Table: quality_incentive_pool_qip_program_data_prime_transitio_7efe0142

py	type	hospital	number	title	report_status	baseline_rate	baseline_annotation_code	target_rate	numerator	numerator_annotation_code	denominator	denominator_annotation_code	achievement_rate	achievement_rate_annotation_code	achievement_value
PY3.5	DPH	Alameda Health System	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.1189	0	0.0216	3317	0	20981	0	0.1581	0	1
PY3.5	DPH	Alameda Health System	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.753	0	0.067	17327	0	20981	0	0.8258	0	1
PY3.5	DPH	Alameda Health System	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.3355	0	0	1439	0	4777	0	0.3012	0	1
PY3.5	DPH	Alameda Health System	1.1.5.f	Screening for Clinical Depression and follow-up	None	0.8463	0	0	15150	0	16968	0	0.8929	0	1
PY3.5	DPH	Alameda Health System	1.1.6.t	Tobacco Assessment and Counseling	None	0.9888	0	0	13796	0	13909	0	0.9919	0	1
PY3.5	DPH	Alameda Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	0.152	0	0.0198	74	0	537	0	0.1378	0	1
PY3.5	DPH	Alameda Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	0.2743	0	0.0419	138	0	537	0	0.257	0	1
PY3.5	DPH	Alameda Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	None	0.6552	0	0.1935	348	0	537	0	0.648	0	1
PY3.5	DPH	Alameda Health System	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.753	0	0.0216	3317	0	20981	0	0.1581	0	1
PY3.5	DPH	Alameda Health System	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.1189	0	0.067	17327	0	20981	0	0.8258	0	1
PY3.5	DPH	Alameda Health System	1.2.10	REAL and/or SO/GI disparity reduction	None	0.3982	0	0	435	0	1236	0	0.3519	0	1
PY3.5	DPH	Alameda Health System	1.2.11	REAL data completeness	None	0.6782	0	0	18490	0	27084	0	0.6827	0	1
PY3.5	DPH	Alameda Health System	1.2.12.f	Screening for Clinical Depression and follow-up	None	0.8463	0	0	15150	0	16968	0	0.8929	0	1
PY3.5	DPH	Alameda Health System	1.2.13	SO/GI data completeness	None	0.8623	0	0	17258	0	19232	0	0.8974	0	1
PY3.5	DPH	Alameda Health System	1.2.14.t	Tobacco Assessment and Counseling	None	0.9888	0	0	13796	0	13909	0	0.9919	0	1
PY3.5	DPH	Alameda Health System	1.2.2	CG-CAHPS: Provider Rating	None	0.7567	0	0	1640	0	2239	0	0.7325	0	0
PY3.5	DPH	Alameda Health System	1.2.3.c	Colorectal Cancer Screening	None	0.6139	0	0	6378	0	9927	0	0.6425	0	1
PY3.5	DPH	Alameda Health System	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.3355	0	0	1439	0	4777	0	0.3012	0	1
PY3.5	DPH	Alameda Health System	1.2.5.b	Controlling Blood Pressure	None	0.6325	0	0	4717	0	7051	0	0.669	0	1
PY3.5	DPH	Alameda Health System	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.9305	0	0	621	0	662	0	0.9381	0	1
PY3.5	DPH	Alameda Health System	1.2.8	Prevention Quality Overall Composite #90	None	0.0089	0	0	355	0	41487	0	0.0086	0	1
PY3.5	DPH	Alameda Health System	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	None	0.926	0	0	13932	0	14330	0	0.9722	0	1
PY3.5	DPH	Alameda Health System	1.3.2	DHCS All-Cause Readmissions	None	0.1824	0	0	152	0	867	0	0.1753	0	0
PY3.5	DPH	Alameda Health System	1.3.3	Influenza Immunization	None	0.8309	0	0	3237	0	3965	0	0.8164	0	1
PY3.5	DPH	Alameda Health System	1.3.5	Request for Specialty Care Expertise Turnaround Time	None	0.8606	0	0	20991	0	27065	0	0.7756	0	1
PY3.5	DPH	Alameda Health System	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	None	0.0426	0	0	1004	0	25329	0	0.0396	0	1
PY3.5	DPH	Alameda Health System	1.3.7	Tobacco Assessment and Counseling	None	0.9892	0	0	5644	0	5690	0	0.9919	0	1
PY3.5	DPH	Alameda Health System	1.5.1.b	Controlling Blood Pressure	None	0.6325	0	0	4717	0	7051	0	0.669	0	1
PY3.5	DPH	Alameda Health System	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.9305	0	0	621	0	662	0	0.9381	0	1
PY3.5	DPH	Alameda Health System	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	None	0.8863	0	0	10215	0	11112	0	0.9193	0	1
PY3.5	DPH	Alameda Health System	1.5.4.t	Tobacco Assessment and Counseling	None	0.9888	0	0	13796	0	13909	0	0.9919	0	1
PY3.5	DPH	Alameda Health System	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	None	0	0	None	Yes	0	BFUSA Cert?	0	1	0	1
PY3.5	DPH	Alameda Health System	2.1.2	Exclusive Breast Milk Feeding (PC-05)	None	0.6638	0	0	161	0	237	0	0.6793	0	1
PY3.5	DPH	Alameda Health System	2.1.3	OB Hemorrhage: Massive Transfusion	None	None	1	0	None	1	865	0	None	1	1
PY3.5	DPH	Alameda Health System	2.1.5	PC-02 Cesarean Section	None	0.1934	0	0	61	0	295	0	0.2068	0	1
PY3.5	DPH	Alameda Health System	2.1.6	Prenatal and Postpartum Care: Postpartum Care	None	0.6697	0	0.713	693	0	901	0	0.7691	0	1
PY3.5	DPH	Alameda Health System	2.1.6	Prenatal and Postpartum Care: Prenatal Care	None	0.8925	0	0.7689	809	0	891	0	0.908	0	1
PY3.5	DPH	Alameda Health System	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	0.2885	0	0	21	0	92	0	0.2283	0	1
PY3.5	DPH	Alameda Health System	2.1.8	Unexpected Newborn Complications (UNC)	None	0.0601	0	0	38	0	713	0	0.0533	0	1
PY3.5	DPH	Alameda Health System	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes	None	0	0	None	Yes	0	10 Debriefs?	0	0	None	n/a
PY3.5	DPH	Alameda Health System	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	None	0	0	None	Yes	0	3 Safety Drills?	0	0	None	n/a
PY3.5	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)	None	1	0	None	16	0	16	0	1	0	1
PY3.5	DPH	Alameda Health System	2.2.1	DHCS All-Cause Readmissions	None	0.1748	0	0	154	0	901	0	0.1709	0	0
PY3.5	DPH	Alameda Health System	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.438	0	0	4450	0	10000	0	0.445	0	0
PY3.5	DPH	Alameda Health System	2.2.3	Medication Reconciliation – 30 days	None	0.9871	0	0	1226	0	1285	0	0.9541	0	1
PY3.5	DPH	Alameda Health System	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.9157	0	0	1876	0	2163	0	0.8673	0	1
PY3.5	DPH	Alameda Health System	2.2.5	Timely Transmission of Transition Record	None	0.5191	0	0	968	0	2096	0	0.4618	0	1
PY3.5	DPH	Alameda Health System	2.3.2	Medication Reconciliation – 30 days	None	0.988	0	0	1160	0	1210	0	0.9587	0	1
PY3.5	DPH	Alameda Health System	2.3.4	Timely Transmission of Transition Record	None	0.55	0	0	929	0	1910	0	0.4864	0	1
PY3.5	DPH	Alameda Health System	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.85	0	0.067	2936	0	3230	0	0.909	0	1
PY3.5	DPH	Alameda Health System	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.1676	0	0.0216	697	0	3230	0	0.2158	0	1
PY3.5	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	None	0.6	0	0	59	0	94	0	0.6277	0	1
PY3.5	DPH	Alameda Health System	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	None	1	0	0	94	0	94	0	1	0	1
PY3.5	DPH	Alameda Health System	2.6.4	Screening for Clinical Depression and follow-up	None	0.8853	0	0	2415	0	2638	0	0.9155	0	1
PY3.5	DPH	Alameda Health System	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	None	0.9771	0	0	3192	0	3242	0	0.9846	0	1
PY3.5	DPH	Alameda Health System	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	None	0.5645	0	0	48	0	80	0	0.6	0	1
PY3.5	DPH	Alameda Health System	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	None	0.1478	0	0	20153	0	131488	0	0.1533	0	1
PY3.5	DPH	Alameda Health System	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	None	0.0985	0	0	63	0	301	0	0.2093	0	1
PY3.5	DPH	Alameda Health System	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR	None	0.644	0	0.6388	7310	0	10000	0	0.731	0	1
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	None	0	0	None	Yes	0	BFUSA Cert?	0	1	0	1
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	2.1.2	Exclusive Breast Milk Feeding (PC-05)	None	0.5689	0	0	173	0	305	0	0.5672	0	1
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	2.1.3	OB Hemorrhage: Massive Transfusion	None	None	1	0	None	1	1809	0	None	1	1
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	2.1.5	PC-02 Cesarean Section	None	0.2628	0	0	136	0	515	0	0.2641	0	0
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	2.1.6	Prenatal and Postpartum Care: Prenatal Care	None	0.1447	0	0.7689	33	0	310	0	0.1065	0	0
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	2.1.6	Prenatal and Postpartum Care: Postpartum Care	None	0.6302	0	0.713	202	0	313	0	0.6454	0	0
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	0.2	0	0	18	0	99	0	0.1818	0	1
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	2.1.8	Unexpected Newborn Complications (UNC)	None	0.0157	0	0	27	0	1461	0	0.0185	0	1
PY3.5	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	None	0	0	None	Yes	0	10 Debriefs?	0	0	None	n/a
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	None	0	0	None	Yes	0	3 Safety Drills?	0	0	None	n/a
PY3.5	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)	None	1	0	None	16	0	16	0	1	0	1
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	2.2.1	DHCS All-Cause Readmissions	None	0.0906	0	0	445	0	4999	0	0.089	0	1
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.4733	0	0	1665	0	3343	0	0.4981	0	1
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	2.2.3	Medication Reconciliation – 30 days	None	1	0	0	42	0	42	0	1	0	1
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.9577	0	0	4236	0	4377	0	0.9678	0	1
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	2.2.5	Timely Transmission of Transition Record	None	0.1532	0	0	858	0	4922	0	0.1743	0	0
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	2.3.2	Medication Reconciliation – 30 days	None	1	0	0	42	0	42	0	1	0	1
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	2.3.4	Timely Transmission of Transition Record	None	0.1292	0	0	130	0	910	0	0.1429	0	0
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	2.7.1	Advance Care Plan	None	0.7674	0	0	445	0	559	0	0.7961	0	1
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	None	0.875	0	0	107	0	127	0	0.8425	0	1
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	None	1	0	0	42	0	42	0	1	0	1
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	None	0.2329	0	0	17	0	51	0	0.3333	0	1
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	None	0.1875	0	0	11	0	53	0	0.2075	0	1
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	None	0.8596	0	0	128	0	154	0	0.8312	0	1
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	None	0.381	0	0	29310	0	83249	0	0.3521	0	1
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	None	0.1111	0	0	32	0	217	0	0.1475	0	1
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR	None	0.693	0	0.6829	5960	0	10000	0	0.596	0	1
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	3.2.2	Appropriate Emergency Department Utilization of CT for Pulmonary Embolism	None	0.5605	0	0	191	0	354	0	0.5395	0	1
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	3.2.3	Use of Imaging Studies for Low Back Pain	None	0.8599	0	0	3414	0	3929	0	0.8689	0	1
PY3.5	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	None	1	0	None	293	0	318	0	0.9214	0	1
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	3.4.1	ePBM-01 Pre-op Anemia Screening, Selected Elective Surgical Patients	None	0.4151	0	0	185	0	490	0	0.3776	0	1
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	3.4.3	ePBM-03 Pre-op Type and Crossmatch, Type and Screen, Selected elective Surgical Patients	None	0.6014	0	0	241	0	491	0	0.4908	0	1
PY3.5	DMPH	Antelope Valley Hospital, Lancaster	3.4.4	ePBM-04 Initial Transfusion Threshold	None	1	0	0	558	0	558	0	1	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.005	0	0.0216	59	0	18530	0	0.0032	0	0
PY3.5	DPH	Arrowhead Regional Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.0256	0	0.067	281	0	18530	0	0.0152	0	0
PY3.5	DPH	Arrowhead Regional Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.3561	0	0	1960	0	5875	0	0.3336	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	None	0.903	0	0	6437	0	7044	0	0.9138	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	1.1.6.t	Tobacco Assessment and Counseling	None	0.9855	0	0	15305	0	15473	0	0.9891	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	None	0.1028	0	0.1935	None	1	97	0	None	1	0
PY3.5	DPH	Arrowhead Regional Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	None	1	0.0198	None	1	97	0	None	1	1
PY3.5	DPH	Arrowhead Regional Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	None	1	0.0419	None	1	97	0	None	1	1
PY3.5	DPH	Arrowhead Regional Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.0256	0	0.067	281	0	18530	0	0.0152	0	0
PY3.5	DPH	Arrowhead Regional Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.005	0	0.0216	59	0	18530	0	0.0032	0	0
PY3.5	DPH	Arrowhead Regional Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	None	0.5693	0	0	975	0	1546	0	0.6307	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	1.2.11	REAL data completeness	None	0.8638	0	0	12277	0	14140	0	0.8682	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	None	0.903	0	0	6430	0	7008	0	0.9175	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	1.2.13	SO/GI data completeness	None	0.9846	0	0	13205	0	13326	0	0.9909	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	1.2.14.t	Tobacco Assessment and Counseling	None	0.9855	0	0	15305	0	15473	0	0.9891	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	1.2.2	CG-CAHPS: Provider Rating	None	0.8206	0	0	1016	0	1243	0	0.8174	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	1.2.3.c	Colorectal Cancer Screening	None	0.5616	0	0	5364	0	9056	0	0.5923	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.3561	0	0	1960	0	5875	0	0.3336	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	1.2.5.b	Controlling Blood Pressure	None	0.5482	0	0	3998	0	7106	0	0.5626	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.8651	0	0	566	0	647	0	0.8748	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	1.2.8	Prevention Quality Overall Composite #90	None	0.0807	0	0	564	0	5604	0	0.1006	0	0
PY3.5	DPH	Arrowhead Regional Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	None	0.8494	0	0	26541	0	29463	0	0.9008	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	1.3.2	DHCS All-Cause Readmissions	None	0.0934	0	0	45	0	422	0	0.1066	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	1.3.3	Influenza Immunization	None	0.3939	0	0	191	0	370	0	0.5162	0	0
PY3.5	DPH	Arrowhead Regional Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	None	0.924	0	0	41237	0	43616	0	0.9455	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	None	0.3651	0	0	11611	0	43616	0	0.2662	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	1.3.7	Tobacco Assessment and Counseling	None	0.9911	0	0	128	0	130	0	0.9846	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	1.7.1	BMI Screening and Follow-up	None	0.6525	0	0	212	0	370	0	0.573	0	1
PY3.5	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)	None	None	1	None	8	0	8	0	1	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity	None	0.6516	0	0.5231	1983	0	2745	0	0.7224	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition	None	0.7501	0	0.5985	2195	0	2745	0	0.7996	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI	None	0.957	0	0.66	2692	0	2745	0	0.9807	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	None	0	0	None	Yes	0	BFUSA Cert?	0	1	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	None	0.7197	0	0	160	0	217	0	0.7373	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	None	1	0	None	1	706	0	None	1	1
PY3.5	DPH	Arrowhead Regional Medical Center	2.1.5	PC-02 Cesarean Section	None	0.25	0	0	45	0	195	0	0.2308	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	None	0.8316	0	0.713	62	0	347	0	0.1787	0	0
PY3.5	DPH	Arrowhead Regional Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	None	0.7354	0	0.7689	66	0	347	0	0.1902	0	0
PY3.5	DPH	Arrowhead Regional Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	0.493	0	0	40	0	70	0	0.5714	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	None	0.0685	0	0	28	0	522	0	0.0536	0	1
PY3.5	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	None	0	0	None	Yes	0	10 Debriefs?	0	0	None	n/a
PY3.5	DPH	Arrowhead Regional Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	None	0	0	None	Yes	0	3 Safety Drills?	0	0	None	n/a
PY3.5	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)	None	1	0	None	16	0	16	0	1	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	2.2.1	DHCS All-Cause Readmissions	None	0.0981	0	0	88	0	808	0	0.1089	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.6546	0	0	554	0	1165	0	0.4755	0	0
PY3.5	DPH	Arrowhead Regional Medical Center	2.2.3	Medication Reconciliation – 30 days	None	0.7859	0	0	267	0	370	0	0.7216	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.9858	0	0	338	0	370	0	0.9135	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	2.2.5	Timely Transmission of Transition Record	None	0.9654	0	0	2787	0	2861	0	0.9741	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	2.3.2	Medication Reconciliation – 30 days	None	0.6846	0	0	268	0	273	0	0.9817	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	2.3.4	Timely Transmission of Transition Record	None	0.8944	0	0	1227	0	1378	0	0.8904	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.0461	0	0.067	98	0	2326	0	0.0421	0	0
PY3.5	DPH	Arrowhead Regional Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.0096	0	0.0216	None	1	2326	0	None	1	0
PY3.5	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	None	0.3516	0	0	47	0	107	0	0.4393	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	None	0.4688	0	0	80	0	154	0	0.5195	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	2.6.4	Screening for Clinical Depression and follow-up	None	0.8945	0	0	1524	0	1666	0	0.9148	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	None	0.8904	0	0	1666	0	1820	0	0.9154	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	None	0.4167	0	0	36	0	83	0	0.4337	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	None	0.2416	0	0	1093	0	7014	0	0.1558	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	None	None	1	0	27	0	1788	0	0.0151	0	1
PY3.5	DPH	Arrowhead Regional Medical Center	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR	None	0.184	0	0.592	1400	0	10000	0	0.14	0	1
PY3.5	DMPH	Bear Valley Community Hospital, Big Bear Lake	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.7011	0	0.067	1778	0	1940	0	0.9165	0	1
PY3.5	DMPH	Bear Valley Community Hospital, Big Bear Lake	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.1317	0	0.0216	253	0	1940	0	0.1304	0	1
PY3.5	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	None	1	0	0	103	0	105	0	0.981	0	1
PY3.5	DMPH	Bear Valley Community Hospital, Big Bear Lake	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	None	1	0	0	105	0	105	0	1	0	1
PY3.5	DMPH	Bear Valley Community Hospital, Big Bear Lake	2.6.4	Screening for Clinical Depression and follow-up	None	0.8531	0	0	793	0	945	0	0.8392	0	1
PY3.5	DMPH	Bear Valley Community Hospital, Big Bear Lake	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	None	1	0	0	105	0	105	0	1	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.5303	0	0.067	31697	0	49483	0	0.6406	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.1528	0	0.0216	8671	0	49483	0	0.1752	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.3031	0	0	2356	0	8811	0	0.2674	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	None	0.6879	0	0	23529	0	29050	0	0.8099	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.1.6.t	Tobacco Assessment and Counseling	None	0.9917	0	0	38357	0	38698	0	0.9912	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	0.0416	0	0.0198	78	0	1908	0	0.0409	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	0.0933	0	0.0419	181	0	1908	0	0.0949	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	None	0.3008	0	0.1935	599	0	1908	0	0.3139	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.5303	0	0.067	31697	0	49483	0	0.6406	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.1528	0	0.0216	8671	0	49483	0	0.1752	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	None	0.6752	0	0	1769	0	2604	0	0.6793	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.2.11	REAL data completeness	None	0.9941	0	0	57964	0	58285	0	0.9945	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	None	0.6879	0	0	23529	0	29050	0	0.8099	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.2.13	SO/GI data completeness	None	0.9953	0	0	40883	0	40976	0	0.9977	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.2.14.t	Tobacco Assessment and Counseling	None	0.9917	0	0	38357	0	38698	0	0.9912	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.2.2	CG-CAHPS: Provider Rating	None	0.7891	0	0	10055	0	12665	0	0.7939	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.2.3.c	Colorectal Cancer Screening	None	0.6032	0	0	12977	0	19248	0	0.6742	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.3031	0	0	2356	0	8811	0	0.2674	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.2.5.b	Controlling Blood Pressure	None	0.71	0	0	8961	0	12522	0	0.7156	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.9221	0	0	1235	0	1336	0	0.9244	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.2.8	Prevention Quality Overall Composite #90	None	0.0069	0	0	488	0	61756	0	0.0079	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	None	1	0	0	17786	0	17786	0	1	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.3.2	DHCS All-Cause Readmissions	None	0.1004	0	0	102	0	1049	0	0.0972	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.3.3	Influenza Immunization	None	0.9481	0	0	16809	0	17857	0	0.9413	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	None	0.8394	0	0	44429	0	52823	0	0.8411	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	None	0.0242	0	0	285	0	12802	0	0.0223	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.3.7	Tobacco Assessment and Counseling	None	0.9924	0	0	27829	0	28035	0	0.9927	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.6.1	BIRADS to Biopsy	None	0.88	0	0	56	0	65	0	0.8615	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.6.2	Breast Cancer Screening	None	0.7138	0	0	9690	0	12421	0	0.7801	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.6.3	Cervical Cancer Screening	None	0.6379	0	0	16770	0	25034	0	0.6699	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.6.4.c	Colorectal Cancer Screening	None	0.6032	0	0	12977	0	19248	0	0.6742	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	None	0.6021	0	0	207	0	335	0	0.6179	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	None	0	0	None	Yes	0	BFUSA Cert?	0	1	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	None	0.7577	0	0	1059	0	1402	0	0.7553	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	0	0	0	None	1	1567	0	None	1	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.1.5	PC-02 Cesarean Section	None	0.1578	0	0	87	0	507	0	0.1716	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	None	0.9316	0	0.7689	1202	0	1286	0	0.9347	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	None	0.8129	0	0.713	1356	0	1503	0	0.9022	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	0.1782	0	0	39	0	217	0	0.1797	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	None	0.0309	0	0	43	0	1332	0	0.0323	0	1
PY3.5	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	None	0	0	None	Yes	0	10 Debriefs?	0	0	None	n/a
PY3.5	DPH	Contra Costa Regional Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	None	0	0	None	Yes	0	3 Safety Drills?	0	0	None	n/a
