 | 0 | 39939 | 0 | 1 | 0.1389 | 0 | 0.0766 | 0 | None | 292028.335 |
| DY14 | DPH | UC San Diego Medical Center | 1.1.3.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 522 | 0 | 3568 | 0 | 1 | 0.1463 | 0 | 0.1843 | 0 | 0 | 584056.67 |
| DY14 | DPH | UC San Diego Medical Center | 1.1.5.f | Screening for Clinical Depression and follow-up | 19914 | 0 | 27472 | 0 | 1 | 0.7249 | 0 | 0.4707 | 0 | 0 | 584056.67 |
| DY14 | DPH | UC San Diego Medical Center | 1.1.6.t | Tobacco Assessment and Counseling | 38577 | 0 | 39163 | 0 | 1 | 0.985 | 0 | 0.9787 | 0 | 0 | 584056.67 |
| DY14 | DPH | UC San Diego Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Follow-up | 930 | 0 | 1831 | 0 | 1 | 0.5079 | 0 | 0.374881066 | 0 | 0.377 | 194685.5567 |
| DY14 | DPH | UC San Diego Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Remission | 207 | 0 | 1831 | 0 | 1 | 0.1131 | 0 | 0.048525214 | 0 | 0.049 | 194685.5567 |
| DY14 | DPH | UC San Diego Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Response | 351 | 0 | 1831 | 0 | 1 | 0.1917 | 0 | 0.1094196 | 0 | 0.0998 | 194685.5567 |
| DY14 | DPH | UC San Diego Medical Center | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 20358 | 0 | 39939 | 0 | 1 | 0.5097 | 0 | 0.0766 | 0 | None | 292028.335 |
| DY14 | DPH | UC San Diego Medical Center | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 5547 | 0 | 39939 | 0 | 1 | 0.1389 | 0 | 0.0766 | 0 | None | 292028.335 |
| DY14 | DPH | UC San Diego Medical Center | 1.2.10 | REAL and/or SO/GI disparity reduction | 1458 | 0 | 1484 | 0 | 1 | 0.9825 | 0 | 0.9724 | 0 | 0 | 584056.67 |
| DY14 | DPH | UC San Diego Medical Center | 1.2.11 | REAL data completeness | 37258 | 0 | 39343 | 0 | 1 | 0.947 | 0 | 0.929 | 0 | 0 | 584056.67 |
| DY14 | DPH | UC San Diego Medical Center | 1.2.12.f | Screening for Clinical Depression and follow-up | 19914 | 0 | 27472 | 0 | 1 | 0.7249 | 0 | 0.4707 | 0 | 0 | 584056.67 |
| DY14 | DPH | UC San Diego Medical Center | 1.2.13 | SO/GI data completeness | 24967 | 0 | 38470 | 0 | 1 | 0.649 | 0 | 0.2982 | 0 | 0 | 584056.67 |
| DY14 | DPH | UC San Diego Medical Center | 1.2.14.t | Tobacco Assessment and Counseling | 38577 | 0 | 39163 | 0 | 1 | 0.985 | 0 | 0.9787 | 0 | 0 | 584056.67 |
| DY14 | DPH | UC San Diego Medical Center | 1.2.2 | CG-CAHPS: Provider Rating | 10421 | 0 | 11628 | 0 | 1 | 0.8962 | 0 | 0.8899 | 0 | 0 | 584056.67 |
| DY14 | DPH | UC San Diego Medical Center | 1.2.3.c | Colorectal Cancer Screening | 15978 | 0 | 19374 | 0 | 1 | 0.8247 | 0 | 0.8044 | 0 | 0 | 584056.67 |
| DY14 | DPH | UC San Diego Medical Center | 1.2.4.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 522 | 0 | 3568 | 0 | 1 | 0.1463 | 0 | 0.1843 | 0 | 0 | 584056.67 |
| DY14 | DPH | UC San Diego Medical Center | 1.2.5.b | Controlling Blood Pressure | 7484 | 0 | 9790 | 0 | 1 | 0.7645 | 0 | 0.7465 | 0 | 0 | 584056.67 |
| DY14 | DPH | UC San Diego Medical Center | 1.2.7.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 3357 | 0 | 3571 | 0 | 1 | 0.9401 | 0 | 0.9336 | 0 | 0 | 584056.67 |
| DY14 | DPH | UC San Diego Medical Center | 1.2.8 | Prevention Quality Overall Composite #90 | 310 | 0 | 41482 | 0 | 0 | 0.0075 | 0 | 0.007 | 0 | 0 | 584056.67 |
| DY14 | DPH | UC San Diego Medical Center | 1.3.1 | Closing the referral loop: receipt of specialist report (CMS50v3) | 56398 | 0 | 62840 | 0 | 1 | 0.8975 | 0 | 0.8825 | 0 | 0 | 584056.67 |
| DY14 | DPH | UC San Diego Medical Center | 1.3.2 | DHCS All-Cause Readmissions | 265 | 0 | 1756 | 0 | 1 | 0.1509 | 0 | 0.1505 | 0 | 0 | 584056.66 |
| DY14 | DPH | UC San Diego Medical Center | 1.3.3 | Influenza Immunization | 15374 | 0 | 17639 | 0 | 1 | 0.8716 | 0 | 0.7028 | 0 | 0 | 584056.66 |
| DY14 | DPH | UC San Diego Medical Center | 1.3.5 | Request for Specialty Care Expertise Turnaround Time | 122257 | 0 | 213153 | 0 | 1 | 0.5736 | 0 | 0.461 | 0 | 0 | 584056.66 |
| DY14 | DPH | UC San Diego Medical Center | 1.3.6 | Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters | 1674 | 0 | 187324 | 0 | 0 | 0.0089 | 0 | 0.0129 | 0 | 0 | 584056.66 |
| DY14 | DPH | UC San Diego Medical Center | 1.3.7 | Tobacco Assessment and Counseling | 24737 | 0 | 25033 | 0 | 1 | 0.9882 | 0 | 0.9891 | 0 | 0 | 584056.66 |
| DY14 | DPH | UC San Diego Medical Center | 1.5.1.b | Controlling Blood Pressure | 7484 | 0 | 9790 | 0 | 1 | 0.7645 | 0 | 0.7465 | 0 | 0 | 584056.66 |
