Table: quality_incentive_pool_qip_program_data_year_4

py	type	hospital	number	abbreviation	title	report_status	baseline_rate	baseline_rate_annotation	target_rate	target_rate_annotation	numerator	numerator_annotation	denominator	denominator_annotation	achievement_rate	achievement_rate_annotation	achievement_value	p4p
'PY4'	'DPH'	'Alameda Health System'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Reported'	'0'	'0'	'44.00%%'	'0'	'1780'	'0'	'1819'	'0'	'97.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Alameda Health System'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DPH'	'Alameda Health System'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'444'	'0'	'1022'	'0'	'43.40%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Alameda Health System'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'374'	'0'	'994'	'0'	'37.60%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Alameda Health System'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Alameda Health System'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'2149'	'0'	'4629'	'0'	'46.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'7874'	'0'	'20041'	'0'	'39.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'5250'	'0'	'11831'	'0'	'44.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	'266'	'0'	'594'	'0'	'44.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Reported'	'0.00%%'	'0'	'48.30%%'	'0'	'1039'	'0'	'1552'	'0'	'67.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'6463'	'0'	'10927'	'0'	'59.20%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Alameda Health System'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Reported'	'0.00%%'	'0'	'15.10%%'	'0'	'517'	'0'	'1185'	'0'	'43.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Reported'	'0.00%%'	'0'	'9.40%%'	'0'	'13875'	'0'	'20266'	'0'	'68.50%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Alameda Health System'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Reported'	'0.00%%'	'0'	'30.90%%'	'0'	'197'	'0'	'546'	'0'	'36.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Reported'	'0.00%%'	'0'	'61.30%%'	'0'	'359'	'0'	'594'	'0'	'60.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Alameda Health System'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Reported'	'0.00%%'	'0'	'19.20%%'	'0'	'16228'	'0'	'23441'	'0'	'69.20%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Alameda Health System'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'15735'	'0'	'26733'	'0'	'58.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'24623'	'0'	'24878'	'0'	'99.00%%'	'0'	'N/A'	''
'PY4'	'DPH'	'Alameda Health System'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'3522'	'0'	'4356'	'0'	'80.90%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Alameda Health System'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'23780'	'0'	'24878'	'0'	'95.60%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Alameda Health System'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-PC15'	'Q-WCC'	'? BMI'	'Reported'	'0.00%%'	'0'	'69.20%%'	'0'	'5182'	'0'	'5679'	'0'	'91.30%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Alameda Health System'	'Q-PC15'	'Q-WCC'	'? Counseling for Nutrition'	'Reported'	'0.00%%'	'0'	'61.10%%'	'0'	'4398'	'0'	'5679'	'0'	'77.40%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Alameda Health System'	'Q-PC15'	'Q-WCC'	'? Counseling for Physical Activity'	'Reported'	'0.00%%'	'0'	'55.80%%'	'0'	'4378'	'0'	'5679'	'0'	'77.10%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Alameda Health System'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'Reported'	'0.00%%'	'0'	'66.40%%'	'0'	'371'	'0'	'603'	'0'	'61.50%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Alameda Health System'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'19'	'0'	'32'	'0'	'59.40%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Alameda Health System'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Reported'	'0.00%%'	'0'	'14.70%%'	'0'	'21'	'0'	'611'	'0'	'3.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'Yes'
'PY4'	'DPH'	'Alameda Health System'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adults)'	'Reported'	'0.00%%'	'0'	'36.10%%'	'0'	'156'	'0'	'260'	'0'	'60.00%%'	'0'	'1'	'YesS'
'PY4'	'DPH'	'Alameda Health System'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adults)'	'Reported'	'0.00%%'	'0'	'4.10%%'	'0'	'45'	'0'	'260'	'0'	'17.30%%'	'0'	'1'	'YesS'
'PY4'	'DPH'	'Alameda Health System'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adults)'	'Reported'	'0.00%%'	'0'	'9.60%%'	'0'	'76'	'0'	'260'	'0'	'29.20%%'	'0'	'1'	'YesS'
'PY4'	'DPH'	'Alameda Health System'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'30.00%%'	'0'	''	'1'	''	'4'	''	'1'	'N/A'	''
'PY4'	'DPH'	'Alameda Health System'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'4.80%%'	'0'	''	'1'	''	'4'	''	'1'	'N/A'	''
'PY4'	'DPH'	'Alameda Health System'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'9.50%%'	'0'	''	'1'	''	'4'	''	'1'	'N/A'	''
'PY4'	'DPH'	'Alameda Health System'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-BH3'	'Q-FUA'	'? 30 Days'	'Reported'	'0.00%%'	'0'	'10.80%%'	'0'	'35'	'0'	'260'	'0'	'13.50%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Alameda Health System'	'Q-BH3'	'Q-FUA'	'? 7 Days'	'Reported'	'0.00%%'	'0'	'7.10%%'	'0'	'28'	'0'	'260'	'0'	'10.80%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Alameda Health System'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Reported'	'0.00%%'	'0'	'4.70%%'	'0'	''	'1'	'623'	'0'	''	'1'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'2709'	'0'	'4881'	'0'	'55.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Reported'	'0.00%%'	'0'	'66.90%%'	'0'	'190'	'0'	'210'	'0'	'90.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Reported'	'0.00%%'	'0'	'71.40%%'	'0'	'439'	'0'	'465'	'0'	'94.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Reported'	'0.00%%'	'0'	'60.40%%'	'0'	'245'	'0'	'258'	'0'	'95.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Alameda Health System'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'1402'	'0'	'3652'	'0'	'38.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'1933'	'0'	'3652'	'0'	'52.90%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Alameda Health System'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Alameda Health System'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Reported'	'0.00%%'	'0'	'77.10%%'	'0'	'414'	'0'	'498'	'0'	'83.10%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Alameda Health System'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Reported'	'0.00%%'	'0'	'59.90%%'	'0'	'347'	'0'	'445'	'0'	'78.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Alameda Health System'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Reported'	'0.00%%'	'0'	'86.30%%'	'0'	'402'	'0'	'410'	'0'	'98.10%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Alameda Health System'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Alameda Health System'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Reported'	'0.00%%'	'0'	'77.00%%'	'0'	'133'	'0'	'141'	'0'	'94.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Alameda Health System'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Reported'	'0.00%%'	'0'	'24.80%%'	'0'	'54'	'0'	'391'	'0'	'13.80%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Alameda Health System'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Alameda Health System'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Reported'	'0.00%%'	'0'	'47.80%%'	'0'	'356'	'0'	'513'	'0'	'69.40%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Alameda Health System'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Reported'	'0.00%%'	'0'	'71.10%%'	'0'	'434'	'0'	'579'	'0'	'75.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Reported'	'0.00%%'	'0'	'79.30%%'	'0'	'462'	'0'	'579'	'0'	'79.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Reported'	'0.00%%'	'0'	'18.70%%'	'0'	'1258'	'0'	'7651'	'0'	'16.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Reported'	'0.00%%'	'0'	'99.20%%'	'0'	'172'	'0'	'177'	'0'	'97.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'1920'	'0'	'2051'	'0'	'93.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Alameda Health System'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Reported'	'0.00%%'	'0'	'44.90%%'	'0'	'833'	'0'	'1458'	'0'	'57.10%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Alameda Health System'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Alameda Health System'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Reported'	'0.00%%'	'0'	'79.00%%'	'0'	'21'	'0'	'34.209'	'0'	'0.614'	'0'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Reported'	'0.00%%'	'0'	'100.00%%'	'0'	'9.92'	'0'	'10.008'	'0'	'0.991'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'112'	'0'	'380'	'0'	'29.50%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'522'	'0'	'1868'	'0'	'27.90%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-IHE2'	'Q-IHE2'	'? Controlling High Blood Pressure (CBP) - -Hispanic/Latino'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'80'	'0'	'180'	'0'	'44.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'1465'	'0'	'2926'	'0'	'50.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'111'	'0'	'408'	'0'	'27.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'3310'	'0'	'6037'	'0'	'54.80%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	'117'	'0'	'490'	'0'	'23.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Reported'	'0.00%%'	'0'	'48.30%%'	'0'	'377'	'0'	'611'	'0'	'61.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'147'	'0'	'489'	'0'	'30.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Reported'	'0.00%%'	'0'	'15.10%%'	'0'	''	'1'	'1632'	'0'	''	'1'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Reported'	'0.00%%'	'0'	'9.40%%'	'0'	'2016'	'0'	'15293'	'0'	'13.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Reported'	'0.00%%'	'0'	'30.90%%'	'0'	'110'	'0'	'309'	'0'	'35.60%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Reported'	'0.00%%'	'0'	'61.30%%'	'0'	'43'	'0'	'867'	'0'	'5.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'49.60%%'	'0'	'3895'	'0'	'4514'	'0'	'86.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'531'	'0'	'1063'	'0'	'50.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'Reported'	'0.00%%'	'0'	'66.40%%'	'0'	'244'	'0'	'373'	'0'	'65.40%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'34'	'0'	'219'	'0'	'15.50%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Reported'	'0.00%%'	'0'	'14.70%%'	'0'	'55'	'0'	'1121'	'0'	'4.90%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adults)'	'Reported'	'0.00%%'	'0'	'36.10%%'	'0'	'542'	'0'	'1074'	'0'	'50.50%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adults)'	'Reported'	'0.00%%'	'0'	'4.10%%'	'0'	'542'	'0'	'1074'	'0'	'50.50%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adults)'	'Reported'	'0.00%%'	'0'	'9.60%%'	'0'	'542'	'0'	'1074'	'0'	'50.50%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'30.00%%'	'0'	''	'1'	''	'1'	''	'1'	'N/A'	''