PY3.5	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)	None	1	0	None	16	0	16	0	1	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.2.1	DHCS All-Cause Readmissions	None	0.0929	0	0	107	0	1154	0	0.0927	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.5651	0	0	331	0	577	0	0.5737	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.2.3	Medication Reconciliation – 30 days	None	0.9968	0	0	2781	0	2793	0	0.9957	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.9965	0	0	4404	0	4424	0	0.9955	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.2.5	Timely Transmission of Transition Record	None	0.7888	0	0	3338	0	3800	0	0.8784	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.3.2	Medication Reconciliation – 30 days	None	0.9943	0	0	1216	0	1226	0	0.9918	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.3.4	Timely Transmission of Transition Record	None	0.8385	0	0	1432	0	1633	0	0.8769	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.4.1	Adolescent Well-Care Visit	None	0.8684	0	0	59	0	74	0	0.7973	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.4.2	Developmental Screening in the First Three Years of Life	None	0.8904	0	0	55	0	74	0	0.7432	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.4.3	Documentation of Current Medications in the Medical Record (0-18 yo)	None	0.9496	0	0	531	0	563	0	0.9432	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.4.4	Screening for Clinical Depression and follow-up	None	0.84	0	0	43	0	51	0	0.8431	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.4.5	Tobacco Assessment and Counseling (13 yo and older)	None	1	0	0	52	0	54	0	0.963	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.4.7	Well Child Visits - Third, Fourth, Fifth, and Sixth Years of life	None	0.875	0	0	38	0	44	0	0.8636	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.4.8	Comprehensive Medical Evaluation Following Foster Youth Placement in Foster Care	None	0.6406	0	0	49	0	70	0	0.7	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.5601	0	0.067	1551	0	2177	0	0.7124	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.108	0	0.0216	275	0	2177	0	0.1263	0	1
PY3.5	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	None	0.8049	0	0	169	0	187	0	0.9037	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	None	0.9878	0	0	184	0	187	0	0.984	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.6.4	Screening for Clinical Depression and follow-up	None	0.6911	0	0	750	0	887	0	0.8455	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	None	0.9006	0	0	2021	0	2222	0	0.9095	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	3.2.2	Appropriate Emergency Department Utilization of CT for Pulmonary Embolism	None	0.9654	0	0	280	0	296	0	0.9459	0	1
PY3.5	DPH	Contra Costa Regional Medical Center	3.2.3	Use of Imaging Studies for Low Back Pain	None	0.8324	0	0	2458	0	2981	0	0.8246	0	1
PY3.5	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	None	0.8691	0	None	1459	0	1841	0	0.7925	0	1
PY3.5	DMPH	Eastern Plumas Health Care, Portol	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.4403	0	0.067	524	0	953	0	0.5498	0	1
PY3.5	DMPH	Eastern Plumas Health Care, Portol	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.4246	0	0.0216	507	0	953	0	0.532	0	1
PY3.5	DMPH	Eastern Plumas Health Care, Portol	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.2966	0	0	32	0	105	0	0.3048	0	1
PY3.5	DMPH	Eastern Plumas Health Care, Portol	1.1.5.f	Screening for Clinical Depression and follow-up	None	0.5147	0	0	310	0	491	0	0.6314	0	1
PY3.5	DMPH	Eastern Plumas Health Care, Portol	1.1.6.t	Tobacco Assessment and Counseling	None	0.827	0	0	794	0	956	0	0.8305	0	1
PY3.5	DMPH	Eastern Plumas Health Care, Portol	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	None	1	0.0198	12	0	108	0	0.1111	0	1
PY3.5	DMPH	Eastern Plumas Health Care, Portol	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	0.219	0	0.0419	28	0	108	0	0.2593	0	1
PY3.5	DMPH	Eastern Plumas Health Care, Portol	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	None	0.7143	0	0.1935	81	0	108	0	0.75	0	1
PY3.5	DMPH	Eastern Plumas Health Care, Portol	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.6495	0	0.067	80	0	107	0	0.7477	0	1
PY3.5	DMPH	Eastern Plumas Health Care, Portol	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.6495	0	0.0216	80	0	107	0	0.7477	0	1
PY3.5	DMPH	Eastern Plumas Health Care, Portol	2.6.2	Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen	None	0.4557	0	0	61	0	83	0	0.7349	0	1
PY3.5	DMPH	Eastern Plumas Health Care, Portol	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	None	0.7595	0	0	53	0	83	0	0.6386	0	1
PY3.5	DMPH	Eastern Plumas Health Care, Portol	2.6.4	Screening for Clinical Depression and follow-up	None	0.5439	0	0	34	0	56	0	0.6071	0	1
PY3.5	DMPH	Eastern Plumas Health Care, Portol	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	None	0.9381	0	0	103	0	107	0	0.9626	0	1
PY3.5	DMPH	El Camino Hospital, Mountain View	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.8933	0	0.067	4403	0	4985	0	0.8832	0	1
PY3.5	DMPH	El Camino Hospital, Mountain View	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.051	0	0.0216	164	0	4985	0	0.0329	0	1
PY3.5	DMPH	El Camino Hospital, Mountain View	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.2588	0	0	150	0	636	0	0.2358	0	1
PY3.5	DMPH	El Camino Hospital, Mountain View	1.1.5.f	Screening for Clinical Depression and follow-up	None	0.8583	0	0	3846	0	4353	0	0.8835	0	1
PY3.5	DMPH	El Camino Hospital, Mountain View	1.1.6.t	Tobacco Assessment and Counseling	None	0.9163	0	0	4091	0	4433	0	0.9229	0	1
PY3.5	DMPH	El Camino Hospital, Mountain View	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	0.2092	0	0.0198	115	0	671	0	0.1714	0	1
PY3.5	DMPH	El Camino Hospital, Mountain View	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	0.3367	0	0.0419	179	0	671	0	0.2668	0	1
PY3.5	DMPH	El Camino Hospital, Mountain View	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	None	0.6693	0	0.1935	364	0	671	0	0.5425	0	1
PY3.5	DMPH	El Camino Hospital, Mountain View	2.1.1	Baby Friendly Hospital designation: BFUSA Designation No	None	0	0	None	No	0	BFUSA Cert?	0	0	0	0
PY3.5	DMPH	El Camino Hospital, Mountain View	2.1.2	Exclusive Breast Milk Feeding (PC-05)	None	0.4881	0	0	36	0	65	0	0.5538	0	1
PY3.5	DMPH	El Camino Hospital, Mountain View	2.1.3	OB Hemorrhage: Massive Transfusion	None	0	0	0	0	0	75	0	0	0	1
PY3.5	DMPH	El Camino Hospital, Mountain View	2.1.5	PC-02 Cesarean Section	None	None	1	0	None	1	None	4	None	1	0
PY3.5	DMPH	El Camino Hospital, Mountain View	2.1.6	Prenatal and Postpartum Care: Prenatal Care	None	0.5926	0	0.7689	112	0	153	0	0.732	0	0
PY3.5	DMPH	El Camino Hospital, Mountain View	2.1.6	Prenatal and Postpartum Care: Postpartum Care	None	0.7407	0	0.713	128	0	153	0	0.8366	0	1
PY3.5	DMPH	El Camino Hospital, Mountain View	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	None	1	0	None	1	None	1	None	1	0
PY3.5	DMPH	El Camino Hospital, Mountain View	2.1.8	Unexpected Newborn Complications (UNC)	None	None	1	0	None	1	65	0	None	1	1
PY3.5	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)	None	1	0	None	32	0	32	0	1	0	1
PY3.5	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	None	0	0	None	Yes	0	10 Debriefs?	0	0	None	n/a
PY3.5	DMPH	El Camino Hospital, Mountain View	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter No	None	0	0	None	No	0	3 Safety Drills?	0	0	None	n/a
PY3.5	DMPH	El Camino Hospital, Mountain View	3.4.1	ePBM-01 Pre-op Anemia Screening, Selected Elective Surgical Patients	None	None	1	0	None	1	None	4	None	1	0
PY3.5	DMPH	El Camino Hospital, Mountain View	3.4.3	ePBM-03 Pre-op Type and Crossmatch, Type and Screen, Selected elective Surgical Patients	None	None	1	0	None	1	None	4	None	1	0
PY3.5	DMPH	El Camino Hospital, Mountain View	3.4.4	ePBM-04 Initial Transfusion Threshold	None	0.9821	0	0	119	0	121	0	0.9835	0	1
PY3.5	DMPH	El Centro Regional Medical Center, El Centro	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.8216	0	0.067	6667	0	8342	0	0.7992	0	1
PY3.5	DMPH	El Centro Regional Medical Center, El Centro	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.0969	0	0.0216	508	0	8342	0	0.0609	0	1
PY3.5	DMPH	El Centro Regional Medical Center, El Centro	1.2.10	REAL and/or SO/GI disparity reduction	None	0.177	0	0	289	0	474	0	0.6097	0	1
PY3.5	DMPH	El Centro Regional Medical Center, El Centro	1.2.11	REAL data completeness	None	0.7584	0	0	9228	0	10062	0	0.9171	0	1
PY3.5	DMPH	El Centro Regional Medical Center, El Centro	1.2.12.f	Screening for Clinical Depression and follow-up	None	0.6981	0	0	5403	0	7176	0	0.7529	0	1
PY3.5	DMPH	El Centro Regional Medical Center, El Centro	1.2.13	SO/GI data completeness	None	0.8492	0	0	5950	0	7169	0	0.83	0	1
PY3.5	DMPH	El Centro Regional Medical Center, El Centro	1.2.14.t	Tobacco Assessment and Counseling	None	0.7096	0	0	4437	0	7169	0	0.6189	0	0
PY3.5	DMPH	El Centro Regional Medical Center, El Centro	1.2.2	CG-CAHPS: Provider Rating	None	0.7596	0	0	1428	0	1939	0	0.7365	0	0
PY3.5	DMPH	El Centro Regional Medical Center, El Centro	1.2.3.c	Colorectal Cancer Screening	None	0.4509	0	0	1631	0	3410	0	0.4783	0	1
PY3.5	DMPH	El Centro Regional Medical Center, El Centro	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.2114	0	0	305	0	1203	0	0.2535	0	1
PY3.5	DMPH	El Centro Regional Medical Center, El Centro	1.2.5.b	Controlling Blood Pressure	None	0.7322	0	0	1332	0	1733	0	0.7686	0	1
PY3.5	DMPH	El Centro Regional Medical Center, El Centro	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.7807	0	0	192	0	235	0	0.817	0	1
PY3.5	DMPH	El Centro Regional Medical Center, El Centro	1.2.8	Prevention Quality Overall Composite #90	None	0.0502	0	0	318	0	7169	0	0.0444	0	0
PY3.5	DMPH	El Centro Regional Medical Center, El Centro	1.7.1	BMI Screening and Follow-up	None	0.6095	0	0	4298	0	6976	0	0.6161	0	1
PY3.5	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)	None	None	1	None	8	0	8	0	1	0	1
PY3.5	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	None	0.5049	0	0.5985	1513	0	2818	0	0.5369	0	0
PY3.5	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	None	0.5049	0	0.5231	1513	0	2818	0	0.5369	0	1
PY3.5	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	None	0.989	0	0.66	2643	0	2818	0	0.9379	0	1
PY3.5	DMPH	El Centro Regional Medical Center, El Centro	3.2.2	Appropriate Emergency Department Utilization of CT for Pulmonary Embolism	None	0.9373	0	0	260	0	290	0	0.8966	0	1
PY3.5	DMPH	El Centro Regional Medical Center, El Centro	3.2.3	Use of Imaging Studies for Low Back Pain	None	0.7897	0	0	465	0	562	0	0.8274	0	1
PY3.5	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	None	0.5731	0	None	220	0	394	0	0.5584	0	1
PY3.5	DMPH	Hazel Hawkins Memorial Hospital, Hollister	2.3.2	Medication Reconciliation – 30 days	None	0.8	0	0	31	0	33	0	0.9394	0	1
PY3.5	DMPH	Hazel Hawkins Memorial Hospital, Hollister	2.3.4	Timely Transmission of Transition Record	None	0.9667	0	0	33	0	33	0	1	0	1
PY3.5	DMPH	Healdsburg District Hospital, Healdsburg	1.5.1.b	Controlling Blood Pressure	None	0.58	0	0	37	0	57	0	0.6491	0	1
PY3.5	DMPH	Healdsburg District Hospital, Healdsburg	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.92	0	0	48	0	51	0	0.9412	0	1
PY3.5	DMPH	Healdsburg District Hospital, Healdsburg	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	None	0.36	0	0	22	0	52	0	0.4231	0	0
PY3.5	DMPH	Healdsburg District Hospital, Healdsburg	1.5.4.t	Tobacco Assessment and Counseling	None	0.9745	0	0	551	0	608	0	0.9063	0	1
PY3.5	DMPH	Healdsburg District Hospital, Healdsburg	1.6.1	BIRADS to Biopsy	None	0	0	0	0	0	0	0	0	0	0
PY3.5	DMPH	Healdsburg District Hospital, Healdsburg	1.6.2	Breast Cancer Screening	None	0.7256	0	0	250	0	354	0	0.7062	0	1
PY3.5	DMPH	Healdsburg District Hospital, Healdsburg	1.6.3	Cervical Cancer Screening	None	0.656	0	0	342	0	498	0	0.6867	0	1
PY3.5	DMPH	Healdsburg District Hospital, Healdsburg	1.6.4.c	Colorectal Cancer Screening	None	0.665	0	0	190	0	292	0	0.6507	0	1
PY3.5	DMPH	Healdsburg District Hospital, Healdsburg	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	None	None	1	0	0	0	0	0	0	0	0
PY3.5	DMPH	Jerold Phelps Community Hospital, Garberville	1.5.1.b	Controlling Blood Pressure	None	0.5333	0	0	22	0	42	0	0.5238	0	0
PY3.5	DMPH	Jerold Phelps Community Hospital, Garberville	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	None	1	0	None	1	None	1	None	1	0
PY3.5	DMPH	Jerold Phelps Community Hospital, Garberville	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	None	0.8691	0	0	240	0	285	0	0.8421	0	1
PY3.5	DMPH	Jerold Phelps Community Hospital, Garberville	1.5.4.t	Tobacco Assessment and Counseling	None	0.9255	0	0	165	0	176	0	0.9375	0	1
PY3.5	DMPH	John C. Fremont Healthcare District, Mariposa	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.9567	0	0.067	734	0	781	0	0.9398	0	1
PY3.5	DMPH	John C. Fremont Healthcare District, Mariposa	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.0548	0	0.0216	41	0	781	0	0.0525	0	1
PY3.5	DMPH	John C. Fremont Healthcare District, Mariposa	1.2.10	REAL and/or SO/GI disparity reduction	None	0.2297	0	0	16	0	72	0	0.2222	0	1
PY3.5	DMPH	John C. Fremont Healthcare District, Mariposa	1.2.11	REAL data completeness	None	0.9767	0	0	730	0	833	0	0.8764	0	1
PY3.5	DMPH	John C. Fremont Healthcare District, Mariposa	1.2.12.f	Screening for Clinical Depression and follow-up	None	0.3657	0	0	463	0	680	0	0.6809	0	1
PY3.5	DMPH	John C. Fremont Healthcare District, Mariposa	1.2.13	SO/GI data completeness	None	0.9877	0	0	644	0	680	0	0.9471	0	1
PY3.5	DMPH	John C. Fremont Healthcare District, Mariposa	1.2.14.t	Tobacco Assessment and Counseling	None	0.8148	0	0	673	0	680	0	0.9897	0	1
PY3.5	DMPH	John C. Fremont Healthcare District, Mariposa	1.2.2	CG-CAHPS: Provider Rating	None	0.8295	0	0	362	0	406	0	0.8916	0	1
PY3.5	DMPH	John C. Fremont Healthcare District, Mariposa	1.2.3.c	Colorectal Cancer Screening	None	0.4282	0	0	149	0	414	0	0.3599	0	1
PY3.5	DMPH	John C. Fremont Healthcare District, Mariposa	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.2035	0	0	23	0	97	0	0.2371	0	1
PY3.5	DMPH	John C. Fremont Healthcare District, Mariposa	1.2.5.b	Controlling Blood Pressure	None	0.6628	0	0	188	0	237	0	0.7932	0	1
PY3.5	DMPH	John C. Fremont Healthcare District, Mariposa	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.8434	0	0	70	0	98	0	0.7143	0	0
PY3.5	DMPH	John C. Fremont Healthcare District, Mariposa	1.2.8	Prevention Quality Overall Composite #90	None	0.0448	0	0	70	0	648	0	0.108	0	0
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.4619	0	0.067	231	0	432	0	0.5347	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.2818	0	0.0216	120	0	432	0	0.2778	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	1.2.10	REAL and/or SO/GI disparity reduction	None	0.6884	0	0	131	0	196	0	0.6684	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	1.2.11	REAL data completeness	None	1	0	0	11900	0	11900	0	1	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	1.2.12.f	Screening for Clinical Depression and follow-up	None	0.7618	0	0	332	0	377	0	0.8806	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	1.2.13	SO/GI data completeness	None	0.3731	0	0	2756	0	6791	0	0.4058	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	1.2.14.t	Tobacco Assessment and Counseling	None	0.935	0	0	399	0	431	0	0.9258	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	1.2.2	CG-CAHPS: Provider Rating	None	0.7972	0	0	1137	0	1417	0	0.8024	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	1.2.3.c	Colorectal Cancer Screening	None	0.4275	0	0	162	0	403	0	0.402	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.3299	0	0	130	0	388	0	0.3351	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	1.2.5.b	Controlling Blood Pressure	None	0.6732	0	0	286	0	364	0	0.7857	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.9038	0	0	153	0	165	0	0.9273	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	1.2.8	Prevention Quality Overall Composite #90	None	0.0277	0	0	672	0	22958	0	0.0293	0	0
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	None	0.5396	0	0	203	0	370	0	0.5486	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	1.3.2	DHCS All-Cause Readmissions	None	0.13	0	0	206	0	1423	0	0.1448	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	1.3.3	Influenza Immunization	None	0.435	0	0	158	0	362	0	0.4365	0	0
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	1.3.5	Request for Specialty Care Expertise Turnaround Time	None	0.6594	0	0	6467	0	9997	0	0.6469	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	None	0.0374	0	0	338	0	11584	0	0.0292	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	1.3.7	Tobacco Assessment and Counseling	None	0.933	0	0	349	0	400	0	0.8725	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	1.5.1.b	Controlling Blood Pressure	None	0.6732	0	0	286	0	364	0	0.7857	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.9038	0	0	153	0	165	0	0.9273	0	1
PY3.5	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	None	0.8486	0	0	307	0	389	0	0.7892	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	1.5.4.t	Tobacco Assessment and Counseling	None	0.935	0	0	399	0	431	0	0.9258	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	2.2.1	DHCS All-Cause Readmissions	None	0.1299	0	0	549	0	4286	0	0.1281	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.4917	0	0	5072	0	10000	0	0.5072	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	2.2.3	Medication Reconciliation – 30 days	None	0.8217	0	0	299	0	371	0	0.8059	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.8867	0	0	319	0	433	0	0.7367	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	2.2.5	Timely Transmission of Transition Record	None	0.3719	0	0	130	0	420	0	0.3095	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	2.3.2	Medication Reconciliation – 30 days	None	0.9579	0	0	168	0	198	0	0.8485	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	2.3.4	Timely Transmission of Transition Record	None	0.4428	0	0	178	0	346	0	0.5145	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.8418	0	0.067	591	0	691	0	0.8553	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.791	0	0.0216	576	0	691	0	0.8336	0	1
PY3.5	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	None	0.6335	0	0	147	0	288	0	0.5104	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	None	0.8725	0	0	268	0	288	0	0.9306	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	2.6.4	Screening for Clinical Depression and follow-up	None	0.9319	0	0	421	0	466	0	0.9034	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	None	0.877	0	0	624	0	1696	0	0.3679	0	0
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	2.7.1	Advance Care Plan	None	0.6947	0	0	237	0	371	0	0.6388	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	None	1	0	0	259	0	259	0	1	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	None	None	4	0	29	0	30	0	0.9667	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	None	0.1382	0	0	122	0	1006	0	0.1213	0	1
PY3.5	DMPH	Kaweah Delta Health Care District, Visalia	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	None	0.2118	0	0	13	0	73	0	0.1781	0	1
PY3.5	DPH	Kern Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.4159	0	0.067	5086	0	12247	0	0.4153	0	1
PY3.5	DPH	Kern Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.4159	0	0.0216	5086	0	12247	0	0.4153	0	1
PY3.5	DPH	Kern Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.3756	0	0	861	0	2525	0	0.341	0	1
PY3.5	DPH	Kern Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	None	0.5925	0	0	4431	0	7314	0	0.6058	0	1
PY3.5	DPH	Kern Medical Center	1.1.6.t	Tobacco Assessment and Counseling	None	0.9788	0	0	9575	0	9839	0	0.9732	0	1
PY3.5	DPH	Kern Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	0.0268	0	0.0198	19	0	523	0	0.0363	0	1
PY3.5	DPH	Kern Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	0.0515	0	0.0419	34	0	523	0	0.065	0	1
PY3.5	DPH	Kern Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	None	0.1946	0	0.1935	123	0	523	0	0.2352	0	1
PY3.5	DPH	Kern Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.4159	0	0.067	5086	0	12247	0	0.4153	0	1
PY3.5	DPH	Kern Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.4159	0	0.0216	5086	0	12247	0	0.4153	0	1
PY3.5	DPH	Kern Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	None	0.9226	0	0	142	0	175	0	0.8114	0	1
PY3.5	DPH	Kern Medical Center	1.2.11	REAL data completeness	None	0.9711	0	0	16067	0	16782	0	0.9574	0	1
PY3.5	DPH	Kern Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	None	0.5925	0	0	4431	0	7314	0	0.6058	0	1
PY3.5	DPH	Kern Medical Center	1.2.13	SO/GI data completeness	None	0.796	0	0	5744	0	9992	0	0.5749	0	1
PY3.5	DPH	Kern Medical Center	1.2.14.t	Tobacco Assessment and Counseling	None	0.9788	0	0	9575	0	9839	0	0.9732	0	1
PY3.5	DPH	Kern Medical Center	1.2.2	CG-CAHPS: Provider Rating	None	0.77	0	0	241	0	317	0	0.7603	0	1
PY3.5	DPH	Kern Medical Center	1.2.3.c	Colorectal Cancer Screening	None	0.644	0	0	2489	0	3933	0	0.6329	0	1
PY3.5	DPH	Kern Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.3756	0	0	861	0	2525	0	0.341	0	1
PY3.5	DPH	Kern Medical Center	1.2.5.b	Controlling Blood Pressure	None	0.6987	0	0	2622	0	3793	0	0.6913	0	1
PY3.5	DPH	Kern Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.9164	0	0	546	0	720	0	0.7583	0	1
PY3.5	DPH	Kern Medical Center	1.2.8	Prevention Quality Overall Composite #90	None	None	1	0	None	1	23249	0	None	1	1
PY3.5	DPH	Kern Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	None	1	0	0	19468	0	19468	0	1	0	1
PY3.5	DPH	Kern Medical Center	1.3.2	DHCS All-Cause Readmissions	None	0.0848	0	0	48	0	492	0	0.0976	0	1
PY3.5	DPH	Kern Medical Center	1.3.3	Influenza Immunization	None	0.5857	0	0	1654	0	2961	0	0.5586	0	1
PY3.5	DPH	Kern Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	None	0.3519	0	0	31789	0	92318	0	0.3443	0	1
PY3.5	DPH	Kern Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	None	0.0605	0	0	4562	0	87171	0	0.0523	0	1
PY3.5	DPH	Kern Medical Center	1.3.7	Tobacco Assessment and Counseling	None	0.9884	0	0	4370	0	4465	0	0.9787	0	1
PY3.5	DPH	Kern Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	None	0.5296	0	0.5	398	0	767	0	0.5189	0	1
PY3.5	DPH	Kern Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	None	0.887	0	0.5	727	0	805	0	0.9031	0	1
PY3.5	DPH	Kern Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	None	0.9625	0	0.5	8715	0	9064	0	0.9615	0	1
PY3.5	DPH	Kern Medical Center	1.4.2	Annual Monitoring for Patients on Persistent Medications	None	0.7987	0	0	4711	0	5406	0	0.8714	0	1
PY3.5	DPH	Kern Medical Center	1.4.3	INR Monitoring for Individuals on Warfarin	None	0.9	0	0	66	0	82	0	0.8049	0	1
PY3.5	DPH	Kern Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	None	0	0	None	Yes	0	BFUSA Cert?	0	1	0	1
PY3.5	DPH	Kern Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	None	0.6873	0	0	513	0	750	0	0.684	0	1
PY3.5	DPH	Kern Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	None	1	0	None	1	990	0	None	1	1
PY3.5	DPH	Kern Medical Center	2.1.5	PC-02 Cesarean Section	None	0.2132	0	0	48	0	193	0	0.2487	0	1
PY3.5	DPH	Kern Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	None	0.7143	0	0.713	638	0	886	0	0.7201	0	1
PY3.5	DPH	Kern Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	None	0.8918	0	0.7689	812	0	906	0	0.8962	0	1
PY3.5	DPH	Kern Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	0.3659	0	0	46	0	113	0	0.4071	0	1
PY3.5	DPH	Kern Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	None	0.0648	0	0	50	0	751	0	0.0666	0	1
PY3.5	DPH	Kern Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes	None	0	0	None	Yes	0	10 Debriefs?	0	0	None	n/a
PY3.5	DPH	Kern Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	None	0	0	None	Yes	0	3 Safety Drills?	0	0	None	n/a
PY3.5	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)	None	1	0	None	16	0	16	0	1	0	1
PY3.5	DPH	Kern Medical Center	2.2.1	DHCS All-Cause Readmissions	None	0.087	0	0	53	0	582	0	0.0911	0	1
PY3.5	DPH	Kern Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.509	0	0	5239	0	10000	0	0.5239	0	1
