| 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)' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '0.3982' | '0' | '0' | '435' | '0' | '1236' | '0' | '0.3519' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'Alameda Health System' | '1.2.11' | 'REAL data completeness' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '0.1824' | '0' | '0' | '152' | '0' | '867' | '0' | '0.1753' | '0' | '0' |
| 'PY3.5' | 'DPH' | 'Alameda Health System' | '1.3.3' | 'Influenza Immunization' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0' | '0' | '' | 'Yes' | '0' | 'BFUSA Cert?' | '0' | '1' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'Alameda Health System' | '2.1.2' | 'Exclusive Breast Milk Feeding (PC-05)' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '865' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DPH' | 'Alameda Health System' | '2.1.5' | 'PC-02 Cesarean Section' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '0' | '0' | '' | 'Yes' | '0' | '10 Debriefs?' | '0' | '0' | '' | 'n/a' |
| 'PY3.5' | 'DPH' | 'Alameda Health System' | '2.1.9' | 'OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes' | '' | '0' | '0' | '' | 'Yes' | '0' | '3 Safety Drills?' | '0' | '0' | '' | '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)' |
'' | '1' | '0' | '' | '16' | '0' | '16' | '0' | '1' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'Alameda Health System' | '2.2.1' | 'DHCS All-Cause Readmissions' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0' | '0' | '' | 'Yes' | '0' | 'BFUSA Cert?' | '0' | '1' | '0' | '1' |
| 'PY3.5' | 'DMPH' | 'Antelope Valley Hospital, Lancaster' | '2.1.2' | 'Exclusive Breast Milk Feeding (PC-05)' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '1809' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DMPH' | 'Antelope Valley Hospital, Lancaster' | '2.1.5' | 'PC-02 Cesarean Section' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '0' | '0' | '' | 'Yes' | '0' | '10 Debriefs?' | '0' | '0' | '' | 'n/a' |
| 'PY3.5' | 'DMPH' | 'Antelope Valley Hospital, Lancaster' | '2.1.9' | 'OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes' | '' | '0' | '0' | '' | 'Yes' | '0' | '3 Safety Drills?' | '0' | '0' | '' | '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)' |
'' | '1' | '0' | '' | '16' | '0' | '16' | '0' | '1' | '0' | '1' |
| 'PY3.5' | 'DMPH' | 'Antelope Valley Hospital, Lancaster' | '2.2.1' | 'DHCS All-Cause Readmissions' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '1' | '0' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '0.1028' | '0' | '0.1935' | '' | '1' | '97' | '0' | '' | '1' | '0' |
| 'PY3.5' | 'DPH' | 'Arrowhead Regional Medical Center' | '1.1.7' | 'Depression Remission or Response for Adolescents and Adults: Depression Remission' | '' | '' | '1' | '0.0198' | '' | '1' | '97' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DPH' | 'Arrowhead Regional Medical Center' | '1.1.7' | 'Depression Remission or Response for Adolescents and Adults: Depression Response' | '' | '' | '1' | '0.0419' | '' | '1' | '97' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DPH' | 'Arrowhead Regional Medical Center' | '1.2.1.a' | 'Alcohol and Drug Misuse (SBIRT): Brief screening only' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '0.0934' | '0' | '0' | '45' | '0' | '422' | '0' | '0.1066' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'Arrowhead Regional Medical Center' | '1.3.3' | 'Influenza Immunization' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' |
'' | '' | '1' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0' | '0' | '' | 'Yes' | '0' | 'BFUSA Cert?' | '0' | '1' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'Arrowhead Regional Medical Center' | '2.1.2' | 'Exclusive Breast Milk Feeding (PC-05)' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '706' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DPH' | 'Arrowhead Regional Medical Center' | '2.1.5' | 'PC-02 Cesarean Section' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '0' | '0' | '' | 'Yes' | '0' | '10 Debriefs?' | '0' | '0' | '' | 'n/a' |
| 'PY3.5' | 'DPH' | 'Arrowhead Regional Medical Center' | '2.1.9' | 'OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes' | '' | '0' | '0' | '' | 'Yes' | '0' | '3 Safety Drills?' | '0' | '0' | '' | '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)' |
