Table: quality_incentive_pool_qip_program_data_year_2

py	type	hospital	number	title	report_status	baseline_rate	baseline_rate_annotation_code	target_rate	numerator	numerator_annotation_code	denominator	denominator_annotation_code	achievement_rate	achievement_rate_annotation_code	achievement_value
PY2	DPH	Alameda Health System	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Alameda Health System	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	51.00%	0	52.70%	1554	0	2690	0	57.80%	0	1
PY2	DPH	Alameda Health System	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	72.70%	0	73.10%	2011	0	2690	0	74.80%	0	1
PY2	DPH	Alameda Health System	Q-PC4	Asthma Medication Ratio (AMR)	Reported	58.70%	0	60.10%	210	0	349	0	60.20%	0	1
PY2	DPH	Alameda Health System	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	51.90%	0	54.40%	1481	0	1940	0	76.30%	0	1
PY2	DPH	Alameda Health System	Q-PC6	7 Day Post-Discharge Follow-Up for High Risk Beneficiaries	Reported	24.20%	0	30.80%	322	0	958	0	33.60%	0	1
PY2	DPH	Alameda Health System	Q-PC7	Children and Adolescent Access to PCP (CAP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Alameda Health System	Q-PC8	Childhood Immunization Status (CIS) Combination 3	Reported	82.80%	0	79.30%	389	0	445	0	87.40%	0	1
PY2	DPH	Alameda Health System	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	61.60%	0	46.70%	170	0	289	0	58.80%	0	1
PY2	DPH	Alameda Health System	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	78.80%	0	80.00%	162	0	194	0	83.50%	0	1
PY2	DPH	Alameda Health System	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	97.40%	0	88.00%	254	0	266	0	95.50%	0	1
PY2	DPH	Alameda Health System	Q-SC3	Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)	Reported	92.70%	0	90.00%	299	0	325	0	92.00%	0	1
PY2	DPH	Alameda Health System	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	93.10%	0	90.00%	190	0	208	0	91.40%	0	1
PY2	DPH	Alameda Health System	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	93.30%	0	83.00%	113	0	121	0	93.40%	0	1
PY2	DPH	Alameda Health System	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	87.00%	0	87.10%	151	0	165	0	91.50%	0	1
PY2	DPH	Alameda Health System	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Alameda Health System	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	99.40%	0	90.00%	290	0	292	0	99.30%	0	1
PY2	DPH	Alameda Health System	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	100.00%	0	90.00%	385	0	385	0	100.00%	0	1
PY2	DPH	Alameda Health System	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	3.70%	0	25.00%	481	0	1186	0	40.60%	0	1
PY2	DPH	Alameda Health System	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Reported	83.00%	0	83.70%	37	0	42	0	88.10%	0	1
PY2	DPH	Alameda Health System	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Reported	62.20%	0	65.00%	64	0	74	0	86.50%	0	1
PY2	DPH	Alameda Health System	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Reported	0.00%	0	10.00%	None	1	244	0	None	1	1
PY2	DPH	Alameda Health System	Q-RU2	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients 18 Years and Older	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Alameda Health System	Q-RU3	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 to 17 years old	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Alameda Health System	Q-RU4	Unplanned Reoperation within the 30 Day Postoperative Period (QPP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Alameda Health System	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	1
PY2	DPH	Alameda Health System	Q-RU5	? RATE #1	Reported	6.10%	0	10.30%	None	1	548	0	None	1	1
PY2	DPH	Alameda Health System	Q-RU5	? RATE #2	Reported	6.80%	0	10.30%	39	0	740	0	5.30%	0	1
PY2	DPH	Arrowhead Regional Medical Center	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	54.30%	0	54.70%	995	0	1843	0	54.00%	0	0
PY2	DPH	Arrowhead Regional Medical Center	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	34.80%	0	47.60%	946	0	1843	0	51.30%	0	1
PY2	DPH	Arrowhead Regional Medical Center	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	36.90%	0	52.70%	1139	0	1843	0	61.80%	0	1
PY2	DPH	Arrowhead Regional Medical Center	Q-PC4	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Arrowhead Regional Medical Center	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Arrowhead Regional Medical Center	Q-PC6	7 Day Post-Discharge Follow-Up for High Risk Beneficiaries	Reported	52.70%	0	56.50%	270	0	395	0	68.40%	0	1
PY2	DPH	Arrowhead Regional Medical Center	Q-PC7	Children and Adolescent Access to PCP (CAP)	Reported	N/A	0	N/A	N/A	3	N/A	3	N/A	3	0
PY2	DPH	Arrowhead Regional Medical Center	Q-PC7	? 12-24 Months	Reported	None	1	N/A	32	0	37	0	86.50%	0	0
PY2	DPH	Arrowhead Regional Medical Center	Q-PC7	? 25 Months-6 Years	Reported	74.20%	0	84.90%	699	0	842	0	83.00%	0	0
PY2	DPH	Arrowhead Regional Medical Center	Q-PC7	? 7-11 Years	Reported	76.60%	0	87.60%	523	0	961	0	54.40%	0	0
PY2	DPH	Arrowhead Regional Medical Center	Q-PC7	? 12-19 Years	Reported	71.80%	0	85.70%	692	0	1340	0	51.60%	0	0
PY2	DPH	Arrowhead Regional Medical Center	Q-PC8	Childhood Immunization Status (CIS) Combination 3	Reported	47.90%	0	62.30%	98	0	141	0	69.50%	0	1
PY2	DPH	Arrowhead Regional Medical Center	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	58.10%	0	46.70%	104	0	192	0	54.20%	0	1
PY2	DPH	Arrowhead Regional Medical Center	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	14.80%	0	25.00%	43	0	66	0	65.20%	0	1
PY2	DPH	Arrowhead Regional Medical Center	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	29.20%	0	50.00%	228	0	249	0	91.60%	0	1
PY2	DPH	Arrowhead Regional Medical Center	Q-SC3	Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)	Reported	24.90%	0	50.00%	150	0	211	0	71.10%	0	1
PY2	DPH	Arrowhead Regional Medical Center	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	24.40%	0	50.00%	240	0	315	0	76.20%	0	1
PY2	DPH	Arrowhead Regional Medical Center	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	38.30%	0	50.00%	210	0	263	0	79.90%	0	1
PY2	DPH	Arrowhead Regional Medical Center	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	40.80%	0	50.00%	135	0	218	0	61.90%	0	1
PY2	DPH	Arrowhead Regional Medical Center	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Arrowhead Regional Medical Center	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	0.00%	0	25.00%	26	0	96	0	27.10%	0	1
PY2	DPH	Arrowhead Regional Medical Center	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	None	1	25.00%	378	0	441	0	85.70%	0	1
PY2	DPH	Arrowhead Regional Medical Center	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	40.00%	0	45.00%	27	0	32	0	84.40%	0	1
PY2	DPH	Arrowhead Regional Medical Center	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Reported	None	1	N/A	None	1	None	4	None	1	0
PY2	DPH	Arrowhead Regional Medical Center	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Reported	None	4	N/A	18	0	None	4	None	4	0
PY2	DPH	Arrowhead Regional Medical Center	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Reported	None	1	10.00%	None	1	75	0	None	1	1
PY2	DPH	Arrowhead Regional Medical Center	Q-RU2	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients 18 Years and Older	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Arrowhead Regional Medical Center	Q-RU3	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 to 17 years old	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Arrowhead Regional Medical Center	Q-RU4	Unplanned Reoperation within the 30 Day Postoperative Period (QPP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Arrowhead Regional Medical Center	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	0
PY2	DPH	Arrowhead Regional Medical Center	Q-RU5	? RATE #1	Reported	24.40%	0	18.00%	13	0	None	4	None	4	0
PY2	DPH	Arrowhead Regional Medical Center	Q-RU5	? RATE #2	Reported	26.30%	0	18.00%	14	0	199	0	7.00%	0	1
PY2	DPH	Contra Costa Regional Medical Center	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	57.70%	0	57.80%	2484	0	4261	0	58.30%	0	1
PY2	DPH	Contra Costa Regional Medical Center	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	55.70%	0	56.90%	2641	0	4261	0	62.00%	0	1