PY3.5	DPH	Kern Medical Center	2.2.3	Medication Reconciliation – 30 days	None	0.6774	0	0	549	0	797	0	0.6888	0	1
PY3.5	DPH	Kern Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.8673	0	0	1457	0	1630	0	0.8939	0	1
PY3.5	DPH	Kern Medical Center	2.2.5	Timely Transmission of Transition Record	None	0.8828	0	0	1180	0	1195	0	0.9874	0	1
PY3.5	DPH	Kern Medical Center	2.3.2	Medication Reconciliation – 30 days	None	0.743	0	0	182	0	259	0	0.7027	0	1
PY3.5	DPH	Kern Medical Center	2.3.4	Timely Transmission of Transition Record	None	0.9806	0	0	393	0	405	0	0.9704	0	1
PY3.5	DPH	Kern Medical Center	2.5.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.5209	0	0.067	256	0	482	0	0.5311	0	1
PY3.5	DPH	Kern Medical Center	2.5.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.5209	0	0.0216	256	0	482	0	0.5311	0	1
PY3.5	DPH	Kern Medical Center	2.5.2	Controlling Blood Pressure	None	0.7263	0	0	104	0	136	0	0.7647	0	1
PY3.5	DPH	Kern Medical Center	2.5.4	Screening for Clinical Depression and follow-up	None	0.6601	0	0	186	0	298	0	0.6242	0	1
PY3.5	DPH	Kern Medical Center	2.5.5	Tobacco Assessment and Counseling	None	0.9908	0	0	429	0	431	0	0.9954	0	1
PY3.5	DPH	Kern Medical Center	3.2.2	Appropriate Emergency Department Utilization of CT for Pulmonary Embolism	None	0.9932	0	0	144	0	154	0	0.9351	0	1
PY3.5	DPH	Kern Medical Center	3.2.3	Use of Imaging Studies for Low Back Pain	None	0.8123	0	0	460	0	569	0	0.8084	0	1
PY3.5	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	None	0.7888	0	None	318	0	723	0	0.4398	0	1
PY3.5	DMPH	Kern Valley Healthcare District, Lake Isabella	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.7803	0	0.067	701	0	821	0	0.8538	0	1
PY3.5	DMPH	Kern Valley Healthcare District, Lake Isabella	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.3616	0	0.0216	281	0	821	0	0.3423	0	1
PY3.5	DMPH	Kern Valley Healthcare District, Lake Isabella	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.314	0	0	27	0	93	0	0.2903	0	1
PY3.5	DMPH	Kern Valley Healthcare District, Lake Isabella	1.1.5.f	Screening for Clinical Depression and follow-up	None	0.7085	0	0	452	0	544	0	0.8309	0	1
PY3.5	DMPH	Kern Valley Healthcare District, Lake Isabella	1.1.6.t	Tobacco Assessment and Counseling	None	0.9762	0	0	725	0	741	0	0.9784	0	1
PY3.5	DMPH	Kern Valley Healthcare District, Lake Isabella	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	None	1	0.0198	None	1	84	0	None	1	1
PY3.5	DMPH	Kern Valley Healthcare District, Lake Isabella	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	None	1	0.0419	14	0	84	0	0.1667	0	1
PY3.5	DMPH	Kern Valley Healthcare District, Lake Isabella	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	None	0.6351	0	0.1935	56	0	84	0	0.6667	0	1
PY3.5	DMPH	Lompoc Valley Medical Center, Lompoc	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	None	0.7972	0	0	2201	0	2681	0	0.821	0	1
PY3.5	DMPH	Lompoc Valley Medical Center, Lompoc	1.3.2	DHCS All-Cause Readmissions	None	None	1	0	None	1	257	0	None	1	1
PY3.5	DMPH	Lompoc Valley Medical Center, Lompoc	1.3.3	Influenza Immunization	None	0.5309	0	0	84	0	760	0	0.1105	0	0
PY3.5	DMPH	Lompoc Valley Medical Center, Lompoc	1.3.5	Request for Specialty Care Expertise Turnaround Time	None	0.7355	0	0	2046	0	2684	0	0.7623	0	1
PY3.5	DMPH	Lompoc Valley Medical Center, Lompoc	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	None	0.0065	0	0	86	0	2767	0	0.0311	0	1
PY3.5	DMPH	Lompoc Valley Medical Center, Lompoc	1.3.7	Tobacco Assessment and Counseling	None	0.9312	0	0	519	0	562	0	0.9235	0	1
PY3.5	DMPH	Lompoc Valley Medical Center, Lompoc	1.5.1.b	Controlling Blood Pressure	None	0.6219	0	0	285	0	402	0	0.709	0	1
PY3.5	DMPH	Lompoc Valley Medical Center, Lompoc	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.8205	0	0	18	0	33	0	0.5455	0	0
PY3.5	DMPH	Lompoc Valley Medical Center, Lompoc	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	None	0.5763	0	0	784	0	1297	0	0.6045	0	1
PY3.5	DMPH	Lompoc Valley Medical Center, Lompoc	1.5.4.t	Tobacco Assessment and Counseling	None	0.8772	0	0	283	0	339	0	0.8348	0	1
PY3.5	DMPH	Lompoc Valley Medical Center, Lompoc	1.7.1	BMI Screening and Follow-up	None	0.588	0	0	147	0	265	0	0.5547	0	1
PY3.5	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)	None	None	1	None	5	0	8	0	0.625	0	0
PY3.5	DMPH	Lompoc Valley Medical Center, Lompoc	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity	None	0.75	0	0.5231	183	0	288	0	0.6354	0	1
PY3.5	DMPH	Lompoc Valley Medical Center, Lompoc	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition	None	0.8371	0	0.5985	225	0	288	0	0.7813	0	1
PY3.5	DMPH	Lompoc Valley Medical Center, Lompoc	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI	None	0.9508	0	0.66	288	0	288	0	1	0	1
PY3.5	DMPH	Lompoc Valley Medical Center, Lompoc	2.2.1	DHCS All-Cause Readmissions	None	0.0601	0	0	34	0	459	0	0.0741	0	1
PY3.5	DMPH	Lompoc Valley Medical Center, Lompoc	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.4189	0	0	314	0	699	0	0.4492	0	0
PY3.5	DMPH	Lompoc Valley Medical Center, Lompoc	2.2.3	Medication Reconciliation – 30 days	None	1	0	0	39	0	39	0	1	0	1
PY3.5	DMPH	Lompoc Valley Medical Center, Lompoc	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.8191	0	0	754	0	801	0	0.9413	0	1
PY3.5	DMPH	Lompoc Valley Medical Center, Lompoc	2.2.5	Timely Transmission of Transition Record	None	0.4751	0	0	570	0	774	0	0.7364	0	1
PY3.5	DMPH	Lompoc Valley Medical Center, Lompoc	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	None	0.413	0	0	70	0	168	0	0.4167	0	1
PY3.5	DMPH	Lompoc Valley Medical Center, Lompoc	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	None	0.1814	0	0	1169	0	6811	0	0.1716	0	1
PY3.5	DMPH	Lompoc Valley Medical Center, Lompoc	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	None	0	0	0	0	0	235	0	0	0	1
PY3.5	DMPH	Lompoc Valley Medical Center, Lompoc	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR	None	2.075	0	1.053	17100	0	10000	0	1.71	0	0
PY3.5	DPH	Los Angeles County Health System	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.7591	0	0.067	304	0	380	0	0.8	0	1
PY3.5	DPH	Los Angeles County Health System	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.114	0	0.0216	40	0	380	0	0.1053	0	1
PY3.5	DPH	Los Angeles County Health System	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.3019	0	0	10757	0	37924	0	0.2836	0	1
PY3.5	DPH	Los Angeles County Health System	1.1.5.f	Screening for Clinical Depression and follow-up	None	0.859	0	0	91986	0	103532	0	0.8885	0	1
PY3.5	DPH	Los Angeles County Health System	1.1.6.t	Tobacco Assessment and Counseling	None	0.9649	0	0	108000	0	112268	0	0.962	0	1
PY3.5	DPH	Los Angeles County Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	0.1237	0	0.0198	194	0	1717	0	0.113	0	1
PY3.5	DPH	Los Angeles County Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	0.1853	0	0.0419	285	0	1717	0	0.166	0	1
PY3.5	DPH	Los Angeles County Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	None	0.4296	0	0.1935	714	0	1717	0	0.4158	0	1
PY3.5	DPH	Los Angeles County Health System	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.7591	0	0.067	304	0	380	0	0.8	0	1
PY3.5	DPH	Los Angeles County Health System	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.114	0	0.0216	40	0	380	0	0.1053	0	1
PY3.5	DPH	Los Angeles County Health System	1.2.10	REAL and/or SO/GI disparity reduction	None	0.6128	0	0	5136	0	7519	0	0.6831	0	1
PY3.5	DPH	Los Angeles County Health System	1.2.11	REAL data completeness	None	0.9992	0	0	138627	0	138774	0	0.9989	0	1
PY3.5	DPH	Los Angeles County Health System	1.2.12.f	Screening for Clinical Depression and follow-up	None	0.859	0	0	91986	0	103532	0	0.8885	0	1
PY3.5	DPH	Los Angeles County Health System	1.2.13	SO/GI data completeness	None	0.8719	0	0	103184	0	117407	0	0.8789	0	1
PY3.5	DPH	Los Angeles County Health System	1.2.14.t	Tobacco Assessment and Counseling	None	0.9649	0	0	108000	0	112268	0	0.962	0	1
PY3.5	DPH	Los Angeles County Health System	1.2.2	CG-CAHPS: Provider Rating	None	0.7575	0	0	5938	0	7781	0	0.7631	0	1
PY3.5	DPH	Los Angeles County Health System	1.2.3.c	Colorectal Cancer Screening	None	0.6753	0	0	45405	0	60786	0	0.747	0	1
PY3.5	DPH	Los Angeles County Health System	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.3019	0	0	10757	0	37924	0	0.2836	0	1
PY3.5	DPH	Los Angeles County Health System	1.2.5.b	Controlling Blood Pressure	None	0.6573	0	0	35458	0	51217	0	0.6923	0	1
PY3.5	DPH	Los Angeles County Health System	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.8846	0	0	4489	0	5003	0	0.8973	0	1
PY3.5	DPH	Los Angeles County Health System	1.2.8	Prevention Quality Overall Composite #90	None	0.0089	0	0	2088	0	224782	0	0.0093	0	1
PY3.5	DPH	Los Angeles County Health System	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	None	0.9235	0	0	91057	0	98504	0	0.9244	0	1
PY3.5	DPH	Los Angeles County Health System	1.3.2	DHCS All-Cause Readmissions	None	0.1562	0	0	1009	0	6559	0	0.1538	0	1
PY3.5	DPH	Los Angeles County Health System	1.3.3	Influenza Immunization	None	0.793	0	0	20013	0	26008	0	0.7695	0	1
PY3.5	DPH	Los Angeles County Health System	1.3.5	Request for Specialty Care Expertise Turnaround Time	None	0.8821	0	0	158828	0	181212	0	0.8765	0	1
PY3.5	DPH	Los Angeles County Health System	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	None	0.2657	0	0	50065	0	185489	0	0.2699	0	1
PY3.5	DPH	Los Angeles County Health System	1.3.7	Tobacco Assessment and Counseling	None	0.9501	0	0	46784	0	49364	0	0.9477	0	1
PY3.5	DPH	Los Angeles County Health System	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	None	0.6526	0	0.5	15194	0	22040	0	0.6894	0	1
PY3.5	DPH	Los Angeles County Health System	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	None	0.9337	0	0.5	31734	0	33823	0	0.9382	0	1
PY3.5	DPH	Los Angeles County Health System	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	None	0.9453	0	0.5	82017	0	86513	0	0.948	0	1
PY3.5	DPH	Los Angeles County Health System	1.4.2	Annual Monitoring for Patients on Persistent Medications	None	0.9222	0	0	40570	0	42768	0	0.9486	0	1
PY3.5	DPH	Los Angeles County Health System	1.4.3	INR Monitoring for Individuals on Warfarin	None	0.8782	0	0	1491	0	1658	0	0.8993	0	1
PY3.5	DPH	Los Angeles County Health System	1.6.1	BIRADS to Biopsy	None	0.6105	0	0	497	0	881	0	0.5641	0	1
PY3.5	DPH	Los Angeles County Health System	1.6.2	Breast Cancer Screening	None	0.7526	0	0	36100	0	47282	0	0.7635	0	1
PY3.5	DPH	Los Angeles County Health System	1.6.3	Cervical Cancer Screening	None	0.5279	0	0	46261	0	82045	0	0.5638	0	1
PY3.5	DPH	Los Angeles County Health System	1.6.4.c	Colorectal Cancer Screening	None	0.6753	0	0	45405	0	60786	0	0.747	0	1
PY3.5	DPH	Los Angeles County Health System	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	None	0.4318	0	0	619	0	1393	0	0.4444	0	1
PY3.5	DPH	Los Angeles County Health System	1.7.1	BMI Screening and Follow-up	None	0.8843	0	0	111129	0	121912	0	0.9116	0	1
PY3.5	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)	None	1	0	None	32	0	32	0	1	0	1
PY3.5	DPH	Los Angeles County Health System	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity	None	0.7601	0	0.5231	15320	0	18433	0	0.8311	0	1
PY3.5	DPH	Los Angeles County Health System	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition	None	0.7716	0	0.5985	15492	0	18433	0	0.8404	0	1
PY3.5	DPH	Los Angeles County Health System	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI	None	0.673	0	0.66	17532	0	18433	0	0.9511	0	1
PY3.5	DPH	Los Angeles County Health System	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	None	0	0	None	Yes	0	BFUSA Cert?	0	1	0	1
PY3.5	DPH	Los Angeles County Health System	2.1.2	Exclusive Breast Milk Feeding (PC-05)	None	0.6275	0	0	960	0	1505	0	0.6379	0	1
PY3.5	DPH	Los Angeles County Health System	2.1.3	OB Hemorrhage: Massive Transfusion	None	0.0081	0	0	14	0	2197	0	0.0064	0	1
PY3.5	DPH	Los Angeles County Health System	2.1.5	PC-02 Cesarean Section	None	0.2123	0	0	143	0	736	0	0.1943	0	1
PY3.5	DPH	Los Angeles County Health System	2.1.6	Prenatal and Postpartum Care: Postpartum Care	None	0.6975	0	0.713	1478	0	1933	0	0.7646	0	1
PY3.5	DPH	Los Angeles County Health System	2.1.6	Prenatal and Postpartum Care: Prenatal Care	None	0.9554	0	0.7689	1858	0	1953	0	0.9514	0	1
PY3.5	DPH	Los Angeles County Health System	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	0.3565	0	0	149	0	416	0	0.3582	0	1
PY3.5	DPH	Los Angeles County Health System	2.1.8	Unexpected Newborn Complications (UNC)	None	0.0539	0	0	84	0	1507	0	0.0557	0	1
PY3.5	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)	None	1	0	None	48	0	48	0	1	0	1
PY3.5	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	None	0	0	None	Yes	0	10 Debriefs?	0	0	0	n/a
PY3.5	DPH	Los Angeles County Health System	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	None	0	0	None	Yes	0	3 Safety Drills?	0	0	0	n/a
PY3.5	DPH	Los Angeles County Health System	2.2.1	DHCS All-Cause Readmissions	None	0.1516	0	0	1076	0	7220	0	0.1490	0	1
PY3.5	DPH	Los Angeles County Health System	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.5318	0	0	3922	0	7008	0	0.5596	0	1
PY3.5	DPH	Los Angeles County Health System	2.2.3	Medication Reconciliation – 30 days	None	0.8621	0	0	9740	0	11002	0	0.8853	0	1
PY3.5	DPH	Los Angeles County Health System	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.9178	0	0	325	0	377	0	0.8621	0	1
PY3.5	DPH	Los Angeles County Health System	2.2.5	Timely Transmission of Transition Record	None	0.7597	0	0	7948	0	10674	0	0.7446	0	1
PY3.5	DPH	Los Angeles County Health System	2.3.2	Medication Reconciliation – 30 days	None	0.8662	0	0	6676	0	7521	0	0.8876	0	1
PY3.5	DPH	Los Angeles County Health System	2.3.4	Timely Transmission of Transition Record	None	0.8028	0	0	5348	0	6775	0	0.7894	0	1
PY3.5	DPH	Los Angeles County Health System	2.5.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.8028	0	0.067	201	0	235	0	0.8553	0	1
PY3.5	DPH	Los Angeles County Health System	2.5.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.2844	0	0.0216	68	0	235	0	0.2894	0	1
PY3.5	DPH	Los Angeles County Health System	2.5.2	Controlling Blood Pressure	None	0.5161	0	0	58	0	100	0	0.58	0	1
PY3.5	DPH	Los Angeles County Health System	2.5.4	Screening for Clinical Depression and follow-up	None	0.6384	0	0	266	0	394	0	0.6751	0	1
PY3.5	DPH	Los Angeles County Health System	2.5.5	Tobacco Assessment and Counseling	None	0.8531	0	0	335	0	403	0	0.8313	0	1
PY3.5	DPH	Los Angeles County Health System	2.7.1	Advance Care Plan	None	0.9932	0	0	17447	0	17738	0	0.9836	0	1
PY3.5	DPH	Los Angeles County Health System	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	None	0.9375	0	0	190	0	208	0	0.9135	0	1
PY3.5	DPH	Los Angeles County Health System	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	None	0.9753	0	0	72	0	74	0	0.973	0	1
PY3.5	DPH	Los Angeles County Health System	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	None	0.0311	0	0	164	0	5100	0	0.0322	0	0
PY3.5	DPH	Los Angeles County Health System	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	None	0.104	0	0	30	0	243	0	0.1235	0	1
PY3.5	DPH	Los Angeles County Health System	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	None	0.6316	0	0	193	0	302	0	0.6391	0	1
PY3.5	DPH	Los Angeles County Health System	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	None	0.084	0	0	45271	0	597918	0	0.0757	0	1
PY3.5	DPH	Los Angeles County Health System	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	None	0.1485	0	0	67	0	377	0	0.1777	0	1
PY3.5	DPH	Los Angeles County Health System	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR	None	0.4564	0	0.592	4465	0	10000	0	0.4465	0	1
PY3.5	DPH	Los Angeles County Health System	3.3.1	Adherence to Medications: Rate 1	None	0.8853	0	0.25	306	0	341	0	0.8974	0	1
PY3.5	DPH	Los Angeles County Health System	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 1	None	0.9893	0	0.25	333	0	340	0	0.9794	0	1
PY3.5	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	None	0.6321	0	0.25	3341	0	4962	0	0.6733	0	1
PY3.5	DMPH	Mammoth Hospital, Mammoth Lakes	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.5457	0	0.067	97	0	324	0	0.2994	0	1
PY3.5	DMPH	Mammoth Hospital, Mammoth Lakes	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.2256	0	0.0216	58	0	324	0	0.179	0	1
PY3.5	DMPH	Mammoth Hospital, Mammoth Lakes	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.253	0	0	26	0	104	0	0.25	0	1
PY3.5	DMPH	Mammoth Hospital, Mammoth Lakes	1.1.5.f	Screening for Clinical Depression and follow-up	None	0.6297	0	0	165	0	270	0	0.6111	0	1
PY3.5	DMPH	Mammoth Hospital, Mammoth Lakes	1.1.6.t	Tobacco Assessment and Counseling	None	0.9176	0	0	293	0	323	0	0.9071	0	1
PY3.5	DMPH	Mammoth Hospital, Mammoth Lakes	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	None	1	0.0198	None	1	75	0	None	1	1
PY3.5	DMPH	Mammoth Hospital, Mammoth Lakes	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	0.2308	0	0.0419	14	0	75	0	0.1867	0	1
PY3.5	DMPH	Mammoth Hospital, Mammoth Lakes	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	None	0.6615	0	0.1935	37	0	75	0	0.4933	0	1
PY3.5	DMPH	Mammoth Hospital, Mammoth Lakes	1.5.1.b	Controlling Blood Pressure	None	0.5267	0	0	67	0	132	0	0.5076	0	0
PY3.5	DMPH	Mammoth Hospital, Mammoth Lakes	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	None	1	0	17	0	None	4	None	4	0
PY3.5	DMPH	Mammoth Hospital, Mammoth Lakes	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	None	0.5982	0	0	158	0	323	0	0.4892	0	0
PY3.5	DMPH	Mammoth Hospital, Mammoth Lakes	1.5.4.t	Tobacco Assessment and Counseling	None	0.9176	0	0	293	0	323	0	0.9071	0	1
PY3.5	DMPH	Mammoth Hospital, Mammoth Lakes	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.8182	0	0.067	51	0	74	0	0.6892	0	1
PY3.5	DMPH	Mammoth Hospital, Mammoth Lakes	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.303	0	0.0216	18	0	74	0	0.2432	0	1
PY3.5	DMPH	Mammoth Hospital, Mammoth Lakes	2.6.2	Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen	None	None	4	0	26	0	None	4	None	4	0
PY3.5	DMPH	Mammoth Hospital, Mammoth Lakes	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	None	None	4	0	28	0	None	4	None	4	0
PY3.5	DMPH	Mammoth Hospital, Mammoth Lakes	2.6.4	Screening for Clinical Depression and follow-up	None	None	4	0	28	0	30	0	0.9333	0	1
PY3.5	DMPH	Mammoth Hospital, Mammoth Lakes	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	None	1	0	0	74	0	74	0	1	0	1
PY3.5	DMPH	Marin General Hospital, Greenbrae	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	None	0	0	None	Yes	0	BFUSA Cert?	0	1	0	1
PY3.5	DMPH	Marin General Hospital, Greenbrae	2.1.2	Exclusive Breast Milk Feeding (PC-05)	None	0.8024	0	0	149	0	187	0	0.7968	0	1
PY3.5	DMPH	Marin General Hospital, Greenbrae	2.1.3	OB Hemorrhage: Massive Transfusion	None	0	0	0	0	0	446	0	0	0	1
PY3.5	DMPH	Marin General Hospital, Greenbrae	2.1.5	PC-02 Cesarean Section	None	0.2979	0	0	32	0	129	0	0.2481	0	1
PY3.5	DMPH	Marin General Hospital, Greenbrae	2.1.6	Prenatal and Postpartum Care: Postpartum Care	None	1	0	0.713	347	0	362	0	0.9586	0	1
PY3.5	DMPH	Marin General Hospital, Greenbrae	2.1.6	Prenatal and Postpartum Care: Prenatal Care	None	0.9603	0	0.7689	362	0	362	0	1	0	1
PY3.5	DMPH	Marin General Hospital, Greenbrae	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	None	1	0	None	1	60	0	None	1	1
PY3.5	DMPH	Marin General Hospital, Greenbrae	2.1.8	Unexpected Newborn Complications (UNC)	None	None	1	0	11	0	396	0	0.0278	0	1
PY3.5	DMPH	Marin General Hospital, Greenbrae	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes	None	0	0	None	Yes	0	10 Debriefs?	0	0	0	n/a
PY3.5	DMPH	Marin General Hospital, Greenbrae	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter No	None	0	0	None	No	0	3 Safety Drills?	0	0	0	n/a
PY3.5	DMPH	Marin General Hospital, Greenbrae	2.1.9	OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed) [Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16)	None	1	0	None	16	0	16	0	1	0	1
PY3.5	DMPH	Marin General Hospital, Greenbrae	2.2.1	DHCS All-Cause Readmissions	None	0.224	0	0	123	0	585	0	0.2103	0	0
PY3.5	DMPH	Marin General Hospital, Greenbrae	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.5238	0	0	5171	0	10000	0	0.5171	0	1
PY3.5	DMPH	Marin General Hospital, Greenbrae	2.2.3	Medication Reconciliation – 30 days	None	0.9331	0	0	550	0	599	0	0.9182	0	1
PY3.5	DMPH	Marin General Hospital, Greenbrae	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.0794	0	0	25	0	335	0	0.0746	0	0
PY3.5	DMPH	Marin General Hospital, Greenbrae	2.2.5	Timely Transmission of Transition Record	None	0.5148	0	0	186	0	336	0	0.5536	0	1
PY3.5	DMPH	Marin General Hospital, Greenbrae	2.3.2	Medication Reconciliation – 30 days	None	0.9129	0	0	287	0	321	0	0.8941	0	1
PY3.5	DMPH	Marin General Hospital, Greenbrae	2.3.4	Timely Transmission of Transition Record	None	0.6235	0	0	227	0	336	0	0.6756	0	1
PY3.5	DMPH	Marin General Hospital, Greenbrae	2.7.1	Advance Care Plan	None	0.9805	0	0	308	0	312	0	0.9872	0	1
PY3.5	DMPH	Marin General Hospital, Greenbrae	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	None	1	0	0	193	0	193	0	1	0	1
PY3.5	DMPH	Marin General Hospital, Greenbrae	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	None	None	4	0	18	0	None	4	None	4	0
PY3.5	DMPH	Marin General Hospital, Greenbrae	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	None	0.3443	0	0	77	0	272	0	0.2831	0	1
PY3.5	DMPH	Marin General Hospital, Greenbrae	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	None	None	1	0	None	1	None	1	None	1	0
PY3.5	DMPH	Mayers Memorial Hospital District, Fall River Mills	1.7.1	BMI Screening and Follow-up	None	None	1	0	None	1	None	4	None	1	0
PY3.5	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)	None	None	1	None	8	0	8	0	1	0	1
PY3.5	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	None	0	0	0.66	0	0	0	0	0	0	0
PY3.5	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	None	0	0	0.5985	0	0	0	0	0	0	0
PY3.5	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	None	0	0	0.5231	0	0	0	0	0	0	0
PY3.5	DMPH	Modoc Medical Center, Alturas	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.7706	0	0.067	541	0	585	0	0.9248	0	1
PY3.5	DMPH	Modoc Medical Center, Alturas	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.2382	0	0.0216	139	0	585	0	0.2376	0	1
PY3.5	DMPH	Modoc Medical Center, Alturas	1.2.10	REAL and/or SO/GI disparity reduction	None	None	1	0	None	1	None	4	None	1	0
PY3.5	DMPH	Modoc Medical Center, Alturas	1.2.11	REAL data completeness	None	0.9828	0	0	798	0	815	0	0.9791	0	1
PY3.5	DMPH	Modoc Medical Center, Alturas	1.2.12.f	Screening for Clinical Depression and follow-up	None	0.9027	0	0	362	0	414	0	0.8744	0	1
PY3.5	DMPH	Modoc Medical Center, Alturas	1.2.13	SO/GI data completeness	None	0.8656	0	0	429	0	545	0	0.7872	0	1
PY3.5	DMPH	Modoc Medical Center, Alturas	1.2.14.t	Tobacco Assessment and Counseling	None	0.9798	0	0	498	0	521	0	0.9559	0	1
PY3.5	DMPH	Modoc Medical Center, Alturas	1.2.2	CG-CAHPS: Provider Rating	None	0.8454	0	0	186	0	240	0	0.775	0	1
PY3.5	DMPH	Modoc Medical Center, Alturas	1.2.3.c	Colorectal Cancer Screening	None	0.5446	0	0	121	0	226	0	0.5354	0	1
PY3.5	DMPH	Modoc Medical Center, Alturas	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.3012	0	0	27	0	84	0	0.3214	0	1
PY3.5	DMPH	Modoc Medical Center, Alturas	1.2.5.b	Controlling Blood Pressure	None	0.521	0	0	88	0	171	0	0.5146	0	0
PY3.5	DMPH	Modoc Medical Center, Alturas	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.7353	0	0	26	0	33	0	0.7879	0	1
PY3.5	DMPH	Modoc Medical Center, Alturas	1.2.8	Prevention Quality Overall Composite #90	None	None	1	0	None	1	520	0	None	1	1
PY3.5	DPH	Natividad Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.8238	0	0.067	5683	0	6792	0	0.8367	0	1