'' | '1' | '0' | '' | '16' | '0' | '16' | '0' | '1' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'Arrowhead Regional Medical Center' | '2.2.1' | 'DHCS All-Cause Readmissions' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '0.0096' | '0' | '0.0216' | '' | '1' | '2326' | '0' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0' | '0' | '' | '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)' | '' | '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' | '' | '0' | '0' | '0' | '' | '1' | '1567' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DPH' | 'Contra Costa Regional Medical Center' | '2.1.5' | 'PC-02 Cesarean Section' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '0' | '0' | '' | 'Yes' | '0' | '10 Debriefs?' | '0' | '0' | '' | 'n/a' |
| 'PY3.5' | 'DPH' | 'Contra Costa Regional Medical Center' | '2.1.9' | 'OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes' | '' | '0' | '0' | '' | 'Yes' | '0' | '3 Safety Drills?' | '0' | '0' | '' | '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)' |
'' | '1' | '0' | '' | '16' | '0' | '16' | '0' | '1' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'Contra Costa Regional Medical Center' | '2.2.1' | 'DHCS All-Cause Readmissions' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0.8691' | '0' | '' | '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' | '' | '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)' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0' | '0' | '' | '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)' | '' | '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' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '' | '4' | '' | '1' | '0' |
| 'PY3.5' | 'DMPH' | 'El Camino Hospital, Mountain View' | '2.1.6' | 'Prenatal and Postpartum Care: Prenatal Care' | '' | '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' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '' | '1' | '' | '1' | '0' |
| 'PY3.5' | 'DMPH' | 'El Camino Hospital, Mountain View' | '2.1.8' | 'Unexpected Newborn Complications (UNC)' | '' | '' | '1' | '0' | '' | '1' | '65' | '0' | '' | '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)' |
'' | '1' | '0' | '' | '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' | '' | '0' | '0' | '' | 'Yes' | '0' | '10 Debriefs?' | '0' | '0' | '' | 'n/a' |
| 'PY3.5' | 'DMPH' | 'El Camino Hospital, Mountain View' | '2.1.9' | 'OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter No' | '' | '0' | '0' | '' | 'No' | '0' | '3 Safety Drills?' | '0' | '0' | '' | 'n/a' |
| 'PY3.5' | 'DMPH' | 'El Camino Hospital, Mountain View' | '3.4.1' | 'ePBM-01 Pre-op Anemia Screening, Selected Elective Surgical Patients' | '' | '' | '1' | '0' | '' | '1' | '' | '4' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '' | '4' | '' | '1' | '0' |
| 'PY3.5' | 'DMPH' | 'El Camino Hospital, Mountain View' | '3.4.4' | 'ePBM-04 Initial Transfusion Threshold' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' |
'' | '' | '1' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0.5731' | '0' | '' | '220' | '0' | '394' | '0' | '0.5584' | '0' | '1' |
| 'PY3.5' | 'DMPH' | 'Hazel Hawkins Memorial Hospital, Hollister' | '2.3.2' | 'Medication Reconciliation 30 days' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0' | '0' | '0' | '0' | '0' | '0' | '0' | '0' | '0' | '0' |
| 'PY3.5' | 'DMPH' | 'Healdsburg District Hospital, Healdsburg' | '1.6.2' | 'Breast Cancer Screening' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '1' | '0' | '0' | '0' | '0' | '0' | '0' | '0' | '0' |
| 'PY3.5' | 'DMPH' | 'Jerold Phelps Community Hospital, Garberville' | '1.5.1.b' | 'Controlling Blood Pressure' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '' | '1' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '0.9226' | '0' | '0' | '142' | '0' | '175' | '0' | '0.8114' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'Kern Medical Center' | '1.2.11' | 'REAL data completeness' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '23249' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DPH' | 'Kern Medical Center' | '1.3.1' | 'Closing the referral loop: receipt of specialist report (CMS50v3)' | '' | '1' | '0' | '0' | '19468' | '0' | '19468' | '0' | '1' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'Kern Medical Center' | '1.3.2' | 'DHCS All-Cause Readmissions' | '' | '0.0848' | '0' | '0' | '48' | '0' | '492' | '0' | '0.0976' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'Kern Medical Center' | '1.3.3' | 'Influenza Immunization' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0' | '0' | '' | 'Yes' | '0' | 'BFUSA Cert?' | '0' | '1' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'Kern Medical Center' | '2.1.2' | 'Exclusive Breast Milk Feeding (PC-05)' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '990' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DPH' | 'Kern Medical Center' | '2.1.5' | 'PC-02 Cesarean Section' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '0' | '0' | '' | 'Yes' | '0' | '10 Debriefs?' | '0' | '0' | '' | 'n/a' |
