Table: quality_incentive_pool_qip_program_data_year_3

py	hospital	type	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
PY3	Alameda Health System	DPH	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	0	0	0.4444	1198	0	2204	0	0.5436	0	1
PY3	Alameda Health System	DPH	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Alameda Health System	DPH	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Alameda Health System	DPH	Q-PC4	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Alameda Health System	DPH	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	0.7634	0	0.3869	1667	0	1906	0	0.8746	0	1
PY3	Alameda Health System	DPH	Q-PC7	Children and Adolescent Access to PCP (CAP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Alameda Health System	DPH	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	0.5882	0	0.2628	166	0	273	0	0.6081	0	1
PY3	Alameda Health System	DPH	Q-PC10	Childhood Immunization Status (CIS) Combination 10	Reported	0	0	0.28	320	0	517	0	0.619	0	1
PY3	Alameda Health System	DPH	Q-PC11	Contraceptive Care - All Women (CCW) Most and Moderately Effective Methods, Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Alameda Health System	DPH	Q-PC12	Chlamydia Screening in Women (CHL), Ages 16-24	Reported	0	0	0.51	363	0	653	0	0.5559	0	1
PY3	Alameda Health System	DPH	Q-PC13	HIV Viral Load Suppression (HVL-AD)	Reported	0	0	0.6636	189	0	224	0	0.8438	0	1
PY3	Alameda Health System	DPH	Q-PC14	Well-Child Visits in the First 15 Months of Life (W15-CH), Six or More well-child visits	Reported	0	0	0.59	68	0	78	0	0.8718	0	1
PY3	Alameda Health System	DPH	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	0.8351	0	0.25	100	0	114	0	0.8772	0	1
PY3	Alameda Health System	DPH	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.9549	0	0.5	204	0	208	0	0.9808	0	1
PY3	Alameda Health System	DPH	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	0.92	0	0.5	237	0	257	0	0.9222	0	1
PY3	Alameda Health System	DPH	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
PY3	Alameda Health System	DPH	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	0.9339	0	0.5	171	0	188	0	0.9096	0	1
PY3	Alameda Health System	DPH	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	0.9152	0	0.5	165	0	173	0	0.9538	0	1
PY3	Alameda Health System	DPH	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Reported	0	0	1.254	None	1	7.267	0	None	1	1
PY3	Alameda Health System	DPH	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	0.9932	0	0.25	542	0	560	0	0.9679	0	1
PY3	Alameda Health System	DPH	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	1	0	0.25	717	0	757	0	0.9472	0	1
PY3	Alameda Health System	DPH	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Alameda Health System	DPH	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Reported	0.881	0	0.25	29	0	33	0	0.8788	0	1
PY3	Alameda Health System	DPH	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Reported	0.8649	0	0.25	48	0	49	0	0.9796	0	1
PY3	Alameda Health System	DPH	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Reported	None	1	0.75	0	0	201	0	0	0	1
PY3	Alameda Health System	DPH	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
PY3	Alameda Health System	DPH	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
PY3	Alameda Health System	DPH	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Reported	None	3	N/A	None	3	None	3	None	3	1
PY3	Alameda Health System	DPH	Q-RU5	? RATE #2	Reported	0.0527	0	0.1675	None	1	418	0	None	1	1
PY3	Alameda Health System	DPH	Q-RU6	Use of Opioids at high Dosage in Persons Without Cancer	Reported	0	0	0.0564	None	1	565	0	None	1	1
PY3	Arrowhead Regional Medical Center	DPH	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	0.5399	0	0.4444	665	0	1191	0	0.5584	0	1
PY3	Arrowhead Regional Medical Center	DPH	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.5133	0	0.5085	672	0	1191	0	0.5642	0	1
PY3	Arrowhead Regional Medical Center	DPH	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	0.618	0	0.562	932	0	1191	0	0.7825	0	1
PY3	Arrowhead Regional Medical Center	DPH	Q-PC4	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Arrowhead Regional Medical Center	DPH	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	0.1826	0	0.3869	386	0	991	0	0.3895	0	1
PY3	Arrowhead Regional Medical Center	DPH	Q-PC7	Children and Adolescent Access to PCP (CAP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Arrowhead Regional Medical Center	DPH	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	0.5417	0	0.2628	188	0	303	0	0.6205	0	1
PY3	Arrowhead Regional Medical Center	DPH	Q-PC10	Childhood Immunization Status (CIS) Combination 10	Reported	0.4438	0	0.28	143	0	340	0	0.4206	0	1
PY3	Arrowhead Regional Medical Center	DPH	Q-PC11	Contraceptive Care - All Women (CCW) Most and Moderately Effective Methods, Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Arrowhead Regional Medical Center	DPH	Q-PC12	Chlamydia Screening in Women (CHL), Ages 16-24	Reported	0.5489	0	0.51	196	0	296	0	0.6622	0	1
PY3	Arrowhead Regional Medical Center	DPH	Q-PC13	HIV Viral Load Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Arrowhead Regional Medical Center	DPH	Q-PC14	Well-Child Visits in the First 15 Months of Life (W15-CH), Six or More well-child visits	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Arrowhead Regional Medical Center	DPH	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	0.6515	0	0.25	142	0	166	0	0.8554	0	1
PY3	Arrowhead Regional Medical Center	DPH	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.9157	0	0.5	309	0	335	0	0.9224	0	1
PY3	Arrowhead Regional Medical Center	DPH	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	0.7109	0	0.5	190	0	280	0	0.6786	0	1
PY3	Arrowhead Regional Medical Center	DPH	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	0.7619	0	0.5	133	0	150	0	0.8867	0	1
PY3	Arrowhead Regional Medical Center	DPH	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	0.7985	0	0.5	351	0	386	0	0.9093	0	1
PY3	Arrowhead Regional Medical Center	DPH	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	0.6193	0	0.5	174	0	248	0	0.7016	0	1
PY3	Arrowhead Regional Medical Center	DPH	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Reported	0.8293	0	1.254	None	1	6.098	0	None	1	1
PY3	Arrowhead Regional Medical Center	DPH	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	0.2708	0	0.25	64	0	103	0	0.6214	0	1
PY3	Arrowhead Regional Medical Center	DPH	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	0.8571	0	0.25	123	0	423	0	0.2908	0	1
PY3	Arrowhead Regional Medical Center	DPH	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	0.8438	0	0.25	70	0	83	0	0.8434	0	1
PY3	Arrowhead Regional Medical Center	DPH	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Arrowhead Regional Medical Center	DPH	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Reported	None	4	N/A	54	0	59	0	0.9153	0	1
PY3	Arrowhead Regional Medical Center	DPH	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Reported	None	1	0.75	25	0	249	0	0.1004	0	1
PY3	Arrowhead Regional Medical Center	DPH	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
PY3	Arrowhead Regional Medical Center	DPH	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
PY3	Arrowhead Regional Medical Center	DPH	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Reported	None	3	N/A	None	3	None	3	None	3	1
PY3	Arrowhead Regional Medical Center	DPH	Q-RU5	? RATE #2	Reported	0.0704	0	0.1675	78	0	472	0	0.1653	0	1
PY3	Arrowhead Regional Medical Center	DPH	Q-RU6	Use of Opioids at high Dosage in Persons Without Cancer	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Contra Costa Regional Medical Center	DPH	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	0.583	0	0.4444	2456	0	4164	0	0.5898	0	1
PY3	Contra Costa Regional Medical Center	DPH	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.6198	0	0.5085	2676	0	4164	0	0.6427	0	1
PY3	Contra Costa Regional Medical Center	DPH	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	0.7709	0	0.562	3222	0	4164	0	0.7738	0	1
PY3	Contra Costa Regional Medical Center	DPH	Q-PC4	Asthma Medication Ratio (AMR)	Reported	0.5795	0	0.5685	715	0	993	0	0.72	0	1
PY3	Contra Costa Regional Medical Center	DPH	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	0.9959	0	0.3869	2167	0	2185	0	0.9918	0	1
PY3	Contra Costa Regional Medical Center	DPH	Q-PC7	Children and Adolescent Access to PCP (CAP)	Reported	None	3	N/A	None	3	None	3	None	3	1