PY3.5	DPH	Natividad Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.5543	0	0.0216	2459	0	6792	0	0.362	0	1
PY3.5	DPH	Natividad Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.3266	0	0	235	0	702	0	0.3348	0	1
PY3.5	DPH	Natividad Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	None	0.789	0	0	3298	0	4029	0	0.8186	0	1
PY3.5	DPH	Natividad Medical Center	1.1.6.t	Tobacco Assessment and Counseling	None	0.9902	0	0	4930	0	4967	0	0.9926	0	1
PY3.5	DPH	Natividad Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	0.1134	0	0.0198	None	1	110	0	None	1	1
PY3.5	DPH	Natividad Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	0.2062	0	0.0419	None	1	110	0	None	1	1
PY3.5	DPH	Natividad Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	None	0.4536	0	0.1935	26	0	110	0	0.2364	0	1
PY3.5	DPH	Natividad Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.8238	0	0.067	5683	0	6792	0	0.8367	0	1
PY3.5	DPH	Natividad Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.5543	0	0.0216	2459	0	6792	0	0.362	0	1
PY3.5	DPH	Natividad Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	None	0.6139	0	0	429	0	674	0	0.6365	0	1
PY3.5	DPH	Natividad Medical Center	1.2.11	REAL data completeness	None	0.8976	0	0	8487	0	9505	0	0.8929	0	1
PY3.5	DPH	Natividad Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	None	0.789	0	0	3298	0	4029	0	0.8186	0	1
PY3.5	DPH	Natividad Medical Center	1.2.13	SO/GI data completeness	None	0.963	0	0	6087	0	6312	0	0.9644	0	1
PY3.5	DPH	Natividad Medical Center	1.2.14.t	Tobacco Assessment and Counseling	None	0.9902	0	0	4930	0	4967	0	0.9926	0	1
PY3.5	DPH	Natividad Medical Center	1.2.2	CG-CAHPS: Provider Rating	None	0.7554	0	0	7542	0	10000	0	0.7542	0	1
PY3.5	DPH	Natividad Medical Center	1.2.3.c	Colorectal Cancer Screening	None	0.6539	0	0	1076	0	1610	0	0.6683	0	1
PY3.5	DPH	Natividad Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.3266	0	0	235	0	702	0	0.3348	0	1
PY3.5	DPH	Natividad Medical Center	1.2.5.b	Controlling Blood Pressure	None	0.7434	0	0	231	0	326	0	0.7086	0	1
PY3.5	DPH	Natividad Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.8629	0	0	163	0	187	0	0.8717	0	1
PY3.5	DPH	Natividad Medical Center	1.2.8	Prevention Quality Overall Composite #90	None	0.0091	0	0	63	0	7229	0	0.0087	0	1
PY3.5	DPH	Natividad Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	None	0.9406	0	0	5352	0	5681	0	0.9421	0	1
PY3.5	DPH	Natividad Medical Center	1.3.2	DHCS All-Cause Readmissions	None	0.0921	0	0	14	0	160	0	0.0875	0	1
PY3.5	DPH	Natividad Medical Center	1.3.3	Influenza Immunization	None	0.7224	0	0	463	0	678	0	0.6829	0	1
PY3.5	DPH	Natividad Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	None	0.6583	0	0	5546	0	10143	0	0.5468	0	1
PY3.5	DPH	Natividad Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	None	0.0028	0	0	13	0	10248	0	0.0013	0	0
PY3.5	DPH	Natividad Medical Center	1.3.7	Tobacco Assessment and Counseling	None	0.9946	0	0	1279	0	1283	0	0.9969	0	1
PY3.5	DPH	Natividad Medical Center	1.5.1.b	Controlling Blood Pressure	None	0.7434	0	0	231	0	326	0	0.7086	0	1
PY3.5	DPH	Natividad Medical Center	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.8629	0	0	163	0	187	0	0.8717	0	1
PY3.5	DPH	Natividad Medical Center	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	None	0.9246	0	0	3682	0	3945	0	0.9333	0	1
PY3.5	DPH	Natividad Medical Center	1.5.4.t	Tobacco Assessment and Counseling	None	0.9902	0	0	4930	0	4967	0	0.9926	0	1
PY3.5	DPH	Natividad Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	None	0	0	None	Yes	0	BFUSA Cert?	0	1	0	1
PY3.5	DPH	Natividad Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	None	0.3907	0	0	208	0	506	0	0.4111	0	0
PY3.5	DPH	Natividad Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	0	0	0	0	0	594	0	0	0	1
PY3.5	DPH	Natividad Medical Center	2.1.5	PC-02 Cesarean Section	None	0.1944	0	0	29	0	132	0	0.2197	0	1
PY3.5	DPH	Natividad Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	None	0.8484	0	0.713	455	0	527	0	0.8634	0	1
PY3.5	DPH	Natividad Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	None	0.9638	0	0.7689	467	0	482	0	0.9689	0	1
PY3.5	DPH	Natividad Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	0.131	0	0	13	0	89	0	0.1461	0	1
PY3.5	DPH	Natividad Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	None	0.0432	0	0	22	0	500	0	0.044	0	1
PY3.5	DPH	Natividad Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) Yes	None	0	0	None	Yes	0	10 Debriefs?	0	0	0	n/a
PY3.5	DPH	Natividad Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	None	0	0	None	Yes	0	3 Safety Drills?	0	0	0	n/a
PY3.5	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)	None	1	0	None	16	0	16	0	1	0	1
PY3.5	DPH	Natividad Medical Center	2.2.1	DHCS All-Cause Readmissions	None	0.0944	0	0	30	0	300	0	0.1000	0	1
PY3.5	DPH	Natividad Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.4516	0	0	4264	0	10000	0	0.4264	0	0
PY3.5	DPH	Natividad Medical Center	2.2.3	Medication Reconciliation – 30 days	None	0.9095	0	0	236	0	256	0	0.9219	0	1
PY3.5	DPH	Natividad Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.9915	0	0	364	0	366	0	0.9945	0	1
PY3.5	DPH	Natividad Medical Center	2.2.5	Timely Transmission of Transition Record	None	0.9827	0	0	358	0	364	0	0.9835	0	1
PY3.5	DPH	Natividad Medical Center	2.3.2	Medication Reconciliation – 30 days	None	None	4	0	43	0	43	0	1	0	1
PY3.5	DPH	Natividad Medical Center	2.3.4	Timely Transmission of Transition Record	None	0.96	0	0	78	0	79	0	0.9873	0	1
PY3.5	DPH	Natividad Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.9271	0	0.067	292	0	308	0	0.9481	0	1
PY3.5	DPH	Natividad Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.6319	0	0.0216	131	0	308	0	0.4253	0	1
PY3.5	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	None	0.4766	0	0	68	0	132	0	0.5152	0	1
PY3.5	DPH	Natividad Medical Center	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	None	0.6328	0	0	87	0	132	0	0.6591	0	1
PY3.5	DPH	Natividad Medical Center	2.6.4	Screening for Clinical Depression and follow-up	None	0.866	0	0	101	0	119	0	0.8487	0	1
PY3.5	DPH	Natividad Medical Center	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	None	0.9293	0	0	300	0	325	0	0.9231	0	1
PY3.5	DPH	Natividad Medical Center	3.4.1	ePBM-01 Pre-op Anemia Screening, Selected Elective Surgical Patients	None	0.5397	0	0	41	0	70	0	0.5857	0	1
PY3.5	DPH	Natividad Medical Center	3.4.3	ePBM-03 Pre-op Type and Crossmatch, Type and Screen, Selected elective Surgical Patients	None	0.7838	0	0	37	0	43	0	0.8605	0	1
PY3.5	DPH	Natividad Medical Center	3.4.4	ePBM-04 Initial Transfusion Threshold	None	1	0	0	214	0	214	0	1	0	1
PY3.5	DMPH	Northern Inyo Hospital, Bishop	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	None	None	1	0	None	1	None	1	None	1	0
PY3.5	DMPH	Northern Inyo Hospital, Bishop	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	None	0.2447	0	0	942	0	3363	0	0.2801	0	1
PY3.5	DMPH	Northern Inyo Hospital, Bishop	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	None	0.1066	0	0	13	0	154	0	0.0844	0	1
PY3.5	DMPH	Northern Inyo Hospital, Bishop	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR	None	5.8685	0	1.053	34600	0	10000	0	3.46	0	0
PY3.5	DMPH	Oak Valley Hospital District, Oakdale	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.4956	0	0.067	2060	0	5435	0	0.379	0	1
PY3.5	DMPH	Oak Valley Hospital District, Oakdale	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.1842	0	0.0216	497	0	5435	0	0.0914	0	1
PY3.5	DMPH	Oak Valley Hospital District, Oakdale	1.2.10	REAL and/or SO/GI disparity reduction	None	0.1785	0	0	58	0	338	0	0.1716	0	1
PY3.5	DMPH	Oak Valley Hospital District, Oakdale	1.2.11	REAL data completeness	None	0.9946	0	0	5479	0	5519	0	0.9928	0	1
PY3.5	DMPH	Oak Valley Hospital District, Oakdale	1.2.12.f	Screening for Clinical Depression and follow-up	None	0.6765	0	0	2149	0	4503	0	0.4772	0	1
PY3.5	DMPH	Oak Valley Hospital District, Oakdale	1.2.13	SO/GI data completeness	None	0.9717	0	0	3007	0	3257	0	0.9232	0	1
PY3.5	DMPH	Oak Valley Hospital District, Oakdale	1.2.14.t	Tobacco Assessment and Counseling	None	0.9612	0	0	2824	0	3181	0	0.8878	0	1
PY3.5	DMPH	Oak Valley Hospital District, Oakdale	1.2.2	CG-CAHPS: Provider Rating	None	0.9443	0	0	10975	0	11695	0	0.9384	0	1
PY3.5	DMPH	Oak Valley Hospital District, Oakdale	1.2.3.c	Colorectal Cancer Screening	None	0.5723	0	0	549	0	1285	0	0.4272	0	1
PY3.5	DMPH	Oak Valley Hospital District, Oakdale	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.2542	0	0	188	0	591	0	0.3181	0	1
PY3.5	DMPH	Oak Valley Hospital District, Oakdale	1.2.5.b	Controlling Blood Pressure	None	0.7035	0	0	129	0	214	0	0.6028	0	1
PY3.5	DMPH	Oak Valley Hospital District, Oakdale	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.9133	0	0	71	0	99	0	0.7172	0	1
PY3.5	DMPH	Oak Valley Hospital District, Oakdale	1.2.8	Prevention Quality Overall Composite #90	None	0.0226	0	0	77	0	4373	0	0.0176	0	0
PY3.5	DMPH	Oak Valley Hospital District, Oakdale	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	None	None	1	0.5	19	0	None	4	None	4	0
PY3.5	DMPH	Oak Valley Hospital District, Oakdale	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	None	0.9711	0	0.5	1553	0	1603	0	0.9688	0	1
PY3.5	DMPH	Oak Valley Hospital District, Oakdale	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	None	0.9608	0	0.5	5368	0	5728	0	0.9372	0	1
PY3.5	DMPH	Oak Valley Hospital District, Oakdale	1.4.2	Annual Monitoring for Patients on Persistent Medications	None	0.9139	0	0	909	0	1028	0	0.8842	0	1
PY3.5	DMPH	Oak Valley Hospital District, Oakdale	1.4.3	INR Monitoring for Individuals on Warfarin	None	None	1	0	None	1	None	4	None	1	0
PY3.5	DMPH	Palo Verde Hospital, Blythe	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.5101	0	0.067	226	0	297	0	0.7609	0	1
PY3.5	DMPH	Palo Verde Hospital, Blythe	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.0738	0	0.0216	53	0	297	0	0.1785	0	1
PY3.5	DMPH	Palo Verde Hospital, Blythe	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.6047	0	0	194	0	438	0	0.4429	0	1
PY3.5	DMPH	Palo Verde Hospital, Blythe	1.1.5.f	Screening for Clinical Depression and follow-up	None	0.3158	0	0	47	0	96	0	0.4896	0	1
PY3.5	DMPH	Palo Verde Hospital, Blythe	1.1.6.t	Tobacco Assessment and Counseling	None	0.9353	0	0	667	0	684	0	0.9751	0	1
PY3.5	DMPH	Palo Verde Hospital, Blythe	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	None	1	0.0198	18	0	101	0	0.1782	0	1
PY3.5	DMPH	Palo Verde Hospital, Blythe	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	None	1	0.0419	18	0	101	0	0.1782	0	1
PY3.5	DMPH	Palo Verde Hospital, Blythe	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	None	0.1719	0	0.1935	26	0	101	0	0.2574	0	1
PY3.5	DMPH	Palo Verde Hospital, Blythe	1.7.1	BMI Screening and Follow-up	None	0.3654	0	0	46	0	93	0	0.4946	0	1
PY3.5	DMPH	Palo Verde Hospital, Blythe	1.7.2	Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met) Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 8)	None	None	1	None	8	0	8	0	1	0	1
PY3.5	DMPH	Palo Verde Hospital, Blythe	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI	None	0.3607	0	0.66	44	0	97	0	0.4536	0	0
PY3.5	DMPH	Palo Verde Hospital, Blythe	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition	None	0.3607	0	0.5985	44	0	97	0	0.4536	0	0
PY3.5	DMPH	Palo Verde Hospital, Blythe	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity	None	0.3607	0	0.5231	44	0	97	0	0.4536	0	0
PY3.5	DMPH	Palo Verde Hospital, Blythe	2.2.1	DHCS All-Cause Readmissions	None	0.1429	0	0	28	0	222	0	0.1261	0	1
PY3.5	DMPH	Palo Verde Hospital, Blythe	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.5775	0	0	102	0	245	0	0.4163	0	0
PY3.5	DMPH	Palo Verde Hospital, Blythe	2.2.3	Medication Reconciliation – 30 days	None	0.641	0	0	257	0	448	0	0.5737	0	0
PY3.5	DMPH	Palo Verde Hospital, Blythe	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.7262	0	0	386	0	518	0	0.7452	0	1
PY3.5	DMPH	Palo Verde Hospital, Blythe	2.2.5	Timely Transmission of Transition Record	None	0.4383	0	0	208	0	467	0	0.4454	0	1
PY3.5	DMPH	Palo Verde Hospital, Blythe	2.3.2	Medication Reconciliation – 30 days	None	0.7108	0	0	342	0	497	0	0.6881	0	1
PY3.5	DMPH	Palo Verde Hospital, Blythe	2.3.4	Timely Transmission of Transition Record	None	0.6259	0	0	101	0	166	0	0.6084	0	1
PY3.5	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	1.7.1	BMI Screening and Follow-up	None	1	0	0	303	0	303	0	1	0	1
PY3.5	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)	None	None	4	None	16	0	16	0	1	0	1
PY3.5	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition	None	1	0	0.5985	276	0	276	0	1	0	1
PY3.5	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity	None	1	0	0.5231	276	0	276	0	1	0	1
PY3.5	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI	None	1	0	0.66	276	0	276	0	1	0	1
PY3.5	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.2.1	DHCS All-Cause Readmissions	None	0.1452	0	0	52	0	373	0	0.1394	0	1
PY3.5	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.5399	0	0	5556	0	10000	0	0.5556	0	1
PY3.5	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.2.3	Medication Reconciliation – 30 days	None	0.9154	0	0	592	0	637	0	0.9294	0	1
PY3.5	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.997	0	0	5422	0	5452	0	0.9945	0	1
PY3.5	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.2.5	Timely Transmission of Transition Record	None	1	0	0	3122	0	3122	0	1	0	1
PY3.5	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.3.2	Medication Reconciliation – 30 days	None	0.963	0	0	671	0	715	0	0.9385	0	1
PY3.5	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.3.4	Timely Transmission of Transition Record	None	1	0	0	2987	0	2987	0	1	0	1
PY3.5	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.7.1	Advance Care Plan	None	1	0	0	318	0	318	0	1	0	1
PY3.5	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	None	1	0	0	243	0	243	0	1	0	1
PY3.5	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	None	1	0	0	47	0	47	0	1	0	1
PY3.5	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	None	0.1462	0	0	284	0	1097	0	0.2589	0	1
PY3.5	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	None	0.3529	0	0	12	0	57	0	0.2105	0	1
PY3.5	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	None	0.8831	0	0	100	0	103	0	0.9709	0	1
PY3.5	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	None	0.137	0	0	24583	0	176298	0	0.1394	0	1
PY3.5	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	None	0.3659	0	0	640	0	1938	0	0.3302	0	1
PY3.5	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR	None	0.573	0	0.592	5840	0	10000	0	0.584	0	1
PY3.5	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.2.2	Appropriate Emergency Department Utilization of CT for Pulmonary Embolism	None	0.9986	0	0	1306	0	1316	0	0.9924	0	1
PY3.5	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.2.3	Use of Imaging Studies for Low Back Pain	None	0.7834	0	0	3095	0	3868	0	0.8002	0	1
PY3.5	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	None	0.4513	0	None	1099	0	2587	0	0.4248	0	1
PY3.5	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.3.1	Adherence to Medications: Rate 1	None	0.629	0	0.7689	101	0	190	0	0.5316	0	0
PY3.5	DMPH	Palomar Medical Center, Escondido (including Pomerado Hospital, Poway)	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 1	None	0.9494	0	None	59	0	60	0	0.9833	0	1
PY3.5	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	None	0.7696	0	0.1368	1371	0	1740	0	0.7879	0	1
PY3.5	DMPH	Pioneers Memorial Healthcare District, Brawley	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	None	0.6286	0	0.5	14	0	None	4	None	4	0
PY3.5	DMPH	Pioneers Memorial Healthcare District, Brawley	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	None	0.4609	0	0.5	46	0	123	0	0.374	0	0
PY3.5	DMPH	Pioneers Memorial Healthcare District, Brawley	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	None	0.942	0	0.5	803	0	846	0	0.9492	0	1
PY3.5	DMPH	Pioneers Memorial Healthcare District, Brawley	1.4.2	Annual Monitoring for Patients on Persistent Medications	None	0.6554	0	0	713	0	871	0	0.8186	0	0
PY3.5	DMPH	Pioneers Memorial Healthcare District, Brawley	1.4.3	INR Monitoring for Individuals on Warfarin	None	None	1	0	None	1	None	1	None	1	0
PY3.5	DMPH	Pioneers Memorial Healthcare District, Brawley	1.6.1	BIRADS to Biopsy	None	None	1	0	None	1	None	1	None	1	0
PY3.5	DMPH	Pioneers Memorial Healthcare District, Brawley	1.6.2	Breast Cancer Screening	None	0.6667	0	0	298	0	415	0	0.7181	0	1
PY3.5	DMPH	Pioneers Memorial Healthcare District, Brawley	1.6.3	Cervical Cancer Screening	None	0.449	0	0	495	0	884	0	0.56	0	1
PY3.5	DMPH	Pioneers Memorial Healthcare District, Brawley	1.6.4.c	Colorectal Cancer Screening	None	0.4189	0	0	247	0	690	0	0.358	0	1
PY3.5	DMPH	Pioneers Memorial Healthcare District, Brawley	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	None	None	1	0	0	0	None	1	None	1	0
PY3.5	DMPH	Pioneers Memorial Healthcare District, Brawley	2.2.1	DHCS All-Cause Readmissions	None	0.1073	0	0	25	0	233	0	0.1073	0	1
PY3.5	DMPH	Pioneers Memorial Healthcare District, Brawley	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.55	0	0	55	0	100	0	0.55	0	1
PY3.5	DMPH	Pioneers Memorial Healthcare District, Brawley	2.2.3	Medication Reconciliation – 30 days	None	0.1493	0	0	127	0	282	0	0.4504	0	0
PY3.5	DMPH	Pioneers Memorial Healthcare District, Brawley	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.7368	0	0	473	0	642	0	0.7368	0	1
PY3.5	DMPH	Pioneers Memorial Healthcare District, Brawley	2.2.5	Timely Transmission of Transition Record	None	0.2339	0	0	113	0	449	0	0.2517	0	1
PY3.5	DMPH	Pioneers Memorial Healthcare District, Brawley	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	None	0.3061	0	0	22	0	49	0	0.449	0	1
PY3.5	DMPH	Pioneers Memorial Healthcare District, Brawley	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	None	0.207	0	0	5425	0	27011	0	0.2008	0	1
PY3.5	DMPH	Pioneers Memorial Healthcare District, Brawley	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	None	0.0513	0	0	284	0	5119	0	0.0555	0	1
PY3.5	DMPH	Pioneers Memorial Healthcare District, Brawley	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR	None	0.851	0	0.8251	10430	0	10000	0	1.043	0	1
PY3.5	DMPH	Plumas District Hospital, Quincy	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.7201	0	0.067	265	0	439	0	0.6036	0	1
PY3.5	DMPH	Plumas District Hospital, Quincy	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.1476	0	0.0216	83	0	439	0	0.1891	0	1
PY3.5	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	None	0.6174	0	0	115	0	172	0	0.6686	0	1
PY3.5	DMPH	Plumas District Hospital, Quincy	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	None	0.8609	0	0	139	0	172	0	0.8081	0	1
PY3.5	DMPH	Plumas District Hospital, Quincy	2.6.4	Screening for Clinical Depression and follow-up	None	0.5433	0	0	151	0	341	0	0.4428	0	0
PY3.5	DMPH	Plumas District Hospital, Quincy	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	None	0.9008	0	0	392	0	439	0	0.8929	0	1
PY3.5	DPH	Riverside University Health System	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.6725	0	0.067	31710	0	43346	0	0.7316	0	1
PY3.5	DPH	Riverside University Health System	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.0417	0	0.0216	2118	0	43346	0	0.0489	0	1
PY3.5	DPH	Riverside University Health System	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.3158	0	0	2332	0	7866	0	0.2965	0	1
PY3.5	DPH	Riverside University Health System	1.1.5.f	Screening for Clinical Depression and follow-up	None	0.9274	0	0	27463	0	28831	0	0.9526	0	1
PY3.5	DPH	Riverside University Health System	1.1.6.t	Tobacco Assessment and Counseling	None	0.965	0	0	34572	0	36070	0	0.9585	0	1
PY3.5	DPH	Riverside University Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	0.0369	0	0.0198	50	0	1840	0	0.0272	0	1
PY3.5	DPH	Riverside University Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	0.0723	0	0.0419	112	0	1840	0	0.0609	0	1
PY3.5	DPH	Riverside University Health System	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	None	0.2948	0	0.1935	532	0	1840	0	0.2891	0	1
PY3.5	DPH	Riverside University Health System	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.6725	0	0.067	31710	0	43346	0	0.7316	0	1
PY3.5	DPH	Riverside University Health System	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.0417	0	0.0216	2118	0	43346	0	0.0489	0	1
PY3.5	DPH	Riverside University Health System	1.2.10	REAL and/or SO/GI disparity reduction	None	0.4375	0	0	30	0	64	0	0.4688	0	1
PY3.5	DPH	Riverside University Health System	1.2.11	REAL data completeness	None	0.9987	0	0	40117	0	40169	0	0.9987	0	1
PY3.5	DPH	Riverside University Health System	1.2.12.f	Screening for Clinical Depression and follow-up	None	0.9274	0	0	27463	0	28831	0	0.9526	0	1
PY3.5	DPH	Riverside University Health System	1.2.13	SO/GI data completeness	None	0.8398	0	0	35823	0	39267	0	0.9123	0	1
PY3.5	DPH	Riverside University Health System	1.2.14.t	Tobacco Assessment and Counseling	None	0.965	0	0	34572	0	36070	0	0.9585	0	1
PY3.5	DPH	Riverside University Health System	1.2.2	CG-CAHPS: Provider Rating	None	0.7918	0	0	945	0	1208	0	0.7823	0	1
PY3.5	DPH	Riverside University Health System	1.2.3.c	Colorectal Cancer Screening	None	0.595	0	0	220	0	400	0	0.55	0	1
PY3.5	DPH	Riverside University Health System	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.3158	0	0	2332	0	7866	0	0.2965	0	1
PY3.5	DPH	Riverside University Health System	1.2.5.b	Controlling Blood Pressure	None	0.6447	0	0	7489	0	11647	0	0.643	0	1
PY3.5	DPH	Riverside University Health System	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.906	0	0	244	0	270	0	0.9037	0	1
PY3.5	DPH	Riverside University Health System	1.2.8	Prevention Quality Overall Composite #90	None	0.0063	0	0	262	0	68473	0	0.0038	0	1
PY3.5	DPH	Riverside University Health System	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	None	0.9414	0	0	11850	0	12587	0	0.9414	0	1
PY3.5	DPH	Riverside University Health System	1.3.2	DHCS All-Cause Readmissions	None	0.1318	0	0	141	0	1099	0	0.1283	0	1
PY3.5	DPH	Riverside University Health System	1.3.3	Influenza Immunization	None	0.6848	0	0	3982	0	6044	0	0.6588	0	1
PY3.5	DPH	Riverside University Health System	1.3.5	Request for Specialty Care Expertise Turnaround Time	None	0.7326	0	0	22225	0	29137	0	0.7628	0	1
PY3.5	DPH	Riverside University Health System	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	None	0.1081	0	0	2020	0	21234	0	0.0951	0	1
PY3.5	DPH	Riverside University Health System	1.3.7	Tobacco Assessment and Counseling	None	0.9741	0	0	5753	0	5880	0	0.9784	0	1
PY3.5	DPH	Riverside University Health System	1.5.1.b	Controlling Blood Pressure	None	0.6447	0	0	7849	0	11647	0	0.6739	0	1
PY3.5	DPH	Riverside University Health System	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.906	0	0	244	0	270	0	0.9037	0	1
PY3.5	DPH	Riverside University Health System	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	None	0.545	0	0	13135	0	24387	0	0.5386	0	1
PY3.5	DPH	Riverside University Health System	1.5.4.t	Tobacco Assessment and Counseling	None	0.965	0	0	34572	0	36070	0	0.9585	0	1
PY3.5	DPH	Riverside University Health System	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	None	0	0	None	Yes	0	BFUSA Cert?	0	1	0	1
PY3.5	DPH	Riverside University Health System	2.1.2	Exclusive Breast Milk Feeding (PC-05)	None	0.7536	0	0	186	0	236	0	0.7881	0	1
PY3.5	DPH	Riverside University Health System	2.1.3	OB Hemorrhage: Massive Transfusion	None	0	0	0	0	0	302	0	0	0	1
PY3.5	DPH	Riverside University Health System	2.1.5	PC-02 Cesarean Section	None	0.2258	0	0	17	0	73	0	0.2329	0	1
PY3.5	DPH	Riverside University Health System	2.1.6	Prenatal and Postpartum Care: Prenatal Care	None	0.8182	0	0.7689	303	0	380	0	0.7974	0	1