| 'PY3.5' | 'DPH' | 'Kern Medical Center' | '2.1.9' | 'OB Hemorrhage Safety Bundle: 3 OB Safety Drills Each Quarter Yes' | '' | '0' | '0' | '' | 'Yes' | '0' | '3 Safety Drills?' | '0' | '0' | '' | '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)' |
'' | '1' | '0' | '' | '16' | '0' | '16' | '0' | '1' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'Kern Medical Center' | '2.2.1' | 'DHCS All-Cause Readmissions' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0.7888' | '0' | '' | '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' | '' | '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)' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '1' | '0.0198' | '' | '1' | '84' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DMPH' | 'Kern Valley Healthcare District, Lake Isabella' | '1.1.7' | 'Depression Remission or Response for Adolescents and Adults: Depression Response' | '' | '' | '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' | '' | '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)' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '257' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DMPH' | 'Lompoc Valley Medical Center, Lompoc' | '1.3.3' | 'Influenza Immunization' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' |
'' | '' | '1' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' |
'' | '1' | '0' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0' | '0' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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)' |
'' | '1' | '0' | '' | '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' | '' | '0' | '0' | '' | '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' | '' | '0' | '0' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '1' | '0.0198' | '' | '1' | '75' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DMPH' | 'Mammoth Hospital, Mammoth Lakes' | '1.1.7' | 'Depression Remission or Response for Adolescents and Adults: Depression Response' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '1' | '0' | '17' | '0' | '' | '4' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '' | '4' | '0' | '26' | '0' | '' | '4' | '' | '4' | '0' |
| 'PY3.5' | 'DMPH' | 'Mammoth Hospital, Mammoth Lakes' | '2.6.3' | 'Patients with chronic pain on long term opioid therapy checked in PDMPs' | '' | '' | '4' | '0' | '28' | '0' | '' | '4' | '' | '4' | '0' |
| 'PY3.5' | 'DMPH' | 'Mammoth Hospital, Mammoth Lakes' | '2.6.4' | 'Screening for Clinical Depression and follow-up' | '' | '' | '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' | '' | '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' | '' | '0' | '0' | '' | 'Yes' | '0' | 'BFUSA Cert?' | '0' | '1' | '0' | '1' |
| 'PY3.5' | 'DMPH' | 'Marin General Hospital, Greenbrae' | '2.1.2' | 'Exclusive Breast Milk Feeding (PC-05)' | '' | '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' | '' | '0' | '0' | '0' | '0' | '0' | '446' | '0' | '0' | '0' | '1' |
| 'PY3.5' | 'DMPH' | 'Marin General Hospital, Greenbrae' | '2.1.5' | 'PC-02 Cesarean Section' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '60' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DMPH' | 'Marin General Hospital, Greenbrae' | '2.1.8' | 'Unexpected Newborn Complications (UNC)' | '' | '' | '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' | '' | '0' | '0' | '' | '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' | '' | '0' | '0' | '' | '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)' |
'' | '1' | '0' | '' | '16' | '0' | '16' | '0' | '1' | '0' | '1' |
| 'PY3.5' | 'DMPH' | 'Marin General Hospital, Greenbrae' | '2.2.1' | 'DHCS All-Cause Readmissions' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '4' | '0' | '18' | '0' | '' | '4' | '' | '4' | '0' |
| 'PY3.5' | 'DMPH' | 'Marin General Hospital, Greenbrae' | '2.7.5' | 'Palliative Care Service Offered at Time of Diagnosis of Advanced Illness' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '' | '1' | '' | '1' | '0' |
| 'PY3.5' | 'DMPH' | 'Mayers Memorial Hospital District, Fall River Mills' | '1.7.1' | 'BMI Screening and Follow-up' | '' | '' | '1' | '0' | '' | '1' | '' | '4' | '' | '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)' |
'' | '' | '1' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '' | '4' | '' | '1' | '0' |