| DY14 | DPH | UC San Diego Medical Center | 1.5.2.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 3357 | 0 | 3571 | 0 | 1 | 0.9401 | 0 | 0.9336 | 0 | 0 | 584056.66 |
| DY14 | DPH | UC San Diego Medical Center | 1.5.3 | PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 18963 | 0 | 21160 | 0 | 1 | 0.8962 | 0 | 0.8057 | 0 | 0 | 584056.66 |
| DY14 | DPH | UC San Diego Medical Center | 1.5.4.t | Tobacco Assessment and Counseling | 38577 | 0 | 39163 | 0 | 1 | 0.985 | 0 | 0.9787 | 0 | 0 | 584056.66 |
| DY14 | DPH | UC San Diego Medical Center | 2.1.1 | Baby Friendly Hospital designation: BFUSA Designation Yes | Yes | 0 | BFUSA Cert? | 0 | 1 | 0 | 0 | None | 0 | None | 600744 |
| DY14 | DPH | UC San Diego Medical Center | 2.1.2 | Exclusive Breast Milk Feeding (PC-05) | 1513 | 0 | 2150 | 0 | 1 | 0.7037 | 0 | 0.6678 | 0 | 0 | 600744 |
| DY14 | DPH | UC San Diego Medical Center | 2.1.3 | OB Hemorrhage: Massive Transfusion | None | 1 | 2918 | 0 | 1 | None | 1 | None | 1 | 0 | 600744 |
| DY14 | DPH | UC San Diego Medical Center | 2.1.4 | OB Hemorrhage: Total Products Transfused | 215 | 0 | 2918 | 0 | 1 | 0.0737 | 0 | 0.1273 | 0 | 0 | 600744 |
| DY14 | DPH | UC San Diego Medical Center | 2.1.5 | PC-02 Cesarean Section | 253 | 0 | 1096 | 0 | 0 | 0.2308 | 0 | 0.1963 | 0 | 0 | 600744 |
| DY14 | DPH | UC San Diego Medical Center | 2.1.6 | Prenatal and Postpartum Care: Prenatal Care | 1956 | 0 | 1969 | 0 | 1 | 0.9934 | 0 | 0.995562951 | 0 | 0.9167 | 300372 |
| DY14 | DPH | UC San Diego Medical Center | 2.1.6 | Prenatal and Postpartum Care: Postpartum Care | 1475 | 0 | 1969 | 0 | 1 | 0.7491 | 0 | 0.757071547 | 0 | 0.7367 | 300372 |
| DY14 | DPH | UC San Diego Medical Center | 2.1.7 | Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage | 93 | 0 | 222 | 0 | 1 | 0.4189 | 0 | 0.314 | 0 | 0 | 600744 |
| DY14 | DPH | UC San Diego Medical Center | 2.1.8 | Unexpected Newborn Complications (UNC) | 127 | 0 | 2081 | 0 | 1 | 0.061 | 0 | 0.071 | 0 | 0 | 600744 |
| DY14 | DPH | UC San Diego Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes | Yes | 0 | 3 Safety Drills? | 0 | n/a | 0 | 0 | None | 0 | None | 200248 |
| DY14 | DPH | UC San Diego Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes | Yes | 0 | 10 Debriefs? | 0 | n/a | 0 | 0 | None | 0 | None | 200248 |
| DY14 | DPH | UC San Diego Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) |
16 | 0 | 16 | 0 | 1 | 1 | 0 | 1 | 0 | None | 200248 |
| DY14 | DPH | UC San Diego Medical Center | 2.2.1 | DHCS All-Cause Readmissions | 269 | 0 | 1831 | 0 | 0 | 0.1469 | 0 | 0.1466 | 0 | 0 | 600744 |
| DY14 | DPH | UC San Diego Medical Center | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 6262 | 0 | 10000 | 0 | 1 | 0.6262 | 0 | 0.6196 | 0 | 0 | 600744 |
| DY14 | DPH | UC San Diego Medical Center | 2.2.3 | Medication Reconciliation 30 days | 3259 | 0 | 3566 | 0 | 1 | 0.9139 | 0 | 0.6864 | 0 | 0 | 600744 |
| DY14 | DPH | UC San Diego Medical Center | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 3122 | 0 | 3130 | 0 | 1 | 0.9974 | 0 | 0.9957 | 0 | 0 | 600744 |
| DY14 | DPH | UC San Diego Medical Center | 2.2.5 | Timely Transmission of Transition Record | 4456 | 0 | 4456 | 0 | 1 | 1 | 0 | 0.8438 | 0 | 0 | 600744 |
| DY14 | DPH | UC San Diego Medical Center | 2.3.2 | Medication Reconciliation 30 days | 166 | 0 | 177 | 0 | 1 | 0.9379 | 0 | 0.7609 | 0 | 0 | 600744 |
| DY14 | DPH | UC San Diego Medical Center | 2.3.4 | Timely Transmission of Transition Record | 209 | 0 | 209 | 0 | 1 | 1 | 0 | 0.8675 | 0 | 0 | 600744 |
| DY14 | DPH | UC San Diego Medical Center | 2.7.1 | Advance Care Plan | 9734 | 0 | 15498 | 0 | 1 | 0.6281 | 0 | 0.4808 | 0 | 0 | 600744 |
| DY14 | DPH | UC San Diego Medical Center | 2.7.3 | MWM #8: Treatment Preferences (documentation) Inpatient | 120 | 0 | 127 | 0 | 1 | 0.9449 | 0 | 0.8939 | 0 | 0 | 600744 |
| DY14 | DPH | UC San Diego Medical Center | 2.7.4 | MWM #8: Treatment Preferences (documentation) Outpatient | 33 | 0 | 36 | 0 | 1 | 0.9167 | 0 | 0.7179 | 0 | 0 | 600744 |
| DY14 | DPH | UC San Diego Medical Center | 2.7.5 | Palliative Care Service Offered at Time of Diagnosis of Advanced Illness | 127 | 0 | 1645 | 0 | 1 | 0.0772 | 0 | 0.2105 | 0 | 0 | 600744 |