PY2	DPH	Contra Costa Regional Medical Center	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	75.70%	0	75.70%	3285	0	4261	0	77.10%	0	1
PY2	DPH	Contra Costa Regional Medical Center	Q-PC4	Asthma Medication Ratio (AMR)	Reported	53.00%	0	55.60%	634	0	1094	0	58.00%	0	1
PY2	DPH	Contra Costa Regional Medical Center	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	99.40%	0	77.60%	2209	0	2218	0	99.60%	0	1
PY2	DPH	Contra Costa Regional Medical Center	Q-PC6	7 Day Post-Discharge Follow-Up for High Risk Beneficiaries	Reported	45.00%	0	49.50%	164	0	274	0	59.90%	0	1
PY2	DPH	Contra Costa Regional Medical Center	Q-PC7	Children and Adolescent Access to PCP (CAP)	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	1
PY2	DPH	Contra Costa Regional Medical Center	Q-PC7	? 12-24 Months	Reported	93.40%	0	93.90%	1163	0	1219	0	95.40%	0	1
PY2	DPH	Contra Costa Regional Medical Center	Q-PC7	? 25 Months-6 Years	Reported	83.20%	0	84.90%	5241	0	6069	0	86.40%	0	1
PY2	DPH	Contra Costa Regional Medical Center	Q-PC7	? 7-11 Years	Reported	85.40%	0	87.60%	4694	0	5277	0	89.00%	0	1
PY2	DPH	Contra Costa Regional Medical Center	Q-PC7	? 12-19 Years	Reported	83.30%	0	85.70%	6103	0	6993	0	87.30%	0	1
PY2	DPH	Contra Costa Regional Medical Center	Q-PC8	Childhood Immunization Status (CIS) Combination 3	Reported	82.40%	0	79.30%	970	0	1139	0	85.20%	0	1
PY2	DPH	Contra Costa Regional Medical Center	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	48.50%	0	46.70%	423	0	847	0	49.90%	0	1
PY2	DPH	Contra Costa Regional Medical Center	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	76.10%	0	77.50%	383	0	465	0	82.40%	0	1
PY2	DPH	Contra Costa Regional Medical Center	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	91.20%	0	88.00%	1647	0	1780	0	92.50%	0	1
PY2	DPH	Contra Costa Regional Medical Center	Q-SC3	Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)	Reported	76.20%	0	77.60%	764	0	969	0	78.80%	0	1
PY2	DPH	Contra Costa Regional Medical Center	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	88.10%	0	88.30%	351	0	383	0	91.60%	0	1
PY2	DPH	Contra Costa Regional Medical Center	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	81.30%	0	81.40%	370	0	448	0	82.60%	0	1
PY2	DPH	Contra Costa Regional Medical Center	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	94.50%	0	88.00%	477	0	489	0	97.60%	0	1
PY2	DPH	Contra Costa Regional Medical Center	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Contra Costa Regional Medical Center	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	96.50%	0	90.00%	517	0	531	0	97.40%	0	1
PY2	DPH	Contra Costa Regional Medical Center	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	98.10%	0	90.00%	597	0	617	0	96.80%	0	1
PY2	DPH	Contra Costa Regional Medical Center	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	None	1	25.00%	101	0	116	0	87.10%	0	1
PY2	DPH	Contra Costa Regional Medical Center	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Contra Costa Regional Medical Center	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Contra Costa Regional Medical Center	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Reported	None	1	10.00%	None	1	1036	0	None	1	1
PY2	DPH	Contra Costa Regional Medical Center	Q-RU2	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients 18 Years and Older	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Contra Costa Regional Medical Center	Q-RU3	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 to 17 years old	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Contra Costa Regional Medical Center	Q-RU4	Unplanned Reoperation within the 30 Day Postoperative Period (QPP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Contra Costa Regional Medical Center	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	1
PY2	DPH	Contra Costa Regional Medical Center	Q-RU5	? RATE #1	Reported	7.20%	0	10.30%	147	0	2200	0	6.70%	0	1
PY2	DPH	Contra Costa Regional Medical Center	Q-RU5	? RATE #2	Reported	9.60%	0	10.30%	174	0	2200	0	7.90%	0	1
PY2	DPH	Kern Medical Center	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	55.00%	0	55.30%	1079	0	1901	0	56.80%	0	1
PY2	DPH	Kern Medical Center	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Kern Medical Center	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	69.70%	0	70.30%	1359	0	1901	0	71.50%	0	1
PY2	DPH	Kern Medical Center	Q-PC4	Asthma Medication Ratio (AMR)	Reported	None	1	55.60%	23	0	31	0	74.20%	0	1
PY2	DPH	Kern Medical Center	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	67.90%	0	68.80%	896	0	1072	0	83.60%	0	1
PY2	DPH	Kern Medical Center	Q-PC6	7 Day Post-Discharge Follow-Up for High Risk Beneficiaries	Reported	25.80%	0	32.20%	47	0	98	0	48.00%	0	1
PY2	DPH	Kern Medical Center	Q-PC7	Children and Adolescent Access to PCP (CAP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Kern Medical Center	Q-PC8	Childhood Immunization Status (CIS) Combination 3	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Kern Medical Center	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	31.10%	0	32.70%	102	0	282	0	36.20%	0	1
PY2	DPH	Kern Medical Center	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	93.50%	0	90.00%	112	0	117	0	95.70%	0	1
PY2	DPH	Kern Medical Center	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	92.00%	0	88.00%	262	0	274	0	95.60%	0	1
PY2	DPH	Kern Medical Center	Q-SC3	Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)	Reported	88.70%	0	88.90%	163	0	174	0	93.70%	0	1
PY2	DPH	Kern Medical Center	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	89.70%	0	89.80%	128	0	133	0	96.20%	0	1
PY2	DPH	Kern Medical Center	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	95.40%	0	83.00%	89	0	91	0	97.80%	0	1
PY2	DPH	Kern Medical Center	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	96.00%	0	88.00%	88	0	91	0	96.70%	0	1
PY2	DPH	Kern Medical Center	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Reported	1.7836	0	1.254	None	1	5.107	0	None	1	1
PY2	DPH	Kern Medical Center	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	100.00%	0	90.00%	1079	0	1079	0	100.00%	0	1
PY2	DPH	Kern Medical Center	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	100.00%	0	90.00%	996	0	997	0	99.90%	0	1
PY2	DPH	Kern Medical Center	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	96.20%	0	90.00%	376	0	412	0	91.30%	0	1
PY2	DPH	Kern Medical Center	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Kern Medical Center	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Reported	96.90%	0	90.00%	31	0	31	0	100.00%	0	1
PY2	DPH	Kern Medical Center	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Reported	0.00%	0	10.00%	0	0	109	0	0.00%	0	1
PY2	DPH	Kern Medical Center	Q-RU2	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients 18 Years and Older	Reported	100.00%	0	90.00%	134	0	147	0	91.20%	0	1
PY2	DPH	Kern Medical Center	Q-RU3	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 to 17 years old	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Kern Medical Center	Q-RU4	Unplanned Reoperation within the 30 Day Postoperative Period (QPP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Kern Medical Center	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	1
PY2	DPH	Kern Medical Center	Q-RU5	? RATE #1	Reported	12.20%	0	12.10%	23	0	470	0	4.90%	0	1
PY2	DPH	Kern Medical Center	Q-RU5	? RATE #2	Reported	11.10%	0	11.10%	36	0	1100	0	3.30%	0	1
PY2	DPH	Los Angeles County Health System	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	52.50%	0	53.10%	8117	0	15264	0	53.20%	0	1
PY2	DPH	Los Angeles County Health System	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	71.90%	0	68.20%	293	0	411	0	71.30%	0	1
PY2	DPH	Los Angeles County Health System	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	66.10%	0	67.10%	10702	0	15264	0	70.10%	0	1
PY2	DPH	Los Angeles County Health System	Q-PC4	Asthma Medication Ratio (AMR)	Reported	47.60%	0	55.60%	1075	0	1520	0	70.70%	0	1
PY2	DPH	Los Angeles County Health System	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	45.70%	0	48.90%	4974	0	7700	0	64.60%	0	1