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'4.80%%'	'0'	''	'1'	''	'1'	''	'1'	'N/A'	''
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'9.50%%'	'0'	''	'1'	''	'1'	''	'1'	'N/A'	''
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Reported'	'0.00%%'	'0'	'4.70%%'	'0'	'24'	'0'	'952'	'0'	'2.50%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'135'	'0'	'323'	'0'	'41.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Reported'	'0.00%%'	'0'	'66.90%%'	'0'	'51'	'0'	'235'	'0'	'21.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Reported'	'0.00%%'	'0'	'71.40%%'	'0'	'85'	'0'	'235'	'0'	'36.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Reported'	'0.00%%'	'0'	'60.40%%'	'0'	'738'	'0'	'990'	'0'	'74.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Reported'	'0.00%%'	'0'	'66.70%%'	'0'	'3176'	'0'	'5918'	'0'	'53.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'826'	'0'	'2929'	'0'	'28.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'1233'	'0'	'2929'	'0'	'42.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Reported'	'0.00%%'	'0'	'77.10%%'	'0'	'11'	'0'	'52'	'0'	'21.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-CAR2'	'Q-PCE'	'? Systemic Corticosteroid'	'Reported'	'0.00%%'	'0'	'63.60%%'	'0'	'136'	'0'	'272'	'0'	'50.00%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-CAR2'	'Q-PCE'	'? Bronchodilator'	'Reported'	'0.00%%'	'0'	'78.70%%'	'0'	'98'	'0'	'272'	'0'	'36.00%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'347'	'0'	'358'	'0'	'96.90%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Reported'	'0.00%%'	'0'	'77.00%%'	'0'	'104'	'0'	'140'	'0'	'74.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Reported'	'0.00%%'	'0'	'71.30%%'	'0'	'116'	'0'	'764'	'0'	'15.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Reported'	'0.00%%'	'0'	'24.80%%'	'0'	'96'	'0'	'584'	'0'	'16.40%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Reported'	'0.00%%'	'0'	'19.70%%'	'0'	'965'	'0'	'5639'	'0'	'17.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Reported'	'0.00%%'	'0'	'47.80%%'	'0'	'406'	'0'	'529'	'0'	'76.80%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Reported'	'0.00%%'	'0'	'71.10%%'	'0'	'124'	'0'	'185'	'0'	'67.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Reported'	'0.00%%'	'0'	'79.30%%'	'0'	'148'	'0'	'185'	'0'	'80.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Reported'	'0.00%%'	'0'	'99.20%%'	'0'	'233'	'0'	'271'	'0'	'86.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Reported'	'0.00%%'	'0'	'44.90%%'	'0'	'73'	'0'	'108'	'0'	'67.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Reported'	'0'	'0'	'1.07'	'0'	'2.54'	'0'	'3.2355'	'0'	'0.7851'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Arrowhead Regional Medical Center'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Reported'	'0.00%%'	'0'	'79.00%%'	'0'	'19'	'0'	'45.488'	'0'	'0.418'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Reported'	'0.00%%'	'0'	'44.00%%'	'0'	'2532'	'0'	'2553'	'0'	'99.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Reported'	'0.00%%'	'0'	'100.00%%'	'0'	'61'	'0'	'81.738'	'0'	'0.746'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'284'	'0'	'972'	'0'	'29.20%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'687'	'0'	'2244'	'0'	'30.60%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-IHE2'	'Q-IHE2'	'? Child and Adolescent Well Care Visits - -Black/African American'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'1708'	'0'	'3430'	'0'	'49.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'5471'	'0'	'8447'	'0'	'64.80%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'15378'	'0'	'24559'	'0'	'62.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'15876'	'0'	'28186'	'0'	'56.30%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	'635'	'0'	'1452'	'0'	'43.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Reported'	'0.00%%'	'0'	'48.30%%'	'0'	'2011'	'0'	'3014'	'0'	'66.70%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'12338'	'0'	'22028'	'0'	'56.00%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Reported'	'0.00%%'	'0'	'15.10%%'	'0'	'2302'	'0'	'3332'	'0'	'69.10%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Reported'	'0.00%%'	'0'	'9.40%%'	'0'	'28807'	'0'	'35088'	'0'	'82.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Reported'	'0.00%%'	'0'	'30.90%%'	'0'	'713'	'0'	'1475'	'0'	'48.30%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'49.60%%'	'0'	'21966'	'0'	'40802'	'0'	'53.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Reported'	'0.00%%'	'0'	'19.20%%'	'0'	'29660'	'0'	'34459'	'0'	'86.10%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'28512'	'0'	'38219'	'0'	'74.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'43416'	'0'	'45166'	'0'	'96.10%%'	'0'	'N/A'	''
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'3469'	'0'	'7188'	'0'	'48.30%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'39700'	'0'	'45166'	'0'	'87.90%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PC15'	'Q-WCC'	'? BMI'	'Reported'	'0.00%%'	'0'	'69.20%%'	'0'	'14486'	'0'	'15825'	'0'	'91.50%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PC15'	'Q-WCC'	'? Counseling for Nutrition'	'Reported'	'0.00%%'	'0'	'61.10%%'	'0'	'13489'	'0'	'15825'	'0'	'85.20%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PC15'	'Q-WCC'	'? Counseling for Physical Activity'	'Reported'	'0.00%%'	'0'	'55.80%%'	'0'	'13495'	'0'	'15825'	'0'	'85.30%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'Reported'	'0.00%%'	'0'	'66.40%%'	'0'	'892'	'0'	'1296'	'0'	'68.80%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'485'	'0'	'622'	'0'	'78.00%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Reported'	'0.00%%'	'0'	'14.70%%'	'0'	'74'	'0'	'1439'	'0'	'5.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Reported'	'0.00%%'	'0'	'4.70%%'	'0'	'18'	'0'	'1121'	'0'	'1.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'4624'	'0'	'7111'	'0'	'65.00%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Reported'	'0.00%%'	'0'	'66.90%%'	'0'	'702'	'0'	'802'	'0'	'87.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Reported'	'0.00%%'	'0'	'71.40%%'	'0'	'1652'	'0'	'1774'	'0'	'93.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Reported'	'0.00%%'	'0'	'60.40%%'	'0'	'406'	'0'	'434'	'0'	'93.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Reported'	'0.00%%'	'0'	'66.70%%'	'0'	'5442'	'0'	'6821'	'0'	'79.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'1730'	'0'	'6335'	'0'	'27.30%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'4120'	'0'	'6335'	'0'	'65.00%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Reported'	'0.00%%'	'0'	'88.30%%'	'0'	'5651'	'0'	'6335'	'0'	'89.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Reported'	'0.00%%'	'0'	'77.10%%'	'0'	'388'	'0'	'474'	'0'	'81.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Reported'	'0.00%%'	'0'	'59.90%%'	'0'	'644'	'0'	'1126'	'0'	'57.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Reported'	'0.00%%'	'0'	'86.30%%'	'0'	'677'	'0'	'709'	'0'	'95.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'79'	'0'	'113'	'0'	'69.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Reported'	'0.00%%'	'0'	'71.30%%'	'0'	'790'	'0'	'925'	'0'	'85.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Reported'	'0.00%%'	'0'	'24.80%%'	'0'	'81'	'0'	'468'	'0'	'17.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Reported'	'0.00%%'	'0'	'47.80%%'	'0'	'1136'	'0'	'1483'	'0'	'76.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Reported'	'0.00%%'	'0'	'71.10%%'	'0'	'799'	'0'	'886'	'0'	'90.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Reported'	'0.00%%'	'0'	'79.30%%'	'0'	'813'	'0'	'886'	'0'	'91.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Reported'	'0.00%%'	'0'	'18.70%%'	'0'	'4445'	'0'	'10345'	'0'	'43.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'804'	'0'	'816'	'0'	'98.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Reported'	'0.00%%'	'0'	'44.90%%'	'0'	'187'	'0'	'190'	'0'	'98.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Contra Costa Regional Medical Center'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Kern Medical Center'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Reported'	'0.00%%'	'0'	'44.00%%'	'0'	'984'	'0'	'1153'	'0'	'85.30%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Kern Medical Center'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Kern Medical Center'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DPH'	'Kern Medical Center'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'Yes'
'PY4'	'DPH'	'Kern Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'91'	'0'	'207'	'0'	'44.00%%'	'0'	'1'	'YesS'
'PY4'	'DPH'	'Kern Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'634'	'0'	'1500'	'0'	'42.30%%'	'0'	'1'	'YesS'