PY3	Contra Costa Regional Medical Center	DPH	Q-PC7	? 12-24 Months	Reported	0.9541	0	0.9364	1013	0	1056	0	0.9593	0	1
PY3	Contra Costa Regional Medical Center	DPH	Q-PC7	? 25 Months-6 Years	Reported	0.8636	0	0.8439	5074	0	5732	0	0.8852	0	1
PY3	Contra Costa Regional Medical Center	DPH	Q-PC7	? 7-11 Years	Reported	0.8895	0	0.8773	4385	0	4891	0	0.8965	0	1
PY3	Contra Costa Regional Medical Center	DPH	Q-PC7	? 12-19 Years	Reported	0.8727	0	0.8581	6155	0	6965	0	0.8837	0	1
PY3	Contra Costa Regional Medical Center	DPH	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	0.4994	0	0.2628	461	0	848	0	0.5436	0	1
PY3	Contra Costa Regional Medical Center	DPH	Q-PC10	Childhood Immunization Status (CIS) Combination 10	Reported	0	0	0.28	1263	0	2569	0	0.4916	0	1
PY3	Contra Costa Regional Medical Center	DPH	Q-PC11	Contraceptive Care - All Women (CCW) Most and Moderately Effective Methods, Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Contra Costa Regional Medical Center	DPH	Q-PC12	Chlamydia Screening in Women (CHL), Ages 16-24	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Contra Costa Regional Medical Center	DPH	Q-PC13	HIV Viral Load Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Contra Costa Regional Medical Center	DPH	Q-PC14	Well-Child Visits in the First 15 Months of Life (W15-CH), Six or More well-child visits	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Contra Costa Regional Medical Center	DPH	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	0.8237	0	0.25	417	0	506	0	0.8241	0	1
PY3	Contra Costa Regional Medical Center	DPH	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.9253	0	0.5	1707	0	1866	0	0.9148	0	1
PY3	Contra Costa Regional Medical Center	DPH	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	0.7884	0	0.5	808	0	1042	0	0.7754	0	1
PY3	Contra Costa Regional Medical Center	DPH	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	0.9164	0	0.5	419	0	459	0	0.9129	0	1
PY3	Contra Costa Regional Medical Center	DPH	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	0.8259	0	0.5	392	0	469	0	0.8358	0	1
PY3	Contra Costa Regional Medical Center	DPH	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	0.9755	0	0.5	480	0	501	0	0.9581	0	1
PY3	Contra Costa Regional Medical Center	DPH	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Contra Costa Regional Medical Center	DPH	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	0.9736	0	0.25	474	0	500	0	0.948	0	1
PY3	Contra Costa Regional Medical Center	DPH	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	0.9676	0	0.25	587	0	606	0	0.9686	0	1
PY3	Contra Costa Regional Medical Center	DPH	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	0.8707	0	0.25	122	0	131	0	0.9313	0	1
PY3	Contra Costa Regional Medical Center	DPH	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Contra Costa Regional Medical Center	DPH	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Contra Costa Regional Medical Center	DPH	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Reported	None	1	0.75	None	1	950	0	None	1	1
PY3	Contra Costa Regional Medical Center	DPH	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
PY3	Contra Costa Regional Medical Center	DPH	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
PY3	Contra Costa Regional Medical Center	DPH	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Reported	None	3	N/A	None	3	None	3	None	3	1
PY3	Contra Costa Regional Medical Center	DPH	Q-RU5	? RATE #2	Reported	0.0791	0	0.1675	115	0	1788	0	0.0643	0	1
PY3	Contra Costa Regional Medical Center	DPH	Q-RU6	Use of Opioids at high Dosage in Persons Without Cancer	Reported	0	0	0.0564	61	0	1483	0	0.0411	0	1
PY3	Kern Medical Center	DPH	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	0.5676	0	0.4444	1103	0	1955	0	0.5642	0	1
PY3	Kern Medical Center	DPH	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Kern Medical Center	DPH	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	0.7149	0	0.562	1326	0	1955	0	0.6783	0	1
PY3	Kern Medical Center	DPH	Q-PC4	Asthma Medication Ratio (AMR)	Reported	0.7419	0	0.5685	29	0	43	0	0.6744	0	1
PY3	Kern Medical Center	DPH	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	0.8358	0	0.3869	866	0	1001	0	0.8651	0	1
PY3	Kern Medical Center	DPH	Q-PC7	Children and Adolescent Access to PCP (CAP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Kern Medical Center	DPH	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	0.3617	0	0.2628	130	0	298	0	0.4362	0	1
PY3	Kern Medical Center	DPH	Q-PC10	Childhood Immunization Status (CIS) Combination 10	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Kern Medical Center	DPH	Q-PC11	Contraceptive Care - All Women (CCW) Most and Moderately Effective Methods, Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Kern Medical Center	DPH	Q-PC12	Chlamydia Screening in Women (CHL), Ages 16-24	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Kern Medical Center	DPH	Q-PC13	HIV Viral Load Suppression (HVL-AD)	Reported	0	0	0.6636	68	0	102	0	0.6667	0	1
PY3	Kern Medical Center	DPH	Q-PC14	Well-Child Visits in the First 15 Months of Life (W15-CH), Six or More well-child visits	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Kern Medical Center	DPH	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	0.9573	0	0.25	90	0	97	0	0.9278	0	1
PY3	Kern Medical Center	DPH	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.9562	0	0.5	290	0	298	0	0.9732	0	1
PY3	Kern Medical Center	DPH	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	0.9368	0	0.5	174	0	187	0	0.9305	0	1
PY3	Kern Medical Center	DPH	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	0.9624	0	0.5	118	0	129	0	0.9147	0	1
PY3	Kern Medical Center	DPH	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	0.978	0	0.5	81	0	82	0	0.9878	0	1
PY3	Kern Medical Center	DPH	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	0.967	0	0.5	82	0	85	0	0.9647	0	1
PY3	Kern Medical Center	DPH	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Kern Medical Center	DPH	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	1	0	0.25	868	0	868	0	1	0	1
PY3	Kern Medical Center	DPH	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	0.999	0	0.25	811	0	811	0	1	0	1
PY3	Kern Medical Center	DPH	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	0.9126	0	0.25	259	0	261	0	0.9923	0	1
PY3	Kern Medical Center	DPH	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Kern Medical Center	DPH	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Reported	1	0	0.25	35	0	35	0	1	0	1
PY3	Kern Medical Center	DPH	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Reported	0	0	0.75	None	1	138	0	None	1	1
PY3	Kern Medical Center	DPH	Q-RU2	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients 18 Years and Older	Reported	0.9116	0	0.5	74	0	76	0	0.9737	0	1
PY3	Kern Medical Center	DPH	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
PY3	Kern Medical Center	DPH	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Reported	None	3	N/A	None	3	None	3	None	3	1
PY3	Kern Medical Center	DPH	Q-RU5	? RATE #2	Reported	0.0327	0	0.1675	12	0	716	0	0.0168	0	1
PY3	Kern Medical Center	DPH	Q-RU6	Use of Opioids at high Dosage in Persons Without Cancer	Reported	0	0	0.0564	0	0	543	0	0	0	1
PY3	Los Angeles County Health System	DPH	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	0.5318	0	0.4444	7286	0	13571	0	0.5369	0	1
PY3	Los Angeles County Health System	DPH	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.7129	0	0.5085	9650	0	13571	0	0.7111	0	1
PY3	Los Angeles County Health System	DPH	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	0.7011	0	0.562	9646	0	13571	0	0.7108	0	1
PY3	Los Angeles County Health System	DPH	Q-PC4	Asthma Medication Ratio (AMR)	Reported	0.7072	0	0.5685	1045	0	1132	0	0.9231	0	1
PY3	Los Angeles County Health System	DPH	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	0.646	0	0.3869	5333	0	7679	0	0.6945	0	1
PY3	Los Angeles County Health System	DPH	Q-PC7	Children and Adolescent Access to PCP (CAP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Los Angeles County Health System	DPH	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	0.6331	0	0.2628	206	0	323	0	0.6378	0	1
PY3	Los Angeles County Health System	DPH	Q-PC10	Childhood Immunization Status (CIS) Combination 10	Reported	0.5356	0	0.28	147	0	323	0	0.4551	0	1