PY2	DPH	Los Angeles County Health System	Q-PC6	7 Day Post-Discharge Follow-Up for High Risk Beneficiaries	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Los Angeles County Health System	Q-PC7	Children and Adolescent Access to PCP (CAP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Los Angeles County Health System	Q-PC8	Childhood Immunization Status (CIS) Combination 3	Reported	86.40%	0	79.30%	267	0	323	0	82.70%	0	1
PY2	DPH	Los Angeles County Health System	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	55.40%	0	46.70%	176	0	278	0	63.30%	0	1
PY2	DPH	Los Angeles County Health System	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	78.80%	0	79.90%	838	0	971	0	86.30%	0	1
PY2	DPH	Los Angeles County Health System	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	93.20%	0	88.00%	3078	0	3341	0	92.10%	0	1
PY2	DPH	Los Angeles County Health System	Q-SC3	Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)	Reported	86.30%	0	86.70%	1620	0	1805	0	89.80%	0	1
PY2	DPH	Los Angeles County Health System	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	85.30%	0	85.80%	1127	0	1293	0	87.20%	0	1
PY2	DPH	Los Angeles County Health System	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	78.80%	0	79.20%	605	0	707	0	85.60%	0	1
PY2	DPH	Los Angeles County Health System	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	89.70%	0	88.00%	648	0	727	0	89.10%	0	1
PY2	DPH	Los Angeles County Health System	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Los Angeles County Health System	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	91.90%	0	90.00%	364	0	377	0	96.60%	0	1
PY2	DPH	Los Angeles County Health System	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	80.80%	0	81.70%	367	0	377	0	97.40%	0	1
PY2	DPH	Los Angeles County Health System	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	57.80%	0	61.10%	317	0	377	0	84.10%	0	1
PY2	DPH	Los Angeles County Health System	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Reported	98.10%	0	90.00%	83	0	87	0	95.40%	0	1
PY2	DPH	Los Angeles County Health System	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Reported	99.50%	0	90.00%	267	0	267	0	100.00%	0	1
PY2	DPH	Los Angeles County Health System	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Reported	None	1	10.00%	None	1	327	0	None	1	1
PY2	DPH	Los Angeles County Health System	Q-RU2	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients 18 Years and Older	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Los Angeles County Health System	Q-RU3	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 to 17 years old	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Los Angeles County Health System	Q-RU4	Unplanned Reoperation within the 30 Day Postoperative Period (QPP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Los Angeles County Health System	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	1
PY2	DPH	Los Angeles County Health System	Q-RU5	? RATE #1	Reported	4.70%	0	10.30%	97	0	1982	0	4.90%	0	1
PY2	DPH	Los Angeles County Health System	Q-RU5	? RATE #2	Reported	9.40%	0	10.30%	296	0	3452	0	8.60%	0	1
PY2	DPH	Natividad Medical Center	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	51.40%	0	52.10%	945	0	1755	0	53.90%	0	1
PY2	DPH	Natividad Medical Center	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Natividad Medical Center	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	73.60%	0	73.80%	1303	0	1755	0	74.30%	0	1
PY2	DPH	Natividad Medical Center	Q-PC4	Asthma Medication Ratio (AMR)	Reported	65.00%	0	65.80%	281	0	421	0	66.80%	0	1
PY2	DPH	Natividad Medical Center	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	57.50%	0	59.50%	501	0	823	0	60.90%	0	1
PY2	DPH	Natividad Medical Center	Q-PC6	7 Day Post-Discharge Follow-Up for High Risk Beneficiaries	Reported	48.90%	0	53.00%	38	0	56	0	67.90%	0	1
PY2	DPH	Natividad Medical Center	Q-PC7	Children and Adolescent Access to PCP (CAP)	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	0.75
PY2	DPH	Natividad Medical Center	Q-PC7	? 12-24 Months	Reported	94.90%	0	95.20%	1397	0	1465	0	95.40%	0	1
PY2	DPH	Natividad Medical Center	Q-PC7	? 25 Months-6 Years	Reported	90.90%	0	91.10%	5936	0	6691	0	88.70%	0	0
PY2	DPH	Natividad Medical Center	Q-PC7	? 7-11 Years	Reported	89.30%	0	90.00%	6105	0	6711	0	91.00%	0	1
PY2	DPH	Natividad Medical Center	Q-PC7	? 12-19 Years	Reported	84.20%	0	85.70%	6679	0	7752	0	86.20%	0	1
PY2	DPH	Natividad Medical Center	Q-PC8	Childhood Immunization Status (CIS) Combination 3	Reported	87.90%	0	79.30%	903	0	1048	0	86.20%	0	1
PY2	DPH	Natividad Medical Center	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	72.90%	0	46.70%	720	0	923	0	78.00%	0	1
PY2	DPH	Natividad Medical Center	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	86.70%	0	87.10%	121	0	137	0	88.30%	0	1
PY2	DPH	Natividad Medical Center	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	80.10%	0	80.90%	257	0	315	0	81.60%	0	1
PY2	DPH	Natividad Medical Center	Q-SC3	Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)	Reported	82.60%	0	83.40%	152	0	182	0	83.50%	0	1
PY2	DPH	Natividad Medical Center	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	82.30%	0	83.10%	62	0	70	0	88.60%	0	1
PY2	DPH	Natividad Medical Center	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	80.00%	0	80.30%	37	0	41	0	90.20%	0	1
PY2	DPH	Natividad Medical Center	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	68.60%	0	70.50%	41	0	41	0	100.00%	0	1
PY2	DPH	Natividad Medical Center	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Natividad Medical Center	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	42.60%	0	47.30%	473	0	747	0	63.30%	0	1
PY2	DPH	Natividad Medical Center	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	64.10%	0	66.70%	663	0	709	0	93.50%	0	1
PY2	DPH	Natividad Medical Center	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	80.50%	0	81.50%	257	0	291	0	88.30%	0	1
PY2	DPH	Natividad Medical Center	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Natividad Medical Center	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Natividad Medical Center	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Reported	None	1	10.00%	0	0	85	0	0.00%	0	1
PY2	DPH	Natividad Medical Center	Q-RU2	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients 18 Years and Older	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Natividad Medical Center	Q-RU3	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 to 17 years old	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Natividad Medical Center	Q-RU4	Unplanned Reoperation within the 30 Day Postoperative Period (QPP)	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	1
PY2	DPH	Natividad Medical Center	Q-RU4	? Adjusted Percentile	Reported	61	0	57.4	N/A	3	N/A	3	57	0	N/A
PY2	DPH	Natividad Medical Center	Q-RU4	? Outlier Status	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	N/A
PY2	DPH	Natividad Medical Center	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	1
PY2	DPH	Natividad Medical Center	Q-RU5	? RATE #1	Reported	7.00%	0	10.30%	None	1	176	0	None	1	1
PY2	DPH	Natividad Medical Center	Q-RU5	? RATE #2	Reported	9.10%	0	10.30%	35	0	461	0	7.60%	0	1
PY2	DPH	Riverside University Health System	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	51.90%	0	52.60%	2168	0	3848	0	56.30%	0	1
PY2	DPH	Riverside University Health System	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	11.40%	0	47.60%	192	0	400	0	48.00%	0	1
PY2	DPH	Riverside University Health System	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	59.80%	0	61.40%	2874	0	3848	0	74.70%	0	1
PY2	DPH	Riverside University Health System	Q-PC4	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Riverside University Health System	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	65.40%	0	66.60%	1380	0	1408	0	98.00%	0	1
PY2	DPH	Riverside University Health System	Q-PC6	7 Day Post-Discharge Follow-Up for High Risk Beneficiaries	Reported	32.20%	0	38.00%	143	0	343	0	41.70%	0	1