PY3.5	DPH	Riverside University Health System	2.1.6	Prenatal and Postpartum Care: Postpartum Care	None	0.7117	0	0.713	303	0	396	0	0.7652	0	1
PY3.5	DPH	Riverside University Health System	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	None	1	0	None	1	35	0	None	1	1
PY3.5	DPH	Riverside University Health System	2.1.8	Unexpected Newborn Complications (UNC)	None	None	1	0	None	1	231	0	None	1	1
PY3.5	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	None	0	0	None	Yes	0	10 Debriefs?	0	0	0	n/a
PY3.5	DPH	Riverside University Health System	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	None	0	0	None	Yes	0	3 Safety Drills?	0	0	0	n/a
PY3.5	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)	None	1	0	None	16	0	16	0	1	0	1
PY3.5	DPH	Riverside University Health System	2.2.1	DHCS All-Cause Readmissions	None	0.1338	0	0	193	0	1398	0	0.1381	0	1
PY3.5	DPH	Riverside University Health System	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.5342	0	0	598	0	1105	0	0.5412	0	1
PY3.5	DPH	Riverside University Health System	2.2.3	Medication Reconciliation – 30 days	None	0.9746	0	0	347	0	356	0	0.9747	0	1
PY3.5	DPH	Riverside University Health System	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.9625	0	0	365	0	386	0	0.9456	0	1
PY3.5	DPH	Riverside University Health System	2.2.5	Timely Transmission of Transition Record	None	0.9789	0	0	3624	0	3731	0	0.9713	0	1
PY3.5	DPH	Riverside University Health System	2.3.2	Medication Reconciliation – 30 days	None	0.9785	0	0	185	0	186	0	0.9946	0	1
PY3.5	DPH	Riverside University Health System	2.3.4	Timely Transmission of Transition Record	None	0.9889	0	0	496	0	505	0	0.9822	0	1
PY3.5	DPH	Riverside University Health System	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.7698	0	0.067	6873	0	8527	0	0.806	0	1
PY3.5	DPH	Riverside University Health System	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.0237	0	0.0216	252	0	8527	0	0.0296	0	1
PY3.5	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	None	0.381	0	0	60	0	139	0	0.4317	0	1
PY3.5	DPH	Riverside University Health System	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	None	1	0	0	139	0	139	0	1	0	1
PY3.5	DPH	Riverside University Health System	2.6.4	Screening for Clinical Depression and follow-up	None	0.9688	0	0	4829	0	4940	0	0.9775	0	1
PY3.5	DPH	Riverside University Health System	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	None	0.9102	0	0	7551	0	8258	0	0.9144	0	1
PY3.5	DPH	Riverside University Health System	3.3.1	Adherence to Medications: Rate 1	None	0.5659	0	0.25	3687	0	6149	0	0.5996	0	1
PY3.5	DPH	Riverside University Health System	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 1	None	0.6032	0	0.25	5267	0	8529	0	0.6175	0	1
PY3.5	DPH	Riverside University Health System	3.3.4	Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 1	None	0.9178	0	0.25	12174	0	12761	0	0.954	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	None	0.9424	0	0.5	1067	0	1083	0	0.9852	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	None	0.7389	0	0.5	1270	0	1731	0	0.7337	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	None	0.928	0	0.5	6675	0	7133	0	0.9358	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	1.4.2	Annual Monitoring for Patients on Persistent Medications	None	0.8247	0	0	2499	0	2862	0	0.8732	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	1.4.3	INR Monitoring for Individuals on Warfarin	None	0.7596	0	0	408	0	502	0	0.8127	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	1.5.1.b	Controlling Blood Pressure	None	0.6306	0	0	1983	0	3128	0	0.634	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.9188	0	0	1111	0	1328	0	0.8366	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	None	0.8954	0	0	13741	0	15376	0	0.8937	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	1.5.4.t	Tobacco Assessment and Counseling	None	0.9716	0	0	14171	0	14443	0	0.9812	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	1.6.1	BIRADS to Biopsy	None	0.9375	0	0	114	0	124	0	0.9194	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	1.6.2	Breast Cancer Screening	None	0.6221	0	0	1719	0	3090	0	0.5563	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	1.6.3	Cervical Cancer Screening	None	0.5753	0	0	3336	0	5160	0	0.6465	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	1.6.4.c	Colorectal Cancer Screening	None	0.6103	0	0	2429	0	5270	0	0.4609	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	None	None	1	0	None	1	None	1	None	1	0
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	2.2.1	DHCS All-Cause Readmissions	None	0.1907	0	0	195	0	983	0	0.1984	0	0
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.5616	0	0	2965	0	5268	0	0.5628	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	2.2.3	Medication Reconciliation – 30 days	None	0.9124	0	0	1283	0	1401	0	0.9158	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.9739	0	0	4775	0	4909	0	0.9727	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	2.2.5	Timely Transmission of Transition Record	None	0.6311	0	0	392	0	400	0	0.98	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	2.3.2	Medication Reconciliation – 30 days	None	0.8971	0	0	767	0	839	0	0.9142	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	2.3.4	Timely Transmission of Transition Record	None	0.695	0	0	400	0	400	0	1	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	2.7.1	Advance Care Plan	None	0.9753	0	0	1117	0	1137	0	0.9824	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	None	0.9775	0	0	92	0	95	0	0.9684	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	None	0.7941	0	0	100	0	154	0	0.6494	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	None	0.2256	0	0	286	0	1202	0	0.2379	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	None	0.3621	0	0	14	0	60	0	0.2333	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	None	0.7455	0	0	96	0	124	0	0.7742	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	None	0.278	0	0	10487	0	37209	0	0.2818	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	None	0.3227	0	0	160	0	501	0	0.3194	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR	None	0.6883	0	0.6787	7465	0	10000	0	0.7465	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	3.4.1	ePBM-01 Pre-op Anemia Screening, Selected Elective Surgical Patients	None	0.3235	0	0	30	0	83	0	0.3614	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	3.4.3	ePBM-03 Pre-op Type and Crossmatch, Type and Screen, Selected elective Surgical Patients	None	0.5224	0	0	46	0	83	0	0.5542	0	1
PY3.5	DMPH	Salinas Valley Memorial Healthcare System	3.4.4	ePBM-04 Initial Transfusion Threshold	None	1	0	0	231	0	231	0	1	0	1
PY3.5	DMPH	San Bernardino Mountains Community Hospital, Lake Arrowhead	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	None	None	4	0.5	30	0	35	0	0.8571	0	1
PY3.5	DMPH	San Bernardino Mountains Community Hospital, Lake Arrowhead	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	None	0.8377	0	0.5	88	0	102	0	0.8627	0	1
PY3.5	DMPH	San Bernardino Mountains Community Hospital, Lake Arrowhead	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	None	0.9744	0	0.5	549	0	572	0	0.9598	0	1
PY3.5	DMPH	San Bernardino Mountains Community Hospital, Lake Arrowhead	1.4.2	Annual Monitoring for Patients on Persistent Medications	None	0.9385	0	0	270	0	280	0	0.9643	0	1
PY3.5	DMPH	San Bernardino Mountains Community Hospital, Lake Arrowhead	1.4.3	INR Monitoring for Individuals on Warfarin	None	None	4	0	36	0	43	0	0.8372	0	1
PY3.5	DPH	San Francisco General Hospital	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.5689	0	0.067	21521	0	34065	0	0.6318	0	1
PY3.5	DPH	San Francisco General Hospital	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.1605	0	0.0216	4382	0	34065	0	0.1286	0	1
PY3.5	DPH	San Francisco General Hospital	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.3082	0	0	1730	0	6610	0	0.2617	0	1
PY3.5	DPH	San Francisco General Hospital	1.1.5.f	Screening for Clinical Depression and follow-up	None	0.6469	0	0	16392	0	23747	0	0.6903	0	1
PY3.5	DPH	San Francisco General Hospital	1.1.6.t	Tobacco Assessment and Counseling	None	0.9819	0	0	27019	0	27374	0	0.987	0	1
PY3.5	DPH	San Francisco General Hospital	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	0.0331	0	0.0198	88	0	2181	0	0.0403	0	1
PY3.5	DPH	San Francisco General Hospital	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	0.075	0	0.0419	191	0	2181	0	0.0876	0	1
PY3.5	DPH	San Francisco General Hospital	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	None	0.3122	0	0.1935	725	0	2181	0	0.3324	0	1
PY3.5	DPH	San Francisco General Hospital	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.5689	0	0.067	21521	0	34065	0	0.6318	0	1
PY3.5	DPH	San Francisco General Hospital	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.1605	0	0.0216	4382	0	34065	0	0.1286	0	1
PY3.5	DPH	San Francisco General Hospital	1.2.10	REAL and/or SO/GI disparity reduction	None	0.5329	0	0	2281	0	3940	0	0.5789	0	1
PY3.5	DPH	San Francisco General Hospital	1.2.11	REAL data completeness	None	0.9859	0	0	34463	0	36444	0	0.9456	0	1
PY3.5	DPH	San Francisco General Hospital	1.2.12.f	Screening for Clinical Depression and follow-up	None	0.6469	0	0	16392	0	23747	0	0.6903	0	1
PY3.5	DPH	San Francisco General Hospital	1.2.13	SO/GI data completeness	None	0.5882	0	0	18090	0	30342	0	0.5962	0	1
PY3.5	DPH	San Francisco General Hospital	1.2.14.t	Tobacco Assessment and Counseling	None	0.9819	0	0	27019	0	27374	0	0.987	0	1
PY3.5	DPH	San Francisco General Hospital	1.2.2	CG-CAHPS: Provider Rating	None	0.8035	0	0	2492	0	3131	0	0.7959	0	1
PY3.5	DPH	San Francisco General Hospital	1.2.3.c	Colorectal Cancer Screening	None	0.6155	0	0	12228	0	18532	0	0.6598	0	1
PY3.5	DPH	San Francisco General Hospital	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.3082	0	0	1730	0	6610	0	0.2617	0	1
PY3.5	DPH	San Francisco General Hospital	1.2.5.b	Controlling Blood Pressure	None	0.7052	0	0	8061	0	11070	0	0.7282	0	1
PY3.5	DPH	San Francisco General Hospital	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.9008	0	0	1811	0	1979	0	0.9151	0	1
PY3.5	DPH	San Francisco General Hospital	1.2.8	Prevention Quality Overall Composite #90	None	0.016	0	0	639	0	40933	0	0.0156	0	0
PY3.5	DPH	San Francisco General Hospital	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	None	0.9979	0	0	53619	0	61547	0	0.8712	0	1
PY3.5	DPH	San Francisco General Hospital	1.3.2	DHCS All-Cause Readmissions	None	0.1451	0	0	186	0	1375	0	0.1353	0	1
PY3.5	DPH	San Francisco General Hospital	1.3.3	Influenza Immunization	None	0.8895	0	0	5887	0	6602	0	0.8917	0	1
PY3.5	DPH	San Francisco General Hospital	1.3.5	Request for Specialty Care Expertise Turnaround Time	None	0.9292	0	0	39107	0	42045	0	0.9301	0	1
PY3.5	DPH	San Francisco General Hospital	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	None	0.2394	0	0	12613	0	46443	0	0.2716	0	1
PY3.5	DPH	San Francisco General Hospital	1.3.7	Tobacco Assessment and Counseling	None	0.9897	0	0	11032	0	11133	0	0.9909	0	1
PY3.5	DPH	San Francisco General Hospital	1.5.1.b	Controlling Blood Pressure	None	0.7052	0	0	8061	0	11070	0	0.7282	0	1
PY3.5	DPH	San Francisco General Hospital	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.9008	0	0	1811	0	1979	0	0.9151	0	1
PY3.5	DPH	San Francisco General Hospital	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	None	0.9309	0	0	16364	0	17695	0	0.9248	0	1
PY3.5	DPH	San Francisco General Hospital	1.5.4.t	Tobacco Assessment and Counseling	None	0.9819	0	0	27019	0	27374	0	0.987	0	1
PY3.5	DPH	San Francisco General Hospital	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	None	0	0	None	Yes	0	BFUSA Cert?	0	1	0	1
PY3.5	DPH	San Francisco General Hospital	2.1.2	Exclusive Breast Milk Feeding (PC-05)	None	0.8006	0	0	569	0	715	0	0.7958	0	1
PY3.5	DPH	San Francisco General Hospital	2.1.3	OB Hemorrhage: Massive Transfusion	None	None	1	0	None	1	860	0	None	1	1
PY3.5	DPH	San Francisco General Hospital	2.1.5	PC-02 Cesarean Section	None	0.1692	0	0	43	0	281	0	0.153	0	1
PY3.5	DPH	San Francisco General Hospital	2.1.6	Prenatal and Postpartum Care: Postpartum Care	None	0.7164	0	0.713	518	0	663	0	0.7813	0	1
PY3.5	DPH	San Francisco General Hospital	2.1.6	Prenatal and Postpartum Care: Prenatal Care	None	0.9188	0	0.7689	640	0	693	0	0.9235	0	1
PY3.5	DPH	San Francisco General Hospital	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	0.331	0	0	45	0	148	0	0.3041	0	1
PY3.5	DPH	San Francisco General Hospital	2.1.8	Unexpected Newborn Complications (UNC)	None	0.0616	0	0	46	0	674	0	0.0682	0	1
PY3.5	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	None	0	0	None	Yes	0	10 Debriefs?	0	0	0	n/a
PY3.5	DPH	San Francisco General Hospital	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	None	0	0	None	Yes	0	3 Safety Drills?	0	0	0	n/a
PY3.5	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)	None	1	0	None	16	0	16	0	1	0	1
PY3.5	DPH	San Francisco General Hospital	2.2.1	DHCS All-Cause Readmissions	None	0.1488	0	0	308	0	2225	0	0.1384	0	1
PY3.5	DPH	San Francisco General Hospital	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.5123	0	0	389	0	792	0	0.4912	0	1
PY3.5	DPH	San Francisco General Hospital	2.2.3	Medication Reconciliation – 30 days	None	0.9713	0	0	3169	0	3509	0	0.9031	0	1
PY3.5	DPH	San Francisco General Hospital	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.9959	0	0	3345	0	3373	0	0.9917	0	1
PY3.5	DPH	San Francisco General Hospital	2.2.5	Timely Transmission of Transition Record	None	0.8675	0	0	4221	0	4966	0	0.8500	0	1
PY3.5	DPH	San Francisco General Hospital	2.3.2	Medication Reconciliation – 30 days	None	0.9764	0	0	991	0	1071	0	0.9253	0	1
PY3.5	DPH	San Francisco General Hospital	2.3.4	Timely Transmission of Transition Record	None	0.9303	0	0	1435	0	1577	0	0.91	0	1
PY3.5	DPH	San Francisco General Hospital	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.6178	0	0.067	3571	0	5286	0	0.6756	0	1
PY3.5	DPH	San Francisco General Hospital	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.2101	0	0.0216	889	0	5286	0	0.1682	0	1
PY3.5	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	None	0.3993	0	0	566	0	1026	0	0.5517	0	1
PY3.5	DPH	San Francisco General Hospital	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	None	0.985	0	0	998	0	1026	0	0.9727	0	1
PY3.5	DPH	San Francisco General Hospital	2.6.4	Screening for Clinical Depression and follow-up	None	0.673	0	0	1992	0	2876	0	0.6926	0	1
PY3.5	DPH	San Francisco General Hospital	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	None	0.8848	0	0	5078	0	5594	0	0.9078	0	1
PY3.5	DPH	San Francisco General Hospital	3.3.1	Adherence to Medications: Rate 1	None	0.7561	0	0.7689	349	0	463	0	0.7538	0	0
PY3.5	DPH	San Francisco General Hospital	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 1	None	0.6712	0	None	98	0	231	0	0.4242	0	1
PY3.5	DPH	San Francisco General Hospital	3.3.4	Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 1	None	0.8123	0	0.1368	1338	0	1734	0	0.7716	0	1
PY3.5	DMPH	San Gorgonio Memorial Hospital, Banning	1.7.1	BMI Screening and Follow-up	None	0.7766	0	0	84	0	107	0	0.785	0	1
PY3.5	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)	None	None	1	None	8	0	8	0	1	0	1
PY3.5	DMPH	San Gorgonio Memorial Hospital, Banning	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI	None	0.9268	0	0.66	93	0	99	0	0.9394	0	1
PY3.5	DMPH	San Gorgonio Memorial Hospital, Banning	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition	None	0.9268	0	0.5985	93	0	99	0	0.9394	0	1
PY3.5	DMPH	San Gorgonio Memorial Hospital, Banning	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity	None	0.9268	0	0.5231	93	0	99	0	0.9394	0	1
PY3.5	DMPH	San Gorgonio Memorial Hospital, Banning	2.2.1	DHCS All-Cause Readmissions	None	0.0931	0	0	33	0	524	0	0.063	0	1
PY3.5	DMPH	San Gorgonio Memorial Hospital, Banning	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.4821	0	0	5042	0	10000	0	0.5042	0	1
PY3.5	DMPH	San Gorgonio Memorial Hospital, Banning	2.2.3	Medication Reconciliation – 30 days	None	None	4	0	36	0	36	0	1	0	1
PY3.5	DMPH	San Gorgonio Memorial Hospital, Banning	2.2.4	Reconciled Medication List Received by Discharged Patients	None	None	4	0	36	0	36	0	1	0	1
PY3.5	DMPH	San Gorgonio Memorial Hospital, Banning	2.2.5	Timely Transmission of Transition Record	None	None	4	0	36	0	36	0	1	0	1
PY3.5	DMPH	San Gorgonio Memorial Hospital, Banning	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	None	0.875	0	0	61	0	63	0	0.9683	0	1
PY3.5	DMPH	San Gorgonio Memorial Hospital, Banning	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	None	0.4616	0	0	5948	0	11838	0	0.5024	0	0
PY3.5	DMPH	San Gorgonio Memorial Hospital, Banning	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	None	0.5	0	0	25	0	53	0	0.4717	0	1
PY3.5	DMPH	San Gorgonio Memorial Hospital, Banning	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR	None	0.877	0	0.8485	7470	0	10000	0	0.747	0	1
PY3.5	DPH	San Joaquin General Hospital	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.277	0	0.067	6612	0	16237	0	0.4072	0	1
PY3.5	DPH	San Joaquin General Hospital	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.0542	0	0.0216	1752	0	16237	0	0.1079	0	1
PY3.5	DPH	San Joaquin General Hospital	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.4001	0	0	1101	0	2980	0	0.3695	0	1
PY3.5	DPH	San Joaquin General Hospital	1.1.5.f	Screening for Clinical Depression and follow-up	None	0.5027	0	0	6808	0	10653	0	0.6391	0	1
PY3.5	DPH	San Joaquin General Hospital	1.1.6.t	Tobacco Assessment and Counseling	None	0.878	0	0	10718	0	12935	0	0.8286	0	1
PY3.5	DPH	San Joaquin General Hospital	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	0.0699	0	0.0198	52	0	530	0	0.0981	0	1
PY3.5	DPH	San Joaquin General Hospital	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	0.0962	0	0.0419	73	0	530	0	0.1377	0	1
PY3.5	DPH	San Joaquin General Hospital	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	None	0.2028	0	0.1935	147	0	530	0	0.2774	0	1
PY3.5	DPH	San Joaquin General Hospital	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.277	0	0.067	6612	0	16237	0	0.4072	0	1
PY3.5	DPH	San Joaquin General Hospital	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.0542	0	0.0216	1752	0	16237	0	0.1079	0	1
PY3.5	DPH	San Joaquin General Hospital	1.2.10	REAL and/or SO/GI disparity reduction	None	0.5841	0	0	477	0	826	0	0.5775	0	1
PY3.5	DPH	San Joaquin General Hospital	1.2.11	REAL data completeness	None	0.9959	0	0	21445	0	21567	0	0.9943	0	1
PY3.5	DPH	San Joaquin General Hospital	1.2.12.f	Screening for Clinical Depression and follow-up	None	0.5027	0	0	6808	0	10653	0	0.6391	0	1
PY3.5	DPH	San Joaquin General Hospital	1.2.13	SO/GI data completeness	None	0.573	0	0	12619	0	14646	0	0.8616	0	1
PY3.5	DPH	San Joaquin General Hospital	1.2.14.t	Tobacco Assessment and Counseling	None	0.878	0	0	10718	0	12935	0	0.8286	0	1
PY3.5	DPH	San Joaquin General Hospital	1.2.2	CG-CAHPS: Provider Rating	None	0.7777	0	0	7800	0	10000	0	0.78	0	1
PY3.5	DPH	San Joaquin General Hospital	1.2.3.c	Colorectal Cancer Screening	None	0.5162	0	0	158	0	370	0	0.427	0	1
PY3.5	DPH	San Joaquin General Hospital	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.4001	0	0	1101	0	2980	0	0.3695	0	1
PY3.5	DPH	San Joaquin General Hospital	1.2.5.b	Controlling Blood Pressure	None	0.5958	0	0	3212	0	5133	0	0.6258	0	1
PY3.5	DPH	San Joaquin General Hospital	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.8658	0	0	801	0	914	0	0.8764	0	1
PY3.5	DPH	San Joaquin General Hospital	1.2.8	Prevention Quality Overall Composite #90	None	0.0065	0	0	201	0	24034	0	0.0084	0	1
PY3.5	DPH	San Joaquin General Hospital	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	None	0.7778	0	0	289	0	351	0	0.8234	0	1
PY3.5	DPH	San Joaquin General Hospital	1.3.2	DHCS All-Cause Readmissions	None	0.1229	0	0	112	0	773	0	0.1449	0	1
PY3.5	DPH	San Joaquin General Hospital	1.3.3	Influenza Immunization	None	0.5783	0	0	150	0	351	0	0.4274	0	0
PY3.5	DPH	San Joaquin General Hospital	1.3.5	Request for Specialty Care Expertise Turnaround Time	None	0.687	0	0	250	0	377	0	0.6631	0	1
PY3.5	DPH	San Joaquin General Hospital	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	None	None	1	0	26	0	377	0	0.069	0	1
PY3.5	DPH	San Joaquin General Hospital	1.3.7	Tobacco Assessment and Counseling	None	0.9208	0	0	2297	0	2712	0	0.847	0	1
PY3.5	DPH	San Joaquin General Hospital	1.6.1	BIRADS to Biopsy	None	None	4	0	18	0	30	0	0.6	0	1
PY3.5	DPH	San Joaquin General Hospital	1.6.2	Breast Cancer Screening	None	0.7273	0	0	271	0	349	0	0.7765	0	1
PY3.5	DPH	San Joaquin General Hospital	1.6.3	Cervical Cancer Screening	None	0.6179	0	0	225	0	370	0	0.6081	0	1
PY3.5	DPH	San Joaquin General Hospital	1.6.4.c	Colorectal Cancer Screening	None	0.5162	0	0	158	0	370	0	0.427	0	1
PY3.5	DPH	San Joaquin General Hospital	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	None	None	1	0	13	0	31	0	0.4194	0	1
PY3.5	DPH	San Joaquin General Hospital	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	None	0	0	None	Yes	0	BFUSA Cert?	0	1	0	1
PY3.5	DPH	San Joaquin General Hospital	2.1.2	Exclusive Breast Milk Feeding (PC-05)	None	0.7085	0	0	532	0	742	0	0.717	0	1
PY3.5	DPH	San Joaquin General Hospital	2.1.3	OB Hemorrhage: Massive Transfusion	None	None	1	0	None	1	1046	0	None	1	1
PY3.5	DPH	San Joaquin General Hospital	2.1.5	PC-02 Cesarean Section	None	0.179	0	0	49	0	260	0	0.1885	0	1
PY3.5	DPH	San Joaquin General Hospital	2.1.6	Prenatal and Postpartum Care: Prenatal Care	None	0.5304	0	0.7689	233	0	411	0	0.5669	0	0
PY3.5	DPH	San Joaquin General Hospital	2.1.6	Prenatal and Postpartum Care: Postpartum Care	None	0.6131	0	0.713	382	0	600	0	0.6367	0	0
PY3.5	DPH	San Joaquin General Hospital	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	0.4237	0	0	28	0	73	0	0.3836	0	1
PY3.5	DPH	San Joaquin General Hospital	2.1.8	Unexpected Newborn Complications (UNC)	None	0.0382	0	0	33	0	778	0	0.0424	0	1
PY3.5	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)	None	1	0	None	16	0	16	0	1	0	1
PY3.5	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	None	0	0	None	Yes	0	10 Debriefs?	0	0	0	n/a
PY3.5	DPH	San Joaquin General Hospital	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	None	0	0	None	Yes	0	3 Safety Drills?	0	0	0	n/a
PY3.5	DPH	San Joaquin General Hospital	2.2.1	DHCS All-Cause Readmissions	None	0.1121	0	0	134	0	1223	0	0.1096	0	1
PY3.5	DPH	San Joaquin General Hospital	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.4	0	0	3930	0	10000	0	0.393	0	0
PY3.5	DPH	San Joaquin General Hospital	2.2.3	Medication Reconciliation – 30 days	None	0.7338	0	0	255	0	323	0	0.7895	0	1
PY3.5	DPH	San Joaquin General Hospital	2.2.4	Reconciled Medication List Received by Discharged Patients	None	1	0	0	343	0	351	0	0.9772	0	1
PY3.5	DPH	San Joaquin General Hospital	2.2.5	Timely Transmission of Transition Record	None	0.747	0	0	317	0	411	0	0.7713	0	1
PY3.5	DPH	San Joaquin General Hospital	2.3.2	Medication Reconciliation – 30 days	None	0.6908	0	0	211	0	278	0	0.759	0	1
PY3.5	DPH	San Joaquin General Hospital	2.3.4	Timely Transmission of Transition Record	None	0.7543	0	0	360	0	411	0	0.8759	0	1
PY3.5	DPH	San Joaquin General Hospital	2.7.1	Advance Care Plan	None	0.6718	0	0	191	0	323	0	0.5913	0	1
PY3.5	DPH	San Joaquin General Hospital	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	None	0.697	0	0	110	0	121	0	0.9091	0	1
PY3.5	DPH	San Joaquin General Hospital	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	None	0.85	0	0	52	0	52	0	1	0	1
PY3.5	DPH	San Joaquin General Hospital	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	None	0.2879	0	0	24	0	121	0	0.1983	0	1