PY3	Los Angeles County Health System	DPH	Q-PC11	Contraceptive Care - All Women (CCW) Most and Moderately Effective Methods, Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Los Angeles County Health System	DPH	Q-PC12	Chlamydia Screening in Women (CHL), Ages 16-24	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Los Angeles County Health System	DPH	Q-PC13	HIV Viral Load Suppression (HVL-AD)	Reported	0.8074	0	0.6636	2261	0	2788	0	0.811	0	1
PY3	Los Angeles County Health System	DPH	Q-PC14	Well-Child Visits in the First 15 Months of Life (W15-CH), Six or More well-child visits	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Los Angeles County Health System	DPH	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	0.863	0	0.25	739	0	849	0	0.8704	0	1
PY3	Los Angeles County Health System	DPH	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.9213	0	0.5	2820	0	2926	0	0.9638	0	1
PY3	Los Angeles County Health System	DPH	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	0.8975	0	0.5	1485	0	1651	0	0.8995	0	1
PY3	Los Angeles County Health System	DPH	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	0.8716	0	0.5	940	0	1054	0	0.8918	0	1
PY3	Los Angeles County Health System	DPH	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	0.8557	0	0.5	580	0	691	0	0.8394	0	1
PY3	Los Angeles County Health System	DPH	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	0.8913	0	0.5	631	0	701	0	0.9001	0	1
PY3	Los Angeles County Health System	DPH	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Los Angeles County Health System	DPH	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	0.9655	0	0.25	370	0	377	0	0.9814	0	1
PY3	Los Angeles County Health System	DPH	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	0.9735	0	0.25	364	0	377	0	0.9655	0	1
PY3	Los Angeles County Health System	DPH	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Los Angeles County Health System	DPH	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Reported	0.954	0	0.25	72	0	73	0	0.9863	0	1
PY3	Los Angeles County Health System	DPH	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Reported	1	0	0.25	177	0	177	0	1	0	1
PY3	Los Angeles County Health System	DPH	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Reported	None	1	0.75	0	0	324	0	0	0	1
PY3	Los Angeles County Health System	DPH	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
PY3	Los Angeles County Health System	DPH	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
PY3	Los Angeles County Health System	DPH	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Reported	None	3	N/A	None	3	None	3	None	3	1
PY3	Los Angeles County Health System	DPH	Q-RU5	? RATE #2	Reported	0.0857	0	0.1675	226	0	2859	0	0.079	0	1
PY3	Los Angeles County Health System	DPH	Q-RU6	Use of Opioids at high Dosage in Persons Without Cancer	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Natividad Medical Center	DPH	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	0.5385	0	0.4444	951	0	1897	0	0.5013	0	1
PY3	Natividad Medical Center	DPH	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.5687	0	0.5085	1063	0	1897	0	0.5604	0	1
PY3	Natividad Medical Center	DPH	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	0.7425	0	0.562	1303	0	1897	0	0.6869	0	1
PY3	Natividad Medical Center	DPH	Q-PC4	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Natividad Medical Center	DPH	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	0.6087	0	0.3869	427	0	737	0	0.5794	0	1
PY3	Natividad Medical Center	DPH	Q-PC7	Children and Adolescent Access to PCP (CAP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Natividad Medical Center	DPH	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	0.7801	0	0.2628	778	0	963	0	0.8079	0	1
PY3	Natividad Medical Center	DPH	Q-PC10	Childhood Immunization Status (CIS) Combination 10	Reported	0	0	0.28	678	0	1091	0	0.6214	0	1
PY3	Natividad Medical Center	DPH	Q-PC11	Contraceptive Care - All Women (CCW) Most and Moderately Effective Methods, Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Natividad Medical Center	DPH	Q-PC12	Chlamydia Screening in Women (CHL), Ages 16-24	Reported	0	0	0.51	171	0	257	0	0.6654	0	1
PY3	Natividad Medical Center	DPH	Q-PC13	HIV Viral Load Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Natividad Medical Center	DPH	Q-PC14	Well-Child Visits in the First 15 Months of Life (W15-CH), Six or More well-child visits	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Natividad Medical Center	DPH	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	0.8832	0	0.25	109	0	126	0	0.8651	0	1
PY3	Natividad Medical Center	DPH	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.8159	0	0.5	242	0	292	0	0.8288	0	1
PY3	Natividad Medical Center	DPH	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	0.8352	0	0.5	138	0	165	0	0.8364	0	1
PY3	Natividad Medical Center	DPH	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	0.8857	0	0.5	59	0	71	0	0.831	0	1
PY3	Natividad Medical Center	DPH	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	0.9024	0	0.5	33	0	37	0	0.8919	0	1
PY3	Natividad Medical Center	DPH	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	1	0	0.5	36	0	37	0	0.973	0	1
PY3	Natividad Medical Center	DPH	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Reported	0.5413	0	1.254	None	1	5.577	0	None	1	1
PY3	Natividad Medical Center	DPH	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	0.6332	0	0.25	344	0	531	0	0.6478	0	1
PY3	Natividad Medical Center	DPH	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	0.9351	0	0.25	451	0	478	0	0.9435	0	1
PY3	Natividad Medical Center	DPH	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	0.8832	0	0.25	150	0	184	0	0.8152	0	1
PY3	Natividad Medical Center	DPH	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Natividad Medical Center	DPH	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Natividad Medical Center	DPH	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Reported	0	0	0.75	None	1	77	0	None	1	1
PY3	Natividad Medical Center	DPH	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
PY3	Natividad Medical Center	DPH	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
PY3	Natividad Medical Center	DPH	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Reported	None	3	N/A	None	3	None	3	None	3	1
PY3	Natividad Medical Center	DPH	Q-RU5	? RATE #2	Reported	0.0759	0	0.1675	24	0	352	0	0.0682	0	1
PY3	Natividad Medical Center	DPH	Q-RU6	Use of Opioids at high Dosage in Persons Without Cancer	Reported	0	0	0.0564	None	1	269	0	None	1	1
PY3	Riverside University Health System	DPH	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	0.5634	0	0.4444	1911	0	3542	0	0.5395	0	1
PY3	Riverside University Health System	DPH	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Riverside University Health System	DPH	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	0.7469	0	0.562	2593	0	3542	0	0.7321	0	1
PY3	Riverside University Health System	DPH	Q-PC4	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Riverside University Health System	DPH	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	0.9801	0	0.3869	1495	0	1527	0	0.979	0	1
PY3	Riverside University Health System	DPH	Q-PC7	Children and Adolescent Access to PCP (CAP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Riverside University Health System	DPH	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	0.3775	0	0.2628	121	0	265	0	0.4566	0	1
PY3	Riverside University Health System	DPH	Q-PC10	Childhood Immunization Status (CIS) Combination 10	Reported	0	0	0.28	73	0	240	0	0.3042	0	1
PY3	Riverside University Health System	DPH	Q-PC11	Contraceptive Care - All Women (CCW) Most and Moderately Effective Methods, Ages 15-44	Reported	0	0	0.1855	4014	0	13993	0	0.2869	0	1
PY3	Riverside University Health System	DPH	Q-PC12	Chlamydia Screening in Women (CHL), Ages 16-24	Reported	0	0	0.51	1562	0	2414	0	0.6471	0	1
PY3	Riverside University Health System	DPH	Q-PC13	HIV Viral Load Suppression (HVL-AD)	Reported	0	0	0.6636	504	0	640	0	0.7875	0	1
PY3	Riverside University Health System	DPH	Q-PC14	Well-Child Visits in the First 15 Months of Life (W15-CH), Six or More well-child visits	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Riverside University Health System	DPH	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	0.8618	0	0.25	127	0	142	0	0.8944	0	1
PY3	Riverside University Health System	DPH	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Riverside University Health System	DPH	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	0.8804	0	0.5	291	0	328	0	0.8872	0	1