PY2	DPH	Riverside University Health System	Q-PC7	Children and Adolescent Access to PCP (CAP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Riverside University Health System	Q-PC8	Childhood Immunization Status (CIS) Combination 3	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Riverside University Health System	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	33.70%	0	35.00%	77	0	204	0	37.80%	0	1
PY2	DPH	Riverside University Health System	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	81.10%	0	82.00%	131	0	152	0	86.20%	0	1
PY2	DPH	Riverside University Health System	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	85.60%	0	85.90%	598	0	670	0	89.30%	0	1
PY2	DPH	Riverside University Health System	Q-SC3	Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)	Reported	86.70%	0	87.10%	162	0	184	0	88.00%	0	1
PY2	DPH	Riverside University Health System	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	66.40%	0	68.70%	178	0	225	0	79.10%	0	1
PY2	DPH	Riverside University Health System	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	84.20%	0	83.00%	152	0	171	0	88.90%	0	1
PY2	DPH	Riverside University Health System	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	81.00%	0	81.70%	166	0	186	0	89.30%	0	1
PY2	DPH	Riverside University Health System	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Reported	1.2177	0	1.1497	None	1	9.83	0	None	1	1
PY2	DPH	Riverside University Health System	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	75.30%	0	76.80%	210	0	257	0	81.70%	0	1
PY2	DPH	Riverside University Health System	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	10.30%	0	25.00%	377	0	418	0	90.20%	0	1
PY2	DPH	Riverside University Health System	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	30.80%	0	36.70%	612	0	882	0	69.40%	0	1
PY2	DPH	Riverside University Health System	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Riverside University Health System	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Reported	84.60%	0	85.20%	59	0	66	0	89.40%	0	1
PY2	DPH	Riverside University Health System	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Reported	0.00%	0	10.00%	0	0	121	0	0.00%	0	1
PY2	DPH	Riverside University Health System	Q-RU2	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients 18 Years and Older	Reported	79.50%	0	80.50%	80	0	97	0	82.50%	0	1
PY2	DPH	Riverside University Health System	Q-RU3	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 to 17 years old	Reported	None	1	29.10%	None	1	41	0	None	1	1
PY2	DPH	Riverside University Health System	Q-RU4	Unplanned Reoperation within the 30 Day Postoperative Period (QPP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Riverside University Health System	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	San Francisco General Hospital	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	61.90%	0	58.50%	2082	0	3369	0	61.80%	0	1
PY2	DPH	San Francisco General Hospital	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	66.20%	0	66.40%	2292	0	3369	0	68.00%	0	1
PY2	DPH	San Francisco General Hospital	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	75.60%	0	75.60%	2586	0	3369	0	76.80%	0	1
PY2	DPH	San Francisco General Hospital	Q-PC4	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	San Francisco General Hospital	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	56.20%	0	58.30%	1675	0	2867	0	58.40%	0	1
PY2	DPH	San Francisco General Hospital	Q-PC6	7 Day Post-Discharge Follow-Up for High Risk Beneficiaries	Reported	49.40%	0	53.40%	244	0	447	0	54.60%	0	1
PY2	DPH	San Francisco General Hospital	Q-PC7	Children and Adolescent Access to PCP (CAP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	San Francisco General Hospital	Q-PC8	Childhood Immunization Status (CIS) Combination 3	Reported	90.20%	0	79.30%	393	0	451	0	87.10%	0	1
PY2	DPH	San Francisco General Hospital	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	65.40%	0	46.70%	194	0	258	0	75.20%	0	1
PY2	DPH	San Francisco General Hospital	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	78.40%	0	79.60%	272	0	340	0	80.00%	0	1
PY2	DPH	San Francisco General Hospital	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	93.90%	0	88.00%	793	0	843	0	94.10%	0	1
PY2	DPH	San Francisco General Hospital	Q-SC3	Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)	Reported	86.40%	0	86.80%	440	0	499	0	88.20%	0	1
PY2	DPH	San Francisco General Hospital	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	96.10%	0	90.00%	213	0	221	0	96.40%	0	1
PY2	DPH	San Francisco General Hospital	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	85.90%	0	83.00%	359	0	424	0	84.70%	0	1
PY2	DPH	San Francisco General Hospital	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	94.30%	0	88.00%	397	0	429	0	92.50%	0	1
PY2	DPH	San Francisco General Hospital	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	San Francisco General Hospital	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	95.30%	0	90.00%	323	0	337	0	95.90%	0	1
PY2	DPH	San Francisco General Hospital	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	96.80%	0	90.00%	324	0	335	0	96.70%	0	1
PY2	DPH	San Francisco General Hospital	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	0.00%	0	25.00%	354	0	621	0	57.00%	0	1
PY2	DPH	San Francisco General Hospital	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Reported	100.00%	0	90.00%	52	0	52	0	100.00%	0	1
PY2	DPH	San Francisco General Hospital	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Reported	100.00%	0	90.00%	90	0	90	0	100.00%	0	1
PY2	DPH	San Francisco General Hospital	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Reported	None	1	10.00%	None	1	171	0	None	1	1
PY2	DPH	San Francisco General Hospital	Q-RU2	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients 18 Years and Older	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	San Francisco General Hospital	Q-RU3	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 to 17 years old	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	San Francisco General Hospital	Q-RU4	Unplanned Reoperation within the 30 Day Postoperative Period (QPP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	San Francisco General Hospital	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	1
PY2	DPH	San Francisco General Hospital	Q-RU5	? RATE #1	Reported	11.40%	0	11.30%	76	0	872	0	8.70%	0	1
PY2	DPH	San Francisco General Hospital	Q-RU5	? RATE #2	Reported	11.40%	0	11.30%	90	0	953	0	9.40%	0	1
PY2	DPH	San Joaquin General Hospital	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	50.00%	0	50.90%	676	0	1281	0	52.80%	0	1
PY2	DPH	San Joaquin General Hospital	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	47.30%	0	49.40%	206	0	411	0	50.10%	0	1
PY2	DPH	San Joaquin General Hospital	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	72.30%	0	72.60%	872	0	1281	0	68.10%	0	0
PY2	DPH	San Joaquin General Hospital	Q-PC4	Asthma Medication Ratio (AMR)	Reported	72.00%	0	72.00%	24	0	33	0	72.70%	0	1
PY2	DPH	San Joaquin General Hospital	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	44.30%	0	47.60%	264	0	278	0	95.00%	0	1
PY2	DPH	San Joaquin General Hospital	Q-PC6	7 Day Post-Discharge Follow-Up for High Risk Beneficiaries	Reported	54.80%	0	58.30%	81	0	137	0	59.10%	0	1
PY2	DPH	San Joaquin General Hospital	Q-PC7	Children and Adolescent Access to PCP (CAP)	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	0.25
PY2	DPH	San Joaquin General Hospital	Q-PC7	? 12-24 Months	Reported	92.30%	0	93.30%	65	0	71	0	91.60%	0	0
PY2	DPH	San Joaquin General Hospital	Q-PC7	? 25 Months-6 Years	Reported	70.70%	0	84.90%	1332	0	1499	0	88.90%	0	1
PY2	DPH	San Joaquin General Hospital	Q-PC7	? 7-11 Years	Reported	66.80%	0	87.60%	1516	0	1756	0	86.30%	0	0
PY2	DPH	San Joaquin General Hospital	Q-PC7	? 12-19 Years	Reported	67.70%	0	85.70%	2388	0	2956	0	80.80%	0	0
PY2	DPH	San Joaquin General Hospital	Q-PC8	Childhood Immunization Status (CIS) Combination 3	Reported	72.80%	0	73.50%	280	0	362	0	77.40%	0	1
PY2	DPH	San Joaquin General Hospital	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	52.30%	0	46.70%	141	0	244	0	57.80%	0	1
PY2	DPH	San Joaquin General Hospital	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	70.40%	0	72.40%	115	0	147	0	78.20%	0	1