PY3.5	DPH	San Joaquin General Hospital	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	None	None	1	0	None	1	None	4	None	1	0
PY3.5	DPH	San Joaquin General Hospital	3.2.2	Appropriate Emergency Department Utilization of CT for Pulmonary Embolism	None	0.6712	0	0	167	0	218	0	0.7661	0	1
PY3.5	DPH	San Joaquin General Hospital	3.2.3	Use of Imaging Studies for Low Back Pain	None	0.1381	0	0	501	0	601	0	0.8336	0	1
PY3.5	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	None	0.7781	0	None	194	0	438	0	0.4429	0	1
PY3.5	DPH	San Mateo Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.1643	0	0.067	2620	0	23655	0	0.1108	0	1
PY3.5	DPH	San Mateo Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.2055	0	0.0216	3455	0	23655	0	0.1461	0	1
PY3.5	DPH	San Mateo Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.29	0	0	1100	0	4311	0	0.2552	0	1
PY3.5	DPH	San Mateo Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	None	0.5688	0	0	9149	0	16012	0	0.5714	0	1
PY3.5	DPH	San Mateo Medical Center	1.1.6.t	Tobacco Assessment and Counseling	None	0.9511	0	0	17405	0	18056	0	0.9639	0	1
PY3.5	DPH	San Mateo Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	0.0567	0	0.0198	44	0	614	0	0.0717	0	1
PY3.5	DPH	San Mateo Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	0.1091	0	0.0419	74	0	614	0	0.1205	0	1
PY3.5	DPH	San Mateo Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	None	0.364	0	0.1935	245	0	614	0	0.399	0	1
PY3.5	DPH	San Mateo Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.1643	0	0.067	2620	0	23655	0	0.1108	0	1
PY3.5	DPH	San Mateo Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.2055	0	0.0216	3455	0	23655	0	0.1461	0	1
PY3.5	DPH	San Mateo Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	None	0.6219	0	0	191	0	300	0	0.6367	0	1
PY3.5	DPH	San Mateo Medical Center	1.2.11	REAL data completeness	None	0.6984	0	0	28484	0	32130	0	0.8865	0	1
PY3.5	DPH	San Mateo Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	None	0.5688	0	0	9149	0	16012	0	0.5714	0	1
PY3.5	DPH	San Mateo Medical Center	1.2.13	SO/GI data completeness	None	0.8631	0	0	18114	0	20752	0	0.8729	0	1
PY3.5	DPH	San Mateo Medical Center	1.2.14.t	Tobacco Assessment and Counseling	None	0.9511	0	0	17405	0	18056	0	0.9639	0	1
PY3.5	DPH	San Mateo Medical Center	1.2.2	CG-CAHPS: Provider Rating	None	0.8298	0	0	366	0	462	0	0.7922	0	1
PY3.5	DPH	San Mateo Medical Center	1.2.3.c	Colorectal Cancer Screening	None	0.5962	0	0	5321	0	8114	0	0.6558	0	1
PY3.5	DPH	San Mateo Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.29	0	0	1100	0	4311	0	0.2552	0	1
PY3.5	DPH	San Mateo Medical Center	1.2.5.b	Controlling Blood Pressure	None	0.6535	0	0	4467	0	6510	0	0.6862	0	1
PY3.5	DPH	San Mateo Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.9557	0	0	764	0	802	0	0.9526	0	1
PY3.5	DPH	San Mateo Medical Center	1.2.8	Prevention Quality Overall Composite #90	None	0.0078	0	0	177	0	20499	0	0.0086	0	1
PY3.5	DPH	San Mateo Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	None	1	0	0	14451	0	14451	0	1	0	1
PY3.5	DPH	San Mateo Medical Center	1.3.2	DHCS All-Cause Readmissions	None	0.0749	0	0	18	0	211	0	0.0853	0	1
PY3.5	DPH	San Mateo Medical Center	1.3.3	Influenza Immunization	None	0.767	0	0	7588	0	10186	0	0.7449	0	1
PY3.5	DPH	San Mateo Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	None	0.3473	0	0	8889	0	23151	0	0.384	0	1
PY3.5	DPH	San Mateo Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	None	0.131	0	0	4621	0	35059	0	0.1318	0	1
PY3.5	DPH	San Mateo Medical Center	1.3.7	Tobacco Assessment and Counseling	None	0.9551	0	0	6015	0	6181	0	0.9731	0	1
PY3.5	DPH	San Mateo Medical Center	1.6.1	BIRADS to Biopsy	None	0.6131	0	0	109	0	167	0	0.6527	0	1
PY3.5	DPH	San Mateo Medical Center	1.6.2	Breast Cancer Screening	None	0.7629	0	0	4142	0	5254	0	0.7884	0	1
PY3.5	DPH	San Mateo Medical Center	1.6.3	Cervical Cancer Screening	None	0.6366	0	0	6281	0	9530	0	0.6591	0	1
PY3.5	DPH	San Mateo Medical Center	1.6.4.c	Colorectal Cancer Screening	None	0.5962	0	0	5321	0	8114	0	0.6558	0	1
PY3.5	DPH	San Mateo Medical Center	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	None	0.5831	0	0	335	0	553	0	0.6058	0	1
PY3.5	DPH	San Mateo Medical Center	2.2.1	DHCS All-Cause Readmissions	None	0.0856	0	0	21	0	251	0	0.0837	0	1
PY3.5	DPH	San Mateo Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.53	0	0	5520	0	10000	0	0.552	0	1
PY3.5	DPH	San Mateo Medical Center	2.2.3	Medication Reconciliation – 30 days	None	0.753	0	0	505	0	701	0	0.7204	0	1
PY3.5	DPH	San Mateo Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.981	0	0	822	0	837	0	0.9821	0	1
PY3.5	DPH	San Mateo Medical Center	2.2.5	Timely Transmission of Transition Record	None	0.9966	0	0	1961	0	1963	0	0.9990	0	1
PY3.5	DPH	San Mateo Medical Center	2.3.2	Medication Reconciliation – 30 days	None	0.7879	0	0	75	0	91	0	0.8242	0	1
PY3.5	DPH	San Mateo Medical Center	2.3.4	Timely Transmission of Transition Record	None	1	0	0	221	0	221	0	1	0	1
PY3.5	DPH	San Mateo Medical Center	2.4.1	Adolescent Well-Care Visit	None	0.8056	0	0	26	0	33	0	0.7879	0	1
PY3.5	DPH	San Mateo Medical Center	2.4.2	Developmental Screening in the First Three Years of Life	None	None	1	0	None	1	None	1	None	1	0
PY3.5	DPH	San Mateo Medical Center	2.4.3	Documentation of Current Medications in the Medical Record (0-18 yo)	None	0.8667	0	0	237	0	259	0	0.9151	0	1
PY3.5	DPH	San Mateo Medical Center	2.4.4	Screening for Clinical Depression and follow-up	None	None	4	0	None	1	None	4	None	1	0
PY3.5	DPH	San Mateo Medical Center	2.4.5	Tobacco Assessment and Counseling (13 yo and older)	None	None	4	0	24	0	None	4	None	4	0
PY3.5	DPH	San Mateo Medical Center	2.4.7	Well Child Visits - Third, Fourth, Fifth, and Sixth Years of life	None	None	4	0	14	0	None	4	None	4	0
PY3.5	DPH	San Mateo Medical Center	2.4.8	Comprehensive Medical Evaluation Following Foster Youth Placement in Foster Care	None	0.4	0	0	None	1	None	4	None	1	0
PY3.5	DPH	San Mateo Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.319	0	0.067	88	0	331	0	0.2659	0	1
PY3.5	DPH	San Mateo Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.3834	0	0.0216	115	0	331	0	0.3474	0	1
PY3.5	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	None	1	0	None	1	None	1	None	1	0
PY3.5	DPH	San Mateo Medical Center	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	None	None	1	0	None	1	None	1	None	1	0
PY3.5	DPH	San Mateo Medical Center	2.6.4	Screening for Clinical Depression and follow-up	None	0.5373	0	0	99	0	178	0	0.5562	0	1
PY3.5	DPH	San Mateo Medical Center	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	None	0.911	0	0	317	0	341	0	0.9296	0	1
PY3.5	DPH	San Mateo Medical Center	3.2.2	Appropriate Emergency Department Utilization of CT for Pulmonary Embolism	None	0.9801	0	0	164	0	168	0	0.9762	0	1
PY3.5	DPH	San Mateo Medical Center	3.2.3	Use of Imaging Studies for Low Back Pain	None	0.9157	0	0	284	0	313	0	0.9073	0	1
PY3.5	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	None	0.6028	0	None	78	0	110	0	0.7091	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.5257	0	0.067	31491	0	56795	0	0.5545	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.1327	0	0.0216	8175	0	56795	0	0.1439	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.2811	0	0	2686	0	10976	0	0.2447	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	None	0.5593	0	0	22400	0	38490	0	0.582	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.1.6.t	Tobacco Assessment and Counseling	None	0.9847	0	0	34911	0	35181	0	0.9923	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	0.0521	0	0.0198	108	0	2252	0	0.048	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	0.1106	0	0.0419	245	0	2252	0	0.1088	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	None	0.4206	0	0.1935	869	0	2252	0	0.3859	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.5257	0	0.067	31491	0	56795	0	0.5545	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.1327	0	0.0216	8175	0	56795	0	0.1439	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	None	0.314	0	0	1300	0	4429	0	0.2935	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.2.11	REAL data completeness	None	0.7963	0	0	51306	0	65399	0	0.7845	0	0
PY3.5	DPH	Santa Clara Valley Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	None	0.5593	0	0	22400	0	38490	0	0.582	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.2.13	SO/GI data completeness	None	0.878	0	0	37562	0	42573	0	0.8823	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.2.14.t	Tobacco Assessment and Counseling	None	0.9847	0	0	34911	0	35181	0	0.9923	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.2.2	CG-CAHPS: Provider Rating	None	0.788	0	0	783	0	1000	0	0.783	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.2.3.c	Colorectal Cancer Screening	None	0.6385	0	0	16102	0	22842	0	0.7049	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.2811	0	0	2686	0	10976	0	0.2447	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.2.5.b	Controlling Blood Pressure	None	0.6064	0	0	7691	0	12080	0	0.6367	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.9455	0	0	1727	0	1816	0	0.951	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.2.8	Prevention Quality Overall Composite #90	None	0.0112	0	0	808	0	65742	0	0.0123	0	0
PY3.5	DPH	Santa Clara Valley Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	None	0.9861	0	0	31565	0	31885	0	0.99	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.3.2	DHCS All-Cause Readmissions	None	0.1426	0	0	222	0	1564	0	0.1419	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.3.3	Influenza Immunization	None	0.7441	0	0	12199	0	15224	0	0.8013	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	None	0.7766	0	0	53740	0	71997	0	0.7464	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	None	0.1398	0	0	11084	0	80318	0	0.138	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.3.7	Tobacco Assessment and Counseling	None	0.993	0	0	24166	0	24291	0	0.9949	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	None	0.4759	0	0.5	3538	0	6439	0	0.5495	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	None	0.9378	0	0.5	8513	0	9003	0	0.9456	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	None	0.923	0	0.5	17675	0	19208	0	0.9202	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.4.2	Annual Monitoring for Patients on Persistent Medications	None	0.8864	0	0	18441	0	20288	0	0.909	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	1.4.3	INR Monitoring for Individuals on Warfarin	None	0.7288	0	0	623	0	766	0	0.8133	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	None	0	0	None	Yes	0	BFUSA Cert?	0	1	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	None	0.7124	0	0	1367	0	1957	0	0.6985	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	None	1	0	None	1	2191	0	None	1	1
PY3.5	DPH	Santa Clara Valley Medical Center	2.1.5	PC-02 Cesarean Section	None	0.2196	0	0	157	0	660	0	0.2379	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	None	0.7036	0	0.713	713	0	868	0	0.8214	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	None	0.8848	0	0.7689	789	0	894	0	0.8826	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	0.2336	0	0	58	0	304	0	0.1908	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	None	0.033	0	0	51	0	1848	0	0.0276	0	1
PY3.5	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)	None	1	0	None	16	0	16	0	1	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 10 Post-event Debriefs Each Quarter (fewer if less than 10 cases) No	None	0	0	None	No	0	10 Debriefs?	0	0	0	n/a
PY3.5	DPH	Santa Clara Valley Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter No	None	0	0	None	No	0	3 Safety Drills?	0	0	0	n/a
PY3.5	DPH	Santa Clara Valley Medical Center	2.2.1	DHCS All-Cause Readmissions	None	0.1478	0	0	250	0	1711	0	0.1461	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.4808	0	0	4922	0	10000	0	0.4922	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	2.2.3	Medication Reconciliation – 30 days	None	0.9889	0	0	3793	0	3798	0	0.9987	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.9591	0	0	7516	0	7541	0	0.9967	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	2.2.5	Timely Transmission of Transition Record	None	0.7067	0	0	4091	0	5887	0	0.6949	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	2.3.2	Medication Reconciliation – 30 days	None	0.9894	0	0	200	0	200	0	1	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	2.3.4	Timely Transmission of Transition Record	None	0.6885	0	0	190	0	295	0	0.6441	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	2.4.1	Adolescent Well-Care Visit	None	0.8539	0	0	113	0	122	0	0.9262	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	2.4.2	Developmental Screening in the First Three Years of Life	None	0.8222	0	0	118	0	137	0	0.8613	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	2.4.3	Documentation of Current Medications in the Medical Record (0-18 yo)	None	0.8129	0	0	1985	0	2312	0	0.8586	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	2.4.4	Screening for Clinical Depression and follow-up	None	0.4407	0	0	40	0	88	0	0.4545	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	2.4.5	Tobacco Assessment and Counseling (13 yo and older)	None	0.8571	0	0	48	0	52	0	0.9231	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	2.4.7	Well Child Visits - Third, Fourth, Fifth, and Sixth Years of life	None	0.8957	0	0	108	0	116	0	0.931	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	2.4.8	Comprehensive Medical Evaluation Following Foster Youth Placement in Foster Care	None	0.9217	0	0	146	0	161	0	0.9068	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	3.3.1	Adherence to Medications: Rate 1	None	0.7883	0	0.25	216	0	265	0	0.8151	0	1
PY3.5	DPH	Santa Clara Valley Medical Center	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 1	None	0.9694	0	0.25	205	0	222	0	0.9234	0	1
PY3.5	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	None	0.4416	0	0.25	3278	0	8373	0	0.3915	0	1
PY3.5	DMPH	Seneca Healthcare District, Chester	2.2.1	DHCS All-Cause Readmissions	None	None	4	0	0	0	None	4	None	4	0
PY3.5	DMPH	Seneca Healthcare District, Chester	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.53	0	0	5200	0	10000	0	0.52	0	1
PY3.5	DMPH	Seneca Healthcare District, Chester	2.2.3	Medication Reconciliation – 30 days	None	0.8444	0	0	49	0	54	0	0.9074	0	1
PY3.5	DMPH	Seneca Healthcare District, Chester	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.5152	0	0	48	0	78	0	0.6154	0	0
PY3.5	DMPH	Seneca Healthcare District, Chester	2.2.5	Timely Transmission of Transition Record	None	1	0	0	60	0	60	0	1	0	1
PY3.5	DMPH	Sierra View District Hospital, Porterville	1.7.1	BMI Screening and Follow-up	None	0.9634	0	0	3691	0	3882	0	0.9508	0	1
PY3.5	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)	None	None	1	None	8	0	8	0	1	0	1
PY3.5	DMPH	Sierra View District Hospital, Porterville	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition	None	0.9778	0	0.5985	773	0	791	0	0.9772	0	1
PY3.5	DMPH	Sierra View District Hospital, Porterville	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity	None	0.9778	0	0.5231	773	0	791	0	0.9772	0	1
PY3.5	DMPH	Sierra View District Hospital, Porterville	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI	None	0.9796	0	0.66	779	0	791	0	0.9848	0	1
PY3.5	DMPH	Sierra View District Hospital, Porterville	2.2.1	DHCS All-Cause Readmissions	None	0.2025	0	0	131	0	715	0	0.1832	0	0
PY3.5	DMPH	Sierra View District Hospital, Porterville	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.428	0	0	4290	0	10000	0	0.429	0	0
PY3.5	DMPH	Sierra View District Hospital, Porterville	2.2.3	Medication Reconciliation – 30 days	None	1	0	0	367	0	367	0	1	0	1
PY3.5	DMPH	Sierra View District Hospital, Porterville	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.9679	0	0	731	0	759	0	0.9631	0	1
PY3.5	DMPH	Sierra View District Hospital, Porterville	2.2.5	Timely Transmission of Transition Record	None	0.4144	0	0	1350	0	3401	0	0.3969	0	1
PY3.5	DMPH	Sierra View District Hospital, Porterville	2.3.2	Medication Reconciliation – 30 days	None	1	0	0	116	0	116	0	1	0	1
PY3.5	DMPH	Sierra View District Hospital, Porterville	2.3.4	Timely Transmission of Transition Record	None	0.8436	0	0	415	0	492	0	0.8435	0	1
PY3.5	DMPH	Sierra View District Hospital, Porterville	2.7.1	Advance Care Plan	None	0.6	0	0	27	0	54	0	0.5	0	1
PY3.5	DMPH	Sierra View District Hospital, Porterville	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	None	0.6765	0	0	47	0	69	0	0.6812	0	1
PY3.5	DMPH	Sierra View District Hospital, Porterville	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	None	None	1	0	None	1	41	0	None	1	0
PY3.5	DMPH	Sierra View District Hospital, Porterville	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	None	0.2834	0	0	182	0	536	0	0.3396	0	1
PY3.5	DMPH	Sierra View District Hospital, Porterville	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	None	0.3043	0	0	17	0	70	0	0.2429	0	1
PY3.5	DMPH	Sonoma Valley Hospital, Sonoma	2.2.1	DHCS All-Cause Readmissions	None	None	1	0	None	1	105	0	None	1	1
PY3.5	DMPH	Sonoma Valley Hospital, Sonoma	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.474	0	0	90	0	192	0	0.4688	0	0
PY3.5	DMPH	Sonoma Valley Hospital, Sonoma	2.2.3	Medication Reconciliation – 30 days	None	0.8625	0	0	20	0	105	0	0.1905	0	0
PY3.5	DMPH	Sonoma Valley Hospital, Sonoma	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.908	0	0	171	0	193	0	0.886	0	1
PY3.5	DMPH	Sonoma Valley Hospital, Sonoma	2.2.5	Timely Transmission of Transition Record	None	0.625	0	0	121	0	193	0	0.6269	0	1
PY3.5	DMPH	Southern Inyo Hospital, Lone Pine	1.2.12.f	Screening for Clinical Depression and follow-up	None	0.2426	0	0	359	0	555	0	0.6468	0	1
PY3.5	DMPH	Southern Inyo Hospital, Lone Pine	1.2.13	SO/GI data completeness	None	0.5663	0	0	310	0	556	0	0.5576	0	1
PY3.5	DMPH	Southern Inyo Hospital, Lone Pine	1.2.14.t	Tobacco Assessment and Counseling	None	0.4388	0	0	129	0	409	0	0.3154	0	0
PY3.5	DMPH	Southern Inyo Hospital, Lone Pine	1.2.3.c	Colorectal Cancer Screening	None	0.359	0	0	67	0	294	0	0.2279	0	0
PY3.5	DMPH	Southern Inyo Hospital, Lone Pine	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	None	1	0	26	0	57	0	0.4561	0	1
PY3.5	DMPH	Southern Inyo Hospital, Lone Pine	1.2.5.b	Controlling Blood Pressure	None	0.5854	0	0	39	0	106	0	0.3679	0	0
PY3.5	DMPH	Tahoe Forest Hospital District, Truckee	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.2023	0	0.067	251	0	1110	0	0.2261	0	1
PY3.5	DMPH	Tahoe Forest Hospital District, Truckee	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.1112	0	0.0216	152	0	1110	0	0.1369	0	1
PY3.5	DMPH	Tahoe Forest Hospital District, Truckee	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.1807	0	0	18	0	83	0	0.2169	0	1
PY3.5	DMPH	Tahoe Forest Hospital District, Truckee	1.1.5.f	Screening for Clinical Depression and follow-up	None	0.3229	0	0	240	0	643	0	0.3733	0	0
PY3.5	DMPH	Tahoe Forest Hospital District, Truckee	1.1.6.t	Tobacco Assessment and Counseling	None	0.954	0	0	793	0	842	0	0.9418	0	1
PY3.5	DMPH	Tahoe Forest Hospital District, Truckee	1.5.1.b	Controlling Blood Pressure	None	0.7059	0	0	116	0	162	0	0.716	0	1
PY3.5	DMPH	Tahoe Forest Hospital District, Truckee	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.8718	0	0	36	0	41	0	0.878	0	1
PY3.5	DMPH	Tahoe Forest Hospital District, Truckee	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	None	0.6633	0	0	346	0	580	0	0.5966	0	1
PY3.5	DMPH	Tahoe Forest Hospital District, Truckee	1.5.4.t	Tobacco Assessment and Counseling	None	0.954	0	0	793	0	842	0	0.9418	0	1
PY3.5	DMPH	Tahoe Forest Hospital District, Truckee	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.3722	0	0.067	74	0	167	0	0.4431	0	1
PY3.5	DMPH	Tahoe Forest Hospital District, Truckee	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.1667	0	0.0216	39	0	167	0	0.2335	0	1
PY3.5	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	None	0.4086	0	0	34	0	102	0	0.3333	0	1
PY3.5	DMPH	Tahoe Forest Hospital District, Truckee	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	None	0.8817	0	0	64	0	102	0	0.6275	0	1
PY3.5	DMPH	Tahoe Forest Hospital District, Truckee	2.6.4	Screening for Clinical Depression and follow-up	None	0.4234	0	0	77	0	143	0	0.5385	0	1
PY3.5	DMPH	Tahoe Forest Hospital District, Truckee	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	None	0.9336	0	0	216	0	234	0	0.9231	0	1
PY3.5	DMPH	Tri-City Medical Center, Oceanside	1.5.1.b	Controlling Blood Pressure	None	0.5175	0	0	1647	0	3107	0	0.5301	0	1
PY3.5	DMPH	Tri-City Medical Center, Oceanside	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	1	0	0	78	0	78	0	1	0	1
PY3.5	DMPH	Tri-City Medical Center, Oceanside	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	None	0.825	0	0	4407	0	5312	0	0.8296	0	1
PY3.5	DMPH	Tri-City Medical Center, Oceanside	1.5.4.t	Tobacco Assessment and Counseling	None	0.9692	0	0	405	0	435	0	0.931	0	1
PY3.5	DMPH	Tri-City Medical Center, Oceanside	1.7.1	BMI Screening and Follow-up	None	0.7744	0	0	2279	0	2964	0	0.7689	0	1
PY3.5	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)	None	None	1	None	8	0	8	0	1	0	1
PY3.5	DMPH	Tri-City Medical Center, Oceanside	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI	None	0	0	0.66	0	0	0	0	0	0	0
PY3.5	DMPH	Tri-City Medical Center, Oceanside	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition	None	0	0	0.5985	0	0	0	0	0	0	0
PY3.5	DMPH	Tri-City Medical Center, Oceanside	1.7.3	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity	None	0	0	0.5231	0	0	0	0	0	0	0
PY3.5	DMPH	Tri-City Medical Center, Oceanside	2.1.1	Baby Friendly Hospital designation: BFUSA Designation No	None	0	0	None	No	0	BFUSA Cert?	0	0	0	0
PY3.5	DMPH	Tri-City Medical Center, Oceanside	2.1.2	Exclusive Breast Milk Feeding (PC-05)	None	0.585	0	0	729	0	1280	0	0.5695	0	1
PY3.5	DMPH	Tri-City Medical Center, Oceanside	2.1.3	OB Hemorrhage: Massive Transfusion	None	None	1	0	None	1	1547	0	None	1	1
PY3.5	DMPH	Tri-City Medical Center, Oceanside	2.1.5	PC-02 Cesarean Section	None	0.1796	0	0	82	0	421	0	0.1948	0	1
PY3.5	DMPH	Tri-City Medical Center, Oceanside	2.1.6	Prenatal and Postpartum Care: Postpartum Care	None	0	0	0.713	0	0	1545	0	0	0	0
PY3.5	DMPH	Tri-City Medical Center, Oceanside	2.1.6	Prenatal and Postpartum Care: Prenatal Care	None	0	0	0.7689	0	0	1545	0	0	0	0
PY3.5	DMPH	Tri-City Medical Center, Oceanside	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	0.2621	0	0	27	0	109	0	0.2477	0	1
PY3.5	DMPH	Tri-City Medical Center, Oceanside	2.1.8	Unexpected Newborn Complications (UNC)	None	0.0621	0	0	70	0	1280	0	0.0547	0	1
PY3.5	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)	None	0.9375	0	None	15	0	16	0	0.9375	0	0
PY3.5	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	None	0	0	None	No	0	10 Debriefs?	0	0	0	n/a
PY3.5	DMPH	Tri-City Medical Center, Oceanside	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter No	None	0	0	None	No	0	3 Safety Drills?	0	0	0	n/a
PY3.5	DMPH	Tri-City Medical Center, Oceanside	2.2.1	DHCS All-Cause Readmissions	None	0.1095	0	0	72	0	602	0	0.1196	0	1
PY3.5	DMPH	Tri-City Medical Center, Oceanside	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.4533	0	0	780	0	1718	0	0.454	0	0
PY3.5	DMPH	Tri-City Medical Center, Oceanside	2.2.3	Medication Reconciliation – 30 days	None	0.0258	0	0	40	0	3328	0	0.012	0	0
PY3.5	DMPH	Tri-City Medical Center, Oceanside	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.9837	0	0	12070	0	12305	0	0.9809	0	1
PY3.5	DMPH	Tri-City Medical Center, Oceanside	2.2.5	Timely Transmission of Transition Record	None	0.9514	0	0	1217	0	1546	0	0.7872	0	1
PY3.5	DMPH	Tri-City Medical Center, Oceanside	2.3.2	Medication Reconciliation – 30 days	None	0.037	0	0	328	0	757	0	0.4333	0	0