| DY14 | DPH | UC San Diego Medical Center | 2.7.6 | Proportion Admitted to Hospice for Less Than 3 Days | None | 1 | 72 | 0 | 1 | None | 1 | 0.0956 | 0 | 0 | 600744 |
| DY14 | DPH | UC San Diego Medical Center | 3.1.1 | Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis | 89 | 0 | 130 | 0 | 1 | 0.6846 | 0 | 0.5688 | 0 | 0 | 450558 |
| DY14 | DPH | UC San Diego Medical Center | 3.1.3 | National Healthcare Safety Network (NHSN) Antimicrobial Use Measure | 65630 | 0 | 216650 | 0 | 0 | 0.3029 | 0 | 0.2793 | 0 | 0 | 450558 |
| DY14 | DPH | UC San Diego Medical Center | 3.1.4 | Peri-operative Prophylactic Antibiotics Administered after Surgical Closure | 2572 | 0 | 5758 | 0 | 1 | 0.4467 | 0 | 0.4889 | 0 | 0 | 450558 |
| DY14 | DPH | UC San Diego Medical Center | 3.1.5 | Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR | 9220 | 0 | 10000 | 0 | 1 | 0.922 | 0 | 0.958 | 0 | 0.9322 | 450558 |
| DY14 | DPH | UC San Diego Medical Center | 3.3.1 | Adherence to Medications: Rate 1 | 2232 | 0 | 2995 | 0 | 1 | 0.7452 | 0 | 0.646310433 | 0 | 0.5963 | 450558 |
| DY14 | DPH | UC San Diego Medical Center | 3.3.1 | Adherence to Medications: Rate 2 | 2377 | 0 | 3196 | 0 | n/a | 0.7437 | 0 | 0.562576437 | 0 | None | 0 |
| DY14 | DPH | UC San Diego Medical Center | 3.3.3 | High-Cost Pharmaceuticals Ordering Protocols: Rate 2 | 345 | 0 | 1728 | 0 | n/a | 0.1997 | 0 | 0.054545455 | 0 | None | 0 |
| DY14 | DPH | UC San Diego Medical Center | 3.3.3 | High-Cost Pharmaceuticals Ordering Protocols: Rate 1 | 342 | 0 | 1678 | 0 | 0.75 | 0.2038 | 0 | 0.035332786 | 0 | 0.25 | 450558 |
| DY14 | 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 | 25630 | 0 | 27628 | 0 | 1 | 0.9277 | 0 | 0.874838861 | 0 | None | 450558 |
| DY14 | 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 | 27119 | 0 | 29252 | 0 | n/a | 0.9271 | 0 | 0.880019497 | 0 | None | 0 |
| DY14 | DPH | UC San Francisco Medical Center | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 32562 | 0 | 34849 | 0 | 1 | 0.9344 | 0 | 0.0329 | 0 | None | 355342.5 |
| DY14 | DPH | UC San Francisco Medical Center | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 1350 | 0 | 34849 | 0 | 0.75 | 0.0387 | 0 | 0.0329 | 0 | None | 355342.5 |
| DY14 | DPH | UC San Francisco Medical Center | 1.1.3.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 642 | 0 | 2633 | 0 | 1 | 0.2438 | 0 | 0.2032 | 0 | 0 | 710685 |
| DY14 | DPH | UC San Francisco Medical Center | 1.1.5.f | Screening for Clinical Depression and follow-up | 17418 | 0 | 28724 | 0 | 1 | 0.6064 | 0 | 0.5374 | 0 | 0 | 710685 |
| DY14 | DPH | UC San Francisco Medical Center | 1.1.6.t | Tobacco Assessment and Counseling | 30981 | 0 | 31759 | 0 | 1 | 0.9755 | 0 | 0.9647 | 0 | 0 | 710685 |
| DY14 | DPH | UC San Francisco Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Follow-up | 274 | 0 | 778 | 0 | 1 | 0.3522 | 0 | 0.225895317 | 0 | 0.2429 | 236895 |
| DY14 | DPH | UC San Francisco Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Remission | 40 | 0 | 778 | 0 | 1 | 0.0514 | 0 | None | 1 | 0.0252 | 236895 |
| DY14 | DPH | UC San Francisco Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Response | 39 | 0 | 778 | 0 | 1 | 0.0501 | 0 | 0.03030303 | 0 | 0.0373 | 236895 |
| DY14 | DPH | UC San Francisco Medical Center | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 32562 | 0 | 34849 | 0 | 1 | 0.9344 | 0 | 0.0329 | 0 | None | 355342.5 |
| DY14 | DPH | UC San Francisco Medical Center | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 1350 | 0 | 34849 | 0 | 0.75 | 0.0387 | 0 | 0.0329 | 0 | None | 355342.5 |
| DY14 | DPH | UC San Francisco Medical Center | 1.2.10 | REAL and/or SO/GI disparity reduction | 509 | 0 | 762 | 0 | 1 | 0.668 | 0 | 0.6419 | 0 | 0 | 710685 |
| DY14 | DPH | UC San Francisco Medical Center | 1.2.11 | REAL data completeness | 42916 | 0 | 42930 | 0 | 1 | 0.9997 | 0 | 0.9998 | 0 | 0 | 710685 |
| DY14 | DPH | UC San Francisco Medical Center | 1.2.12.f | Screening for Clinical Depression and follow-up | 17418 | 0 | 28724 | 0 | 1 | 0.6064 | 0 | 0.5374 | 0 | 0 | 710685 |
| DY14 | DPH | UC San Francisco Medical Center | 1.2.13 | SO/GI data completeness | 12076 | 0 | 32685 | 0 | 1 | 0.3695 | 0 | 0.004 | 0 | 0 | 710685 |
| DY14 | DPH | UC San Francisco Medical Center | 1.2.14.t | Tobacco Assessment and Counseling | 30981 | 0 | 31759 | 0 | 1 | 0.9755 | 0 | 0.9647 | 0 | 0 | 710685 |