PY2	DPH	San Joaquin General Hospital	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	83.20%	0	83.70%	316	0	361	0	87.50%	0	1
PY2	DPH	San Joaquin General Hospital	Q-SC3	Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)	Reported	86.80%	0	87.10%	184	0	210	0	87.60%	0	1
PY2	DPH	San Joaquin General Hospital	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	83.70%	0	84.30%	117	0	131	0	89.30%	0	1
PY2	DPH	San Joaquin General Hospital	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	76.30%	0	76.90%	111	0	117	0	94.90%	0	1
PY2	DPH	San Joaquin General Hospital	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	76.30%	0	77.40%	97	0	103	0	94.20%	0	1
PY2	DPH	San Joaquin General Hospital	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Reported	None	1	1.132	14	0	9.117	0	1.5356	0	0
PY2	DPH	San Joaquin General Hospital	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	71.60%	0	73.40%	242	0	323	0	74.90%	0	1
PY2	DPH	San Joaquin General Hospital	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	83.70%	0	84.30%	229	0	278	0	82.40%	0	0
PY2	DPH	San Joaquin General Hospital	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	93.80%	0	90.00%	110	0	121	0	90.90%	0	1
PY2	DPH	San Joaquin General Hospital	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	San Joaquin General Hospital	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Reported	79.10%	0	80.20%	70	0	72	0	97.20%	0	1
PY2	DPH	San Joaquin General Hospital	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	San Joaquin General Hospital	Q-RU2	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients 18 Years and Older	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	San Joaquin General Hospital	Q-RU3	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 to 17 years old	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	San Joaquin General Hospital	Q-RU4	Unplanned Reoperation within the 30 Day Postoperative Period (QPP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	San Joaquin General Hospital	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Santa Clara Valley Medical Center	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	54.90%	0	55.20%	3222	0	5449	0	59.10%	0	1
PY2	DPH	Santa Clara Valley Medical Center	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	48.30%	0	50.30%	3729	0	5449	0	68.40%	0	1
PY2	DPH	Santa Clara Valley Medical Center	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	67.50%	0	68.30%	3811	0	5449	0	69.90%	0	1
PY2	DPH	Santa Clara Valley Medical Center	Q-PC4	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Santa Clara Valley Medical Center	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	37.50%	0	41.50%	1955	0	3721	0	52.50%	0	1
PY2	DPH	Santa Clara Valley Medical Center	Q-PC6	7 Day Post-Discharge Follow-Up for High Risk Beneficiaries	Reported	9.60%	0	25.00%	301	0	1564	0	19.30%	0	0
PY2	DPH	Santa Clara Valley Medical Center	Q-PC7	Children and Adolescent Access to PCP (CAP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Santa Clara Valley Medical Center	Q-PC8	Childhood Immunization Status (CIS) Combination 3	Reported	75.70%	0	76.10%	772	0	878	0	87.90%	0	1
PY2	DPH	Santa Clara Valley Medical Center	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	51.00%	0	46.70%	474	0	974	0	48.70%	0	1
PY2	DPH	Santa Clara Valley Medical Center	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	65.40%	0	67.90%	422	0	601	0	70.20%	0	1
PY2	DPH	Santa Clara Valley Medical Center	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	83.90%	0	84.30%	1209	0	1400	0	86.40%	0	1
PY2	DPH	Santa Clara Valley Medical Center	Q-SC3	Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)	Reported	71.80%	0	73.60%	719	0	936	0	76.80%	0	1
PY2	DPH	Santa Clara Valley Medical Center	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	35.40%	0	50.00%	371	0	511	0	72.60%	0	1
PY2	DPH	Santa Clara Valley Medical Center	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Santa Clara Valley Medical Center	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	0.00%	0	N/A	408	0	537	0	76.00%	0	0
PY2	DPH	Santa Clara Valley Medical Center	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Reported	1.0675	0	1.0146	11	0	13	0	0.8462	0	1
PY2	DPH	Santa Clara Valley Medical Center	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	71.80%	0	73.60%	1357	0	1817	0	74.70%	0	1
PY2	DPH	Santa Clara Valley Medical Center	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	96.10%	0	90.00%	1065	0	1119	0	95.20%	0	1
PY2	DPH	Santa Clara Valley Medical Center	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	11.80%	0	25.00%	195	0	609	0	32.00%	0	1
PY2	DPH	Santa Clara Valley Medical Center	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Reported	85.30%	0	85.80%	29	0	41	0	70.70%	0	0
PY2	DPH	Santa Clara Valley Medical Center	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Reported	96.40%	0	90.00%	86	0	90	0	95.60%	0	1
PY2	DPH	Santa Clara Valley Medical Center	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Santa Clara Valley Medical Center	Q-RU2	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients 18 Years and Older	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Santa Clara Valley Medical Center	Q-RU3	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 to 17 years old	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Santa Clara Valley Medical Center	Q-RU4	Unplanned Reoperation within the 30 Day Postoperative Period (QPP)	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	0
PY2	DPH	Santa Clara Valley Medical Center	Q-RU4	? Adjusted Percentile	Reported	32	0	31.3	N/A	3	N/A	3	42	0	N/A
PY2	DPH	Santa Clara Valley Medical Center	Q-RU4	? Outlier Status	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	N/A
PY2	DPH	Santa Clara Valley Medical Center	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	1
PY2	DPH	Santa Clara Valley Medical Center	Q-RU5	? RATE #1	Reported	6.50%	0	10.30%	49	0	788	0	6.20%	0	1
PY2	DPH	Santa Clara Valley Medical Center	Q-RU5	? RATE #2	Reported	7.10%	0	10.30%	71	0	932	0	7.60%	0	1
PY2	DPH	San Mateo Medical Center	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	63.10%	0	58.50%	1122	0	1806	0	62.10%	0	1
PY2	DPH	San Mateo Medical Center	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	98.40%	0	68.20%	1784	0	1806	0	98.80%	0	1
PY2	DPH	San Mateo Medical Center	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	73.80%	0	74.00%	1372	0	1806	0	76.00%	0	1
PY2	DPH	San Mateo Medical Center	Q-PC4	Asthma Medication Ratio (AMR)	Reported	60.60%	0	61.80%	120	0	193	0	62.20%	0	1
PY2	DPH	San Mateo Medical Center	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	48.20%	0	51.10%	338	0	595	0	56.80%	0	1
PY2	DPH	San Mateo Medical Center	Q-PC6	7 Day Post-Discharge Follow-Up for High Risk Beneficiaries	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	San Mateo Medical Center	Q-PC7	Children and Adolescent Access to PCP (CAP)	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	1
PY2	DPH	San Mateo Medical Center	Q-PC7	? 12-24 Months	Reported	100.00%	0	97.90%	278	0	278	0	100.00%	0	1
PY2	DPH	San Mateo Medical Center	Q-PC7	? 25 Months-6 Years	Reported	91.20%	0	91.40%	2080	0	2189	0	95.00%	0	1
PY2	DPH	San Mateo Medical Center	Q-PC7	? 7-11 Years	Reported	85.40%	0	87.60%	1884	0	1952	0	96.50%	0	1
PY2	DPH	San Mateo Medical Center	Q-PC7	? 12-19 Years	Reported	79.40%	0	85.70%	2519	0	2629	0	95.80%	0	1
PY2	DPH	San Mateo Medical Center	Q-PC8	Childhood Immunization Status (CIS) Combination 3	Reported	67.60%	0	68.80%	285	0	319	0	89.30%	0	1
PY2	DPH	San Mateo Medical Center	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	66.30%	0	46.70%	174	0	253	0	68.80%	0	1
PY2	DPH	San Mateo Medical Center	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	78.90%	0	80.00%	269	0	333	0	80.80%	0	1
PY2	DPH	San Mateo Medical Center	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	89.00%	0	88.00%	635	0	693	0	91.60%	0	1
PY2	DPH	San Mateo Medical Center	Q-SC3	Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)	Reported	88.80%	0	88.90%	290	0	322	0	90.10%	0	1