PY3	Riverside University Health System	DPH	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
PY3	Riverside University Health System	DPH	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	0.8889	0	0.5	155	0	179	0	0.8659	0	1
PY3	Riverside University Health System	DPH	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
PY3	Riverside University Health System	DPH	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Reported	None	1	1.254	None	1	10.712	0	None	1	1
PY3	Riverside University Health System	DPH	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	0.8171	0	0.25	177	0	209	0	0.8469	0	1
PY3	Riverside University Health System	DPH	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	0.9019	0	0.25	415	0	419	0	0.9905	0	1
PY3	Riverside University Health System	DPH	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Riverside University Health System	DPH	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Riverside University Health System	DPH	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Reported	0.8939	0	0.25	55	0	55	0	1	0	1
PY3	Riverside University Health System	DPH	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Reported	0	0	0.75	None	1	149	0	None	1	1
PY3	Riverside University Health System	DPH	Q-RU2	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients 18 Years and Older	Reported	0.8247	0	0.5	182	0	194	0	0.9381	0	1
PY3	Riverside University Health System	DPH	Q-RU3	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 to 17 years old	Reported	None	1	0.5	None	1	63	0	None	1	1
PY3	Riverside University Health System	DPH	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Reported	None	3	N/A	None	3	None	3	None	3	1
PY3	Riverside University Health System	DPH	Q-RU5	? RATE #2	Reported	0	0	0.1675	68	0	2433	0	0.0279	0	1
PY3	Riverside University Health System	DPH	Q-RU6	Use of Opioids at high Dosage in Persons Without Cancer	Reported	0	0	0.0564	32	0	1422	0	0.0225	0	1
PY3	San Francisco General Hospital	DPH	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	0.618	0	0.4444	1294	0	2358	0	0.5488	0	1
PY3	San Francisco General Hospital	DPH	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.6803	0	0.5085	1425	0	2358	0	0.6043	0	1
PY3	San Francisco General Hospital	DPH	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	0.7676	0	0.562	1703	0	2358	0	0.7222	0	1
PY3	San Francisco General Hospital	DPH	Q-PC4	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	San Francisco General Hospital	DPH	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	0.5842	0	0.3869	1569	0	2145	0	0.7315	0	1
PY3	San Francisco General Hospital	DPH	Q-PC7	Children and Adolescent Access to PCP (CAP)	Reported	None	3	N/A	None	3	None	3	None	3	1
PY3	San Francisco General Hospital	DPH	Q-PC7	? 12-24 Months	Reported	0	0	0.9364	338	0	353	0	0.9575	0	1
PY3	San Francisco General Hospital	DPH	Q-PC7	? 25 Months-6 Years	Reported	0	0	0.8439	1867	0	2161	0	0.864	0	1
PY3	San Francisco General Hospital	DPH	Q-PC7	? 7-11 Years	Reported	0	0	0.8773	1537	0	1733	0	0.8869	0	1
PY3	San Francisco General Hospital	DPH	Q-PC7	? 12-19 Years	Reported	0	0	0.8581	1923	0	2187	0	0.8793	0	1
PY3	San Francisco General Hospital	DPH	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	0.7519	0	0.2628	209	0	272	0	0.7684	0	1
PY3	San Francisco General Hospital	DPH	Q-PC10	Childhood Immunization Status (CIS) Combination 10	Reported	0	0	0.28	290	0	475	0	0.6105	0	1
PY3	San Francisco General Hospital	DPH	Q-PC11	Contraceptive Care - All Women (CCW) Most and Moderately Effective Methods, Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	San Francisco General Hospital	DPH	Q-PC12	Chlamydia Screening in Women (CHL), Ages 16-24	Reported	0	0	0.51	546	0	702	0	0.7778	0	1
PY3	San Francisco General Hospital	DPH	Q-PC13	HIV Viral Load Suppression (HVL-AD)	Reported	0	0	0.6636	1316	0	1636	0	0.8044	0	1
PY3	San Francisco General Hospital	DPH	Q-PC14	Well-Child Visits in the First 15 Months of Life (W15-CH), Six or More well-child visits	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	San Francisco General Hospital	DPH	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	0.8	0	0.25	231	0	289	0	0.7993	0	1
PY3	San Francisco General Hospital	DPH	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.9407	0	0.5	703	0	760	0	0.925	0	1
PY3	San Francisco General Hospital	DPH	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	0.8818	0	0.5	315	0	365	0	0.863	0	1
PY3	San Francisco General Hospital	DPH	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	0.9638	0	0.5	158	0	162	0	0.9753	0	1
PY3	San Francisco General Hospital	DPH	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	0.8467	0	0.5	385	0	457	0	0.8425	0	1
PY3	San Francisco General Hospital	DPH	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	0.9254	0	0.5	396	0	428	0	0.9252	0	1
PY3	San Francisco General Hospital	DPH	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	San Francisco General Hospital	DPH	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	0.9585	0	0.25	325	0	355	0	0.9155	0	1
PY3	San Francisco General Hospital	DPH	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	0.9672	0	0.25	712	0	753	0	0.9456	0	1
PY3	San Francisco General Hospital	DPH	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	0.57	0	0.25	300	0	409	0	0.7335	0	1
PY3	San Francisco General Hospital	DPH	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Reported	1	0	0.25	44	0	44	0	1	0	1
PY3	San Francisco General Hospital	DPH	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	San Francisco General Hospital	DPH	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Reported	None	1	0.75	None	1	173	0	None	1	1
PY3	San Francisco General Hospital	DPH	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
PY3	San Francisco General Hospital	DPH	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
PY3	San Francisco General Hospital	DPH	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	San Francisco General Hospital	DPH	Q-RU6	Use of Opioids at high Dosage in Persons Without Cancer	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	San Joaquin General Hospital	DPH	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	0.5277	0	0.4444	960	0	1916	0	0.501	0	1
PY3	San Joaquin General Hospital	DPH	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.5012	0	0.5085	216	0	411	0	0.5255	0	1
PY3	San Joaquin General Hospital	DPH	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	0.6807	0	0.562	1280	0	1916	0	0.6681	0	1
PY3	San Joaquin General Hospital	DPH	Q-PC4	Asthma Medication Ratio (AMR)	Reported	0.7273	0	0.5685	37	0	59	0	0.6271	0	1
PY3	San Joaquin General Hospital	DPH	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	0.9496	0	0.3869	121	0	249	0	0.4859	0	1
PY3	San Joaquin General Hospital	DPH	Q-PC7	Children and Adolescent Access to PCP (CAP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	San Joaquin General Hospital	DPH	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	0.5779	0	0.2628	83	0	169	0	0.4911	0	1
PY3	San Joaquin General Hospital	DPH	Q-PC10	Childhood Immunization Status (CIS) Combination 10	Reported	0	0	0.28	180	0	409	0	0.4401	0	1
PY3	San Joaquin General Hospital	DPH	Q-PC11	Contraceptive Care - All Women (CCW) Most and Moderately Effective Methods, Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	San Joaquin General Hospital	DPH	Q-PC12	Chlamydia Screening in Women (CHL), Ages 16-24	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	San Joaquin General Hospital	DPH	Q-PC13	HIV Viral Load Suppression (HVL-AD)	Reported	0	0	0.6636	31	0	43	0	0.7209	0	1
PY3	San Joaquin General Hospital	DPH	Q-PC14	Well-Child Visits in the First 15 Months of Life (W15-CH), Six or More well-child visits	Reported	0	0	0.59	260	0	489	0	0.5317	0	0
PY3	San Joaquin General Hospital	DPH	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	0.7823	0	0.25	110	0	157	0	0.7006	0	1
PY3	San Joaquin General Hospital	DPH	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.8753	0	0.5	273	0	353	0	0.7734	0	1
PY3	San Joaquin General Hospital	DPH	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	0.8762	0	0.5	170	0	212	0	0.8019	0	1
PY3	San Joaquin General Hospital	DPH	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	0.8931	0	0.5	125	0	138	0	0.9058	0	1
PY3	San Joaquin General Hospital	DPH	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	0.9487	0	0.5	116	0	135	0	0.8593	0	1