| DY14 | DPH | UC San Francisco Medical Center | 1.2.2 | CG-CAHPS: Provider Rating | 8180 | 0 | 9622 | 0 | 1 | 0.8501 | 0 | 0.8392 | 0 | 0 | 710685 |
| DY14 | DPH | UC San Francisco Medical Center | 1.2.3.c | Colorectal Cancer Screening | 10860 | 0 | 14244 | 0 | 1 | 0.7624 | 0 | 0.7678 | 0 | 0 | 710685 |
| DY14 | DPH | UC San Francisco Medical Center | 1.2.4.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 642 | 0 | 2633 | 0 | 1 | 0.2438 | 0 | 0.2032 | 0 | 0 | 710685 |
| DY14 | DPH | UC San Francisco Medical Center | 1.2.5.b | Controlling Blood Pressure | 4336 | 0 | 5640 | 0 | 1 | 0.7688 | 0 | 0.7416 | 0 | 0 | 710685 |
| DY14 | DPH | UC San Francisco Medical Center | 1.2.7.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 1112 | 0 | 1231 | 0 | 0 | 0.9033 | 0 | 0.9162 | 0 | 0 | 710685 |
| DY14 | DPH | UC San Francisco Medical Center | 1.2.8 | Prevention Quality Overall Composite #90 | 318 | 0 | 34002 | 0 | 1 | 0.0094 | 0 | 0.0111 | 0 | 0 | 710685 |
| DY14 | DPH | UC San Francisco Medical Center | 1.3.1 | Closing the referral loop: receipt of specialist report (CMS50v3) | 55405 | 0 | 61400 | 0 | 1 | 0.9024 | 0 | 0.901 | 0 | 0 | 710685 |
| DY14 | DPH | UC San Francisco Medical Center | 1.3.2 | DHCS All-Cause Readmissions | 209 | 0 | 1679 | 0 | 1 | 0.1245 | 0 | 0.1329 | 0 | 0 | 710685 |
| DY14 | DPH | UC San Francisco Medical Center | 1.3.3 | Influenza Immunization | 12726 | 0 | 14619 | 0 | 1 | 0.8705 | 0 | 0.8595 | 0 | 0 | 710685 |
| DY14 | DPH | UC San Francisco Medical Center | 1.3.5 | Request for Specialty Care Expertise Turnaround Time | 119384 | 0 | 145001 | 0 | 0 | 0.8233 | 0 | 0.8264 | 0 | 0 | 710685 |
| DY14 | DPH | UC San Francisco Medical Center | 1.3.6 | Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters | 98348 | 0 | 271246 | 0 | 1 | 0.3626 | 0 | 0.0199 | 0 | 0 | 710685 |
| DY14 | DPH | UC San Francisco Medical Center | 1.3.7 | Tobacco Assessment and Counseling | 15703 | 0 | 15979 | 0 | 1 | 0.9827 | 0 | 0.9806 | 0 | 0 | 710685 |
| DY14 | DPH | UC San Francisco Medical Center | 1.6.1 | BIRADS to Biopsy | 68 | 0 | 109 | 0 | 1 | 0.6239 | 0 | 0.5209 | 0 | 0 | 710685 |
| DY14 | DPH | UC San Francisco Medical Center | 1.6.2 | Breast Cancer Screening | 6129 | 0 | 7795 | 0 | 1 | 0.7863 | 0 | 0.7901 | 0 | 0 | 710685 |
| DY14 | DPH | UC San Francisco Medical Center | 1.6.3 | Cervical Cancer Screening | 9246 | 0 | 12272 | 0 | 1 | 0.7534 | 0 | 0.7624 | 0 | 0 | 710685 |
| DY14 | DPH | UC San Francisco Medical Center | 1.6.4.c | Colorectal Cancer Screening | 10860 | 0 | 14244 | 0 | 1 | 0.7624 | 0 | 0.7678 | 0 | 0 | 710685 |
| DY14 | DPH | UC San Francisco Medical Center | 1.6.5 | Receipt of appropriate follow-up for abnormal CRC screening | 30 | 0 | 56 | 0 | 1 | 0.5357 | 0 | 0.4043 | 0 | 0 | 710685 |
| DY14 | DPH | UC San Francisco Medical Center | 2.1.1 | Baby Friendly Hospital designation: [Numerator] Dissemination Elements Completed (If your system as more than one hospital, please enter the sum of all elements completed) [Denominator] Dissemination Elements Required (if your system has more than one hospital, multiply the number of hospitals by 11) |
11 | 0 | None | 4 | 1 | None | 4 | None | 0 | None | 0 |
| DY14 | DPH | UC San Francisco Medical Center | 2.1.1 | Baby Friendly Hospital designation: BFUSA Designation No | No | 0 | BFUSA Cert? | 0 | See other 2.1.1 row for AV | 0 | 0 | None | 0 | None | 758064 |
| DY14 | DPH | UC San Francisco Medical Center | 2.1.2 | Exclusive Breast Milk Feeding (PC-05) | 1570 | 0 | 1879 | 0 | 1 | 0.8356 | 0 | 0.7692 | 0 | 0 | 758064 |
| DY14 | DPH | UC San Francisco Medical Center | 2.1.3 | OB Hemorrhage: Massive Transfusion | None | 1 | 2360 | 0 | 1 | None | 1 | None | 1 | 0 | 758064 |
| DY14 | DPH | UC San Francisco Medical Center | 2.1.4 | OB Hemorrhage: Total Products Transfused | 239 | 0 | 2360 | 0 | 1 | 0.1013 | 0 | 0.0833 | 0 | 0 | 758064 |
| DY14 | DPH | UC San Francisco Medical Center | 2.1.5 | PC-02 Cesarean Section | 277 | 0 | 1178 | 0 | 0 | 0.2351 | 0 | 0.2174 | 0 | 0 | 758064 |
| DY14 | DPH | UC San Francisco Medical Center | 2.1.6 | Prenatal and Postpartum Care: Prenatal Care | 2259 | 0 | 2352 | 0 | 1 | 0.9605 | 0 | 0.972153972 | 0 | 0.9167 | 379032 |
| DY14 | DPH | UC San Francisco Medical Center | 2.1.6 | Prenatal and Postpartum Care: Postpartum Care | 1874 | 0 | 2352 | 0 | 1 | 0.7968 | 0 | 0.806715807 | 0 | 0.7367 | 379032 |