| 'PY3.5' | 'DMPH' | 'Modoc Medical Center, Alturas' | '1.2.11' | 'REAL data completeness' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '520' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DPH' | 'Natividad Medical Center' | '1.1.1.a' | 'Alcohol and Drug Misuse (SBIRT): Brief screening only' | '' | '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)' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '0.1134' | '0' | '0.0198' | '' | '1' | '110' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DPH' | 'Natividad Medical Center' | '1.1.7' | 'Depression Remission or Response for Adolescents and Adults: Depression Response' | '' | '0.2062' | '0' | '0.0419' | '' | '1' | '110' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DPH' | 'Natividad Medical Center' | '1.1.7' | 'Depression Remission or Response for Adolescents and Adults: Follow-up' | '' | '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' | '' | '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)' | '' | '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' | '' | '0.6139' | '0' | '0' | '429' | '0' | '674' | '0' | '0.6365' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'Natividad Medical Center' | '1.2.11' | 'REAL data completeness' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '0.0921' | '0' | '0' | '14' | '0' | '160' | '0' | '0.0875' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'Natividad Medical Center' | '1.3.3' | 'Influenza Immunization' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0' | '0' | '' | 'Yes' | '0' | 'BFUSA Cert?' | '0' | '1' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'Natividad Medical Center' | '2.1.2' | 'Exclusive Breast Milk Feeding (PC-05)' | '' | '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' | '' | '0' | '0' | '0' | '0' | '0' | '594' | '0' | '0' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'Natividad Medical Center' | '2.1.5' | 'PC-02 Cesarean Section' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '0' | '0' | '' | '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' | '' | '0' | '0' | '' | '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)' |
'' | '1' | '0' | '' | '16' | '0' | '16' | '0' | '1' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'Natividad Medical Center' | '2.2.1' | 'DHCS All-Cause Readmissions' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '4' | '0' | '43' | '0' | '43' | '0' | '1' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'Natividad Medical Center' | '2.3.4' | 'Timely Transmission of Transition Record' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '' | '1' | '' | '1' | '0' |
| 'PY3.5' | 'DMPH' | 'Northern Inyo Hospital, Bishop' | '3.1.3' | 'National Healthcare Safety Network (NHSN) Antimicrobial Use Measure' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '1' | '0.5' | '19' | '0' | '' | '4' | '' | '4' | '0' |
| 'PY3.5' | 'DMPH' | 'Oak Valley Hospital District, Oakdale' | '1.4.1' | 'Abnormal Results Follow-Up: Abnormal BIRADS Follow-up' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '' | '4' | '' | '1' | '0' |
| 'PY3.5' | 'DMPH' | 'Palo Verde Hospital, Blythe' | '1.1.1.a' | 'Alcohol and Drug Misuse (SBIRT): Brief screening only' | '' | '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)' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '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' | '' | '' | '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' | '' | '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' | '' | '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)' |
'' | '' | '1' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' |
'' | '' | '4' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0.4513' | '0' | '' | '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' | '' | '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' | '' | '0.9494' | '0' | '' | '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' | '' | '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' | '' | '0.6286' | '0' | '0.5' | '14' | '0' | '' | '4' | '' | '4' | '0' |
| 'PY3.5' | 'DMPH' | 'Pioneers Memorial Healthcare District, Brawley' | '1.4.1' | 'Abnormal Results Follow-Up: Abnormal BIRADS Follow-up' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '' | '1' | '' | '1' | '0' |
| 'PY3.5' | 'DMPH' | 'Pioneers Memorial Healthcare District, Brawley' | '1.6.1' | 'BIRADS to Biopsy' | '' | '' | '1' | '0' | '' | '1' | '' | '1' | '' | '1' | '0' |
| 'PY3.5' | 'DMPH' | 'Pioneers Memorial Healthcare District, Brawley' | '1.6.2' | 'Breast Cancer Screening' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '1' | '0' | '0' | '0' | '' | '1' | '' | '1' | '0' |