PY3	San Joaquin General Hospital	DPH	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	0.9417	0	0.5	127	0	134	0	0.9478	0	1
PY3	San Joaquin General Hospital	DPH	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Reported	None	1	1.254	11	0	10.958	0	1.0038	0	1
PY3	San Joaquin General Hospital	DPH	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	0.7492	0	0.25	291	0	303	0	0.9604	0	1
PY3	San Joaquin General Hospital	DPH	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	0.8237	0	0.25	334	0	398	0	0.8392	0	1
PY3	San Joaquin General Hospital	DPH	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	0.9091	0	0.25	82	0	88	0	0.9318	0	1
PY3	San Joaquin General Hospital	DPH	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	San Joaquin General Hospital	DPH	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Reported	0.9722	0	0.25	96	0	97	0	0.9897	0	1
PY3	San Joaquin General Hospital	DPH	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
PY3	San Joaquin General Hospital	DPH	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
PY3	San Joaquin General Hospital	DPH	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
PY3	San Joaquin General Hospital	DPH	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	San Joaquin General Hospital	DPH	Q-RU6	Use of Opioids at high Dosage in Persons Without Cancer	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Santa Clara Valley Medical Center	DPH	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	0.5913	0	0.4444	2668	0	4783	0	0.5578	0	1
PY3	Santa Clara Valley Medical Center	DPH	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.6843	0	0.5085	2944	0	4783	0	0.6155	0	1
PY3	Santa Clara Valley Medical Center	DPH	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	0.6994	0	0.562	3151	0	4783	0	0.6588	0	1
PY3	Santa Clara Valley Medical Center	DPH	Q-PC4	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Santa Clara Valley Medical Center	DPH	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	0.5254	0	0.3869	2002	0	3961	0	0.5054	0	1
PY3	Santa Clara Valley Medical Center	DPH	Q-PC7	Children and Adolescent Access to PCP (CAP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Santa Clara Valley Medical Center	DPH	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	0.4867	0	0.2628	600	0	1210	0	0.4959	0	1
PY3	Santa Clara Valley Medical Center	DPH	Q-PC10	Childhood Immunization Status (CIS) Combination 10	Reported	0	0	0.28	1110	0	1706	0	0.6506	0	1
PY3	Santa Clara Valley Medical Center	DPH	Q-PC11	Contraceptive Care - All Women (CCW) Most and Moderately Effective Methods, Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Santa Clara Valley Medical Center	DPH	Q-PC12	Chlamydia Screening in Women (CHL), Ages 16-24	Reported	0	0	0.51	893	0	1451	0	0.6154	0	1
PY3	Santa Clara Valley Medical Center	DPH	Q-PC13	HIV Viral Load Suppression (HVL-AD)	Reported	0	0	0.6636	474	0	556	0	0.8525	0	1
PY3	Santa Clara Valley Medical Center	DPH	Q-PC14	Well-Child Visits in the First 15 Months of Life (W15-CH), Six or More well-child visits	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Santa Clara Valley Medical Center	DPH	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	0.7022	0	0.25	298	0	423	0	0.7045	0	1
PY3	Santa Clara Valley Medical Center	DPH	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.8636	0	0.5	965	0	1047	0	0.9217	0	1
PY3	Santa Clara Valley Medical Center	DPH	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	0.7682	0	0.5	436	0	561	0	0.7772	0	1
PY3	Santa Clara Valley Medical Center	DPH	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	0.726	0	0.5	336	0	369	0	0.9106	0	1
PY3	Santa Clara Valley Medical Center	DPH	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	0	0	N/A	408	0	459	0	0.8889	0	1
PY3	Santa Clara Valley Medical Center	DPH	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	0.7598	0	0.5	426	0	459	0	0.9281	0	1
PY3	Santa Clara Valley Medical Center	DPH	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Santa Clara Valley Medical Center	DPH	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	0.7468	0	0.25	1330	0	1489	0	0.8932	0	1
PY3	Santa Clara Valley Medical Center	DPH	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	0.9517	0	0.25	1195	0	1257	0	0.9507	0	1
PY3	Santa Clara Valley Medical Center	DPH	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	0.3202	0	0.25	482	0	720	0	0.6694	0	1
PY3	Santa Clara Valley Medical Center	DPH	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Reported	0.7073	0	0.25	33	0	49	0	0.6735	0	1
PY3	Santa Clara Valley Medical Center	DPH	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Reported	0.9556	0	0.25	90	0	115	0	0.7826	0	1
PY3	Santa Clara Valley Medical Center	DPH	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
PY3	Santa Clara Valley Medical Center	DPH	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
PY3	Santa Clara Valley Medical Center	DPH	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
PY3	Santa Clara Valley Medical Center	DPH	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Reported	None	3	N/A	None	3	None	3	None	3	1
PY3	Santa Clara Valley Medical Center	DPH	Q-RU5	? RATE #2	Reported	0.0762	0	0.1675	136	0	1215	0	0.1119	0	1
PY3	Santa Clara Valley Medical Center	DPH	Q-RU6	Use of Opioids at high Dosage in Persons Without Cancer	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	San Mateo Medical Center	DPH	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	0.6213	0	0.4444	729	0	1257	0	0.58	0	1
PY3	San Mateo Medical Center	DPH	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.9878	0	0.5085	1239	0	1257	0	0.9857	0	1
PY3	San Mateo Medical Center	DPH	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	0.7597	0	0.562	943	0	1257	0	0.7502	0	1
PY3	San Mateo Medical Center	DPH	Q-PC4	Asthma Medication Ratio (AMR)	Reported	0.6218	0	0.5685	97	0	102	0	0.951	0	1
PY3	San Mateo Medical Center	DPH	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	0.5681	0	0.3869	196	0	387	0	0.5065	0	1
PY3	San Mateo Medical Center	DPH	Q-PC7	Children and Adolescent Access to PCP (CAP)	Reported	None	3	N/A	None	3	None	3	None	3	1
PY3	San Mateo Medical Center	DPH	Q-PC7	? 12-24 Months	Reported	1	0	0.9364	255	0	256	0	0.9961	0	1
PY3	San Mateo Medical Center	DPH	Q-PC7	? 25 Months-6 Years	Reported	0.9502	0	0.8439	2104	0	2150	0	0.9786	0	1
PY3	San Mateo Medical Center	DPH	Q-PC7	? 7-11 Years	Reported	0.9652	0	0.8773	1866	0	1879	0	0.9931	0	1
PY3	San Mateo Medical Center	DPH	Q-PC7	? 12-19 Years	Reported	0.9582	0	0.8581	2668	0	2685	0	0.9937	0	1
PY3	San Mateo Medical Center	DPH	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	0.6877	0	0.2628	196	0	286	0	0.6853	0	1
PY3	San Mateo Medical Center	DPH	Q-PC10	Childhood Immunization Status (CIS) Combination 10	Reported	0.7335	0	0.28	200	0	298	0	0.6711	0	1
PY3	San Mateo Medical Center	DPH	Q-PC11	Contraceptive Care - All Women (CCW) Most and Moderately Effective Methods, Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	San Mateo Medical Center	DPH	Q-PC12	Chlamydia Screening in Women (CHL), Ages 16-24	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	San Mateo Medical Center	DPH	Q-PC13	HIV Viral Load Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	San Mateo Medical Center	DPH	Q-PC14	Well-Child Visits in the First 15 Months of Life (W15-CH), Six or More well-child visits	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	San Mateo Medical Center	DPH	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	0.8078	0	0.25	113	0	140	0	0.8071	0	1
PY3	San Mateo Medical Center	DPH	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.9163	0	0.5	339	0	369	0	0.9187	0	1
PY3	San Mateo Medical Center	DPH	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	0.9006	0	0.5	160	0	192	0	0.8333	0	1
PY3	San Mateo Medical Center	DPH	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	0.9096	0	0.5	100	0	109	0	0.9174	0	1
PY3	San Mateo Medical Center	DPH	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	0.9077	0	0.5	38	0	41	0	0.9268	0	1
PY3	San Mateo Medical Center	DPH	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	0.9625	0	0.5	48	0	49	0	0.9796	0	1
PY3	San Mateo Medical Center	DPH	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	San Mateo Medical Center	DPH	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	0.969	0	0.25	314	0	459	0	0.6841	0	1