| DY14 | DPH | UC San Francisco Medical Center | 2.1.7 | Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage | 127 | 0 | 525 | 0 | 1 | 0.2419 | 0 | 0.2255 | 0 | 0 | 758064 |
| DY14 | DPH | UC San Francisco Medical Center | 2.1.8 | Unexpected Newborn Complications (UNC) | 75 | 0 | 1906 | 0 | 1 | 0.0393 | 0 | 0.0406 | 0 | 0 | 758064 |
| DY14 | DPH | UC San Francisco Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) |
16 | 0 | 16 | 0 | 1 | 1 | 0 | 1 | 0 | None | 252688 |
| DY14 | DPH | UC San Francisco Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes | Yes | 0 | 3 Safety Drills? | 0 | n/a | 0 | 0 | None | 0 | None | 252688 |
| DY14 | DPH | UC San Francisco Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes | Yes | 0 | 10 Debriefs? | 0 | n/a | 0 | 0 | None | 0 | None | 252688 |
| DY14 | DPH | UC San Francisco Medical Center | 2.2.1 | DHCS All-Cause Readmissions | 222 | 0 | 1750 | 0 | 1 | 0.1269 | 0 | 0.1291 | 0 | 0 | 758064 |
| DY14 | DPH | UC San Francisco Medical Center | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 6509 | 0 | 10000 | 0 | 1 | 0.6509 | 0 | 0.6393 | 0 | 0 | 758064 |
| DY14 | DPH | UC San Francisco Medical Center | 2.2.3 | Medication Reconciliation 30 days | 1533 | 0 | 1537 | 0 | 1 | 0.9974 | 0 | 0.9906 | 0 | 0 | 758064 |
| DY14 | DPH | UC San Francisco Medical Center | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 3919 | 0 | 3956 | 0 | 1 | 0.9906 | 0 | 0.992 | 0 | 0 | 758064 |
| DY14 | DPH | UC San Francisco Medical Center | 2.2.5 | Timely Transmission of Transition Record | 4645 | 0 | 4747 | 0 | 1 | 0.9785 | 0 | 0.9807 | 0 | 0 | 758064 |
| DY14 | DPH | UC San Francisco Medical Center | 2.3.2 | Medication Reconciliation 30 days | 138 | 0 | 138 | 0 | 1 | 1 | 0 | 0.9922 | 0 | 0 | 758064 |
| DY14 | DPH | UC San Francisco Medical Center | 2.3.4 | Timely Transmission of Transition Record | 277 | 0 | 278 | 0 | 1 | 0.9964 | 0 | 0.9839 | 0 | 0 | 758064 |
| DY14 | DPH | UC San Francisco Medical Center | 2.7.1 | Advance Care Plan | 9807 | 0 | 10593 | 0 | 1 | 0.9258 | 0 | 0.9193 | 0 | 0 | 758064 |
| DY14 | DPH | UC San Francisco Medical Center | 2.7.3 | MWM #8: Treatment Preferences (documentation) Inpatient | 101 | 0 | 109 | 0 | 1 | 0.9266 | 0 | 0.8851 | 0 | 0 | 758064 |
| DY14 | DPH | UC San Francisco Medical Center | 2.7.4 | MWM #8: Treatment Preferences (documentation) Outpatient | 79 | 0 | 87 | 0 | 1 | 0.908 | 0 | 0.8378 | 0 | 0 | 758064 |
| DY14 | DPH | UC San Francisco Medical Center | 2.7.5 | Palliative Care Service Offered at Time of Diagnosis of Advanced Illness | 106 | 0 | 1007 | 0 | 1 | 0.1053 | 0 | 0.2361 | 0 | 0 | 758064 |
| DY14 | DPH | UC San Francisco Medical Center | 2.7.6 | Proportion Admitted to Hospice for Less Than 3 Days | None | 1 | 53 | 0 | 1 | None | 1 | None | 1 | 0 | 758064 |
| DY14 | DPH | UC San Francisco Medical Center | 3.3.1 | Adherence to Medications: Rate 2 | 170 | 0 | 193 | 0 | n/a | 0.8808 | 0 | 0.803921569 | 0 | None | 0 |
| DY14 | DPH | UC San Francisco Medical Center | 3.3.1 | Adherence to Medications: Rate 1 | 140 | 0 | 162 | 0 | 1 | 0.8642 | 0 | 0.838709677 | 0 | 0.8448 | 1989918 |
| DY14 | DPH | UC San Francisco Medical Center | 3.3.3 | High-Cost Pharmaceuticals Ordering Protocols: Rate 1 | 44 | 0 | 53 | 0 | 1 | 0.8302 | 0 | None | 1 | 0.3689 | 0 |
| DY14 | DPH | UC San Francisco Medical Center | 3.3.3 | High-Cost Pharmaceuticals Ordering Protocols: Rate 2 | 63 | 0 | 72 | 0 | n/a | 0.875 | 0 | 0.309859155 | 0 | None | 0 |
| DY14 | 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 | 134 | 0 | 287 | 0 | n/a | 0.4669 | 0 | 0.394366197 | 0 | None | 0 |
| DY14 | 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 | 106 | 0 | 232 | 0 | 1 | 0.4569 | 0 | 0.474509804 | 0 | None | 1989918 |
| DY14 | DPH | Ventura County Medical Center | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 25657 | 0 | 49175 | 0 | 1 | 0.5217 | 0 | 0.1087 | 0 | None | 786170.02 |
| DY14 | DPH | Ventura County Medical Center | 1.1.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 8867 | 0 | 49175 | 0 | 1 | 0.1803 | 0 | 0.1087 | 0 | None | 786170.02 |
| DY14 | DPH | Ventura County Medical Center | 1.1.3.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 1285 | 0 | 6521 | 0 | 1 | 0.1971 | 0 | 0.2016 | 0 | 0 | 1572340.04 |