| 'PY3.5' | 'DMPH' | 'Pioneers Memorial Healthcare District, Brawley' | '2.2.1' | 'DHCS All-Cause Readmissions' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '0.1318' | '0' | '0' | '141' | '0' | '1099' | '0' | '0.1283' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'Riverside University Health System' | '1.3.3' | 'Influenza Immunization' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0' | '0' | '' | 'Yes' | '0' | 'BFUSA Cert?' | '0' | '1' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'Riverside University Health System' | '2.1.2' | 'Exclusive Breast Milk Feeding (PC-05)' | '' | '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' | '' | '0' | '0' | '0' | '0' | '0' | '302' | '0' | '0' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'Riverside University Health System' | '2.1.5' | 'PC-02 Cesarean Section' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '35' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DPH' | 'Riverside University Health System' | '2.1.8' | 'Unexpected Newborn Complications (UNC)' | '' | '' | '1' | '0' | '' | '1' | '231' | '0' | '' | '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' | '' | '0' | '0' | '' | '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' | '' | '0' | '0' | '' | '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)' |
'' | '1' | '0' | '' | '16' | '0' | '16' | '0' | '1' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'Riverside University Health System' | '2.2.1' | 'DHCS All-Cause Readmissions' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '' | '1' | '' | '1' | '0' |
| 'PY3.5' | 'DMPH' | 'Salinas Valley Memorial Healthcare System' | '2.2.1' | 'DHCS All-Cause Readmissions' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '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' | '' | '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)' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '0.1451' | '0' | '0' | '186' | '0' | '1375' | '0' | '0.1353' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'San Francisco General Hospital' | '1.3.3' | 'Influenza Immunization' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0' | '0' | '' | 'Yes' | '0' | 'BFUSA Cert?' | '0' | '1' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'San Francisco General Hospital' | '2.1.2' | 'Exclusive Breast Milk Feeding (PC-05)' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '860' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DPH' | 'San Francisco General Hospital' | '2.1.5' | 'PC-02 Cesarean Section' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '0' | '0' | '' | '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' | '' | '0' | '0' | '' | '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)' |
'' | '1' | '0' | '' | '16' | '0' | '16' | '0' | '1' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'San Francisco General Hospital' | '2.2.1' | 'DHCS All-Cause Readmissions' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0.6712' | '0' | '' | '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' | '' | '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' | '' | '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)' |
'' | '' | '1' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '' | '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' | '' | '' | '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' | '' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '0.1229' | '0' | '0' | '112' | '0' | '773' | '0' | '0.1449' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'San Joaquin General Hospital' | '1.3.3' | 'Influenza Immunization' | '' | '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' | '' | '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' | '' | '' | '1' | '0' | '26' | '0' | '377' | '0' | '0.069' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'San Joaquin General Hospital' | '1.3.7' | 'Tobacco Assessment and Counseling' | '' | '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' | '' | '' | '4' | '0' | '18' | '0' | '30' | '0' | '0.6' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'San Joaquin General Hospital' | '1.6.2' | 'Breast Cancer Screening' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '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' | '' | '0' | '0' | '' | 'Yes' | '0' | 'BFUSA Cert?' | '0' | '1' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'San Joaquin General Hospital' | '2.1.2' | 'Exclusive Breast Milk Feeding (PC-05)' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '1046' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DPH' | 'San Joaquin General Hospital' | '2.1.5' | 'PC-02 Cesarean Section' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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)' |
'' | '1' | '0' | '' | '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' | '' | '0' | '0' | '' | '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' | '' | '0' | '0' | '' | 'Yes' | '0' | '3 Safety Drills?' | '0' | '0' | '0' | 'n/a' |
| 'PY3.5' | 'DPH' | 'San Joaquin General Hospital' | '2.2.1' | 'DHCS All-Cause Readmissions' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '' | '4' | '' | '1' | '0' |