'PY4'	'DPH'	'Kern Medical Center'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Kern Medical Center'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'963'	'0'	'2147'	'0'	'44.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'3355'	'0'	'10285'	'0'	'32.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'4220'	'0'	'12567'	'0'	'33.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	'191'	'0'	'821'	'0'	'23.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Reported'	'0.00%%'	'0'	'48.30%%'	'0'	'565'	'0'	'1524'	'0'	'37.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'2260'	'0'	'5006'	'0'	'45.20%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Kern Medical Center'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Reported'	'0.00%%'	'0'	'15.10%%'	'0'	'70'	'0'	'2239'	'0'	'3.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Reported'	'0.00%%'	'0'	'9.40%%'	'0'	'5429'	'0'	'12941'	'0'	'42.00%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Kern Medical Center'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Reported'	'0.00%%'	'0'	'30.90%%'	'0'	'152'	'0'	'1000'	'0'	'15.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Reported'	'0.00%%'	'0'	'61.30%%'	'0'	'309'	'0'	'823'	'0'	'37.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'49.60%%'	'0'	'6847'	'0'	'15659'	'0'	'43.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Reported'	'0.00%%'	'0'	'19.20%%'	'0'	'5141'	'0'	'12378'	'0'	'41.50%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Kern Medical Center'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'6159'	'0'	'15093'	'0'	'40.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'Yes'
'PY4'	'DPH'	'Kern Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'13387'	'0'	'13631'	'0'	'98.20%%'	'0'	'N/A'	''
'PY4'	'DPH'	'Kern Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'635'	'0'	'2185'	'0'	'29.10%%'	'0'	'1'	'YesS'
'PY4'	'DPH'	'Kern Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'11837'	'0'	'13631'	'0'	'86.80%%'	'0'	'1'	'YesS'
'PY4'	'DPH'	'Kern Medical Center'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-PC15'	'Q-WCC'	'? BMI'	'Reported'	'0.00%%'	'0'	'69.20%%'	'0'	'4387'	'0'	'4513'	'0'	'97.20%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Kern Medical Center'	'Q-PC15'	'Q-WCC'	'? Counseling for Nutrition'	'Reported'	'0.00%%'	'0'	'61.10%%'	'0'	'686'	'0'	'4513'	'0'	'15.20%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Kern Medical Center'	'Q-PC15'	'Q-WCC'	'? Counseling for Physical Activity'	'Reported'	'0.00%%'	'0'	'55.80%%'	'0'	'563'	'0'	'4513'	'0'	'12.50%%'	'0'	'1'	'Nos'
'PY4'	'DPH'	'Kern Medical Center'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'Reported'	'0.00%%'	'0'	'66.40%%'	'0'	'300'	'0'	'892'	'0'	'33.60%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Kern Medical Center'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'227'	'0'	'569'	'0'	'39.90%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Kern Medical Center'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Reported'	'0.00%%'	'0'	'14.70%%'	'0'	'13'	'0'	'473'	'0'	'2.80%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Kern Medical Center'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Kern Medical Center'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Kern Medical Center'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Reported'	'0.00%%'	'0'	'4.70%%'	'0'	'0'	'0'	'377'	'0'	'0.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'1550'	'0'	'2748'	'0'	'56.40%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Kern Medical Center'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Reported'	'0.00%%'	'0'	'66.90%%'	'0'	'179'	'0'	'206'	'0'	'86.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Reported'	'0.00%%'	'0'	'71.40%%'	'0'	'344'	'0'	'367'	'0'	'93.70%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Kern Medical Center'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Reported'	'0.00%%'	'0'	'60.40%%'	'0'	'61'	'0'	'62'	'0'	'98.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Reported'	'0.00%%'	'0'	'66.70%%'	'0'	'1752'	'0'	'2373'	'0'	'73.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'1065'	'0'	'2384'	'0'	'44.70%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Kern Medical Center'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'696'	'0'	'2384'	'0'	'29.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Reported'	'0.00%%'	'0'	'88.30%%'	'0'	'1952'	'0'	'2384'	'0'	'81.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Reported'	'0.00%%'	'0'	'77.10%%'	'0'	'63'	'0'	'97'	'0'	'65.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Reported'	'0.00%%'	'0'	'59.90%%'	'0'	'130'	'0'	'275'	'0'	'47.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Kern Medical Center'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Kern Medical Center'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Kern Medical Center'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Reported'	'0.00%%'	'0'	'77.00%%'	'0'	'218'	'0'	'249'	'0'	'87.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Reported'	'0.00%%'	'0'	'71.30%%'	'0'	'117'	'0'	'172'	'0'	'68.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Reported'	'0.00%%'	'0'	'24.80%%'	'0'	'130'	'0'	'538'	'0'	'24.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Kern Medical Center'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Reported'	'0.00%%'	'0'	'47.80%%'	'0'	'1110'	'0'	'1672'	'0'	'66.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Reported'	'0.00%%'	'0'	'71.10%%'	'0'	'227'	'0'	'764'	'0'	'29.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Reported'	'0.00%%'	'0'	'79.30%%'	'0'	'232'	'0'	'764'	'0'	'30.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Reported'	'0.00%%'	'0'	'18.70%%'	'0'	'1277'	'0'	'1465'	'0'	'87.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Reported'	'0.00%%'	'0'	'99.20%%'	'0'	'30'	'0'	'30'	'0'	'100.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'982'	'0'	'1085'	'0'	'90.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Reported'	'0.00%%'	'0'	'44.90%%'	'0'	'544'	'0'	'606'	'0'	'89.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Kern Medical Center'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Kern Medical Center'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Reported'	'0.00%%'	'0'	'44.00%%'	'0'	'7485'	'0'	'8653'	'0'	'86.50%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'995'	'0'	'2638'	'0'	'37.70%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'4345'	'0'	'11213'	'0'	'38.80%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'9311'	'0'	'17255'	'0'	'54.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'26743'	'0'	'64661'	'0'	'41.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'14087'	'0'	'36739'	'0'	'38.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	'150'	'0'	'323'	'0'	'46.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Reported'	'0.00%%'	'0'	'48.30%%'	'0'	'3190'	'0'	'5337'	'0'	'59.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'34061'	'0'	'58074'	'0'	'58.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Reported'	'0.00%%'	'0'	'15.10%%'	'0'	'223'	'0'	'411'	'0'	'54.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Reported'	'0.00%%'	'0'	'9.40%%'	'0'	'36496'	'0'	'66493'	'0'	'54.90%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Reported'	'0.00%%'	'0'	'30.90%%'	'0'	'126'	'0'	'323'	'0'	'39.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Reported'	'0.00%%'	'0'	'61.30%%'	'0'	'1056'	'0'	'1836'	'0'	'57.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Reported'	'0.00%%'	'0'	'19.20%%'	'0'	'49246'	'0'	'84832'	'0'	'58.10%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'80855'	'0'	'100901'	'0'	'80.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'121425'	'0'	'135294'	'0'	'89.80%%'	'0'	'1'	''
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'7889'	'0'	'13835'	'0'	'57.00%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'115479'	'0'	'135293'	'0'	'85.40%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PC15'	'Q-WCC'	'? BMI'	'Reported'	'0.00%%'	'0'	'69.20%%'	'0'	'13479'	'0'	'16427'	'0'	'82.10%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PC15'	'Q-WCC'	'? Counseling for Nutrition'	'Reported'	'0.00%%'	'0'	'61.10%%'	'0'	'12031'	'0'	'16427'	'0'	'73.20%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PC15'	'Q-WCC'	'? Counseling for Physical Activity'	'Reported'	'0.00%%'	'0'	'55.80%%'	'0'	'11857'	'0'	'16427'	'0'	'72.20%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'Reported'	'0.00%%'	'0'	'66.40%%'	'0'	'1090'	'0'	'1741'	'0'	'62.60%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'435'	'0'	'666'	'0'	'65.30%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Reported'	'0.00%%'	'0'	'14.70%%'	'0'	'150'	'0'	'2181'	'0'	'6.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adults)'	'Reported'	'0.00%%'	'0'	'36.10%%'	'0'	'496'	'0'	'1013'	'0'	'49.00%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adults)'	'Reported'	'0.00%%'	'0'	'4.10%%'	'0'	'143'	'0'	'1013'	'0'	'14.10%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adults)'	'Reported'	'0.00%%'	'0'	'9.60%%'	'0'	'206'	'0'	'1013'	'0'	'20.30%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'30.00%%'	'0'	'22'	'0'	'59'	'0'	'37.30%%'	'0'	'1'	''
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'4.80%%'	'0'	''	'1'	'59'	'0'	''	'1'	'1'	''
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'9.50%%'	'0'	''	'1'	'59'	'0'	''	'1'	'1'	''