| DY14 | DPH | Ventura County Medical Center | 1.1.5.f | Screening for Clinical Depression and follow-up | 21161 | 0 | 33925 | 0 | 1 | 0.6238 | 0 | 0.4978 | 0 | 0 | 1572340.04 |
| DY14 | DPH | Ventura County Medical Center | 1.1.6.t | Tobacco Assessment and Counseling | 35188 | 0 | 35829 | 0 | 1 | 0.9821 | 0 | 0.9734 | 0 | 0 | 1572340.04 |
| DY14 | DPH | Ventura County Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Response | 130 | 0 | 1600 | 0 | 1 | 0.0813 | 0 | 0.200692042 | 0 | 0.0778 | 524113.3467 |
| DY14 | DPH | Ventura County Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Follow-up | 356 | 0 | 1600 | 0 | 1 | 0.2225 | 0 | 0.038927336 | 0 | 0.2202 | 524113.3467 |
| DY14 | DPH | Ventura County Medical Center | 1.1.7 | Depression Remission or Response for Adolescents and Adults: Depression Remission | 67 | 0 | 1600 | 0 | 1 | 0.0419 | 0 | 0.075259516 | 0 | 0.0404 | 524113.3467 |
| DY14 | DPH | Ventura County Medical Center | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): Brief screening only | 25657 | 0 | 49175 | 0 | 1 | 0.5217 | 0 | 0.1087 | 0 | None | 786170.02 |
| DY14 | DPH | Ventura County Medical Center | 1.2.1.a | Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings) | 8867 | 0 | 49175 | 0 | 1 | 0.1803 | 0 | 0.1087 | 0 | None | 786170.02 |
| DY14 | DPH | Ventura County Medical Center | 1.2.10 | REAL and/or SO/GI disparity reduction | 960 | 0 | 1477 | 0 | 1 | 0.65 | 0 | 0.6401 | 0 | 0 | 1572340.04 |
| DY14 | DPH | Ventura County Medical Center | 1.2.11 | REAL data completeness | 65696 | 0 | 65700 | 0 | 1 | 0.9999 | 0 | 0.9998 | 0 | 0 | 1572340.04 |
| DY14 | DPH | Ventura County Medical Center | 1.2.12.f | Screening for Clinical Depression and follow-up | 21161 | 0 | 33925 | 0 | 1 | 0.6238 | 0 | 0.4978 | 0 | 0 | 1572340.04 |
| DY14 | DPH | Ventura County Medical Center | 1.2.13 | SO/GI data completeness | 34911 | 0 | 37999 | 0 | 1 | 0.9187 | 0 | 0.6988 | 0 | 0 | 1572340.04 |
| DY14 | DPH | Ventura County Medical Center | 1.2.14.t | Tobacco Assessment and Counseling | 35188 | 0 | 35829 | 0 | 1 | 0.9821 | 0 | 0.9734 | 0 | 0 | 1572340.04 |
| DY14 | DPH | Ventura County Medical Center | 1.2.2 | CG-CAHPS: Provider Rating | 16768 | 0 | 20774 | 0 | 1 | 0.8072 | 0 | 0.8018 | 0 | 0 | 1572340.04 |
| DY14 | DPH | Ventura County Medical Center | 1.2.3.c | Colorectal Cancer Screening | 8841 | 0 | 15232 | 0 | 1 | 0.5804 | 0 | 0.5298 | 0 | 0 | 1572340.04 |
| DY14 | DPH | Ventura County Medical Center | 1.2.4.d | Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) | 1285 | 0 | 6521 | 0 | 1 | 0.1971 | 0 | 0.2016 | 0 | 0 | 1572340.04 |
| DY14 | DPH | Ventura County Medical Center | 1.2.5.b | Controlling Blood Pressure | 10129 | 0 | 13964 | 0 | 1 | 0.7254 | 0 | 0.7076 | 0 | 0 | 1572340.04 |
| DY14 | DPH | Ventura County Medical Center | 1.2.7.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 771 | 0 | 831 | 0 | 1 | 0.9278 | 0 | 0.9121 | 0 | 0 | 1572340.04 |
| DY14 | DPH | Ventura County Medical Center | 1.2.8 | Prevention Quality Overall Composite #90 | 395 | 0 | 48762 | 0 | 1 | 0.0081 | 0 | 0.0085 | 0 | 0 | 1572340.04 |
| DY14 | DPH | Ventura County Medical Center | 1.3.1 | Closing the referral loop: receipt of specialist report (CMS50v3) | 10576 | 0 | 22492 | 0 | 1 | 0.4702 | 0 | 0.3472 | 0 | 0 | 1572340.04 |
| DY14 | DPH | Ventura County Medical Center | 1.3.2 | DHCS All-Cause Readmissions | 133 | 0 | 1164 | 0 | 1 | 0.1143 | 0 | 0.1321 | 0 | 0 | 1572340.04 |
| DY14 | DPH | Ventura County Medical Center | 1.3.3 | Influenza Immunization | 7691 | 0 | 10749 | 0 | 1 | 0.7155 | 0 | 0.6433 | 0 | 0 | 1572340.03 |
| DY14 | DPH | Ventura County Medical Center | 1.3.5 | Request for Specialty Care Expertise Turnaround Time | 36114 | 0 | 52715 | 0 | 1 | 0.6851 | 0 | 0.5272 | 0 | 0 | 1572340.03 |
| DY14 | DPH | Ventura County Medical Center | 1.3.6 | Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters | 4271 | 0 | 48041 | 0 | 1 | 0.0889 | 0 | 0.0093 | 0 | 0 | 1572340.03 |
| DY14 | DPH | Ventura County Medical Center | 1.3.7 | Tobacco Assessment and Counseling | 17843 | 0 | 18046 | 0 | 1 | 0.9888 | 0 | 0.9839 | 0 | 0 | 1572340.03 |
| DY14 | DPH | Ventura County Medical Center | 1.5.1.b | Controlling Blood Pressure | 10129 | 0 | 13964 | 0 | 1 | 0.7254 | 0 | 0.7076 | 0 | 0 | 1572340.03 |