| 'PY3.5' | 'DPH' | 'San Joaquin General Hospital' | '3.2.2' | 'Appropriate Emergency Department Utilization of CT for Pulmonary Embolism' | '' | '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' | '' | '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' | '' | '0.7781' | '0' | '' | '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' | '' | '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)' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '1' | '0' | '0' | '14451' | '0' | '14451' | '0' | '1' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'San Mateo Medical Center' | '1.3.2' | 'DHCS All-Cause Readmissions' | '' | '0.0749' | '0' | '0' | '18' | '0' | '211' | '0' | '0.0853' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'San Mateo Medical Center' | '1.3.3' | 'Influenza Immunization' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '1' | '0' | '0' | '221' | '0' | '221' | '0' | '1' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'San Mateo Medical Center' | '2.4.1' | 'Adolescent Well-Care Visit' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '' | '1' | '' | '1' | '0' |
| 'PY3.5' | 'DPH' | 'San Mateo Medical Center' | '2.4.3' | 'Documentation of Current Medications in the Medical Record (0-18 yo)' | '' | '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' | '' | '' | '4' | '0' | '' | '1' | '' | '4' | '' | '1' | '0' |
| 'PY3.5' | 'DPH' | 'San Mateo Medical Center' | '2.4.5' | 'Tobacco Assessment and Counseling (13 yo and older)' | '' | '' | '4' | '0' | '24' | '0' | '' | '4' | '' | '4' | '0' |
| 'PY3.5' | 'DPH' | 'San Mateo Medical Center' | '2.4.7' | 'Well Child Visits - Third, Fourth, Fifth, and Sixth Years of life' | '' | '' | '4' | '0' | '14' | '0' | '' | '4' | '' | '4' | '0' |
| 'PY3.5' | 'DPH' | 'San Mateo Medical Center' | '2.4.8' | 'Comprehensive Medical Evaluation Following Foster Youth Placement in Foster Care' | '' | '0.4' | '0' | '0' | '' | '1' | '' | '4' | '' | '1' | '0' |
| 'PY3.5' | 'DPH' | 'San Mateo Medical Center' | '2.6.1' | 'Alcohol and Drug Misuse (SBIRT): Brief screening only' | '' | '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)' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '' | '1' | '' | '1' | '0' |
| 'PY3.5' | 'DPH' | 'San Mateo Medical Center' | '2.6.3' | 'Patients with chronic pain on long term opioid therapy checked in PDMPs' | '' | '' | '1' | '0' | '' | '1' | '' | '1' | '' | '1' | '0' |
| 'PY3.5' | 'DPH' | 'San Mateo Medical Center' | '2.6.4' | 'Screening for Clinical Depression and follow-up' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0.6028' | '0' | '' | '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' | '' | '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)' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0' | '0' | '' | '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)' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '2191' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DPH' | 'Santa Clara Valley Medical Center' | '2.1.5' | 'PC-02 Cesarean Section' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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)' |
'' | '1' | '0' | '' | '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' | '' | '0' | '0' | '' | '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' | '' | '0' | '0' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '4' | '0' | '0' | '0' | '' | '4' | '' | '4' | '0' |
| 'PY3.5' | 'DMPH' | 'Seneca Healthcare District, Chester' | '2.2.2' | 'H-CAHPS: Care Transition Metrics (3)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' |
'' | '' | '1' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '41' | '0' | '' | '1' | '0' |
| 'PY3.5' | 'DMPH' | 'Sierra View District Hospital, Porterville' | '2.7.5' | 'Palliative Care Service Offered at Time of Diagnosis of Advanced Illness' | '' | '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' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '105' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DMPH' | 'Sonoma Valley Hospital, Sonoma' | '2.2.2' | 'H-CAHPS: Care Transition Metrics (3)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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%%)' | '' | '' | '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' | '' | '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' | '' | '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)' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' |
'' | '' | '1' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0' | '0' | '' | '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)' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '1547' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DMPH' | 'Tri-City Medical Center, Oceanside' | '2.1.5' | 'PC-02 Cesarean Section' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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)' |