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'9566'	'0'	'17731'	'0'	'54.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Reported'	'0.00%%'	'0'	'66.90%%'	'0'	'2055'	'0'	'2352'	'0'	'87.40%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Reported'	'0.00%%'	'0'	'71.40%%'	'0'	'3945'	'0'	'4723'	'0'	'83.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Reported'	'0.00%%'	'0'	'60.40%%'	'0'	'1826'	'0'	'2135'	'0'	'85.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Reported'	'0.00%%'	'0'	'66.70%%'	'0'	'14351'	'0'	'18675'	'0'	'76.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'6590'	'0'	'17248'	'0'	'38.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'9260'	'0'	'17248'	'0'	'53.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Reported'	'0.00%%'	'0'	'77.10%%'	'0'	'2866'	'0'	'3436'	'0'	'83.40%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Reported'	'0.00%%'	'0'	'59.90%%'	'0'	'975'	'0'	'1515'	'0'	'64.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Reported'	'0.00%%'	'0'	'86.30%%'	'0'	'522'	'0'	'527'	'0'	'99.10%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'52'	'0'	'56'	'0'	'92.90%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Reported'	'0.00%%'	'0'	'71.30%%'	'0'	'1073'	'0'	'1263'	'0'	'85.00%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Reported'	'0.00%%'	'0'	'47.80%%'	'0'	'1103'	'0'	'1845'	'0'	'59.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Reported'	'0.00%%'	'0'	'71.10%%'	'0'	'1196'	'0'	'1590'	'0'	'75.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Reported'	'0.00%%'	'0'	'79.30%%'	'0'	'1343'	'0'	'1590'	'0'	'84.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Reported'	'0.00%%'	'0'	'18.70%%'	'0'	'24747'	'0'	'26473'	'0'	'93.50%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Reported'	'0.00%%'	'0'	'99.20%%'	'0'	'218'	'0'	'218'	'0'	'100.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'354'	'0'	'380'	'0'	'93.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Reported'	'0.00%%'	'0'	'44.90%%'	'0'	'298'	'0'	'323'	'0'	'92.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Reported'	'0'	'0'	'1.07'	'0'	'16'	'0'	'38.275'	'0'	'0.418'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Los Angeles County Health System'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Reported'	'0.00%%'	'0'	'79.00%%'	'0'	'112'	'0'	'191.927'	'0'	'0.584'	'0'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Reported'	'0.00%%'	'0'	'44.00%%'	'0'	'487'	'0'	'1278'	'0'	'38.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Reported'	'0.00%%'	'0'	'100.00%%'	'0'	'49'	'0'	'147'	'0'	'0.333'	'0'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DPH'	'Natividad Medical Center'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'14'	'0'	'41'	'0'	'34.20%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'396'	'0'	'1060'	'0'	'37.40%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Natividad Medical Center'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'802'	'0'	'1588'	'0'	'50.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'4072'	'0'	'7414'	'0'	'54.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'11516'	'0'	'23950'	'0'	'48.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	'722'	'0'	'1328'	'0'	'54.40%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Reported'	'0.00%%'	'0'	'48.30%%'	'0'	'180'	'0'	'345'	'0'	'52.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'3578'	'0'	'6169'	'0'	'58.00%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Reported'	'0.00%%'	'0'	'15.10%%'	'0'	'22'	'0'	'2914'	'0'	'0.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Reported'	'0.00%%'	'0'	'9.40%%'	'0'	'6244'	'0'	'11099'	'0'	'56.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Reported'	'0.00%%'	'0'	'30.90%%'	'0'	'866'	'0'	'1442'	'0'	'60.10%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Reported'	'0.00%%'	'0'	'61.30%%'	'0'	'1027'	'0'	'1335'	'0'	'76.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Natividad Medical Center'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Reported'	'0.00%%'	'0'	'19.20%%'	'0'	'14902'	'0'	'25689'	'0'	'58.00%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'14350'	'0'	'22089'	'0'	'65.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'12783'	'0'	'13312'	'0'	'96.00%%'	'0'	'1'	''
'PY4'	'DPH'	'Natividad Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'599'	'0'	'1022'	'0'	'58.60%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'12360'	'0'	'13312'	'0'	'92.90%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Natividad Medical Center'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'Reported'	'0.00%%'	'0'	'66.40%%'	'0'	'728'	'0'	'1291'	'0'	'56.40%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'137'	'0'	'297'	'0'	'46.10%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Reported'	'0.00%%'	'0'	'14.70%%'	'0'	'21'	'0'	'542'	'0'	'3.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adults)'	'Reported'	'0.00%%'	'0'	'36.10%%'	'0'	'91'	'0'	'229'	'0'	'39.70%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adults)'	'Reported'	'0.00%%'	'0'	'4.10%%'	'0'	'18'	'0'	'229'	'0'	'7.90%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adults)'	'Reported'	'0.00%%'	'0'	'9.60%%'	'0'	'36'	'0'	'229'	'0'	'15.70%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'30.00%%'	'0'	'12'	'0'	'48'	'0'	'25.00%%'	'0'	'0'	''
'PY4'	'DPH'	'Natividad Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'4.80%%'	'0'	''	'1'	'48'	'0'	''	'1'	'0'	''
'PY4'	'DPH'	'Natividad Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'9.50%%'	'0'	''	'1'	'48'	'0'	''	'1'	'0'	''
'PY4'	'DPH'	'Natividad Medical Center'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-BH3'	'Q-FUA'	'? 30 Days'	'Reported'	'0.00%%'	'0'	'10.80%%'	'0'	''	'1'	'201'	'0'	''	'1'	'1'	'NoS'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-BH3'	'Q-FUA'	'? 7 Days'	'Reported'	'0.00%%'	'0'	'7.10%%'	'0'	''	'1'	'201'	'0'	''	'1'	'1'	'NoS'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Reported'	'0.00%%'	'0'	'4.70%%'	'0'	'16'	'0'	'278'	'0'	'5.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'1278'	'0'	'2080'	'0'	'61.40%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Reported'	'0.00%%'	'0'	'66.90%%'	'0'	'131'	'0'	'166'	'0'	'78.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Reported'	'0.00%%'	'0'	'71.40%%'	'0'	'224'	'0'	'286'	'0'	'78.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Reported'	'0.00%%'	'0'	'60.40%%'	'0'	'40'	'0'	'47'	'0'	'85.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Reported'	'0.00%%'	'0'	'66.70%%'	'0'	'996'	'0'	'1319'	'0'	'75.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'490'	'0'	'1395'	'0'	'35.10%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'800'	'0'	'1395'	'0'	'57.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Natividad Medical Center'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Reported'	'0.00%%'	'0'	'77.10%%'	'0'	'131'	'0'	'165'	'0'	'79.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Reported'	'0.00%%'	'0'	'59.90%%'	'0'	'364'	'0'	'366'	'0'	'99.50%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Natividad Medical Center'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Reported'	'0.00%%'	'0'	'86.30%%'	'0'	'1118'	'0'	'1123'	'0'	'99.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'35'	'0'	'35'	'0'	'100.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Natividad Medical Center'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Natividad Medical Center'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Reported'	'0.00%%'	'0'	'24.80%%'	'0'	'87'	'0'	'433'	'0'	'20.10%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Reported'	'0.00%%'	'0'	'19.70%%'	'0'	'1857'	'0'	'8792'	'0'	'21.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Natividad Medical Center'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Reported'	'0.00%%'	'0'	'71.10%%'	'0'	'308'	'0'	'362'	'0'	'85.10%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Reported'	'0.00%%'	'0'	'79.30%%'	'0'	'290'	'0'	'362'	'0'	'80.10%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Natividad Medical Center'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Natividad Medical Center'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'896'	'0'	'970'	'0'	'92.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Reported'	'0.00%%'	'0'	'44.90%%'	'0'	'375'	'0'	'427'	'0'	'87.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Reported'	'0'	'0'	'1.07'	'0'	'1'	'0'	'5.672'	'0'	'0.1763'	'0'	'1'	'No'
'PY4'	'DPH'	'Natividad Medical Center'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Reported'	'0.00%%'	'0'	'79.00%%'	'0'	'8'	'0'	'20.742'	'0'	'0.386'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Reported'	'0.00%%'	'0'	'44.00%%'	'0'	'431'	'0'	'442'	'0'	'97.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Riverside University Health System'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DPH'	'Riverside University Health System'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'214'	'0'	'614'	'0'	'34.90%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Riverside University Health System'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'1204'	'0'	'3534'	'0'	'34.10%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Riverside University Health System'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Riverside University Health System'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'2935'	'0'	'5669'	'0'	'51.80%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Riverside University Health System'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'12221'	'0'	'27727'	'0'	'44.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'6294'	'0'	'18602'	'0'	'33.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	'205'	'0'	'1164'	'0'	'17.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Reported'	'0.00%%'	'0'	'48.30%%'	'0'	'2072'	'0'	'2966'	'0'	'69.90%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Riverside University Health System'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'9322'	'0'	'20328'	'0'	'45.90%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Riverside University Health System'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Reported'	'0.00%%'	'0'	'15.10%%'	'0'	'801'	'0'	'2768'	'0'	'28.90%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Riverside University Health System'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Reported'	'0.00%%'	'0'	'9.40%%'	'0'	'20236'	'0'	'27772'	'0'	'72.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Reported'	'0.00%%'	'0'	'30.90%%'	'0'	'159'	'0'	'775'	'0'	'20.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Reported'	'0.00%%'	'0'	'61.30%%'	'0'	'426'	'0'	'869'	'0'	'49.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Riverside University Health System'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Reported'	'0.00%%'	'0'	'19.20%%'	'0'	'16139'	'0'	'32254'	'0'	'50.00%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Riverside University Health System'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'38054'	'0'	'56741'	'0'	'67.10%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Riverside University Health System'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'Yes'