PY2	DPH	San Mateo Medical Center	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	89.90%	0	90.00%	161	0	177	0	91.00%	0	1
PY2	DPH	San Mateo Medical Center	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	89.80%	0	83.00%	59	0	65	0	90.80%	0	1
PY2	DPH	San Mateo Medical Center	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	70.90%	0	72.60%	77	0	80	0	96.30%	0	1
PY2	DPH	San Mateo Medical Center	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	San Mateo Medical Center	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	96.50%	0	90.00%	532	0	549	0	96.90%	0	1
PY2	DPH	San Mateo Medical Center	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	66.90%	0	69.20%	525	0	529	0	99.20%	0	1
PY2	DPH	San Mateo Medical Center	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	45.60%	0	50.00%	97	0	134	0	72.40%	0	1
PY2	DPH	San Mateo Medical Center	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	San Mateo Medical Center	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	San Mateo Medical Center	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Reported	None	1	10.00%	None	1	205	0	None	1	1
PY2	DPH	San Mateo Medical Center	Q-RU2	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients 18 Years and Older	Reported	80.80%	0	81.70%	77	0	94	0	81.90%	0	1
PY2	DPH	San Mateo Medical Center	Q-RU3	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 to 17 years old	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	San Mateo Medical Center	Q-RU4	Unplanned Reoperation within the 30 Day Postoperative Period (QPP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	San Mateo Medical Center	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	1
PY2	DPH	San Mateo Medical Center	Q-RU5	? RATE #1	Reported	7.70%	0	10.30%	82	0	1106	0	7.40%	0	1
PY2	DPH	San Mateo Medical Center	Q-RU5	? RATE #2	Reported	8.40%	0	10.30%	126	0	1696	0	7.40%	0	1
PY2	DPH	UC Davis Medical Center	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC Davis Medical Center	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC Davis Medical Center	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC Davis Medical Center	Q-PC4	Asthma Medication Ratio (AMR)	Reported	0	0	N/A	0	0	0	0	0.00%	0	0
PY2	DPH	UC Davis Medical Center	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	77.30%	0	77.30%	87	0	87	0	100.00%	0	1
PY2	DPH	UC Davis Medical Center	Q-PC6	7 Day Post-Discharge Follow-Up for High Risk Beneficiaries	Reported	84.50%	0	85.00%	None	1	None	4	None	1	0
PY2	DPH	UC Davis Medical Center	Q-PC7	Children and Adolescent Access to PCP (CAP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC Davis Medical Center	Q-PC8	Childhood Immunization Status (CIS) Combination 3	Reported	0.00%	0	N/A	None	1	None	1	None	1	0
PY2	DPH	UC Davis Medical Center	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC Davis Medical Center	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	None	1	N/A	None	1	None	4	None	1	0
PY2	DPH	UC Davis Medical Center	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	76.50%	0	77.60%	33	0	44	0	75.00%	0	0
PY2	DPH	UC Davis Medical Center	Q-SC3	Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)	Reported	None	4	N/A	22	0	None	4	None	4	0
PY2	DPH	UC Davis Medical Center	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	None	4	N/A	15	0	None	4	None	4	0
PY2	DPH	UC Davis Medical Center	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	None	1	N/A	15	0	None	4	None	4	0
PY2	DPH	UC Davis Medical Center	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	None	1	N/A	19	0	None	4	None	4	0
PY2	DPH	UC Davis Medical Center	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Reported	0.9128	0	0.8753	36	0	35.62	0	1.0107	0	0
PY2	DPH	UC Davis Medical Center	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	85.00%	0	85.50%	912	0	1103	0	82.70%	0	0
PY2	DPH	UC Davis Medical Center	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	98.50%	0	90.00%	1245	0	1303	0	95.60%	0	1
PY2	DPH	UC Davis Medical Center	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	53.20%	0	56.80%	277	0	317	0	87.40%	0	1
PY2	DPH	UC Davis Medical Center	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Reported	None	4	N/A	28	0	31	0	90.30%	0	0
PY2	DPH	UC Davis Medical Center	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Reported	100.00%	0	90.00%	62	0	65	0	95.40%	0	1
PY2	DPH	UC Davis Medical Center	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Reported	None	4	N/A	0	0	None	4	None	4	0
PY2	DPH	UC Davis Medical Center	Q-RU2	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients 18 Years and Older	Reported	88.00%	0	88.20%	117	0	146	0	80.10%	0	0
PY2	DPH	UC Davis Medical Center	Q-RU3	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 to 17 years old	Reported	12.40%	0	12.20%	None	1	82	0	None	1	1
PY2	DPH	UC Davis Medical Center	Q-RU4	Unplanned Reoperation within the 30 Day Postoperative Period (QPP)	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	0
PY2	DPH	UC Davis Medical Center	Q-RU4	? Adjusted Percentile	Reported	45	0	43	N/A	3	N/A	3	67	0	N/A
PY2	DPH	UC Davis Medical Center	Q-RU4	? Outlier Status	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	N/A
PY2	DPH	UC Davis Medical Center	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC Irvine Medical Center	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC Irvine Medical Center	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC Irvine Medical Center	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	64.90%	0	66.00%	718	0	1071	0	67.00%	0	1
PY2	DPH	UC Irvine Medical Center	Q-PC4	Asthma Medication Ratio (AMR)	Reported	50.80%	0	55.60%	59	0	106	0	55.70%	0	1
PY2	DPH	UC Irvine Medical Center	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	53.80%	0	56.10%	519	0	524	0	99.10%	0	1
PY2	DPH	UC Irvine Medical Center	Q-PC6	7 Day Post-Discharge Follow-Up for High Risk Beneficiaries	Reported	40.30%	0	45.20%	58	0	112	0	51.80%	0	1
PY2	DPH	UC Irvine Medical Center	Q-PC7	Children and Adolescent Access to PCP (CAP)	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	0.5
PY2	DPH	UC Irvine Medical Center	Q-PC7	? 12-24 Months	Reported	96.60%	0	96.80%	279	0	281	0	99.30%	0	1
PY2	DPH	UC Irvine Medical Center	Q-PC7	? 25 Months-6 Years	Reported	81.00%	0	84.90%	1040	0	1189	0	87.50%	0	1
PY2	DPH	UC Irvine Medical Center	Q-PC7	? 7-11 Years	Reported	84.40%	0	87.60%	488	0	560	0	87.10%	0	0
PY2	DPH	UC Irvine Medical Center	Q-PC7	? 12-19 Years	Reported	82.80%	0	85.70%	944	0	1109	0	85.10%	0	0
PY2	DPH	UC Irvine Medical Center	Q-PC8	Childhood Immunization Status (CIS) Combination 3	Reported	71.70%	0	72.50%	166	0	217	0	76.50%	0	1
PY2	DPH	UC Irvine Medical Center	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	41.90%	0	42.40%	54	0	121	0	44.60%	0	1
PY2	DPH	UC Irvine Medical Center	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	73.10%	0	74.80%	86	0	106	0	81.10%	0	1
PY2	DPH	UC Irvine Medical Center	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	79.20%	0	80.00%	222	0	256	0	86.70%	0	1
PY2	DPH	UC Irvine Medical Center	Q-SC3	Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)	Reported	83.90%	0	84.50%	153	0	177	0	86.40%	0	1
PY2	DPH	UC Irvine Medical Center	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	89.00%	0	89.10%	114	0	125	0	91.20%	0	1
PY2	DPH	UC Irvine Medical Center	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	81.10%	0	81.30%	134	0	151	0	88.70%	0	1
PY2	DPH	UC Irvine Medical Center	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	83.30%	0	83.80%	142	0	146	0	97.30%	0	1
PY2	DPH	UC Irvine Medical Center	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC Irvine Medical Center	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	56.00%	0	59.40%	1452	0	1814	0	80.00%	0	1
PY2	DPH	UC Irvine Medical Center	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC Irvine Medical Center	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	2.60%	0	25.00%	582	0	1587	0	36.70%	0	1
PY2	DPH	UC Irvine Medical Center	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC Irvine Medical Center	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Reported	92.20%	0	90.00%	94	0	94	0	100.00%	0	1