'' | '0.9375' | '0' | '' | '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' | '' | '0' | '0' | '' | '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' | '' | '0' | '0' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0.9519' | '0' | '0.5' | '' | '1' | '' | '1' | '' | '1' | '0' |
| 'PY3.5' | 'DMPH' | 'Trinity Hospital, Weaverville' | '1.4.1' | 'Abnormal Results Follow-Up: Abnormal INR Follow-up' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '' | '1' | '' | '1' | '0' |
| 'PY3.5' | 'DMPH' | 'Trinity Hospital, Weaverville' | '1.6.1' | 'BIRADS to Biopsy' | '' | '' | '1' | '0' | '' | '1' | '' | '1' | '' | '1' | '0' |
| 'PY3.5' | 'DMPH' | 'Trinity Hospital, Weaverville' | '1.6.2' | 'Breast Cancer Screening' | '' | '0.5637' | '0' | '0' | '119' | '0' | '199' | '0' | '0.598' | '0' | '1' |
| 'PY3.5' | 'DMPH' | 'Trinity Hospital, Weaverville' | '1.6.3' | 'Cervical Cancer Screening' | '' | '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' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '' | '1' | '' | '1' | '0' |
| 'PY3.5' | 'DPH' | 'UC Davis Medical Center' | '1.1.1.a' | 'Alcohol and Drug Misuse (SBIRT): Brief screening only' | '' | '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)' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '0.1707' | '0' | '0' | '109' | '0' | '750' | '0' | '0.1453' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'UC Davis Medical Center' | '1.3.3' | 'Influenza Immunization' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0' | '0' | '' | 'Yes' | '0' | 'BFUSA Cert?' | '0' | '1' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'UC Davis Medical Center' | '2.1.2' | 'Exclusive Breast Milk Feeding (PC-05)' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '1193' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DPH' | 'UC Davis Medical Center' | '2.1.5' | 'PC-02 Cesarean Section' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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)' |
'' | '1' | '0' | '' | '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' | '' | '0' | '0' | '' | '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' | '' | '0' | '0' | '' | 'Yes' | '0' | '3 Safety Drills?' | '0' | '0' | '0' | 'n/a' |
| 'PY3.5' | 'DPH' | 'UC Davis Medical Center' | '2.2.1' | 'DHCS All-Cause Readmissions' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0.7989' | '0' | '' | '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' | '' | '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)' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '0.1344' | '0' | '0' | '167' | '0' | '1361' | '0' | '0.1227' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'UC Irvine Medical Center' | '1.3.3' | 'Influenza Immunization' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0' | '0' | '' | 'Yes' | '0' | 'BFUSA Cert?' | '0' | '1' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'UC Irvine Medical Center' | '2.1.2' | 'Exclusive Breast Milk Feeding (PC-05)' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '1458' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DPH' | 'UC Irvine Medical Center' | '2.1.5' | 'PC-02 Cesarean Section' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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)' |
'' | '1' | '0' | '' | '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' | '' | '0' | '0' | '' | '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' | '' | '0' | '0' | '' | 'Yes' | '0' | '3 Safety Drills?' | '0' | '0' | '0' | 'n/a' |
| 'PY3.5' | 'DPH' | 'UC Irvine Medical Center' | '2.2.1' | 'DHCS All-Cause Readmissions' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0' | '0' | '' | '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)' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '522' | '0' | '' | '1' | '0' |
| 'PY3.5' | 'DPH' | 'UC Los Angeles Medical Center' | '2.1.5' | 'PC-02 Cesarean Section' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '' | '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)' |
'' | '1' | '0' | '' | '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' | '' | '0' | '0' | '' | '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' | '' | '0' | '0' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0.053' | '0' | '' | '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' | '' | '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)' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0' | '0' | '' | '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)' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '3230' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DPH' | 'UC San Diego Medical Center' | '2.1.5' | 'PC-02 Cesarean Section' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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)' |