'PY4'	'DPH'	'Riverside University Health System'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'31202'	'0'	'34906'	'0'	'89.40%%'	'0'	'1'	''
'PY4'	'DPH'	'Riverside University Health System'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'3214'	'0'	'5158'	'0'	'62.30%%'	'0'	'1'	'YesS'
'PY4'	'DPH'	'Riverside University Health System'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'29814'	'0'	'34906'	'0'	'85.40%%'	'0'	'1'	'YesS'
'PY4'	'DPH'	'Riverside University Health System'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Riverside University Health System'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'Reported'	'0.00%%'	'0'	'66.40%%'	'0'	'300'	'0'	'608'	'0'	'49.30%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Riverside University Health System'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'72'	'0'	'303'	'0'	'23.80%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Riverside University Health System'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Reported'	'0.00%%'	'0'	'14.70%%'	'0'	'130'	'0'	'2385'	'0'	'5.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adults)'	'Reported'	'0.00%%'	'0'	'36.10%%'	'0'	'528'	'0'	'1170'	'0'	'45.10%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Riverside University Health System'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adults)'	'Reported'	'0.00%%'	'0'	'4.10%%'	'0'	'134'	'0'	'1170'	'0'	'11.50%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Riverside University Health System'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adults)'	'Reported'	'0.00%%'	'0'	'9.60%%'	'0'	'206'	'0'	'1170'	'0'	'17.60%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Riverside University Health System'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'30.00%%'	'0'	'18'	'0'	'66'	'0'	'27.30%%'	'0'	'1'	''
'PY4'	'DPH'	'Riverside University Health System'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'4.80%%'	'0'	''	'1'	'66'	'0'	''	'1'	'1'	''
'PY4'	'DPH'	'Riverside University Health System'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'9.50%%'	'0'	''	'1'	'66'	'0'	''	'1'	'1'	''
'PY4'	'DPH'	'Riverside University Health System'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Riverside University Health System'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Reported'	'0.00%%'	'0'	'4.70%%'	'0'	'39'	'0'	'1526'	'0'	'2.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'3835'	'0'	'6286'	'0'	'61.00%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Riverside University Health System'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Reported'	'0.00%%'	'0'	'66.90%%'	'0'	'260'	'0'	'283'	'0'	'91.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Reported'	'0.00%%'	'0'	'71.40%%'	'0'	'949'	'0'	'1107'	'0'	'85.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Reported'	'0.00%%'	'0'	'60.40%%'	'0'	'224'	'0'	'330'	'0'	'67.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Riverside University Health System'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'1961'	'0'	'5795'	'0'	'33.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'3445'	'0'	'5795'	'0'	'59.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Reported'	'0.00%%'	'0'	'88.30%%'	'0'	'4991'	'0'	'5795'	'0'	'86.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Reported'	'0.00%%'	'0'	'77.10%%'	'0'	'390'	'0'	'473'	'0'	'82.50%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Riverside University Health System'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Reported'	'0.00%%'	'0'	'59.90%%'	'0'	'542'	'0'	'884'	'0'	'61.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Riverside University Health System'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Reported'	'0.00%%'	'0'	'86.30%%'	'0'	'90'	'0'	'90'	'0'	'100.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'23'	'0'	'45'	'0'	'51.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Reported'	'0.00%%'	'0'	'77.00%%'	'0'	'127'	'0'	'220'	'0'	'57.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Reported'	'0.00%%'	'0'	'71.30%%'	'0'	'411'	'0'	'461'	'0'	'89.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Reported'	'0.00%%'	'0'	'24.80%%'	'0'	'85'	'0'	'400'	'0'	'21.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Riverside University Health System'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Reported'	'0.00%%'	'0'	'47.80%%'	'0'	'767'	'0'	'1115'	'0'	'68.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Reported'	'0.00%%'	'0'	'71.10%%'	'0'	'1233'	'0'	'1710'	'0'	'72.10%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Riverside University Health System'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Reported'	'0.00%%'	'0'	'79.30%%'	'0'	'1049'	'0'	'1710'	'0'	'61.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Riverside University Health System'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Reported'	'0.00%%'	'0'	'99.20%%'	'0'	'237'	'0'	'237'	'0'	'100.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'315'	'0'	'320'	'0'	'98.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Riverside University Health System'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Reported'	'0'	'0'	'1.07'	'0'	'2'	'0'	'10.908'	'0'	'0.1834'	'0'	'1'	'No'
'PY4'	'DPH'	'Riverside University Health System'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Reported'	'0.00%%'	'0'	'79.00%%'	'0'	'32'	'0'	'57.676'	'0'	'0.555'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Reported'	'0.00%%'	'0'	'44.00%%'	'0'	'2259'	'0'	'2287'	'0'	'98.80%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'230'	'0'	'739'	'0'	'31.10%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'369'	'0'	'1013'	'0'	'36.40%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-IHE2'	'Q-IHE2'	'? Controlling High Blood Pressure (CBP) - -Black/African American'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'658'	'0'	'1292'	'0'	'50.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'2392'	'0'	'4732'	'0'	'50.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'5213'	'0'	'10948'	'0'	'47.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'4422'	'0'	'9352'	'0'	'47.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	'253'	'0'	'554'	'0'	'45.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Reported'	'0.00%%'	'0'	'48.30%%'	'0'	'621'	'0'	'837'	'0'	'74.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'9112'	'0'	'15150'	'0'	'60.20%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Reported'	'0.00%%'	'0'	'15.10%%'	'0'	'825'	'0'	'1456'	'0'	'56.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Reported'	'0.00%%'	'0'	'9.40%%'	'0'	'12386'	'0'	'15359'	'0'	'80.60%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Reported'	'0.00%%'	'0'	'30.90%%'	'0'	'288'	'0'	'492'	'0'	'58.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Reported'	'0.00%%'	'0'	'61.30%%'	'0'	'432'	'0'	'535'	'0'	'80.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Reported'	'0.00%%'	'0'	'19.20%%'	'0'	'16177'	'0'	'21573'	'0'	'75.00%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'13758'	'0'	'22202'	'0'	'62.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'Yes'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0'	'0'	'N/A'	'0'	'32445'	'0'	'33257'	'0'	'97.60%%'	'0'	'N/A'	''
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'5596'	'0'	'7346'	'0'	'76.20%%'	'0'	'1'	'YesS'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'30695'	'0'	'33257'	'0'	'92.30%%'	'0'	'1'	'YesS'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'Reported'	'0.00%%'	'0'	'66.40%%'	'0'	'428'	'0'	'488'	'0'	'87.70%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'135'	'0'	'193'	'0'	'70.00%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Reported'	'0.00%%'	'0'	'14.70%%'	'0'	'51'	'0'	'583'	'0'	'8.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adults)'	'Reported'	'0.00%%'	'0'	'36.10%%'	'0'	'168'	'0'	'556'	'0'	'30.20%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adults)'	'Reported'	'0.00%%'	'0'	'4.10%%'	'0'	'18'	'0'	'556'	'0'	'3.20%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adults)'	'Reported'	'0.00%%'	'0'	'9.60%%'	'0'	'32'	'0'	'556'	'0'	'5.80%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'30.00%%'	'0'	'12'	'0'	'55'	'0'	'21.80%%'	'0'	'N/A'	''
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'4.80%%'	'0'	'0'	'0'	'55'	'0'	'0.00%%'	'0'	'N/A'	''
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'9.50%%'	'0'	''	'1'	'55'	'0'	''	'1'	'N/A'	''