| DY14 | DPH | Ventura County Medical Center | 1.5.2.i | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 771 | 0 | 831 | 0 | 1 | 0.9278 | 0 | 0.9121 | 0 | 0 | 1572340.03 |
| DY14 | DPH | Ventura County Medical Center | 1.5.3 | PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 21827 | 0 | 23586 | 0 | 1 | 0.9254 | 0 | 0.7272 | 0 | 0 | 1572340.03 |
| DY14 | DPH | Ventura County Medical Center | 1.5.4.t | Tobacco Assessment and Counseling | 35188 | 0 | 35829 | 0 | 1 | 0.9821 | 0 | 0.9734 | 0 | 0 | 1572340.03 |
| DY14 | DPH | Ventura County Medical Center | 2.1.1 | Baby Friendly Hospital designation: BFUSA Designation Yes | Yes | 0 | BFUSA Cert? | 0 | 1 | 0 | 0 | None | 0 | None | 1476632.31 |
| DY14 | DPH | Ventura County Medical Center | 2.1.2 | Exclusive Breast Milk Feeding (PC-05) | 674 | 0 | 1059 | 0 | 0 | 0.6364 | 0 | 0.6544 | 0 | 0 | 1476632.31 |
| DY14 | DPH | Ventura County Medical Center | 2.1.3 | OB Hemorrhage: Massive Transfusion | None | 1 | 1328 | 0 | 1 | None | 1 | None | 1 | 0 | 1476632.31 |
| DY14 | DPH | Ventura County Medical Center | 2.1.4 | OB Hemorrhage: Total Products Transfused | 50 | 0 | 1328 | 0 | 1 | 0.0377 | 0 | 0.0182 | 0 | 0 | 1476632.31 |
| DY14 | DPH | Ventura County Medical Center | 2.1.5 | PC-02 Cesarean Section | 58 | 0 | 339 | 0 | 1 | 0.1711 | 0 | 0.184 | 0 | 0 | 1476632.31 |
| DY14 | DPH | Ventura County Medical Center | 2.1.6 | Prenatal and Postpartum Care: Prenatal Care | 1470 | 0 | 1560 | 0 | 1 | 0.9423 | 0 | 0.828904731 | 0 | 0.8377 | 738316.155 |
| DY14 | DPH | Ventura County Medical Center | 2.1.6 | Prenatal and Postpartum Care: Postpartum Care | 1207 | 0 | 1560 | 0 | 1 | 0.7737 | 0 | 0.741412832 | 0 | 0.7367 | 738316.155 |
| DY14 | DPH | Ventura County Medical Center | 2.1.7 | Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage | 26 | 0 | 141 | 0 | 1 | 0.1844 | 0 | 0.1461 | 0 | 0 | 1476632.31 |
| DY14 | DPH | Ventura County Medical Center | 2.1.8 | Unexpected Newborn Complications (UNC) | 40 | 0 | 1084 | 0 | 1 | 0.0369 | 0 | 0.0382 | 0 | 0 | 1476632.31 |
| DY14 | DPH | Ventura County Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) |
32 | 0 | 32 | 0 | 1 | 1 | 0 | 1 | 0 | None | 492210.77 |
| DY14 | DPH | Ventura County Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes | Yes | 0 | 3 Safety Drills? | 0 | n/a | 0 | 0 | None | 0 | None | 492210.77 |
| DY14 | DPH | Ventura County Medical Center | 2.1.9 | OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes | Yes | 0 | 10 Debriefs? | 0 | n/a | 0 | 0 | None | 0 | None | 492210.77 |
| DY14 | DPH | Ventura County Medical Center | 2.2.1 | DHCS All-Cause Readmissions | 172 | 0 | 1425 | 0 | 1 | 0.1207 | 0 | 0.1386 | 0 | 0 | 1476632.31 |
| DY14 | DPH | Ventura County Medical Center | 2.2.2 | H-CAHPS: Care Transition Metrics (3) | 5480 | 0 | 10000 | 0 | 0 | 0.548 | 0 | 0.5522 | 0 | 0 | 1476632.3 |
| DY14 | DPH | Ventura County Medical Center | 2.2.3 | Medication Reconciliation 30 days | 2032 | 0 | 2224 | 0 | 1 | 0.9137 | 0 | 0.841 | 0 | 0 | 1476632.3 |
| DY14 | DPH | Ventura County Medical Center | 2.2.4 | Reconciled Medication List Received by Discharged Patients | 4951 | 0 | 5842 | 0 | 1 | 0.8475 | 0 | 0.5903 | 0 | 0 | 1476632.3 |
| DY14 | DPH | Ventura County Medical Center | 2.2.5 | Timely Transmission of Transition Record | 3800 | 0 | 4590 | 0 | 1 | 0.8279 | 0 | 0.2994 | 0 | 0 | 1476632.3 |
| DY14 | DPH | Ventura County Medical Center | 2.3.2 | Medication Reconciliation 30 days | 327 | 0 | 360 | 0 | 1 | 0.9083 | 0 | 0.8674 | 0 | 0 | 1476632.3 |
| DY14 | DPH | Ventura County Medical Center | 2.3.4 | Timely Transmission of Transition Record | 657 | 0 | 884 | 0 | 1 | 0.7432 | 0 | 0.3878 | 0 | 0 | 1476632.3 |
| DY14 | DPH | Ventura County Medical Center | 2.4.1 | Adolescent Well-Care Visit | 82 | 0 | 114 | 0 | 1 | 0.7193 | 0 | 0.6875 | 0 | 0 | 1476632.3 |
| DY14 | DPH | Ventura County Medical Center | 2.4.2 | Developmental Screening in the First Three Years of Life | 87 | 0 | 151 | 0 | 1 | 0.5762 | 0 | 0.5432 | 0 | 0 | 1476632.3 |
| DY14 | DPH | Ventura County Medical Center | 2.4.3 | Documentation of Current Medications in the Medical Record (0-18 yo) | 1242 | 0 | 1457 | 0 | 1 | 0.8524 | 0 | 0.798 | 0 | 0 | 1476632.3 |
| DY14 | DPH | Ventura County Medical Center | 2.4.4 | Screening for Clinical Depression and follow-up | 45 | 0 | 78 | 0 | 1 | 0.5769 | 0 | 0.4627 | 0 | 0 | 1476632.3 |