PY2	DPH	UC Irvine Medical Center	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Reported	None	1	10.00%	None	1	135	0	None	1	1
PY2	DPH	UC Irvine Medical Center	Q-RU2	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients 18 Years and Older	Reported	17.90%	0	50.00%	244	0	421	0	58.00%	0	1
PY2	DPH	UC Irvine Medical Center	Q-RU3	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 to 17 years old	Reported	None	1	10.00%	None	1	61	0	None	1	1
PY2	DPH	UC Irvine Medical Center	Q-RU4	Unplanned Reoperation within the 30 Day Postoperative Period (QPP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC Irvine Medical Center	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	1
PY2	DPH	UC Irvine Medical Center	Q-RU5	? RATE #1	Reported	16.00%	0	15.40%	19	0	180	0	10.60%	0	1
PY2	DPH	UC Irvine Medical Center	Q-RU5	? RATE #2	Reported	11.10%	0	11.00%	37	0	446	0	8.30%	0	1
PY2	DPH	UC Los Angeles Medical Center	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	56.50%	0	56.70%	39	0	70	0	55.70%	0	0
PY2	DPH	UC Los Angeles Medical Center	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	35.90%	0	47.60%	27	0	70	0	38.60%	0	0
PY2	DPH	UC Los Angeles Medical Center	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	73.90%	0	74.10%	54	0	70	0	77.10%	0	1
PY2	DPH	UC Los Angeles Medical Center	Q-PC4	Asthma Medication Ratio (AMR)	Reported	None	4	N/A	None	1	None	4	None	1	0
PY2	DPH	UC Los Angeles Medical Center	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	69.70%	0	70.50%	55	0	55	0	100.00%	0	1
PY2	DPH	UC Los Angeles Medical Center	Q-PC6	7 Day Post-Discharge Follow-Up for High Risk Beneficiaries	Reported	None	1	N/A	None	1	None	1	None	1	0
PY2	DPH	UC Los Angeles Medical Center	Q-PC7	Children and Adolescent Access to PCP (CAP)	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	0
PY2	DPH	UC Los Angeles Medical Center	Q-PC7	? 12-24 Months	Reported	97.00%	0	97.10%	118	0	134	0	88.10%	0	0
PY2	DPH	UC Los Angeles Medical Center	Q-PC7	? 25 Months-6 Years	Reported	84.60%	0	85.40%	737	0	1019	0	72.30%	0	0
PY2	DPH	UC Los Angeles Medical Center	Q-PC7	? 7-11 Years	Reported	88.70%	0	89.40%	650	0	773	0	84.10%	0	0
PY2	DPH	UC Los Angeles Medical Center	Q-PC7	? 12-19 Years	Reported	90.10%	0	90.50%	965	0	1126	0	85.70%	0	0
PY2	DPH	UC Los Angeles Medical Center	Q-PC8	Childhood Immunization Status (CIS) Combination 3	Reported	67.10%	0	68.30%	100	0	147	0	68.00%	0	0.75
PY2	DPH	UC Los Angeles Medical Center	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	30.30%	0	31.90%	46	0	97	0	47.40%	0	1
PY2	DPH	UC Los Angeles Medical Center	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	None	1	N/A	None	1	None	1	None	1	0
PY2	DPH	UC Los Angeles Medical Center	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	68.40%	0	70.40%	26	0	30	0	86.70%	0	1
PY2	DPH	UC Los Angeles Medical Center	Q-SC3	Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC Los Angeles Medical Center	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC Los Angeles Medical Center	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC Los Angeles Medical Center	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC Los Angeles Medical Center	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Reported	0.8464	0	0.8156	24	0	30.819	0	0.7787	0	1
PY2	DPH	UC Los Angeles Medical Center	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	80.70%	0	81.70%	634	0	741	0	85.60%	0	1
PY2	DPH	UC Los Angeles Medical Center	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	93.30%	0	90.00%	803	0	831	0	96.60%	0	1
PY2	DPH	UC Los Angeles Medical Center	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	23.00%	0	29.70%	783	0	974	0	80.40%	0	1
PY2	DPH	UC Los Angeles Medical Center	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC Los Angeles Medical Center	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Reported	100.00%	0	90.00%	46	0	46	0	100.00%	0	1
PY2	DPH	UC Los Angeles Medical Center	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC Los Angeles Medical Center	Q-RU2	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients 18 Years and Older	Reported	91.80%	0	90.00%	280	0	285	0	98.30%	0	1
PY2	DPH	UC Los Angeles Medical Center	Q-RU3	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 to 17 years old	Reported	0.00%	0	10.00%	0	0	51	0	0.00%	0	1
PY2	DPH	UC Los Angeles Medical Center	Q-RU4	Unplanned Reoperation within the 30 Day Postoperative Period (QPP)	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	1
PY2	DPH	UC Los Angeles Medical Center	Q-RU4	? Adjusted Percentile	Reported	40	0	38.5	N/A	3	N/A	3	33	0	N/A
PY2	DPH	UC Los Angeles Medical Center	Q-RU4	? Outlier Status	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	N/A
PY2	DPH	UC Los Angeles Medical Center	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	1
PY2	DPH	UC Los Angeles Medical Center	Q-RU5	? RATE #1	Reported	None	1	18.00%	None	1	39	0	None	1	1
PY2	DPH	UC Los Angeles Medical Center	Q-RU5	? RATE #2	Reported	None	1	12.60%	None	1	56	0	None	1	1
PY2	DPH	UC San Diego Medical Center	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	69.00%	0	58.50%	259	0	398	0	65.10%	0	1
PY2	DPH	UC San Diego Medical Center	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	57.60%	0	58.60%	260	0	398	0	65.30%	0	1
PY2	DPH	UC San Diego Medical Center	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	69.80%	0	70.40%	297	0	398	0	74.60%	0	1
PY2	DPH	UC San Diego Medical Center	Q-PC4	Asthma Medication Ratio (AMR)	Reported	73.00%	0	72.40%	36	0	59	0	61.00%	0	0
PY2	DPH	UC San Diego Medical Center	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	61.60%	0	63.20%	237	0	271	0	87.50%	0	1
PY2	DPH	UC San Diego Medical Center	Q-PC6	7 Day Post-Discharge Follow-Up for High Risk Beneficiaries	Reported	45.50%	0	49.90%	29	0	51	0	56.90%	0	1
PY2	DPH	UC San Diego Medical Center	Q-PC7	Children and Adolescent Access to PCP (CAP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC San Diego Medical Center	Q-PC8	Childhood Immunization Status (CIS) Combination 3	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC San Diego Medical Center	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC San Diego Medical Center	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	94.30%	0	90.00%	94	0	101	0	93.10%	0	1
PY2	DPH	UC San Diego Medical Center	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	84.10%	0	84.50%	210	0	227	0	92.50%	0	1
PY2	DPH	UC San Diego Medical Center	Q-SC3	Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)	Reported	65.40%	0	67.90%	108	0	124	0	87.10%	0	1
PY2	DPH	UC San Diego Medical Center	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	75.80%	0	77.20%	80	0	89	0	89.90%	0	1
PY2	DPH	UC San Diego Medical Center	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	83.30%	0	83.00%	58	0	63	0	92.10%	0	1
PY2	DPH	UC San Diego Medical Center	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	94.40%	0	88.00%	57	0	61	0	93.40%	0	1
PY2	DPH	UC San Diego Medical Center	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Reported	1.4551	0	1.254	24	0	38.649	0	0.621	0	1
PY2	DPH	UC San Diego Medical Center	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	61.80%	0	64.70%	379	0	504	0	75.20%	0	1
PY2	DPH	UC San Diego Medical Center	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	61.50%	0	64.30%	763	0	1019	0	74.90%	0	1
PY2	DPH	UC San Diego Medical Center	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	39.80%	0	44.80%	761	0	1392	0	54.70%	0	1
PY2	DPH	UC San Diego Medical Center	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC San Diego Medical Center	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Reported	98.10%	0	90.00%	42	0	42	0	100.00%	0	1
PY2	DPH	UC San Diego Medical Center	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC San Diego Medical Center	Q-RU2	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients 18 Years and Older	Reported	0.00%	0	N/A	0	0	0	0	0.00%	0	0
PY2	DPH	UC San Diego Medical Center	Q-RU3	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 to 17 years old	Reported	0.00%	0	N/A	0	0	0	0	0.00%	0	0