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'2702'	'0'	'4757'	'0'	'56.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Reported'	'0.00%%'	'0'	'66.90%%'	'0'	'382'	'0'	'428'	'0'	'89.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Reported'	'0.00%%'	'0'	'71.40%%'	'0'	'769'	'0'	'857'	'0'	'89.70%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Reported'	'0.00%%'	'0'	'60.40%%'	'0'	'291'	'0'	'321'	'0'	'90.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Reported'	'0.00%%'	'0'	'66.70%%'	'0'	'3082'	'0'	'4041'	'0'	'76.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'1005'	'0'	'3429'	'0'	'29.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'1917'	'0'	'3397'	'0'	'56.40%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Reported'	'0.00%%'	'0'	'88.30%%'	'0'	'3079'	'0'	'3397'	'0'	'90.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Reported'	'0.00%%'	'0'	'77.10%%'	'0'	'1777'	'0'	'2104'	'0'	'84.50%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Reported'	'0.00%%'	'0'	'59.90%%'	'0'	'226'	'0'	'487'	'0'	'46.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-CAR2'	'Q-PCE'	'? Systemic Corticosteroid'	'Reported'	'0.00%%'	'0'	'63.60%%'	'0'	'65'	'0'	'104'	'0'	'62.50%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-CAR2'	'Q-PCE'	'? Bronchodilator'	'Reported'	'0.00%%'	'0'	'78.70%%'	'0'	'100'	'0'	'104'	'0'	'96.20%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Reported'	'0.00%%'	'0'	'86.30%%'	'0'	'350'	'0'	'356'	'0'	'98.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'35'	'0'	'35'	'0'	'100.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Reported'	'0.00%%'	'0'	'24.80%%'	'0'	'58'	'0'	'290'	'0'	'20.00%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Reported'	'0.00%%'	'0'	'19.70%%'	'0'	'2026'	'0'	'8376'	'0'	'24.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Reported'	'0.00%%'	'0'	'47.80%%'	'0'	'605'	'0'	'730'	'0'	'82.90%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Reported'	'0.00%%'	'0'	'71.10%%'	'0'	'271'	'0'	'311'	'0'	'87.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Reported'	'0.00%%'	'0'	'79.30%%'	'0'	'263'	'0'	'311'	'0'	'84.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Reported'	'0.00%%'	'0'	'99.20%%'	'0'	'238'	'0'	'238'	'0'	'100.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'340'	'0'	'377'	'0'	'90.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Reported'	'0.00%%'	'0'	'44.90%%'	'0'	'308'	'0'	'356'	'0'	'86.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Francisco General Hospital'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Reported'	'0.00%%'	'0'	'100.00%%'	'0'	'149'	'0'	'1061'	'0'	'0.14'	'0'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'107'	'0'	'216'	'0'	'49.50%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'178'	'0'	'357'	'0'	'49.90%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'831'	'0'	'1974'	'0'	'42.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'3285'	'0'	'11431'	'0'	'28.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'4424'	'0'	'11464'	'0'	'38.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	'68'	'0'	'299'	'0'	'22.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Reported'	'0.00%%'	'0'	'48.30%%'	'0'	'224'	'0'	'418'	'0'	'53.60%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'2447'	'0'	'4687'	'0'	'52.20%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Reported'	'0.00%%'	'0'	'15.10%%'	'0'	'267'	'0'	'411'	'0'	'65.00%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Reported'	'0.00%%'	'0'	'9.40%%'	'0'	'3499'	'0'	'10523'	'0'	'33.30%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Reported'	'0.00%%'	'0'	'30.90%%'	'0'	'69'	'0'	'179'	'0'	'38.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Reported'	'0.00%%'	'0'	'61.30%%'	'0'	'3425'	'0'	'5933'	'0'	'57.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'49.60%%'	'0'	'3750'	'0'	'16766'	'0'	'22.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Reported'	'0.00%%'	'0'	'19.20%%'	'0'	'108'	'0'	'351'	'0'	'30.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'8562'	'0'	'19279'	'0'	'44.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'21941'	'0'	'23795'	'0'	'92.20%%'	'0'	'1'	''
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'1730'	'0'	'3842'	'0'	'45.00%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'19868'	'0'	'23795'	'0'	'83.50%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PC15'	'Q-WCC'	'? BMI'	'Reported'	'0.00%%'	'0'	'69.20%%'	'0'	'4081'	'0'	'4445'	'0'	'91.80%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PC15'	'Q-WCC'	'? Counseling for Nutrition'	'Reported'	'0.00%%'	'0'	'61.10%%'	'0'	'3295'	'0'	'4445'	'0'	'74.10%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PC15'	'Q-WCC'	'? Counseling for Physical Activity'	'Reported'	'0.00%%'	'0'	'55.80%%'	'0'	'3316'	'0'	'4445'	'0'	'74.60%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'Reported'	'0.00%%'	'0'	'66.40%%'	'0'	'239'	'0'	'518'	'0'	'46.10%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'71'	'0'	'144'	'0'	'49.30%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Reported'	'0.00%%'	'0'	'14.70%%'	'0'	'18'	'0'	'355'	'0'	'5.10%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adults)'	'Reported'	'0.00%%'	'0'	'36.10%%'	'0'	'17'	'0'	'176'	'0'	'9.70%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adults)'	'Reported'	'0.00%%'	'0'	'4.10%%'	'0'	''	'1'	'176'	'0'	''	'1'	'1'	'NoS'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adults)'	'Reported'	'0.00%%'	'0'	'9.60%%'	'0'	''	'1'	'176'	'0'	''	'1'	'1'	'NOS'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'30.00%%'	'0'	'0'	'0'	''	'1'	''	'1'	'1'	''
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'4.80%%'	'0'	'0'	'0'	''	'1'	''	'1'	'1'	''
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'9.50%%'	'0'	'0'	'0'	''	'1'	''	'1'	'1'	''
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-BH3'	'Q-FUA'	'? 30 Days'	'Reported'	'0.00%%'	'0'	'10.80%%'	'0'	''	'1'	'77'	'0'	''	'1'	'1'	'NoS'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-BH3'	'Q-FUA'	'? 7 Days'	'Reported'	'0.00%%'	'0'	'7.10%%'	'0'	''	'1'	'77'	'0'	''	'1'	'1'	'NoS'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'843'	'0'	'2187'	'0'	'38.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Reported'	'0.00%%'	'0'	'71.40%%'	'0'	'239'	'0'	'277'	'0'	'86.30%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Reported'	'0.00%%'	'0'	'66.70%%'	'0'	'897'	'0'	'1139'	'0'	'78.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'764'	'0'	'1743'	'0'	'43.80%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'139'	'0'	'411'	'0'	'33.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Reported'	'0.00%%'	'0'	'77.10%%'	'0'	'44'	'0'	'92'	'0'	'47.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Reported'	'0.00%%'	'0'	'59.90%%'	'0'	'97'	'0'	'172'	'0'	'56.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Reported'	'0.00%%'	'0'	'86.30%%'	'0'	'542'	'0'	'567'	'0'	'95.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Reported'	'0.00%%'	'0'	'71.30%%'	'0'	'427'	'0'	'498'	'0'	'85.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Reported'	'0.00%%'	'0'	'24.80%%'	'0'	'80'	'0'	'405'	'0'	'19.80%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Reported'	'0.00%%'	'0'	'19.70%%'	'0'	'469'	'0'	'10261'	'0'	'4.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Reported'	'0.00%%'	'0'	'47.80%%'	'0'	'821'	'0'	'1172'	'0'	'70.10%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Reported'	'0.00%%'	'0'	'71.10%%'	'0'	'87'	'0'	'143'	'0'	'60.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Reported'	'0.00%%'	'0'	'79.30%%'	'0'	'103'	'0'	'143'	'0'	'72.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Reported'	'0.00%%'	'0'	'18.70%%'	'0'	'59'	'0'	'270'	'0'	'21.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Reported'	'0.00%%'	'0'	'99.20%%'	'0'	'84'	'0'	'84'	'0'	'100.00%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'338'	'0'	'384'	'0'	'88.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Reported'	'0'	'0'	'1.07'	'0'	'19'	'0'	'11.29'	'0'	'1.6829'	'0'	'1'	'No'
'PY4'	'DPH'	'San Joaquin General Hospital'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Reported'	'0.00%%'	'0'	'79.00%%'	'0'	'9'	'0'	'22.836'	'0'	'0.394'	'0'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Reported'	'0.00%%'	'0'	'44.00%%'	'0'	'175'	'0'	'321'	'0'	'54.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'31'	'0'	'92'	'0'	'33.70%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'289'	'0'	'861'	'0'	'33.60%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-IHE2'	'Q-IHE2'	'? Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention - Rate 1 (informational only) -Black/African American'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'359'	'0'	'363'	'0'	'98.90%%'	'0'	'0'	''
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-IHE2'	'Q-IHE2'	'? Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention - Rate 2 -Black/African American'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'73'	'0'	'120'	'0'	'60.80%%'	'0'	'1'	''
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-IHE2'	'Q-IHE2'	'? Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention - Rate 3 -Black/African American'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'312'	'0'	'363'	'0'	'86.00%%'	'0'	'1'	''
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'941'	'0'	'1321'	'0'	'71.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'2718'	'0'	'3928'	'0'	'69.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'7461'	'0'	'9631'	'0'	'77.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	'301'	'0'	'429'	'0'	'70.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Reported'	'0.00%%'	'0'	'48.30%%'	'0'	'952'	'0'	'1193'	'0'	'79.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'5101'	'0'	'8835'	'0'	'57.70%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Reported'	'0.00%%'	'0'	'15.10%%'	'0'	'570'	'0'	'895'	'0'	'63.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Reported'	'0.00%%'	'0'	'9.40%%'	'0'	'7416'	'0'	'10956'	'0'	'67.70%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Reported'	'0.00%%'	'0'	'30.90%%'	'0'	'316'	'0'	'558'	'0'	'56.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Reported'	'0.00%%'	'0'	'61.30%%'	'0'	'402'	'0'	'429'	'0'	'93.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'49.60%%'	'0'	'7242'	'0'	'19261'	'0'	'37.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Reported'	'0.00%%'	'0'	'19.20%%'	'0'	'8618'	'0'	'13687'	'0'	'63.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'12681'	'0'	'22869'	'0'	'55.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'10732'	'0'	'10810'	'0'	'99.30%%'	'0'	'N/A'	''