PY3	San Mateo Medical Center	DPH	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	0.9924	0	0.25	449	0	456	0	0.9846	0	1
PY3	San Mateo Medical Center	DPH	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	0.7239	0	0.25	68	0	86	0	0.7907	0	1
PY3	San Mateo Medical Center	DPH	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	San Mateo Medical Center	DPH	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	San Mateo Medical Center	DPH	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Reported	None	1	0.75	None	1	110	0	None	1	1
PY3	San Mateo Medical Center	DPH	Q-RU2	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients 18 Years and Older	Reported	0.8191	0	0.5	124	0	147	0	0.8435	0	1
PY3	San Mateo Medical Center	DPH	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
PY3	San Mateo Medical Center	DPH	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Reported	None	3	N/A	None	3	None	3	None	3	1
PY3	San Mateo Medical Center	DPH	Q-RU5	? RATE #2	Reported	0.0743	0	0.1675	67	0	1073	0	0.0624	0	1
PY3	San Mateo Medical Center	DPH	Q-RU6	Use of Opioids at high Dosage in Persons Without Cancer	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC Davis Medical Center	DPH	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	0	0	0.4444	60	0	106	0	0.566	0	1
PY3	UC Davis Medical Center	DPH	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0	0	0.5085	81	0	106	0	0.7642	0	1
PY3	UC Davis Medical Center	DPH	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	0	0	0.562	89	0	106	0	0.8396	0	1
PY3	UC Davis Medical Center	DPH	Q-PC4	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC Davis Medical Center	DPH	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	1	0	0.3869	167	0	234	0	0.7137	0	1
PY3	UC Davis Medical Center	DPH	Q-PC7	Children and Adolescent Access to PCP (CAP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC Davis Medical Center	DPH	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC Davis Medical Center	DPH	Q-PC10	Childhood Immunization Status (CIS) Combination 10	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC Davis Medical Center	DPH	Q-PC11	Contraceptive Care - All Women (CCW) Most and Moderately Effective Methods, Ages 15-44	Reported	0	0	0.1855	100	0	242	0	0.4132	0	1
PY3	UC Davis Medical Center	DPH	Q-PC12	Chlamydia Screening in Women (CHL), Ages 16-24	Reported	0	0	0.51	21	0	38	0	0.5526	0	1
PY3	UC Davis Medical Center	DPH	Q-PC13	HIV Viral Load Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC Davis Medical Center	DPH	Q-PC14	Well-Child Visits in the First 15 Months of Life (W15-CH), Six or More well-child visits	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC Davis Medical Center	DPH	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC Davis Medical Center	DPH	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.75	0	0.5	46	0	59	0	0.7797	0	1
PY3	UC Davis Medical Center	DPH	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	0.5	36	0	37	0	0.973	0	1
PY3	UC Davis Medical Center	DPH	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
PY3	UC Davis Medical Center	DPH	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	None	4	0.5	58	0	68	0	0.8529	0	1
PY3	UC Davis Medical Center	DPH	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	None	4	0.5	83	0	84	0	0.9881	0	1
PY3	UC Davis Medical Center	DPH	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Reported	1.0107	0	1.254	36	0	38.106	0	0.9447	0	1
PY3	UC Davis Medical Center	DPH	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	0.8268	0	0.25	1406	0	1768	0	0.7952	0	1
PY3	UC Davis Medical Center	DPH	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	0.9555	0	0.25	2005	0	2196	0	0.913	0	1
PY3	UC Davis Medical Center	DPH	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	0.8738	0	0.25	304	0	323	0	0.9412	0	1
PY3	UC Davis Medical Center	DPH	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Reported	0.9032	0	0.25	35	0	38	0	0.9211	0	1
PY3	UC Davis Medical Center	DPH	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Reported	0.9538	0	0.25	76	0	81	0	0.9383	0	1
PY3	UC Davis Medical Center	DPH	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Reported	None	4	0.75	0	0	73	0	0	0	1
PY3	UC Davis Medical Center	DPH	Q-RU2	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients 18 Years and Older	Reported	0.8014	0	0.5	271	0	278	0	0.9748	0	1
PY3	UC Davis Medical Center	DPH	Q-RU3	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 to 17 years old	Reported	None	1	0.5	None	1	132	0	None	1	1
PY3	UC Davis Medical Center	DPH	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Reported	None	3	N/A	None	3	None	3	None	3	1
PY3	UC Davis Medical Center	DPH	Q-RU5	? RATE #2	Reported	0	0	0.1675	None	1	84	0	None	1	1
PY3	UC Davis Medical Center	DPH	Q-RU6	Use of Opioids at high Dosage in Persons Without Cancer	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC Irvine Medical Center	DPH	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	0.45	0	0.4444	544	0	1065	0	0.5108	0	1
PY3	UC Irvine Medical Center	DPH	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC Irvine Medical Center	DPH	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	0.6704	0	0.562	764	0	1065	0	0.7174	0	1
PY3	UC Irvine Medical Center	DPH	Q-PC4	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC Irvine Medical Center	DPH	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	0.9905	0	0.3869	504	0	507	0	0.9941	0	1
PY3	UC Irvine Medical Center	DPH	Q-PC7	Children and Adolescent Access to PCP (CAP)	Reported	None	3	N/A	None	3	None	3	None	3	1
PY3	UC Irvine Medical Center	DPH	Q-PC7	? 12-24 Months	Reported	0.9929	0	0.9364	282	0	290	0	0.9724	0	1
PY3	UC Irvine Medical Center	DPH	Q-PC7	? 25 Months-6 Years	Reported	0.8747	0	0.8439	1189	0	1344	0	0.8847	0	1
PY3	UC Irvine Medical Center	DPH	Q-PC7	? 7-11 Years	Reported	0.8714	0	0.8773	736	0	821	0	0.8965	0	1
PY3	UC Irvine Medical Center	DPH	Q-PC7	? 12-19 Years	Reported	0.8512	0	0.8581	1285	0	1451	0	0.8856	0	1
PY3	UC Irvine Medical Center	DPH	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	0.4463	0	0.2628	70	0	145	0	0.4828	0	1
PY3	UC Irvine Medical Center	DPH	Q-PC10	Childhood Immunization Status (CIS) Combination 10	Reported	0.4778	0	0.28	175	0	306	0	0.5719	0	1
PY3	UC Irvine Medical Center	DPH	Q-PC11	Contraceptive Care - All Women (CCW) Most and Moderately Effective Methods, Ages 15-44	Reported	0.2129	0	0.1855	685	0	3054	0	0.2243	0	1
PY3	UC Irvine Medical Center	DPH	Q-PC12	Chlamydia Screening in Women (CHL), Ages 16-24	Reported	0.5981	0	0.51	522	0	844	0	0.6185	0	1
PY3	UC Irvine Medical Center	DPH	Q-PC13	HIV Viral Load Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC Irvine Medical Center	DPH	Q-PC14	Well-Child Visits in the First 15 Months of Life (W15-CH), Six or More well-child visits	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC Irvine Medical Center	DPH	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	0.8113	0	0.25	102	0	117	0	0.8718	0	1
PY3	UC Irvine Medical Center	DPH	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.8672	0	0.5	221	0	272	0	0.8125	0	1
PY3	UC Irvine Medical Center	DPH	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	0.8644	0	0.5	176	0	194	0	0.9072	0	1
PY3	UC Irvine Medical Center	DPH	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	0.912	0	0.5	124	0	134	0	0.9254	0	1
PY3	UC Irvine Medical Center	DPH	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	0.8874	0	0.5	151	0	165	0	0.9152	0	1
PY3	UC Irvine Medical Center	DPH	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	0.9726	0	0.5	161	0	162	0	0.9938	0	1
PY3	UC Irvine Medical Center	DPH	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Reported	0.8606	0	1.254	30	0	34.858	0	0.8606	0	1
PY3	UC Irvine Medical Center	DPH	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	0.8004	0	0.25	371	0	531	0	0.6987	0	1
PY3	UC Irvine Medical Center	DPH	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC Irvine Medical Center	DPH	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC Irvine Medical Center	DPH	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Reported	0.8333	0	0.25	36	0	48	0	0.75	0	1
PY3	UC Irvine Medical Center	DPH	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC Irvine Medical Center	DPH	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Reported	None	1	0.75	17	0	153	0	0.1111	0	1
PY3	UC Irvine Medical Center	DPH	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