PY2	DPH	UC San Diego Medical Center	Q-RU4	Unplanned Reoperation within the 30 Day Postoperative Period (QPP)	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	1
PY2	DPH	UC San Diego Medical Center	Q-RU4	? Adjusted Percentile	Reported	64	0	60.1	N/A	3	N/A	3	24	0	N/A
PY2	DPH	UC San Diego Medical Center	Q-RU4	? Outlier Status	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	N/A
PY2	DPH	UC San Diego Medical Center	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC San Francisco Medical Center	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	54.70%	0	55.10%	388	0	666	0	58.30%	0	1
PY2	DPH	UC San Francisco Medical Center	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	65.70%	0	65.90%	440	0	666	0	66.10%	0	1
PY2	DPH	UC San Francisco Medical Center	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	66.10%	0	67.10%	486	0	666	0	73.00%	0	1
PY2	DPH	UC San Francisco Medical Center	Q-PC4	Asthma Medication Ratio (AMR)	Reported	52.20%	0	55.60%	115	0	199	0	57.80%	0	1
PY2	DPH	UC San Francisco Medical Center	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	48.70%	0	51.60%	323	0	326	0	99.10%	0	1
PY2	DPH	UC San Francisco Medical Center	Q-PC6	7 Day Post-Discharge Follow-Up for High Risk Beneficiaries	Reported	60.20%	0	63.20%	69	0	105	0	65.70%	0	1
PY2	DPH	UC San Francisco Medical Center	Q-PC7	Children and Adolescent Access to PCP (CAP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC San Francisco Medical Center	Q-PC8	Childhood Immunization Status (CIS) Combination 3	Reported	80.50%	0	79.30%	188	0	224	0	83.90%	0	1
PY2	DPH	UC San Francisco Medical Center	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC San Francisco Medical Center	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	89.50%	0	89.50%	65	0	67	0	97.00%	0	1
PY2	DPH	UC San Francisco Medical Center	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	89.80%	0	88.00%	156	0	158	0	98.70%	0	1
PY2	DPH	UC San Francisco Medical Center	Q-SC3	Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)	Reported	70.50%	0	72.40%	97	0	101	0	96.00%	0	1
PY2	DPH	UC San Francisco Medical Center	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	78.60%	0	79.70%	82	0	82	0	100.00%	0	1
PY2	DPH	UC San Francisco Medical Center	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	82.50%	0	82.60%	96	0	102	0	94.10%	0	1
PY2	DPH	UC San Francisco Medical Center	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	67.50%	0	69.60%	89	0	89	0	100.00%	0	1
PY2	DPH	UC San Francisco Medical Center	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Reported	0.8812	0	0.8469	46	0	54.806	0	0.8393	0	1
PY2	DPH	UC San Francisco Medical Center	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	64.90%	0	67.40%	2266	0	2469	0	91.80%	0	1
PY2	DPH	UC San Francisco Medical Center	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	90.70%	0	90.00%	2963	0	3010	0	98.40%	0	1
PY2	DPH	UC San Francisco Medical Center	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	1.60%	0	25.00%	555	0	1280	0	43.40%	0	1
PY2	DPH	UC San Francisco Medical Center	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC San Francisco Medical Center	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Reported	84.20%	0	84.80%	31	0	32	0	96.90%	0	1
PY2	DPH	UC San Francisco Medical Center	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Reported	8.40%	0	10.00%	0	0	150	0	0.00%	0	1
PY2	DPH	UC San Francisco Medical Center	Q-RU2	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients 18 Years and Older	Reported	42.90%	0	50.00%	131	0	170	0	77.10%	0	1
PY2	DPH	UC San Francisco Medical Center	Q-RU3	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 to 17 years old	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC San Francisco Medical Center	Q-RU4	Unplanned Reoperation within the 30 Day Postoperative Period (QPP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	UC San Francisco Medical Center	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Ventura County Medical Center	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	59.80%	0	58.50%	1752	0	2770	0	63.30%	0	1
PY2	DPH	Ventura County Medical Center	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	42.70%	0	47.60%	1494	0	2770	0	53.90%	0	1
PY2	DPH	Ventura County Medical Center	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	74.20%	0	74.30%	2101	0	2770	0	75.90%	0	1
PY2	DPH	Ventura County Medical Center	Q-PC4	Asthma Medication Ratio (AMR)	Reported	50.30%	0	55.60%	407	0	617	0	66.00%	0	1
PY2	DPH	Ventura County Medical Center	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	54.10%	0	56.40%	940	0	1592	0	59.10%	0	1
PY2	DPH	Ventura County Medical Center	Q-PC6	7 Day Post-Discharge Follow-Up for High Risk Beneficiaries	Reported	47.20%	0	51.50%	212	0	403	0	52.60%	0	1
PY2	DPH	Ventura County Medical Center	Q-PC7	Children and Adolescent Access to PCP (CAP)	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	1
PY2	DPH	Ventura County Medical Center	Q-PC7	? 12-24 Months	Reported	93.80%	0	94.20%	1436	0	1503	0	95.50%	0	1
PY2	DPH	Ventura County Medical Center	Q-PC7	? 25 Months-6 Years	Reported	84.50%	0	85.30%	7243	0	8267	0	87.60%	0	1
PY2	DPH	Ventura County Medical Center	Q-PC7	? 7-11 Years	Reported	82.10%	0	87.60%	7231	0	8016	0	90.20%	0	1
PY2	DPH	Ventura County Medical Center	Q-PC7	? 12-19 Years	Reported	78.60%	0	85.70%	8785	0	10068	0	87.30%	0	1
PY2	DPH	Ventura County Medical Center	Q-PC8	Childhood Immunization Status (CIS) Combination 3	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Ventura County Medical Center	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	33.80%	0	35.10%	406	0	1049	0	38.70%	0	1
PY2	DPH	Ventura County Medical Center	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	75.30%	0	76.70%	103	0	129	0	79.80%	0	1
PY2	DPH	Ventura County Medical Center	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	85.40%	0	85.70%	425	0	476	0	89.30%	0	1
PY2	DPH	Ventura County Medical Center	Q-SC3	Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)	Reported	81.30%	0	82.20%	213	0	249	0	85.50%	0	1
PY2	DPH	Ventura County Medical Center	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	86.60%	0	86.90%	61	0	67	0	91.00%	0	1
PY2	DPH	Ventura County Medical Center	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	89.20%	0	83.00%	115	0	133	0	86.50%	0	1
PY2	DPH	Ventura County Medical Center	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	91.80%	0	88.00%	86	0	91	0	94.50%	0	1
PY2	DPH	Ventura County Medical Center	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Ventura County Medical Center	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	82.10%	0	82.90%	913	0	1091	0	83.70%	0	1
PY2	DPH	Ventura County Medical Center	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	95.30%	0	90.00%	1030	0	1082	0	95.20%	0	1
PY2	DPH	Ventura County Medical Center	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	0.00%	0	25.00%	148	0	181	0	81.80%	0	1
PY2	DPH	Ventura County Medical Center	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Ventura County Medical Center	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Ventura County Medical Center	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Reported	None	1	10.00%	None	1	125	0	None	1	1
PY2	DPH	Ventura County Medical Center	Q-RU2	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients 18 Years and Older	Reported	61.70%	0	64.50%	99	0	134	0	73.90%	0	1
PY2	DPH	Ventura County Medical Center	Q-RU3	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 to 17 years old	Not Reported	None	None	None	None	None	None	None	None	None	None
PY2	DPH	Ventura County Medical Center	Q-RU4	Unplanned Reoperation within the 30 Day Postoperative Period (QPP)	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	0
PY2	DPH	Ventura County Medical Center	Q-RU4	? Adjusted Percentile	Reported	39	0	37.6	N/A	3	N/A	3	44	0	N/A
PY2	DPH	Ventura County Medical Center	Q-RU4	? Outlier Status	Reported	N/A	3	N/A	N/A	3	N/A	3	N/A	3	N/A
PY2	DPH	Ventura County Medical Center	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Not Reported	None	None	None	None	None	None	None	None	None	None