PY3.5	DMPH	Tri-City Medical Center, Oceanside	2.3.4	Timely Transmission of Transition Record	None	0.6003	0	0	1217	0	1546	0	0.7872	0	1
PY3.5	DMPH	Tri-City Medical Center, Oceanside	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	None	0.8298	0	0	65	0	75	0	0.8667	0	1
PY3.5	DMPH	Tri-City Medical Center, Oceanside	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	None	0.316	0	0	14859	0	48469	0	0.3066	0	1
PY3.5	DMPH	Tri-City Medical Center, Oceanside	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	None	0.9304	0	0	1501	0	1610	0	0.9323	0	0
PY3.5	DMPH	Tri-City Medical Center, Oceanside	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR	None	1.0615	0	1.053	6672	0	10000	0	0.6672	0	1
PY3.5	DMPH	Trinity Hospital, Weaverville	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	None	0.9519	0	0.5	None	1	None	1	None	1	0
PY3.5	DMPH	Trinity Hospital, Weaverville	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	None	0.9211	0	0.5	51	0	51	0	1	0	1
PY3.5	DMPH	Trinity Hospital, Weaverville	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	None	0.9441	0	0.5	477	0	495	0	0.9636	0	1
PY3.5	DMPH	Trinity Hospital, Weaverville	1.4.2	Annual Monitoring for Patients on Persistent Medications	None	0.9531	0	0	179	0	202	0	0.8861	0	1
PY3.5	DMPH	Trinity Hospital, Weaverville	1.4.3	INR Monitoring for Individuals on Warfarin	None	None	1	0	None	1	None	1	None	1	0
PY3.5	DMPH	Trinity Hospital, Weaverville	1.6.1	BIRADS to Biopsy	None	None	1	0	None	1	None	1	None	1	0
PY3.5	DMPH	Trinity Hospital, Weaverville	1.6.2	Breast Cancer Screening	None	0.5637	0	0	119	0	199	0	0.598	0	1
PY3.5	DMPH	Trinity Hospital, Weaverville	1.6.3	Cervical Cancer Screening	None	0.5511	0	0	211	0	347	0	0.6081	0	1
PY3.5	DMPH	Trinity Hospital, Weaverville	1.6.4.c	Colorectal Cancer Screening	None	0.4447	0	0	172	0	373	0	0.4611	0	1
PY3.5	DMPH	Trinity Hospital, Weaverville	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	None	None	1	0	None	1	None	1	None	1	0
PY3.5	DPH	UC Davis Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.0214	0	0.067	1950	0	64846	0	0.0301	0	0
PY3.5	DPH	UC Davis Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.0228	0	0.0216	1491	0	64846	0	0.023	0	1
PY3.5	DPH	UC Davis Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.2225	0	0	1627	0	7384	0	0.2203	0	1
PY3.5	DPH	UC Davis Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	None	0.6493	0	0	32650	0	42424	0	0.7696	0	1
PY3.5	DPH	UC Davis Medical Center	1.1.6.t	Tobacco Assessment and Counseling	None	0.9786	0	0	54729	0	55845	0	0.98	0	1
PY3.5	DPH	UC Davis Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	0.0352	0	0.0198	114	0	2919	0	0.0391	0	1
PY3.5	DPH	UC Davis Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	0.062	0	0.0419	198	0	2919	0	0.0678	0	1
PY3.5	DPH	UC Davis Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	None	0.2532	0	0.1935	786	0	2919	0	0.2693	0	1
PY3.5	DPH	UC Davis Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.0214	0	0.067	1950	0	64846	0	0.0301	0	0
PY3.5	DPH	UC Davis Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.0228	0	0.0216	1491	0	64846	0	0.023	0	1
PY3.5	DPH	UC Davis Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	None	0.2677	0	0	228	0	816	0	0.2794	0	1
PY3.5	DPH	UC Davis Medical Center	1.2.11	REAL data completeness	None	0.7849	0	0	56559	0	71797	0	0.7878	0	1
PY3.5	DPH	UC Davis Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	None	0.6493	0	0	32650	0	42424	0	0.7696	0	1
PY3.5	DPH	UC Davis Medical Center	1.2.13	SO/GI data completeness	None	0.9254	0	0	57101	0	61041	0	0.9355	0	1
PY3.5	DPH	UC Davis Medical Center	1.2.14.t	Tobacco Assessment and Counseling	None	0.9786	0	0	54729	0	55845	0	0.98	0	1
PY3.5	DPH	UC Davis Medical Center	1.2.2	CG-CAHPS: Provider Rating	None	0.8816	0	0	23774	0	27218	0	0.8735	0	1
PY3.5	DPH	UC Davis Medical Center	1.2.3.c	Colorectal Cancer Screening	None	0.7777	0	0	24362	0	31201	0	0.7808	0	1
PY3.5	DPH	UC Davis Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.2225	0	0	1627	0	7384	0	0.2203	0	1
PY3.5	DPH	UC Davis Medical Center	1.2.5.b	Controlling Blood Pressure	None	0.6949	0	0	13364	0	18553	0	0.7203	0	1
PY3.5	DPH	UC Davis Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.8752	0	0	2717	0	3095	0	0.8779	0	1
PY3.5	DPH	UC Davis Medical Center	1.2.8	Prevention Quality Overall Composite #90	None	0.0079	0	0	512	0	61080	0	0.0084	0	1
PY3.5	DPH	UC Davis Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	None	0.7806	0	0	68065	0	87608	0	0.7769	0	1
PY3.5	DPH	UC Davis Medical Center	1.3.2	DHCS All-Cause Readmissions	None	0.1707	0	0	109	0	750	0	0.1453	0	1
PY3.5	DPH	UC Davis Medical Center	1.3.3	Influenza Immunization	None	0.9082	0	0	20165	0	22536	0	0.8948	0	1
PY3.5	DPH	UC Davis Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	None	0.7282	0	0	87748	0	118003	0	0.7436	0	1
PY3.5	DPH	UC Davis Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	None	0.0376	0	0	2294	0	114364	0	0.0201	0	0
PY3.5	DPH	UC Davis Medical Center	1.3.7	Tobacco Assessment and Counseling	None	0.9865	0	0	25206	0	25520	0	0.9877	0	1
PY3.5	DPH	UC Davis Medical Center	1.5.1.b	Controlling Blood Pressure	None	0.6949	0	0	13364	0	18553	0	0.7203	0	1
PY3.5	DPH	UC Davis Medical Center	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.8752	0	0	2717	0	3095	0	0.8779	0	1
PY3.5	DPH	UC Davis Medical Center	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	None	0.8066	0	0	28036	0	34315	0	0.817	0	1
PY3.5	DPH	UC Davis Medical Center	1.5.4.t	Tobacco Assessment and Counseling	None	0.9786	0	0	54729	0	55845	0	0.98	0	1
PY3.5	DPH	UC Davis Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	None	0	0	None	Yes	0	BFUSA Cert?	0	1	0	1
PY3.5	DPH	UC Davis Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	None	0.6513	0	0	220	0	339	0	0.649	0	1
PY3.5	DPH	UC Davis Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	None	1	0	None	1	1193	0	None	1	1
PY3.5	DPH	UC Davis Medical Center	2.1.5	PC-02 Cesarean Section	None	0.2621	0	0	100	0	394	0	0.2538	0	0
PY3.5	DPH	UC Davis Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	None	0.7267	0	0.713	548	0	693	0	0.7908	0	1
PY3.5	DPH	UC Davis Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	None	0.8648	0	0.7689	625	0	693	0	0.9019	0	1
PY3.5	DPH	UC Davis Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	0.3351	0	0	57	0	180	0	0.3167	0	1
PY3.5	DPH	UC Davis Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	None	0.0292	0	0	31	0	881	0	0.0352	0	1
PY3.5	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)	None	1	0	None	16	0	16	0	1	0	1
PY3.5	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	None	0	0	None	Yes	0	10 Debriefs?	0	0	0	n/a
PY3.5	DPH	UC Davis Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	None	0	0	None	Yes	0	3 Safety Drills?	0	0	0	n/a
PY3.5	DPH	UC Davis Medical Center	2.2.1	DHCS All-Cause Readmissions	None	0.1702	0	0	111	0	759	0	0.1462	0	1
PY3.5	DPH	UC Davis Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.5739	0	0	2192	0	3894	0	0.5629	0	1
PY3.5	DPH	UC Davis Medical Center	2.2.3	Medication Reconciliation – 30 days	None	0.9539	0	0	3174	0	3310	0	0.9589	0	1
PY3.5	DPH	UC Davis Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.9995	0	0	6510	0	6536	0	0.996	0	1
PY3.5	DPH	UC Davis Medical Center	2.2.5	Timely Transmission of Transition Record	None	0.9542	0	0	5012	0	5230	0	0.9583	0	1
PY3.5	DPH	UC Davis Medical Center	2.3.2	Medication Reconciliation – 30 days	None	0.9581	0	0	1148	0	1197	0	0.9591	0	1
PY3.5	DPH	UC Davis Medical Center	2.3.4	Timely Transmission of Transition Record	None	0.9641	0	0	1627	0	1684	0	0.9662	0	1
PY3.5	DPH	UC Davis Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.0242	0	0.067	259	0	6462	0	0.0401	0	0
PY3.5	DPH	UC Davis Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.0405	0	0.0216	260	0	6462	0	0.0402	0	1
PY3.5	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	None	0.6414	0	0	1960	0	2856	0	0.6863	0	1
PY3.5	DPH	UC Davis Medical Center	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	None	0.9688	0	0	2789	0	2856	0	0.9765	0	1
PY3.5	DPH	UC Davis Medical Center	2.6.4	Screening for Clinical Depression and follow-up	None	0.6959	0	0	2753	0	3420	0	0.805	0	1
PY3.5	DPH	UC Davis Medical Center	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	None	0.8457	0	0	5565	0	6495	0	0.8568	0	1
PY3.5	DPH	UC Davis Medical Center	3.2.2	Appropriate Emergency Department Utilization of CT for Pulmonary Embolism	None	0.9781	0	0	1162	0	1185	0	0.9806	0	1
PY3.5	DPH	UC Davis Medical Center	3.2.3	Use of Imaging Studies for Low Back Pain	None	0.7181	0	0	717	0	1021	0	0.7023	0	1
PY3.5	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	None	0.7989	0	None	2259	0	3014	0	0.7495	0	1
PY3.5	DPH	UC Irvine Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.0389	0	0.067	684	0	20520	0	0.0333	0	0
PY3.5	DPH	UC Irvine Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.2579	0	0.0216	6161	0	20520	0	0.3002	0	1
PY3.5	DPH	UC Irvine Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.2841	0	0	916	0	3475	0	0.2636	0	1
PY3.5	DPH	UC Irvine Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	None	0.7613	0	0	12274	0	15299	0	0.8023	0	1
PY3.5	DPH	UC Irvine Medical Center	1.1.6.t	Tobacco Assessment and Counseling	None	0.9701	0	0	18099	0	18506	0	0.978	0	1
PY3.5	DPH	UC Irvine Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	0.1784	0	0.0198	107	0	695	0	0.154	0	1
PY3.5	DPH	UC Irvine Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	0.2161	0	0.0419	134	0	695	0	0.1928	0	1
PY3.5	DPH	UC Irvine Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	None	0.3828	0	0.1935	269	0	695	0	0.3871	0	1
PY3.5	DPH	UC Irvine Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.0389	0	0.067	684	0	20520	0	0.0333	0	0
PY3.5	DPH	UC Irvine Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.2579	0	0.0216	6161	0	20520	0	0.3002	0	1
PY3.5	DPH	UC Irvine Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	None	0.5983	0	0	1623	0	2659	0	0.6104	0	1
PY3.5	DPH	UC Irvine Medical Center	1.2.11	REAL data completeness	None	0.9884	0	0	24866	0	25143	0	0.989	0	1
PY3.5	DPH	UC Irvine Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	None	0.7613	0	0	12274	0	15299	0	0.8023	0	1
PY3.5	DPH	UC Irvine Medical Center	1.2.13	SO/GI data completeness	None	0.4125	0	0	8249	0	18707	0	0.441	0	1
PY3.5	DPH	UC Irvine Medical Center	1.2.14.t	Tobacco Assessment and Counseling	None	0.9701	0	0	18099	0	18506	0	0.978	0	1
PY3.5	DPH	UC Irvine Medical Center	1.2.2	CG-CAHPS: Provider Rating	None	0.8802	0	0	24633	0	28167	0	0.8745	0	1
PY3.5	DPH	UC Irvine Medical Center	1.2.3.c	Colorectal Cancer Screening	None	0.6215	0	0	5075	0	7593	0	0.6684	0	1
PY3.5	DPH	UC Irvine Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.2841	0	0	916	0	3475	0	0.2636	0	1
PY3.5	DPH	UC Irvine Medical Center	1.2.5.b	Controlling Blood Pressure	None	0.6627	0	0	3930	0	5690	0	0.6907	0	1
PY3.5	DPH	UC Irvine Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.7926	0	0	645	0	806	0	0.8002	0	1
PY3.5	DPH	UC Irvine Medical Center	1.2.8	Prevention Quality Overall Composite #90	None	0.0127	0	0	333	0	21654	0	0.0154	0	0
PY3.5	DPH	UC Irvine Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	None	0.9405	0	0	5569	0	6296	0	0.8845	0	1
PY3.5	DPH	UC Irvine Medical Center	1.3.2	DHCS All-Cause Readmissions	None	0.1344	0	0	167	0	1361	0	0.1227	0	1
PY3.5	DPH	UC Irvine Medical Center	1.3.3	Influenza Immunization	None	0.7341	0	0	6614	0	9361	0	0.7065	0	1
PY3.5	DPH	UC Irvine Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	None	0.028	0	0	353	0	11242	0	0.0314	0	0
PY3.5	DPH	UC Irvine Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	None	0.0639	0	0	972	0	59546	0	0.0163	0	0
PY3.5	DPH	UC Irvine Medical Center	1.3.7	Tobacco Assessment and Counseling	None	0.9893	0	0	9573	0	9715	0	0.9854	0	1
PY3.5	DPH	UC Irvine Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	None	0.8047	0	0.5	857	0	1073	0	0.7987	0	1
PY3.5	DPH	UC Irvine Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	None	0.9777	0	0.5	2517	0	2678	0	0.9399	0	1
PY3.5	DPH	UC Irvine Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	None	0.9963	0	0.5	11679	0	12263	0	0.9524	0	1
PY3.5	DPH	UC Irvine Medical Center	1.4.2	Annual Monitoring for Patients on Persistent Medications	None	0.8716	0	0	6222	0	6915	0	0.8998	0	1
PY3.5	DPH	UC Irvine Medical Center	1.4.3	INR Monitoring for Individuals on Warfarin	None	0.6325	0	0	145	0	224	0	0.6473	0	1
PY3.5	DPH	UC Irvine Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	None	0	0	None	Yes	0	BFUSA Cert?	0	1	0	1
PY3.5	DPH	UC Irvine Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	None	0.7474	0	0	142	0	199	0	0.7136	0	1
PY3.5	DPH	UC Irvine Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	None	1	0	None	1	1458	0	None	1	1
PY3.5	DPH	UC Irvine Medical Center	2.1.5	PC-02 Cesarean Section	None	0.1826	0	0	97	0	421	0	0.2304	0	1
PY3.5	DPH	UC Irvine Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	None	0.9601	0	0.7689	481	0	747	0	0.6439	0	0
PY3.5	DPH	UC Irvine Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	None	0.7445	0	0.713	568	0	695	0	0.8173	0	1
PY3.5	DPH	UC Irvine Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	0.3043	0	0	65	0	218	0	0.2982	0	1
PY3.5	DPH	UC Irvine Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	None	0.0302	0	0	28	0	898	0	0.0312	0	1
PY3.5	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)	None	1	0	None	16	0	16	0	1	0	1
PY3.5	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	None	0	0	None	Yes	0	10 Debriefs?	0	0	0	n/a
PY3.5	DPH	UC Irvine Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	None	0	0	None	Yes	0	3 Safety Drills?	0	0	0	n/a
PY3.5	DPH	UC Irvine Medical Center	2.2.1	DHCS All-Cause Readmissions	None	0.1307	0	0	176	0	1465	0	0.1201	0	1
PY3.5	DPH	UC Irvine Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.5959	0	0	6004	0	10000	0	0.6004	0	1
PY3.5	DPH	UC Irvine Medical Center	2.2.3	Medication Reconciliation – 30 days	None	0.9518	0	0	1931	0	2080	0	0.9284	0	1
PY3.5	DPH	UC Irvine Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.9487	0	0	3884	0	4028	0	0.9643	0	1
PY3.5	DPH	UC Irvine Medical Center	2.2.5	Timely Transmission of Transition Record	None	0.7173	0	0	1764	0	2399	0	0.7353	0	1
PY3.5	DPH	UC Irvine Medical Center	2.3.2	Medication Reconciliation – 30 days	None	0.9613	0	0	1391	0	1485	0	0.9367	0	1
PY3.5	DPH	UC Irvine Medical Center	2.3.4	Timely Transmission of Transition Record	None	0.7711	0	0	1306	0	1818	0	0.7184	0	1
PY3.5	DPH	UC Irvine Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.0308	0	0.067	26	0	1045	0	0.0249	0	0
PY3.5	DPH	UC Irvine Medical Center	2.6.1	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.45	0	0.0216	538	0	1045	0	0.5148	0	1
PY3.5	DPH	UC Irvine Medical Center	2.6.2	Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen	None	0.1235	0	0	54	0	488	0	0.1107	0	0
PY3.5	DPH	UC Irvine Medical Center	2.6.3	Patients with chronic pain on long term opioid therapy checked in PDMPs	None	0.7716	0	0	378	0	488	0	0.7746	0	1
PY3.5	DPH	UC Irvine Medical Center	2.6.4	Screening for Clinical Depression and follow-up	None	0.8947	0	0	579	0	659	0	0.8786	0	1
PY3.5	DPH	UC Irvine Medical Center	2.6.5	Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy	None	0.92	0	0	938	0	1026	0	0.9142	0	1
PY3.5	DPH	UC Irvine Medical Center	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	None	0.4225	0	0	83	0	215	0	0.386	0	1
PY3.5	DPH	UC Irvine Medical Center	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	None	0.4985	0	0	74939	0	161582	0	0.4638	0	1
PY3.5	DPH	UC Irvine Medical Center	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	None	0.2276	0	0	995	0	3925	0	0.2535	0	1
PY3.5	DPH	UC Irvine Medical Center	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR	None	0.4677	0	0.592	4796	0	10000	0	0.4796	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.0859	0	0.0216	11458	0	143728	0	0.0797	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.9242	0	0.067	132924	0	143728	0	0.9248	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.1479	0	0	1404	0	10232	0	0.1372	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	None	0.6801	0	0	81807	0	109997	0	0.7437	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.1.6.t	Tobacco Assessment and Counseling	None	0.9676	0	0	130438	0	134884	0	0.967	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	0.1278	0	0.0198	640	0	5097	0	0.1256	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	0.1827	0	0.0419	918	0	5097	0	0.1801	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	None	0.3804	0	0.1935	1945	0	5097	0	0.3816	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.0859	0	0.0216	11458	0	143728	0	0.0797	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.9242	0	0.067	132924	0	143728	0	0.9248	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	None	0.5928	0	0	1889	0	3079	0	0.6135	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.2.11	REAL data completeness	None	0.2843	0	0	45592	0	163691	0	0.2785	0	0
PY3.5	DPH	UC Los Angeles Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	None	0.6801	0	0	81807	0	109997	0	0.7437	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.2.13	SO/GI data completeness	None	0.1628	0	0	47499	0	135826	0	0.3497	0	0
PY3.5	DPH	UC Los Angeles Medical Center	1.2.14.t	Tobacco Assessment and Counseling	None	0.9676	0	0	130438	0	134884	0	0.967	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.2.2	CG-CAHPS: Provider Rating	None	0.8473	0	0	339	0	401	0	0.8454	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.2.3.c	Colorectal Cancer Screening	None	0.6398	0	0	36893	0	57064	0	0.6465	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.1479	0	0	1404	0	10232	0	0.1372	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.2.5.b	Controlling Blood Pressure	None	0.6311	0	0	21277	0	32559	0	0.6535	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.7038	0	0	6365	0	9023	0	0.7054	0	0
PY3.5	DPH	UC Los Angeles Medical Center	1.2.8	Prevention Quality Overall Composite #90	None	0.0045	0	0	606	0	135256	0	0.0045	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	None	0.9977	0	0	33352	0	33377	0	0.9993	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.3.2	DHCS All-Cause Readmissions	None	0.118	0	0	224	0	1885	0	0.1188	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.3.3	Influenza Immunization	None	0.6818	0	0	59070	0	87035	0	0.6787	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	None	0.448	0	0	4500	0	9528	0	0.4723	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	None	0.1793	0	0	1521	0	6943	0	0.2191	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.3.7	Tobacco Assessment and Counseling	None	0.9817	0	0	59599	0	60805	0	0.9802	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal BIRADS Follow-up	None	0.7567	0	0.5	7708	0	10159	0	0.7587	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal INR Follow-up	None	0.9494	0	0.5	16964	0	17787	0	0.9537	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.4.1	Abnormal Results Follow-Up: Abnormal Potassium Follow-up	None	0.9575	0	0.5	85713	0	89456	0	0.9582	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.4.2	Annual Monitoring for Patients on Persistent Medications	None	0.9025	0	0	40476	0	44178	0	0.9162	0	1
PY3.5	DPH	UC Los Angeles Medical Center	1.4.3	INR Monitoring for Individuals on Warfarin	None	0.5918	0	0	730	0	1109	0	0.6583	0	1
PY3.5	DPH	UC Los Angeles Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	None	0	0	None	Yes	0	BFUSA Cert?	0	1	0	1
PY3.5	DPH	UC Los Angeles Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	None	0.7488	0	0	338	0	448	0	0.7545	0	1
PY3.5	DPH	UC Los Angeles Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	None	1	0	None	1	522	0	None	1	0
PY3.5	DPH	UC Los Angeles Medical Center	2.1.5	PC-02 Cesarean Section	None	0.1969	0	0	52	0	271	0	0.1919	0	1
PY3.5	DPH	UC Los Angeles Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	None	0.6937	0	0.713	1669	0	2056	0	0.8118	0	1
PY3.5	DPH	UC Los Angeles Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	None	0.942	0	0.7689	1936	0	2056	0	0.9416	0	1
PY3.5	DPH	UC Los Angeles Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	0.2167	0	0	16	0	64	0	0.25	0	1
PY3.5	DPH	UC Los Angeles Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	None	None	1	0	13	0	434	0	0.03	0	1
PY3.5	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)	None	1	0	None	32	0	32	0	1	0	1
PY3.5	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	None	0	0	None	Yes	0	10 Debriefs?	0	0	0	n/a
PY3.5	DPH	UC Los Angeles Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	None	0	0	None	Yes	0	3 Safety Drills?	0	0	0	n/a
PY3.5	DPH	UC Los Angeles Medical Center	2.2.1	DHCS All-Cause Readmissions	None	0.1186	0	0	224	0	1918	0	0.1168	0	1
PY3.5	DPH	UC Los Angeles Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.628	0	0	6280	0	10000	0	0.628	0	1
PY3.5	DPH	UC Los Angeles Medical Center	2.2.3	Medication Reconciliation – 30 days	None	0.9998	0	0	5952	0	5953	0	0.9998	0	1
PY3.5	DPH	UC Los Angeles Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.98	0	0	10255	0	10456	0	0.9808	0	1
PY3.5	DPH	UC Los Angeles Medical Center	2.2.5	Timely Transmission of Transition Record	None	0.9974	0	0	7849	0	7868	0	0.9976	0	1
PY3.5	DPH	UC Los Angeles Medical Center	2.3.2	Medication Reconciliation – 30 days	None	0.9996	0	0	3196	0	3197	0	0.9997	0	1
PY3.5	DPH	UC Los Angeles Medical Center	2.3.4	Timely Transmission of Transition Record	None	0.9865	0	0	3965	0	4029	0	0.9841	0	1
PY3.5	DPH	UC Los Angeles Medical Center	2.7.1	Advance Care Plan	None	0.3783	0	0	15385	0	40259	0	0.3822	0	1
PY3.5	DPH	UC Los Angeles Medical Center	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	None	0.9499	0	0	460	0	478	0	0.9623	0	1
PY3.5	DPH	UC Los Angeles Medical Center	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	None	0.9713	0	0	300	0	311	0	0.9646	0	1
PY3.5	DPH	UC Los Angeles Medical Center	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	None	0.056	0	0	196	0	3327	0	0.0589	0	0
PY3.5	DPH	UC Los Angeles Medical Center	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	None	0.0847	0	0	20	0	176	0	0.1136	0	1
PY3.5	DPH	UC Los Angeles Medical Center	3.3.1	Adherence to Medications: Rate 1	None	0.8183	0	0.25	590	0	743	0	0.7941	0	1
PY3.5	DPH	UC Los Angeles Medical Center	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 1	None	0.053	0	None	35	0	1082	0	0.0323	0	1
PY3.5	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	None	0.8946	0	0.1368	3507	0	3861	0	0.9083	0	1
PY3.5	DPH	UC San Diego Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.1532	0	0.0216	6160	0	41807	0	0.1473	0	1
PY3.5	DPH	UC San Diego Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.5596	0	0.067	22887	0	41807	0	0.5474	0	1
PY3.5	DPH	UC San Diego Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.169	0	0	574	0	3659	0	0.1569	0	1
PY3.5	DPH	UC San Diego Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	None	0.7164	0	0	21413	0	28280	0	0.7572	0	1
PY3.5	DPH	UC San Diego Medical Center	1.1.6.t	Tobacco Assessment and Counseling	None	0.9887	0	0	39851	0	40331	0	0.9881	0	1
PY3.5	DPH	UC San Diego Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	0.1215	0	0.0198	293	0	2480	0	0.1181	0	1
PY3.5	DPH	UC San Diego Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	0.1921	0	0.0419	481	0	2480	0	0.194	0	1
PY3.5	DPH	UC San Diego Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	None	0.4885	0	0.1935	1255	0	2480	0	0.506	0	1
PY3.5	DPH	UC San Diego Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.1532	0	0.0216	6160	0	41807	0	0.1473	0	1
PY3.5	DPH	UC San Diego Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.5596	0	0.067	22887	0	41807	0	0.5474	0	1
PY3.5	DPH	UC San Diego Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	None	0.9903	0	0	1488	0	1503	0	0.99	0	1