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'730'	'0'	'1565'	'0'	'46.70%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'9877'	'0'	'10810'	'0'	'91.40%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PC15'	'Q-WCC'	'? BMI'	'Reported'	'0.00%%'	'0'	'69.20%%'	'0'	'6552'	'0'	'7326'	'0'	'89.40%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PC15'	'Q-WCC'	'? Counseling for Nutrition'	'Reported'	'0.00%%'	'0'	'61.10%%'	'0'	'6355'	'0'	'7326'	'0'	'86.80%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PC15'	'Q-WCC'	'? Counseling for Physical Activity'	'Reported'	'0.00%%'	'0'	'55.80%%'	'0'	'1245'	'0'	'7326'	'0'	'17.00%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'Reported'	'0.00%%'	'0'	'66.40%%'	'0'	'375'	'0'	'439'	'0'	'85.40%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'102'	'0'	'164'	'0'	'62.20%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Reported'	'0.00%%'	'0'	'14.70%%'	'0'	'25'	'0'	'244'	'0'	'10.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adults)'	'Reported'	'0.00%%'	'0'	'36.10%%'	'0'	'150'	'0'	'539'	'0'	'27.80%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adults)'	'Reported'	'0.00%%'	'0'	'4.10%%'	'0'	'39'	'0'	'539'	'0'	'7.20%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adults)'	'Reported'	'0.00%%'	'0'	'9.60%%'	'0'	'59'	'0'	'539'	'0'	'11.00%%'	'0'	'1'	'Nos'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'30.00%%'	'0'	'22'	'0'	'125'	'0'	'17.60%%'	'0'	'N/A'	''
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'4.80%%'	'0'	''	'1'	'125'	'0'	''	'1'	'N/A'	''
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'9.50%%'	'0'	''	'1'	'125'	'0'	''	'1'	'N/A'	''
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'1583'	'0'	'3052'	'0'	'51.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Reported'	'0.00%%'	'0'	'66.90%%'	'0'	'140'	'0'	'163'	'0'	'85.90%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Reported'	'0.00%%'	'0'	'71.40%%'	'0'	'429'	'0'	'465'	'0'	'92.30%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Reported'	'0.00%%'	'0'	'60.40%%'	'0'	'35'	'0'	'41'	'0'	'85.40%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Reported'	'0.00%%'	'0'	'66.70%%'	'0'	'2471'	'0'	'3246'	'0'	'76.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'554'	'0'	'1939'	'0'	'28.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'1198'	'0'	'1939'	'0'	'61.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Reported'	'0.00%%'	'0'	'77.10%%'	'0'	'279'	'0'	'364'	'0'	'76.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Reported'	'0.00%%'	'0'	'59.90%%'	'0'	'54'	'0'	'63'	'0'	'85.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-CAR2'	'Q-PCE'	'? Systemic Corticosteroid'	'Reported'	'0.00%%'	'0'	'63.60%%'	'0'	'11'	'0'	''	'4'	''	'4'	'1'	'NoS'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-CAR2'	'Q-PCE'	'? Bronchodilator'	'Reported'	'0.00%%'	'0'	'78.70%%'	'0'	''	'1'	''	'4'	''	'1'	'1'	'NoS'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Reported'	'0.00%%'	'0'	'86.30%%'	'0'	'279'	'0'	'279'	'0'	'100.00%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	''	'1'	''	'1'	''	'1'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Reported'	'0.00%%'	'0'	'77.00%%'	'0'	'105'	'0'	'127'	'0'	'82.70%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Reported'	'0.00%%'	'0'	'71.30%%'	'0'	'247'	'0'	'262'	'0'	'94.30%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Reported'	'0.00%%'	'0'	'71.10%%'	'0'	'261'	'0'	'276'	'0'	'94.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Reported'	'0.00%%'	'0'	'79.30%%'	'0'	'236'	'0'	'268'	'0'	'88.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Reported'	'0.00%%'	'0'	'18.70%%'	'0'	''	'1'	'4933'	'0'	''	'1'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'374'	'0'	'376'	'0'	'99.50%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Reported'	'0.00%%'	'0'	'44.90%%'	'0'	'52'	'0'	'75'	'0'	'69.30%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Reported'	'0.00%%'	'0'	'44.00%%'	'0'	'3810'	'0'	'3892'	'0'	'97.90%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Reported'	'0.00%%'	'0'	'100.00%%'	'0'	'159'	'0'	'260.038'	'0'	'0.611'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'Yes'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'151'	'0'	'405'	'0'	'37.30%%'	'0'	'1'	'YesS'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'1228'	'0'	'2813'	'0'	'43.70%%'	'0'	'1'	'YesS'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'3014'	'0'	'5407'	'0'	'55.70%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'8551'	'0'	'16890'	'0'	'50.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'15279'	'0'	'33679'	'0'	'45.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	'1142'	'0'	'1926'	'0'	'59.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Reported'	'0.00%%'	'0'	'48.30%%'	'0'	'1896'	'0'	'3129'	'0'	'60.60%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'9324'	'0'	'16156'	'0'	'57.70%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Reported'	'0.00%%'	'0'	'15.10%%'	'0'	'3233'	'0'	'4424'	'0'	'73.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Reported'	'0.00%%'	'0'	'9.40%%'	'0'	'19015'	'0'	'27605'	'0'	'68.90%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Reported'	'0.00%%'	'0'	'30.90%%'	'0'	'635'	'0'	'2091'	'0'	'30.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Reported'	'0.00%%'	'0'	'61.30%%'	'0'	'1541'	'0'	'2059'	'0'	'74.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Reported'	'0.00%%'	'0'	'19.20%%'	'0'	'24229'	'0'	'49054'	'0'	'49.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'10672'	'0'	'27386'	'0'	'39.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'41089'	'0'	'42305'	'0'	'97.10%%'	'0'	'0'	''
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'2263'	'0'	'6455'	'0'	'35.10%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'36897'	'0'	'42305'	'0'	'87.20%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PC15'	'Q-WCC'	'? BMI'	'Reported'	'0.00%%'	'0'	'69.20%%'	'0'	'15224'	'0'	'18347'	'0'	'83.00%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PC15'	'Q-WCC'	'? Counseling for Nutrition'	'Reported'	'0.00%%'	'0'	'61.10%%'	'0'	'12825'	'0'	'18347'	'0'	'69.90%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PC15'	'Q-WCC'	'? Counseling for Physical Activity'	'Reported'	'0.00%%'	'0'	'55.80%%'	'0'	'12466'	'0'	'18347'	'0'	'68.00%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'Yes'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'Reported'	'0.00%%'	'0'	'66.40%%'	'0'	'1377'	'0'	'1984'	'0'	'69.40%%'	'0'	'1'	'YesS'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'467'	'0'	'721'	'0'	'64.80%%'	'0'	'1'	'YesS'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Reported'	'0.00%%'	'0'	'14.70%%'	'0'	'87'	'0'	'911'	'0'	'9.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adults)'	'Reported'	'0.00%%'	'0'	'36.10%%'	'0'	'146'	'0'	'609'	'0'	'24.00%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adults)'	'Reported'	'0.00%%'	'0'	'4.10%%'	'0'	'35'	'0'	'609'	'0'	'5.80%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adults)'	'Reported'	'0.00%%'	'0'	'9.60%%'	'0'	'54'	'0'	'609'	'0'	'8.90%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'30.00%%'	'0'	'0'	'0'	''	'1'	''	'1'	'0'	''
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'4.80%%'	'0'	'0'	'0'	''	'1'	''	'1'	'0'	''
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'9.50%%'	'0'	'0'	'0'	''	'1'	''	'1'	'0'	''
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Reported'	'0.00%%'	'0'	'4.70%%'	'0'	'29'	'0'	'760'	'0'	'3.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'2786'	'0'	'5965'	'0'	'46.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Reported'	'0.00%%'	'0'	'66.90%%'	'0'	'655'	'0'	'795'	'0'	'82.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Reported'	'0.00%%'	'0'	'71.40%%'	'0'	'711'	'0'	'750'	'0'	'94.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Reported'	'0.00%%'	'0'	'60.40%%'	'0'	'562'	'0'	'643'	'0'	'87.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'2376'	'0'	'6694'	'0'	'35.50%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'5618'	'0'	'6694'	'0'	'83.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Reported'	'0.00%%'	'0'	'88.30%%'	'0'	'6008'	'0'	'6694'	'0'	'89.80%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Reported'	'0.00%%'	'0'	'77.10%%'	'0'	'641'	'0'	'784'	'0'	'81.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Reported'	'0.00%%'	'0'	'59.90%%'	'0'	'632'	'0'	'1174'	'0'	'53.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Reported'	'0.00%%'	'0'	'77.00%%'	'0'	'118'	'0'	'118'	'0'	'100.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Reported'	'0.00%%'	'0'	'47.80%%'	'0'	'2155'	'0'	'3063'	'0'	'70.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Reported'	'0.00%%'	'0'	'71.10%%'	'0'	'587'	'0'	'771'	'0'	'76.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Reported'	'0.00%%'	'0'	'79.30%%'	'0'	'633'	'0'	'771'	'0'	'82.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Reported'	'0.00%%'	'0'	'18.70%%'	'0'	'4567'	'0'	'12158'	'0'	'37.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Reported'	'0.00%%'	'0'	'99.20%%'	'0'	'324'	'0'	'324'	'0'	'100.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'4539'	'0'	'4551'	'0'	'99.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Reported'	'0.00%%'	'0'	'44.90%%'	'0'	'1829'	'0'	'2480'	'0'	'73.80%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Reported'	'0'	'0'	'1.07'	'0'	'35'	'0'	'18.731'	'0'	'1.8686'	'0'	'1'	'No'
'PY4'	'DPH'	'Santa Clara Valley Medical Center'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Reported'	'0.00%%'	'0'	'79.00%%'	'0'	'68'	'0'	'105.746'	'0'	'0.643'	'0'	'1'	'No'
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'San Mateo Medical Center'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Reported'	'0.00%%'	'0'	'44.00%%'	'0'	'284'	'0'	'285'	'0'	'99.70%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'26'	'0'	'66'	'0'	'39.40%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'30'	'0'	'75'	'0'	'40.00%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'130'	'0'	'242'	'0'	'53.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'558'	'0'	'1108'	'0'	'50.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'458'	'0'	'1682'	'0'	'27.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	'31'	'0'	'159'	'0'	'19.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Reported'	'0.00%%'	'0'	'48.30%%'	'0'	'55'	'0'	'90'	'0'	'61.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'2165'	'0'	'4884'	'0'	'44.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Reported'	'0.00%%'	'0'	'15.10%%'	'0'	'23'	'0'	'291'	'0'	'7.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Reported'	'0.00%%'	'0'	'9.40%%'	'0'	'1246'	'0'	'1562'	'0'	'79.80%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Reported'	'0.00%%'	'0'	'30.90%%'	'0'	'24'	'0'	'104'	'0'	'23.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Reported'	'0.00%%'	'0'	'61.30%%'	'0'	'43'	'0'	'159'	'0'	'27.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Reported'	'0.00%%'	'0'	'19.20%%'	'0'	'8948'	'0'	'22558'	'0'	'39.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'2641'	'0'	'9863'	'0'	'26.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'16084'	'0'	'17365'	'0'	'92.60%%'	'0'	'N/A'	''