PY3	UC Irvine Medical Center	DPH	Q-RU3	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 to 17 years old	Reported	None	1	0.5	None	1	90	0	None	1	1
PY3	UC Irvine Medical Center	DPH	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC Irvine Medical Center	DPH	Q-RU6	Use of Opioids at high Dosage in Persons Without Cancer	Reported	0.0444	0	0.0564	None	1	249	0	None	1	1
PY3	UC Los Angeles Medical Center	DPH	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	0.5571	0	0.4444	26	0	51	0	0.5098	0	1
PY3	UC Los Angeles Medical Center	DPH	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.3857	0	0.5085	26	0	51	0	0.5098	0	1
PY3	UC Los Angeles Medical Center	DPH	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	0.7714	0	0.562	40	0	51	0	0.7843	0	1
PY3	UC Los Angeles Medical Center	DPH	Q-PC4	Asthma Medication Ratio (AMR)	Reported	None	1	0.5685	65	0	65	0	1	0	1
PY3	UC Los Angeles Medical Center	DPH	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	1	0	0.3869	47	0	47	0	1	0	1
PY3	UC Los Angeles Medical Center	DPH	Q-PC7	Children and Adolescent Access to PCP (CAP)	Reported	None	3	N/A	None	3	None	3	None	3	1
PY3	UC Los Angeles Medical Center	DPH	Q-PC7	? 12-24 Months	Reported	0.8806	0	0.9364	144	0	146	0	0.9863	0	1
PY3	UC Los Angeles Medical Center	DPH	Q-PC7	? 25 Months-6 Years	Reported	0.7233	0	0.8439	884	0	1010	0	0.8752	0	1
PY3	UC Los Angeles Medical Center	DPH	Q-PC7	? 7-11 Years	Reported	0.8409	0	0.8773	745	0	830	0	0.8976	0	1
PY3	UC Los Angeles Medical Center	DPH	Q-PC7	? 12-19 Years	Reported	0.857	0	0.8581	1078	0	1181	0	0.9128	0	1
PY3	UC Los Angeles Medical Center	DPH	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	0.4742	0	0.2628	66	0	149	0	0.443	0	1
PY3	UC Los Angeles Medical Center	DPH	Q-PC10	Childhood Immunization Status (CIS) Combination 10	Reported	0	0	0.28	71	0	173	0	0.4104	0	1
PY3	UC Los Angeles Medical Center	DPH	Q-PC11	Contraceptive Care - All Women (CCW) Most and Moderately Effective Methods, Ages 15-44	Reported	0	0	0.1855	168	0	510	0	0.3294	0	1
PY3	UC Los Angeles Medical Center	DPH	Q-PC12	Chlamydia Screening in Women (CHL), Ages 16-24	Reported	0	0	0.51	79	0	137	0	0.5766	0	1
PY3	UC Los Angeles Medical Center	DPH	Q-PC13	HIV Viral Load Suppression (HVL-AD)	Reported	0	0	0.6636	40	0	59	0	0.678	0	1
PY3	UC Los Angeles Medical Center	DPH	Q-PC14	Well-Child Visits in the First 15 Months of Life (W15-CH), Six or More well-child visits	Reported	0	0	0.59	39	0	65	0	0.6	0	1
PY3	UC Los Angeles Medical Center	DPH	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC Los Angeles Medical Center	DPH	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC Los Angeles Medical Center	DPH	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
PY3	UC Los Angeles Medical Center	DPH	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
PY3	UC Los Angeles Medical Center	DPH	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
PY3	UC Los Angeles Medical Center	DPH	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
PY3	UC Los Angeles Medical Center	DPH	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Reported	0.7787	0	1.254	20	0	30.955	0	0.6461	0	1
PY3	UC Los Angeles Medical Center	DPH	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	0.8556	0	0.25	639	0	743	0	0.86	0	1
PY3	UC Los Angeles Medical Center	DPH	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	0.9663	0	0.25	819	0	888	0	0.9223	0	1
PY3	UC Los Angeles Medical Center	DPH	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	0.8039	0	0.25	1000	0	1365	0	0.7326	0	1
PY3	UC Los Angeles Medical Center	DPH	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC Los Angeles Medical Center	DPH	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Reported	1	0	0.25	43	0	43	0	1	0	1
PY3	UC Los Angeles Medical Center	DPH	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
PY3	UC Los Angeles Medical Center	DPH	Q-RU2	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients 18 Years and Older	Reported	0.9825	0	0.5	509	0	531	0	0.9586	0	1
PY3	UC Los Angeles Medical Center	DPH	Q-RU3	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 to 17 years old	Reported	0	0	0.5	0	0	78	0	0	0	1
PY3	UC Los Angeles Medical Center	DPH	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Reported	None	3	N/A	None	3	None	3	None	3	1
PY3	UC Los Angeles Medical Center	DPH	Q-RU5	? RATE #2	Reported	None	1	0.1675	None	1	37	0	None	1	1
PY3	UC Los Angeles Medical Center	DPH	Q-RU6	Use of Opioids at high Dosage in Persons Without Cancer	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC San Diego Medical Center	DPH	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	0.6508	0	0.4444	228	0	359	0	0.6351	0	1
PY3	UC San Diego Medical Center	DPH	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.6533	0	0.5085	186	0	359	0	0.5181	0	1
PY3	UC San Diego Medical Center	DPH	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	0.7462	0	0.562	250	0	359	0	0.6964	0	1
PY3	UC San Diego Medical Center	DPH	Q-PC4	Asthma Medication Ratio (AMR)	Reported	0.6102	0	0.5685	52	0	83	0	0.6265	0	1
PY3	UC San Diego Medical Center	DPH	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	0.8745	0	0.3869	202	0	248	0	0.8145	0	1
PY3	UC San Diego Medical Center	DPH	Q-PC7	Children and Adolescent Access to PCP (CAP)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC San Diego Medical Center	DPH	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC San Diego Medical Center	DPH	Q-PC10	Childhood Immunization Status (CIS) Combination 10	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC San Diego Medical Center	DPH	Q-PC11	Contraceptive Care - All Women (CCW) Most and Moderately Effective Methods, Ages 15-44	Reported	0	0	0.1855	223	0	701	0	0.3181	0	1
PY3	UC San Diego Medical Center	DPH	Q-PC12	Chlamydia Screening in Women (CHL), Ages 16-24	Reported	0	0	0.51	37	0	60	0	0.6167	0	1
PY3	UC San Diego Medical Center	DPH	Q-PC13	HIV Viral Load Suppression (HVL-AD)	Reported	0	0	0.6636	644	0	803	0	0.802	0	1
PY3	UC San Diego Medical Center	DPH	Q-PC14	Well-Child Visits in the First 15 Months of Life (W15-CH), Six or More well-child visits	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC San Diego Medical Center	DPH	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	0.9307	0	0.25	75	0	84	0	0.8929	0	1
PY3	UC San Diego Medical Center	DPH	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.9251	0	0.5	178	0	198	0	0.899	0	1
PY3	UC San Diego Medical Center	DPH	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	0.871	0	0.5	91	0	98	0	0.9286	0	1
PY3	UC San Diego Medical Center	DPH	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	0.8989	0	0.5	55	0	61	0	0.9016	0	1
PY3	UC San Diego Medical Center	DPH	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	0.9206	0	0.5	58	0	61	0	0.9508	0	1
PY3	UC San Diego Medical Center	DPH	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	0.9344	0	0.5	60	0	61	0	0.9836	0	1
PY3	UC San Diego Medical Center	DPH	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Reported	0.621	0	1.254	28	0	44.11	0	0.6348	0	1
PY3	UC San Diego Medical Center	DPH	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	0.752	0	0.25	1026	0	1233	0	0.8321	0	1
PY3	UC San Diego Medical Center	DPH	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	0.7488	0	0.25	1103	0	1306	0	0.8446	0	1
PY3	UC San Diego Medical Center	DPH	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	0.5467	0	0.25	1093	0	1384	0	0.7897	0	1
PY3	UC San Diego Medical Center	DPH	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC San Diego Medical Center	DPH	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Reported	1	0	0.25	48	0	49	0	0.9796	0	1
PY3	UC San Diego Medical Center	DPH	Q-RU1	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients (QPP)	Reported	None	1	0.75	None	1	178	0	None	1	1
PY3	UC San Diego Medical Center	DPH	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
PY3	UC San Diego Medical Center	DPH	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
PY3	UC San Diego Medical Center	DPH	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC San Diego Medical Center	DPH	Q-RU6	Use of Opioids at high Dosage in Persons Without Cancer	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC San Francisco Medical Center	DPH	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	0.5826	0	0.4444	308	0	502	0	0.6135	0	1
PY3	UC San Francisco Medical Center	DPH	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.6607	0	0.5085	313	0	502	0	0.6235	0	1