| DY14 | DPH | Ventura County Medical Center | 2.4.5 | Tobacco Assessment and Counseling (13 yo and older) | 63 | 0 | 63 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 1476632.3 |
| DY14 | DPH | Ventura County Medical Center | 2.4.7 | Well Child Visits - Third, Fourth, Fifth, and Sixth Years of life | 103 | 0 | 122 | 0 | 1 | 0.8443 | 0 | 0.8732 | 0 | 0 | 1476632.3 |
| DY14 | DPH | Ventura County Medical Center | 2.4.8 | Comprehensive Medical Evaluation Following Foster Youth Placement in Foster Care | 70 | 0 | 84 | 0 | 1 | 0.8333 | 0 | 0.775 | 0 | 0 | 1476632.3 |
| DY14 | DPH | Ventura County Medical Center | 3.4.1 | ePBM-01 Pre-op Anemia Screening, Selected Elective Surgical Patients | 105 | 0 | 185 | 0 | 1 | 0.5676 | 0 | 0.4915 | 0 | 0 | 2830212 |
| DY14 | DPH | Ventura County Medical Center | 3.4.3 | ePBM-03 Pre-op Type and Crossmatch, Type and Screen, Selected elective Surgical Patients | 190 | 0 | 210 | 0 | 1 | 0.9048 | 0 | 0.8841 | 0 | 0 | 2830212 |
| DY14 | DPH | Ventura County Medical Center | 3.4.4 | ePBM-04 Initial Transfusion Threshold | 355 | 0 | 355 | 0 | 1 | 1 | 0 | 0.9951 | 0 | 0 | 2830212 |
| DY14 | DMPH | Washington Hospital Healthcare System, Fremont | 2.1.1 | Baby Friendly Hospital designation: BFUSA Designation Yes | Yes | 0 | BFUSA Cert? | 0 | 1 | 0 | 0 | None | 0 | None | 573000 |
| DY14 | DMPH | Washington Hospital Healthcare System, Fremont | 2.1.2 | Exclusive Breast Milk Feeding (PC-05) | 83 | 0 | 120 | 0 | 0 | 0.6917 | 0 | 0.6908 | 0 | 0 | 573000 |
| DY14 | DMPH | Washington Hospital Healthcare System, Fremont | 2.1.3 | OB Hemorrhage: Massive Transfusion | 0 | 0 | 149 | 0 | 1 | 0 | 0 | None | 1 | 0 | 573000 |
| DY14 | DMPH | Washington Hospital Healthcare System, Fremont | 2.1.4 | OB Hemorrhage: Total Products Transfused | None | 1 | 149 | 0 | 1 | None | 1 | None | 1 | 0 | 573000 |
| DY14 | DMPH | Washington Hospital Healthcare System, Fremont | 2.1.5 | PC-02 Cesarean Section | None | 1 | 44 | 0 | 0 | None | 1 | 0.169 | 0 | 0 | 573000 |
| DY14 | DMPH | Washington Hospital Healthcare System, Fremont | 2.1.6 | Prenatal and Postpartum Care: Prenatal Care | 513 | 0 | 541 | 0 | 1 | 0.9482 | 0 | 0.932454695 | 0 | 0.9167 | 286500 |
| DY14 | DMPH | Washington Hospital Healthcare System, Fremont | 2.1.6 | Prenatal and Postpartum Care: Postpartum Care | 454 | 0 | 541 | 0 | 1 | 0.8392 | 0 | 0.84184514 | 0 | 0.7367 | 286500 |
| DY14 | DMPH | Washington Hospital Healthcare System, Fremont | 2.1.7 | Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage | None | 1 | None | 1 | 0 | None | 1 | None | 1 | 0 | 0 |
| DY14 | DMPH | Washington Hospital Healthcare System, Fremont | 2.1.8 | Unexpected Newborn Complications (UNC) | None | 1 | 125 | 0 | 1 | None | 1 | None | 1 | 0 | 573000 |
| DY14 | DMPH | Washington Hospital Healthcare System, Fremont | 2.1.9 | OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes | Yes | 0 | 3 Safety Drills? | 0 | n/a | 0 | 0 | None | 0 | None | 191000 |
| DY14 | DMPH | Washington Hospital Healthcare System, Fremont | 2.1.9 | OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes | Yes | 0 | 10 Debriefs? | 0 | n/a | 0 | 0 | None | 0 | None | 191000 |
| DY14 | DMPH | Washington Hospital Healthcare System, Fremont | 2.1.9 | OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) |
16 | 0 | 16 | 0 | 1 | 1 | 0 | 1 | 0 | None | 191000 |
| DY14 | DMPH | Washington Hospital Healthcare System, Fremont | 2.7.1 | Advance Care Plan | 202 | 0 | 267 | 0 | 1 | 0.7566 | 0 | 0.6156 | 0 | 0 | 573000 |
| DY14 | DMPH | Washington Hospital Healthcare System, Fremont | 2.7.3 | MWM #8: Treatment Preferences (documentation) Inpatient | 116 | 0 | 122 | 0 | 1 | 0.9508 | 0 | 0.9667 | 0 | 0 | 573000 |
| DY14 | DMPH | Washington Hospital Healthcare System, Fremont | 2.7.4 | MWM #8: Treatment Preferences (documentation) Outpatient | 29 | 0 | 31 | 0 | 1 | 0.9355 | 0 | None | 1 | 0 | 0 |
| DY14 | DMPH | Washington Hospital Healthcare System, Fremont | 2.7.5 | Palliative Care Service Offered at Time of Diagnosis of Advanced Illness | 63 | 0 | 456 | 0 | 1 | 0.1382 | 0 | 0.1293 | 0 | 0 | 573000 |
| DY14 | DMPH | Washington Hospital Healthcare System, Fremont | 2.7.6 | Proportion Admitted to Hospice for Less Than 3 Days | None | 1 | 38 | 0 | 1 | None | 1 | None | 1 | 0 | 573000 |