'' | '1' | '0' | '' | '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' | '' | '0' | '0' | '' | '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' | '' | '0' | '0' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '1' | '0' | '0' | '232' | '0' | '232' | '0' | '1' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'UC San Diego Medical Center' | '2.7.1' | 'Advance Care Plan' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '84' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DPH' | 'UC San Diego Medical Center' | '3.1.1' | 'Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0.2839' | '0' | '' | '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' | '' | '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)' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0' | '0' | '' | '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)' | '' | '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' | '' | '0.005' | '0' | '0' | '' | '1' | '2376' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DPH' | 'UC San Francisco Medical Center' | '2.1.5' | 'PC-02 Cesarean Section' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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)' |
'' | '1' | '0' | '' | '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' | '' | '0' | '0' | '' | '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' | '' | '0' | '0' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '104' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DPH' | 'UC San Francisco Medical Center' | '3.3.1' | 'Adherence to Medications: Rate 1' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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%%)' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '0.0999' | '0' | '0' | '84' | '0' | '791' | '0' | '0.1062' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'Ventura County Medical Center' | '1.3.3' | 'Influenza Immunization' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0' | '0' | '' | 'Yes' | '0' | 'BFUSA Cert?' | '0' | '1' | '0' | '1' |
| 'PY3.5' | 'DPH' | 'Ventura County Medical Center' | '2.1.2' | 'Exclusive Breast Milk Feeding (PC-05)' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '1362' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DPH' | 'Ventura County Medical Center' | '2.1.5' | 'PC-02 Cesarean Section' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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)' |
'' | '1' | '0' | '' | '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' | '' | '0' | '0' | '' | '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' | '' | '0' | '0' | '' | 'Yes' | '0' | '3 Safety Drills?' | '0' | '0' | '0' | 'n/a' |
| 'PY3.5' | 'DPH' | 'Ventura County Medical Center' | '2.2.1' | 'DHCS All-Cause Readmissions' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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)' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0' | '0' | '' | '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)' | '' | '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' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '40' | '0' | '' | '1' | '1' |
| 'PY3.5' | 'DMPH' | 'Washington Hospital Healthcare System, Fremont' | '2.1.6' | 'Prenatal and Postpartum Care: Postpartum Care' | '' | '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' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '' | '1' | '' | '1' | '0' |
| 'PY3.5' | 'DMPH' | 'Washington Hospital Healthcare System, Fremont' | '2.1.8' | 'Unexpected Newborn Complications (UNC)' | '' | '' | '1' | '0' | '' | '1' | '96' | '0' | '' | '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)' |
'' | '1' | '0' | '' | '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' | '' | '0' | '0' | '' | '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' | '' | '0' | '0' | '' | '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' | '' | '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)' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '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' | '' | '0.9556' | '0' | '0' | '27' | '0' | '' | '4' | '' | '4' | '0' |
| 'PY3.5' | 'DMPH' | 'Washington Hospital Healthcare System, Fremont' | '2.7.5' | 'Palliative Care Service Offered at Time of Diagnosis of Advanced Illness' | '' | '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' | '' | '' | '1' | '0' | '' | '1' | '40' | '0' | '' | '1' | '1' |