PY3	UC San Francisco Medical Center	DPH	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	0.7297	0	0.562	357	0	502	0	0.7112	0	1
PY3	UC San Francisco Medical Center	DPH	Q-PC4	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC San Francisco Medical Center	DPH	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	0.9908	0	0.3869	446	0	454	0	0.9824	0	1
PY3	UC San Francisco Medical Center	DPH	Q-PC7	Children and Adolescent Access to PCP (CAP)	Reported	None	3	N/A	None	3	None	3	None	3	1
PY3	UC San Francisco Medical Center	DPH	Q-PC7	? 12-24 Months	Reported	0	0	0.9364	207	0	215	0	0.9628	0	1
PY3	UC San Francisco Medical Center	DPH	Q-PC7	? 25 Months-6 Years	Reported	0	0	0.8439	1105	0	1257	0	0.8791	0	1
PY3	UC San Francisco Medical Center	DPH	Q-PC7	? 7-11 Years	Reported	0	0	0.8773	902	0	988	0	0.913	0	1
PY3	UC San Francisco Medical Center	DPH	Q-PC7	? 12-19 Years	Reported	0	0	0.8581	1270	0	1405	0	0.9039	0	1
PY3	UC San Francisco Medical Center	DPH	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	0	0	0.2628	73	0	170	0	0.4294	0	1
PY3	UC San Francisco Medical Center	DPH	Q-PC10	Childhood Immunization Status (CIS) Combination 10	Reported	0	0	0.28	170	0	272	0	0.625	0	1
PY3	UC San Francisco Medical Center	DPH	Q-PC11	Contraceptive Care - All Women (CCW) Most and Moderately Effective Methods, Ages 15-44	Reported	0	0	0.1855	820	0	2401	0	0.3415	0	1
PY3	UC San Francisco Medical Center	DPH	Q-PC12	Chlamydia Screening in Women (CHL), Ages 16-24	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC San Francisco Medical Center	DPH	Q-PC13	HIV Viral Load Suppression (HVL-AD)	Reported	0	0	0.6636	165	0	180	0	0.9167	0	1
PY3	UC San Francisco Medical Center	DPH	Q-PC14	Well-Child Visits in the First 15 Months of Life (W15-CH), Six or More well-child visits	Reported	0	0	0.59	101	0	135	0	0.7481	0	1
PY3	UC San Francisco Medical Center	DPH	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	0.9701	0	0.25	42	0	42	0	1	0	1
PY3	UC San Francisco Medical Center	DPH	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.9873	0	0.5	120	0	122	0	0.9836	0	1
PY3	UC San Francisco Medical Center	DPH	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	0.9604	0	0.5	57	0	59	0	0.9661	0	1
PY3	UC San Francisco Medical Center	DPH	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	1	0	0.5	53	0	53	0	1	0	1
PY3	UC San Francisco Medical Center	DPH	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	0.9412	0	0.5	64	0	68	0	0.9412	0	1
PY3	UC San Francisco Medical Center	DPH	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	1	0	0.5	63	0	64	0	0.9844	0	1
PY3	UC San Francisco Medical Center	DPH	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC San Francisco Medical Center	DPH	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	0.9178	0	0.25	2579	0	3112	0	0.8287	0	1
PY3	UC San Francisco Medical Center	DPH	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	0.9844	0	0.25	3639	0	3697	0	0.9843	0	1
PY3	UC San Francisco Medical Center	DPH	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	0.4336	0	0.25	1192	0	1658	0	0.7189	0	1
PY3	UC San Francisco Medical Center	DPH	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC San Francisco Medical Center	DPH	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Reported	0.9688	0	0.25	29	0	30	0	0.9667	0	1
PY3	UC San Francisco Medical Center	DPH	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
PY3	UC San Francisco Medical Center	DPH	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
PY3	UC San Francisco Medical Center	DPH	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
PY3	UC San Francisco Medical Center	DPH	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	UC San Francisco Medical Center	DPH	Q-RU6	Use of Opioids at high Dosage in Persons Without Cancer	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Ventura County Medical Center	DPH	Q-PC1	Comprehensive Diabetes Care: A1C Control (<8%) (CDC-H8)	Reported	0.6325	0	0.4444	1633	0	2633	0	0.6202	0	1
PY3	Ventura County Medical Center	DPH	Q-PC2	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.5394	0	0.5085	1613	0	2633	0	0.6126	0	1
PY3	Ventura County Medical Center	DPH	Q-PC3	Comprehensive Diabetes Care: Blood Pressure Control (CDC-BP)	Reported	0.7585	0	0.562	1978	0	2633	0	0.7512	0	1
PY3	Ventura County Medical Center	DPH	Q-PC4	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Ventura County Medical Center	DPH	Q-PC5	Medication Reconciliation Post Discharge (MRP)	Reported	0.5905	0	0.3869	952	0	1576	0	0.6041	0	1
PY3	Ventura County Medical Center	DPH	Q-PC7	Children and Adolescent Access to PCP (CAP)	Reported	None	3	N/A	None	3	None	3	None	3	1
PY3	Ventura County Medical Center	DPH	Q-PC7	? 12-24 Months	Reported	0.9554	0	0.9364	1376	0	1436	0	0.9582	0	1
PY3	Ventura County Medical Center	DPH	Q-PC7	? 25 Months-6 Years	Reported	0.8761	0	0.8439	6911	0	7736	0	0.8934	0	1
PY3	Ventura County Medical Center	DPH	Q-PC7	? 7-11 Years	Reported	0.9021	0	0.8773	7266	0	7923	0	0.9171	0	1
PY3	Ventura County Medical Center	DPH	Q-PC7	? 12-19 Years	Reported	0.8726	0	0.8581	9936	0	11223	0	0.8853	0	1
PY3	Ventura County Medical Center	DPH	Q-PC9	Immunization for Adolescents (IMA) Combination 2	Reported	0.387	0	0.2628	537	0	1461	0	0.3676	0	1
PY3	Ventura County Medical Center	DPH	Q-PC10	Childhood Immunization Status (CIS) Combination 10	Reported	0	0	0.28	600	0	1579	0	0.38	0	1
PY3	Ventura County Medical Center	DPH	Q-PC11	Contraceptive Care - All Women (CCW) Most and Moderately Effective Methods, Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Ventura County Medical Center	DPH	Q-PC12	Chlamydia Screening in Women (CHL), Ages 16-24	Reported	0	0	0.51	1172	0	2247	0	0.5216	0	1
PY3	Ventura County Medical Center	DPH	Q-PC13	HIV Viral Load Suppression (HVL-AD)	Reported	0	0	0.6636	150	0	201	0	0.7463	0	1
PY3	Ventura County Medical Center	DPH	Q-PC14	Well-Child Visits in the First 15 Months of Life (W15-CH), Six or More well-child visits	Reported	0	0	0.59	298	0	393	0	0.7583	0	1
PY3	Ventura County Medical Center	DPH	Q-SC1	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Reported	0.7984	0	0.25	99	0	141	0	0.7021	0	1
PY3	Ventura County Medical Center	DPH	Q-SC2	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.8929	0	0.5	384	0	440	0	0.8727	0	1
PY3	Ventura County Medical Center	DPH	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	0.8554	0	0.5	200	0	234	0	0.8547	0	1
PY3	Ventura County Medical Center	DPH	Q-SC4	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Reported	0.9104	0	0.5	75	0	84	0	0.8929	0	1
PY3	Ventura County Medical Center	DPH	Q-SC5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin-Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction	Reported	0.8647	0	0.5	116	0	136	0	0.8529	0	1
PY3	Ventura County Medical Center	DPH	Q-SC6	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction	Reported	0.9451	0	0.5	78	0	88	0	0.8864	0	1
PY3	Ventura County Medical Center	DPH	Q-IP1	Surgical Site Infection (SSI) (Reported as SIR)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Ventura County Medical Center	DPH	Q-IP2	Perioperative Care: Selection of Prophylactic Antibiotic - 1st OR 2nd Generation Cephalosporin	Reported	0.8368	0	0.25	833	0	962	0	0.8659	0	1
PY3	Ventura County Medical Center	DPH	Q-IP3	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis	Reported	0.9519	0	0.25	1047	0	1070	0	0.9785	0	1
PY3	Ventura County Medical Center	DPH	Q-IP4	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Reported	0.8177	0	0.25	132	0	163	0	0.8098	0	1
PY3	Ventura County Medical Center	DPH	Q-IP5	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Ventura County Medical Center	DPH	Q-IP6	Stroke: Discharged on Antithrombotic Therapy (TJC STK-2)	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Ventura County Medical Center	DPH	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
PY3	Ventura County Medical Center	DPH	Q-RU2	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients 18 Years and Older	Reported	0.7388	0	0.5	150	0	197	0	0.7614	0	1
PY3	Ventura County Medical Center	DPH	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
PY3	Ventura County Medical Center	DPH	Q-RU5	Concurrent Use of Opioids and Benzodiazepines	Not Reported	None	None	None	None	None	None	None	None	None	None
PY3	Ventura County Medical Center	DPH	Q-RU6	Use of Opioids at high Dosage in Persons Without Cancer	Not Reported	None	None	None	None	None	None	None	None	None	None