PY3.5	DPH	UC San Diego Medical Center	1.2.11	REAL data completeness	None	0.9436	0	0	39297	0	41661	0	0.9433	0	1
PY3.5	DPH	UC San Diego Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	None	0.7164	0	0	21413	0	28280	0	0.7572	0	1
PY3.5	DPH	UC San Diego Medical Center	1.2.13	SO/GI data completeness	None	0.7097	0	0	29156	0	40297	0	0.7235	0	1
PY3.5	DPH	UC San Diego Medical Center	1.2.14.t	Tobacco Assessment and Counseling	None	0.9887	0	0	39851	0	40331	0	0.9881	0	1
PY3.5	DPH	UC San Diego Medical Center	1.2.2	CG-CAHPS: Provider Rating	None	0.9021	0	0	10543	0	11736	0	0.8983	0	1
PY3.5	DPH	UC San Diego Medical Center	1.2.3.c	Colorectal Cancer Screening	None	0.8159	0	0	16599	0	19904	0	0.834	0	1
PY3.5	DPH	UC San Diego Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.169	0	0	574	0	3659	0	0.1569	0	1
PY3.5	DPH	UC San Diego Medical Center	1.2.5.b	Controlling Blood Pressure	None	0.6712	0	0	7476	0	10786	0	0.6931	0	1
PY3.5	DPH	UC San Diego Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.9232	0	0	3441	0	3734	0	0.9215	0	1
PY3.5	DPH	UC San Diego Medical Center	1.2.8	Prevention Quality Overall Composite #90	None	0.0063	0	0	301	0	42963	0	0.007	0	1
PY3.5	DPH	UC San Diego Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	None	0.9072	0	0	62811	0	69051	0	0.9096	0	1
PY3.5	DPH	UC San Diego Medical Center	1.3.2	DHCS All-Cause Readmissions	None	0.1559	0	0	299	0	1930	0	0.1549	0	1
PY3.5	DPH	UC San Diego Medical Center	1.3.3	Influenza Immunization	None	0.9155	0	0	14234	0	16795	0	0.8475	0	1
PY3.5	DPH	UC San Diego Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	None	0.6228	0	0	139903	0	231477	0	0.6044	0	1
PY3.5	DPH	UC San Diego Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	None	0.0226	0	0	2252	0	218174	0	0.0103	0	0
PY3.5	DPH	UC San Diego Medical Center	1.3.7	Tobacco Assessment and Counseling	None	0.9915	0	0	25719	0	25957	0	0.9908	0	1
PY3.5	DPH	UC San Diego Medical Center	1.5.1.b	Controlling Blood Pressure	None	0.6712	0	0	7476	0	10786	0	0.6931	0	1
PY3.5	DPH	UC San Diego Medical Center	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.9232	0	0	3441	0	3734	0	0.9215	0	1
PY3.5	DPH	UC San Diego Medical Center	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	None	0.9137	0	0	20368	0	21940	0	0.9284	0	1
PY3.5	DPH	UC San Diego Medical Center	1.5.4.t	Tobacco Assessment and Counseling	None	0.9887	0	0	39851	0	40331	0	0.9881	0	1
PY3.5	DPH	UC San Diego Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	None	0	0	None	Yes	0	BFUSA Cert?	0	1	0	1
PY3.5	DPH	UC San Diego Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	None	0.8402	0	0	2072	0	2516	0	0.8235	0	1
PY3.5	DPH	UC San Diego Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	None	1	0	None	1	3230	0	None	1	1
PY3.5	DPH	UC San Diego Medical Center	2.1.5	PC-02 Cesarean Section	None	0.2274	0	0	269	0	1222	0	0.2201	0	1
PY3.5	DPH	UC San Diego Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	None	0.7335	0	0.713	1756	0	2035	0	0.8629	0	1
PY3.5	DPH	UC San Diego Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	None	0.9956	0	0.7689	2176	0	2192	0	0.9927	0	1
PY3.5	DPH	UC San Diego Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	0.3447	0	0	89	0	262	0	0.3397	0	1
PY3.5	DPH	UC San Diego Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	None	0.0469	0	0	121	0	2444	0	0.0495	0	1
PY3.5	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)	None	1	0	None	16	0	16	0	1	0	1
PY3.5	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	None	0	0	None	Yes	0	10 Debriefs?	0	0	0	n/a
PY3.5	DPH	UC San Diego Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	None	0	0	None	Yes	0	3 Safety Drills?	0	0	0	n/a
PY3.5	DPH	UC San Diego Medical Center	2.2.1	DHCS All-Cause Readmissions	None	0.1543	0	0	308	0	2065	0	0.1492	0	1
PY3.5	DPH	UC San Diego Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.6328	0	0	6276	0	10000	0	0.6276	0	1
PY3.5	DPH	UC San Diego Medical Center	2.2.3	Medication Reconciliation – 30 days	None	0.9684	0	0	2834	0	2935	0	0.9656	0	1
PY3.5	DPH	UC San Diego Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.9966	0	0	3257	0	3266	0	0.9972	0	1
PY3.5	DPH	UC San Diego Medical Center	2.2.5	Timely Transmission of Transition Record	None	1	0	0	4546	0	4546	0	1.0000	0	1
PY3.5	DPH	UC San Diego Medical Center	2.3.2	Medication Reconciliation – 30 days	None	0.9778	0	0	166	0	173	0	0.9595	0	1
PY3.5	DPH	UC San Diego Medical Center	2.3.4	Timely Transmission of Transition Record	None	1	0	0	232	0	232	0	1	0	1
PY3.5	DPH	UC San Diego Medical Center	2.7.1	Advance Care Plan	None	0.692	0	0	10940	0	16233	0	0.6739	0	1
PY3.5	DPH	UC San Diego Medical Center	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	None	0.9792	0	0	142	0	149	0	0.953	0	1
PY3.5	DPH	UC San Diego Medical Center	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	None	0.9792	0	0	57	0	59	0	0.9661	0	1
PY3.5	DPH	UC San Diego Medical Center	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	None	0.0878	0	0	157	0	1708	0	0.0919	0	0
PY3.5	DPH	UC San Diego Medical Center	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	None	None	1	0	None	1	84	0	None	1	1
PY3.5	DPH	UC San Diego Medical Center	3.1.1	Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis	None	0.7456	0	0	76	0	108	0	0.7037	0	1
PY3.5	DPH	UC San Diego Medical Center	3.1.3	National Healthcare Safety Network (NHSN) Antimicrobial Use Measure	None	0.3236	0	0	70130	0	220127	0	0.3186	0	1
PY3.5	DPH	UC San Diego Medical Center	3.1.4	Peri-operative Prophylactic Antibiotics Administered after Surgical Closure	None	0.3347	0	0	1967	0	5476	0	0.3592	0	1
PY3.5	DPH	UC San Diego Medical Center	3.1.5	Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR	None	0.663	0	0.6559	6575	0	10000	0	0.6575	0	1
PY3.5	DPH	UC San Diego Medical Center	3.3.1	Adherence to Medications: Rate 1	None	0.7845	0	0.7971	2667	0	3479	0	0.7666	0	0
PY3.5	DPH	UC San Diego Medical Center	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 1	None	0.2839	0	None	484	0	1763	0	0.2745	0	1
PY3.5	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	None	0.971	0	0.1368	25524	0	26160	0	0.9757	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.0322	0	0.0216	1484	0	38358	0	0.0387	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.9512	0	0.067	36421	0	38358	0	0.9495	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.2228	0	0	547	0	2755	0	0.1985	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	None	0.7133	0	0	24713	0	31191	0	0.7923	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.1.6.t	Tobacco Assessment and Counseling	None	0.9726	0	0	33754	0	34661	0	0.9738	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	0.0981	0	0.0419	61	0	848	0	0.0719	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	0.0959	0	0.0198	72	0	848	0	0.0849	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	None	0.5615	0	0.1935	408	0	848	0	0.4811	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.0322	0	0.0216	1484	0	38358	0	0.0387	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.9512	0	0.067	36421	0	38358	0	0.9495	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	None	0.6194	0	0	610	0	960	0	0.6354	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.2.11	REAL data completeness	None	0.9983	0	0	46732	0	46840	0	0.9977	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	None	0.7133	0	0	24713	0	31191	0	0.7923	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.2.13	SO/GI data completeness	None	0.6883	0	0	25861	0	35983	0	0.7187	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.2.14.t	Tobacco Assessment and Counseling	None	0.9726	0	0	33754	0	34661	0	0.9738	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.2.2	CG-CAHPS: Provider Rating	None	0.8751	0	0	9165	0	10373	0	0.8835	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.2.3.c	Colorectal Cancer Screening	None	0.7469	0	0	12020	0	15137	0	0.7941	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.2228	0	0	547	0	2755	0	0.1985	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.2.5.b	Controlling Blood Pressure	None	0.669	0	0	5150	0	7197	0	0.7156	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.9281	0	0	1370	0	1515	0	0.9043	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.2.8	Prevention Quality Overall Composite #90	None	0.0071	0	0	340	0	36882	0	0.0092	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	None	0.8961	0	0	75073	0	82834	0	0.9063	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.3.2	DHCS All-Cause Readmissions	None	0.1315	0	0	97	0	839	0	0.1156	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.3.3	Influenza Immunization	None	0.8903	0	0	11368	0	13173	0	0.8630	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	None	0.8534	0	0	167668	0	199519	0	0.8404	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	None	0.5883	0	0	129859	0	328874	0	0.3949	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.3.7	Tobacco Assessment and Counseling	None	0.9835	0	0	17095	0	17393	0	0.9829	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.6.1	BIRADS to Biopsy	None	0.7031	0	0	76	0	122	0	0.6230	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.6.2	Breast Cancer Screening	None	0.7484	0	0	6453	0	8324	0	0.7752	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.6.3	Cervical Cancer Screening	None	0.7535	0	0	10578	0	13525	0	0.7821	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.6.4.c	Colorectal Cancer Screening	None	0.7469	0	0	12020	0	15137	0	0.7941	0	1
PY3.5	DPH	UC San Francisco Medical Center	1.6.5	Receipt of appropriate follow-up for abnormal CRC screening	None	0.4366	0	0	27	0	51	0	0.5294	0	1
PY3.5	DPH	UC San Francisco Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation No	None	0	0	None	No	0	BFUSA Cert?	0	0	0	0
PY3.5	DPH	UC San Francisco Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	None	0.8303	0	0	1565	0	1844	0	0.8487	0	1
PY3.5	DPH	UC San Francisco Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	0.005	0	0	None	1	2376	0	None	1	1
PY3.5	DPH	UC San Francisco Medical Center	2.1.5	PC-02 Cesarean Section	None	0.1867	0	0	240	0	1208	0	0.1987	0	1
PY3.5	DPH	UC San Francisco Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	None	0.8042	0	0.713	1981	0	2146	0	0.9231	0	1
PY3.5	DPH	UC San Francisco Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	None	0.9585	0	0.7689	2271	0	2344	0	0.9689	0	1
PY3.5	DPH	UC San Francisco Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	0.343	0	0	155	0	501	0	0.3094	0	1
PY3.5	DPH	UC San Francisco Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	None	0.0484	0	0	83	0	1822	0	0.0456	0	1
PY3.5	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)	None	1	0	None	16	0	16	0	1	0	1
PY3.5	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	None	0	0	None	Yes	0	10 Debriefs?	0	0	0	n/a
PY3.5	DPH	UC San Francisco Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	None	0	0	None	Yes	0	3 Safety Drills?	0	0	0	n/a
PY3.5	DPH	UC San Francisco Medical Center	2.2.1	DHCS All-Cause Readmissions	None	0.1312	0	0	110	0	909	0	0.1210	0	1
PY3.5	DPH	UC San Francisco Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.6536	0	0	6431	0	10000	0	0.6431	0	1
PY3.5	DPH	UC San Francisco Medical Center	2.2.3	Medication Reconciliation – 30 days	None	0.9975	0	0	1541	0	1546	0	0.9968	0	1
PY3.5	DPH	UC San Francisco Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.995	0	0	4015	0	4040	0	0.9938	0	1
PY3.5	DPH	UC San Francisco Medical Center	2.2.5	Timely Transmission of Transition Record	None	0.9829	0	0	4726	0	4811	0	0.9823	0	1
PY3.5	DPH	UC San Francisco Medical Center	2.3.2	Medication Reconciliation – 30 days	None	0.9753	0	0	126	0	127	0	0.9921	0	1
PY3.5	DPH	UC San Francisco Medical Center	2.3.4	Timely Transmission of Transition Record	None	1	0	0	251	0	256	0	0.9805	0	1
PY3.5	DPH	UC San Francisco Medical Center	2.7.1	Advance Care Plan	None	0.9484	0	0	10822	0	11397	0	0.9495	0	1
PY3.5	DPH	UC San Francisco Medical Center	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	None	0.9221	0	0	78	0	89	0	0.8764	0	1
PY3.5	DPH	UC San Francisco Medical Center	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	None	0.9412	0	0	61	0	64	0	0.9531	0	1
PY3.5	DPH	UC San Francisco Medical Center	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	None	0.0783	0	0	115	0	1144	0	0.1005	0	1
PY3.5	DPH	UC San Francisco Medical Center	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	None	None	1	0	None	1	104	0	None	1	1
PY3.5	DPH	UC San Francisco Medical Center	3.3.1	Adherence to Medications: Rate 1	None	0.913	0	0.25	246	0	286	0	0.8601	0	1
PY3.5	DPH	UC San Francisco Medical Center	3.3.3	High-Cost Pharmaceuticals Ordering Protocols: Rate 1	None	0.7143	0	0.25	226	0	259	0	0.8726	0	1
PY3.5	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	None	0.725	0	0.25	46	0	71	0	0.6479	0	1
PY3.5	DPH	Ventura County Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.2048	0	0.0216	11872	0	51425	0	0.2309	0	1
PY3.5	DPH	Ventura County Medical Center	1.1.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.596	0	0.067	32129	0	51425	0	0.6248	0	1
PY3.5	DPH	Ventura County Medical Center	1.1.3.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.2446	0	0	1458	0	6575	0	0.2217	0	1
PY3.5	DPH	Ventura County Medical Center	1.1.5.f	Screening for Clinical Depression and follow-up	None	0.6009	0	0	21797	0	34467	0	0.6324	0	1
PY3.5	DPH	Ventura County Medical Center	1.1.6.t	Tobacco Assessment and Counseling	None	0.9849	0	0	35763	0	36247	0	0.9866	0	1
PY3.5	DPH	Ventura County Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Remission	None	0.0419	0	0.0198	61	0	1723	0	0.0354	0	1
PY3.5	DPH	Ventura County Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Depression Response	None	0.0844	0	0.0419	130	0	1723	0	0.0754	0	1
PY3.5	DPH	Ventura County Medical Center	1.1.7	Depression Remission or Response for Adolescents and Adults: Follow-up	None	0.2719	0	0.1935	386	0	1723	0	0.224	0	1
PY3.5	DPH	Ventura County Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): SBIRT services (excluding brief screenings)	None	0.2048	0	0.0216	11872	0	51425	0	0.2309	0	1
PY3.5	DPH	Ventura County Medical Center	1.2.1.a	Alcohol and Drug Misuse (SBIRT): Brief screening only	None	0.596	0	0.067	32129	0	51425	0	0.6248	0	1
PY3.5	DPH	Ventura County Medical Center	1.2.10	REAL and/or SO/GI disparity reduction	None	0.6334	0	0	807	0	1169	0	0.6903	0	1
PY3.5	DPH	Ventura County Medical Center	1.2.11	REAL data completeness	None	0.999	0	0	66719	0	66818	0	0.9985	0	1
PY3.5	DPH	Ventura County Medical Center	1.2.12.f	Screening for Clinical Depression and follow-up	None	0.6009	0	0	21797	0	34467	0	0.6324	0	1
PY3.5	DPH	Ventura County Medical Center	1.2.13	SO/GI data completeness	None	0.9259	0	0	35713	0	38561	0	0.9261	0	1
PY3.5	DPH	Ventura County Medical Center	1.2.14.t	Tobacco Assessment and Counseling	None	0.9849	0	0	35763	0	36247	0	0.9866	0	1
PY3.5	DPH	Ventura County Medical Center	1.2.2	CG-CAHPS: Provider Rating	None	0.8212	0	0	42721	0	52208	0	0.8183	0	1
PY3.5	DPH	Ventura County Medical Center	1.2.3.c	Colorectal Cancer Screening	None	0.5409	0	0	8753	0	15288	0	0.5725	0	1
PY3.5	DPH	Ventura County Medical Center	1.2.4.d	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)	None	0.2446	0	0	1458	0	6575	0	0.2217	0	1
PY3.5	DPH	Ventura County Medical Center	1.2.5.b	Controlling Blood Pressure	None	0.6772	0	0	8322	0	11755	0	0.708	0	1
PY3.5	DPH	Ventura County Medical Center	1.2.7.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.9306	0	0	765	0	817	0	0.9364	0	1
PY3.5	DPH	Ventura County Medical Center	1.2.8	Prevention Quality Overall Composite #90	None	0.0073	0	0	378	0	48497	0	0.0078	0	1
PY3.5	DPH	Ventura County Medical Center	1.3.1	Closing the referral loop: receipt of specialist report (CMS50v3)	None	0.9843	0	0	19765	0	20053	0	0.9856	0	1
PY3.5	DPH	Ventura County Medical Center	1.3.2	DHCS All-Cause Readmissions	None	0.0999	0	0	84	0	791	0	0.1062	0	1
PY3.5	DPH	Ventura County Medical Center	1.3.3	Influenza Immunization	None	0.8109	0	0	7351	0	9538	0	0.7707	0	1
PY3.5	DPH	Ventura County Medical Center	1.3.5	Request for Specialty Care Expertise Turnaround Time	None	0.7506	0	0	35568	0	47822	0	0.7438	0	1
PY3.5	DPH	Ventura County Medical Center	1.3.6	Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters	None	0.1874	0	0	6911	0	47043	0	0.1469	0	1
PY3.5	DPH	Ventura County Medical Center	1.3.7	Tobacco Assessment and Counseling	None	0.9898	0	0	16980	0	17137	0	0.9908	0	1
PY3.5	DPH	Ventura County Medical Center	1.5.1.b	Controlling Blood Pressure	None	0.6772	0	0	8322	0	11755	0	0.708	0	1
PY3.5	DPH	Ventura County Medical Center	1.5.2.i	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	None	0.9306	0	0	765	0	817	0	0.9364	0	1
PY3.5	DPH	Ventura County Medical Center	1.5.3	PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	None	0.8897	0	0	21605	0	23824	0	0.9069	0	1
PY3.5	DPH	Ventura County Medical Center	1.5.4.t	Tobacco Assessment and Counseling	None	0.9849	0	0	35763	0	36247	0	0.9866	0	1
PY3.5	DPH	Ventura County Medical Center	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	None	0	0	None	Yes	0	BFUSA Cert?	0	1	0	1
PY3.5	DPH	Ventura County Medical Center	2.1.2	Exclusive Breast Milk Feeding (PC-05)	None	0.7155	0	0	755	0	1071	0	0.7049	0	1
PY3.5	DPH	Ventura County Medical Center	2.1.3	OB Hemorrhage: Massive Transfusion	None	None	1	0	None	1	1362	0	None	1	1
PY3.5	DPH	Ventura County Medical Center	2.1.5	PC-02 Cesarean Section	None	0.1899	0	0	55	0	336	0	0.1637	0	1
PY3.5	DPH	Ventura County Medical Center	2.1.6	Prenatal and Postpartum Care: Postpartum Care	None	0.8427	0	0.713	1196	0	1401	0	0.8537	0	1
PY3.5	DPH	Ventura County Medical Center	2.1.6	Prenatal and Postpartum Care: Prenatal Care	None	0.9307	0	0.7689	1310	0	1401	0	0.935	0	1
PY3.5	DPH	Ventura County Medical Center	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	0.1935	0	0	25	0	126	0	0.1984	0	1
PY3.5	DPH	Ventura County Medical Center	2.1.8	Unexpected Newborn Complications (UNC)	None	0.0351	0	0	39	0	1102	0	0.0354	0	1
PY3.5	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)	None	1	0	None	32	0	32	0	1	0	1
PY3.5	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	None	0	0	None	Yes	0	10 Debriefs?	0	0	0	n/a
PY3.5	DPH	Ventura County Medical Center	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	None	0	0	None	Yes	0	3 Safety Drills?	0	0	0	n/a
PY3.5	DPH	Ventura County Medical Center	2.2.1	DHCS All-Cause Readmissions	None	0.0909	0	0	97	0	1024	0	0.0947	0	1
PY3.5	DPH	Ventura County Medical Center	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.572	0	0	5720	0	10000	0	0.572	0	1
PY3.5	DPH	Ventura County Medical Center	2.2.3	Medication Reconciliation – 30 days	None	0.9213	0	0	1998	0	2115	0	0.9447	0	1
PY3.5	DPH	Ventura County Medical Center	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.9087	0	0	5333	0	5925	0	0.9001	0	1
PY3.5	DPH	Ventura County Medical Center	2.2.5	Timely Transmission of Transition Record	None	0.8691	0	0	3615	0	4190	0	0.8628	0	1
PY3.5	DPH	Ventura County Medical Center	2.3.2	Medication Reconciliation – 30 days	None	0.9291	0	0	315	0	324	0	0.9722	0	1
PY3.5	DPH	Ventura County Medical Center	2.3.4	Timely Transmission of Transition Record	None	0.8669	0	0	479	0	558	0	0.8584	0	1
PY3.5	DPH	Ventura County Medical Center	2.4.1	Adolescent Well-Care Visit	None	0.5702	0	0	72	0	109	0	0.6606	0	1
PY3.5	DPH	Ventura County Medical Center	2.4.2	Developmental Screening in the First Three Years of Life	None	0.8496	0	0	93	0	142	0	0.6549	0	1
PY3.5	DPH	Ventura County Medical Center	2.4.3	Documentation of Current Medications in the Medical Record (0-18 yo)	None	0.877	0	0	1346	0	1544	0	0.8718	0	1
PY3.5	DPH	Ventura County Medical Center	2.4.4	Screening for Clinical Depression and follow-up	None	0.6053	0	0	48	0	71	0	0.6761	0	1
PY3.5	DPH	Ventura County Medical Center	2.4.5	Tobacco Assessment and Counseling (13 yo and older)	None	0.9333	0	0	43	0	46	0	0.9348	0	1
PY3.5	DPH	Ventura County Medical Center	2.4.7	Well Child Visits - Third, Fourth, Fifth, and Sixth Years of life	None	0.7771	0	0	124	0	148	0	0.8378	0	1
PY3.5	DPH	Ventura County Medical Center	2.4.8	Comprehensive Medical Evaluation Following Foster Youth Placement in Foster Care	None	0.2366	0	0	33	0	106	0	0.3113	0	1
PY3.5	DPH	Ventura County Medical Center	3.4.1	ePBM-01 Pre-op Anemia Screening, Selected Elective Surgical Patients	None	0.4531	0	0	112	0	201	0	0.5572	0	1
PY3.5	DPH	Ventura County Medical Center	3.4.3	ePBM-03 Pre-op Type and Crossmatch, Type and Screen, Selected elective Surgical Patients	None	0.922	0	0	215	0	228	0	0.943	0	1
PY3.5	DPH	Ventura County Medical Center	3.4.4	ePBM-04 Initial Transfusion Threshold	None	0.9916	0	0	369	0	370	0	0.9973	0	1
PY3.5	DMPH	Washington Hospital Healthcare System, Fremont	2.1.1	Baby Friendly Hospital designation: BFUSA Designation Yes	None	0	0	None	Yes	0	BFUSA Cert?	0	1	0	1
PY3.5	DMPH	Washington Hospital Healthcare System, Fremont	2.1.2	Exclusive Breast Milk Feeding (PC-05)	None	0.7097	0	0	68	0	95	0	0.7158	0	1
PY3.5	DMPH	Washington Hospital Healthcare System, Fremont	2.1.3	OB Hemorrhage: Massive Transfusion	None	0	0	0	0	0	120	0	0	0	1
PY3.5	DMPH	Washington Hospital Healthcare System, Fremont	2.1.5	PC-02 Cesarean Section	None	None	1	0	None	1	40	0	None	1	1
PY3.5	DMPH	Washington Hospital Healthcare System, Fremont	2.1.6	Prenatal and Postpartum Care: Postpartum Care	None	0.8574	0	0.713	497	0	538	0	0.9238	0	1
PY3.5	DMPH	Washington Hospital Healthcare System, Fremont	2.1.6	Prenatal and Postpartum Care: Prenatal Care	None	0.9397	0	0.7689	515	0	545	0	0.945	0	1
PY3.5	DMPH	Washington Hospital Healthcare System, Fremont	2.1.7	Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage	None	None	1	0	None	1	None	1	None	1	0
PY3.5	DMPH	Washington Hospital Healthcare System, Fremont	2.1.8	Unexpected Newborn Complications (UNC)	None	None	1	0	None	1	96	0	None	1	1
PY3.5	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)	None	1	0	None	16	0	16	0	1	0	1
PY3.5	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	None	0	0	None	Yes	0	10 Debriefs?	0	0	0	n/a
PY3.5	DMPH	Washington Hospital Healthcare System, Fremont	2.1.9	OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes	None	0	0	None	Yes	0	3 Safety Drills?	0	0	0	n/a
PY3.5	DMPH	Washington Hospital Healthcare System, Fremont	2.2.1	DHCS All-Cause Readmissions	None	0.1572	0	0	206	0	1237	0	0.1665	0	0
PY3.5	DMPH	Washington Hospital Healthcare System, Fremont	2.2.2	H-CAHPS: Care Transition Metrics (3)	None	0.5435	0	0	2493	0	4714	0	0.5289	0	1
PY3.5	DMPH	Washington Hospital Healthcare System, Fremont	2.2.3	Medication Reconciliation – 30 days	None	0.897	0	0	770	0	796	0	0.9673	0	1
PY3.5	DMPH	Washington Hospital Healthcare System, Fremont	2.2.4	Reconciled Medication List Received by Discharged Patients	None	0.9359	0	0	3278	0	3576	0	0.9167	0	1
PY3.5	DMPH	Washington Hospital Healthcare System, Fremont	2.2.5	Timely Transmission of Transition Record	None	0.9526	0	0	3224	0	3515	0	0.9172	0	1
PY3.5	DMPH	Washington Hospital Healthcare System, Fremont	2.7.1	Advance Care Plan	None	0.8341	0	0	208	0	256	0	0.8125	0	1
PY3.5	DMPH	Washington Hospital Healthcare System, Fremont	2.7.3	MWM #8: Treatment Preferences (documentation) Inpatient	None	0.9764	0	0	134	0	137	0	0.9781	0	1
PY3.5	DMPH	Washington Hospital Healthcare System, Fremont	2.7.4	MWM #8: Treatment Preferences (documentation) Outpatient	None	0.9556	0	0	27	0	None	4	None	4	0
PY3.5	DMPH	Washington Hospital Healthcare System, Fremont	2.7.5	Palliative Care Service Offered at Time of Diagnosis of Advanced Illness	None	0.1218	0	0	69	0	486	0	0.142	0	1
PY3.5	DMPH	Washington Hospital Healthcare System, Fremont	2.7.6	Proportion Admitted to Hospice for Less Than 3 Days	None	None	1	0	None	1	40	0	None	1	1