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'1018'	'0'	'2386'	'0'	'42.70%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'14447'	'0'	'17096'	'0'	'84.50%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'Reported'	'0.00%%'	'0'	'66.40%%'	'0'	'38'	'0'	'120'	'0'	'31.70%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	''	'1'	'36'	'0'	''	'1'	'1'	'NoS'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Reported'	'0.00%%'	'0'	'14.70%%'	'0'	''	'1'	'114'	'0'	''	'1'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adults)'	'Reported'	'0.00%%'	'0'	'36.10%%'	'0'	'22'	'0'	'38'	'0'	'57.90%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adults)'	'Reported'	'0.00%%'	'0'	'4.10%%'	'0'	''	'1'	'38'	'0'	''	'1'	'1'	'NoS'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adults)'	'Reported'	'0.00%%'	'0'	'9.60%%'	'0'	''	'1'	'38'	'0'	''	'1'	'1'	'NoS'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'30.00%%'	'0'	'0'	'0'	''	'1'	''	'1'	'N/A'	''
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'4.80%%'	'0'	'0'	'0'	''	'1'	''	'1'	'N/A'	''
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'9.50%%'	'0'	'0'	'0'	''	'1'	''	'1'	'N/A'	''
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Reported'	'0.00%%'	'0'	'4.70%%'	'0'	''	'1'	'93'	'0'	''	'1'	'1'	'Yes'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'108'	'0'	'172'	'0'	'62.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Reported'	'0.00%%'	'0'	'66.90%%'	'0'	'291'	'0'	'355'	'0'	'82.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Reported'	'0.00%%'	'0'	'71.40%%'	'0'	'753'	'0'	'878'	'0'	'85.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Reported'	'0.00%%'	'0'	'60.40%%'	'0'	'669'	'0'	'727'	'0'	'92.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Reported'	'0.00%%'	'0'	'66.70%%'	'0'	'307'	'0'	'408'	'0'	'75.30%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'94'	'0'	'283'	'0'	'33.20%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'192'	'0'	'283'	'0'	'67.80%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Reported'	'0.00%%'	'0'	'88.30%%'	'0'	'265'	'0'	'283'	'0'	'93.60%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Reported'	'0.00%%'	'0'	'77.10%%'	'0'	'84'	'0'	'108'	'0'	'77.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Reported'	'0.00%%'	'0'	'59.90%%'	'0'	'48'	'0'	'82'	'0'	'58.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Reported'	'0.00%%'	'0'	'77.00%%'	'0'	'298'	'0'	'325'	'0'	'91.70%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Reported'	'0.00%%'	'0'	'71.30%%'	'0'	'42'	'0'	'50'	'0'	'84.00%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Reported'	'0.00%%'	'0'	'24.80%%'	'0'	'65'	'0'	'191'	'0'	'34.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Reported'	'0.00%%'	'0'	'19.70%%'	'0'	'216'	'0'	'967'	'0'	'22.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Reported'	'0.00%%'	'0'	'47.80%%'	'0'	'253'	'0'	'496'	'0'	'51.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Reported'	'0.00%%'	'0'	'71.10%%'	'0'	'39'	'0'	'54'	'0'	'72.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Reported'	'0.00%%'	'0'	'79.30%%'	'0'	'41'	'0'	'54'	'0'	'75.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Reported'	'0.00%%'	'0'	'18.70%%'	'0'	'1176'	'0'	'6353'	'0'	'18.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'11723'	'0'	'11996'	'0'	'97.70%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Reported'	'0.00%%'	'0'	'44.90%%'	'0'	'341'	'0'	'361'	'0'	'94.50%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Reported'	'0'	'0'	'1.07'	'0'	'48'	'0'	'42.8'	'0'	'1.1215'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Davis Medical Center'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Reported'	'0.00%%'	'0'	'79.00%%'	'0'	'52'	'0'	'97.67'	'0'	'0.532'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Reported'	'0.00%%'	'0'	'44.00%%'	'0'	'956'	'0'	'957'	'0'	'99.90%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	''	'1'	'35'	'0'	''	'1'	'1'	'NoS'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'342'	'0'	'1054'	'0'	'32.50%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'567'	'0'	'1079'	'0'	'52.60%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'3126'	'0'	'5849'	'0'	'53.50%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'2831'	'0'	'6299'	'0'	'44.90%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	'256'	'0'	'465'	'0'	'55.10%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Reported'	'0.00%%'	'0'	'48.30%%'	'0'	'499'	'0'	'778'	'0'	'64.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'3003'	'0'	'5759'	'0'	'52.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Reported'	'0.00%%'	'0'	'15.10%%'	'0'	'606'	'0'	'1364'	'0'	'44.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Reported'	'0.00%%'	'0'	'9.40%%'	'0'	'4838'	'0'	'8206'	'0'	'59.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Reported'	'0.00%%'	'0'	'30.90%%'	'0'	'103'	'0'	'264'	'0'	'39.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Reported'	'0.00%%'	'0'	'61.30%%'	'0'	'214'	'0'	'465'	'0'	'46.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'49.60%%'	'0'	'9085'	'0'	'15115'	'0'	'60.10%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Reported'	'0.00%%'	'0'	'19.20%%'	'0'	'8880'	'0'	'20481'	'0'	'43.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'9266'	'0'	'17209'	'0'	'53.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'21706'	'0'	'22446'	'0'	'96.70%%'	'0'	'1'	''
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'544'	'0'	'1676'	'0'	'32.50%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'20331'	'0'	'22203'	'0'	'91.60%%'	'0'	'1'	'Nos'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'Yes'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PC15'	'Q-WCC'	'? BMI'	'Reported'	'0.00%%'	'0'	'69.20%%'	'0'	'3283'	'0'	'3337'	'0'	'98.40%%'	'0'	'1'	'YesS'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PC15'	'Q-WCC'	'? Counseling for Nutrition'	'Reported'	'0.00%%'	'0'	'61.10%%'	'0'	'2723'	'0'	'3337'	'0'	'81.60%%'	'0'	'1'	'YesS'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PC15'	'Q-WCC'	'? Counseling for Physical Activity'	'Reported'	'0.00%%'	'0'	'55.80%%'	'0'	'2717'	'0'	'3337'	'0'	'81.40%%'	'0'	'1'	'YesS'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'Reported'	'0.00%%'	'0'	'66.40%%'	'0'	'273'	'0'	'421'	'0'	'64.90%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'116'	'0'	'183'	'0'	'63.40%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Reported'	'0.00%%'	'0'	'14.70%%'	'0'	'16'	'0'	'292'	'0'	'5.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adults)'	'Reported'	'0.00%%'	'0'	'36.10%%'	'0'	'58'	'0'	'194'	'0'	'29.90%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adults)'	'Reported'	'0.00%%'	'0'	'4.10%%'	'0'	'27'	'0'	'194'	'0'	'13.90%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adults)'	'Reported'	'0.00%%'	'0'	'9.60%%'	'0'	'33'	'0'	'194'	'0'	'17.00%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'30.00%%'	'0'	''	'1'	''	'4'	''	'1'	'1'	''
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'4.80%%'	'0'	''	'1'	''	'4'	''	'1'	'1'	''
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'9.50%%'	'0'	''	'1'	''	'4'	''	'1'	'1'	''
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-BH3'	'Q-FUA'	'? 30 Days'	'Reported'	'0.00%%'	'0'	'10.80%%'	'0'	''	'1'	'35'	'0'	''	'1'	'1'	'NoS'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-BH3'	'Q-FUA'	'? 7 Days'	'Reported'	'0.00%%'	'0'	'7.10%%'	'0'	''	'1'	'35'	'0'	''	'1'	'1'	'NoS'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Reported'	'0.00%%'	'0'	'4.70%%'	'0'	'12'	'0'	'252'	'0'	'4.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'680'	'0'	'1173'	'0'	'58.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Reported'	'0.00%%'	'0'	'71.40%%'	'0'	'291'	'0'	'336'	'0'	'86.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Reported'	'0.00%%'	'0'	'60.40%%'	'0'	'74'	'0'	'82'	'0'	'90.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'449'	'0'	'1400'	'0'	'32.10%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'438'	'0'	'1400'	'0'	'31.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Reported'	'0.00%%'	'0'	'88.30%%'	'0'	'1265'	'0'	'1400'	'0'	'90.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Reported'	'0.00%%'	'0'	'77.10%%'	'0'	'251'	'0'	'340'	'0'	'73.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Reported'	'0.00%%'	'0'	'59.90%%'	'0'	'122'	'0'	'173'	'0'	'70.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Reported'	'0.00%%'	'0'	'86.30%%'	'0'	'308'	'0'	'314'	'0'	'98.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Reported'	'0.00%%'	'0'	'77.00%%'	'0'	'687'	'0'	'1246'	'0'	'55.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Reported'	'0.00%%'	'0'	'71.30%%'	'0'	'300'	'0'	'358'	'0'	'83.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Reported'	'0.00%%'	'0'	'24.80%%'	'0'	'46'	'0'	'262'	'0'	'17.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Reported'	'0.00%%'	'0'	'19.70%%'	'0'	'1536'	'0'	'5589'	'0'	'27.50%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Reported'	'0.00%%'	'0'	'47.80%%'	'0'	'103'	'0'	'170'	'0'	'60.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Reported'	'0.00%%'	'0'	'71.10%%'	'0'	'366'	'0'	'445'	'0'	'82.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Reported'	'0.00%%'	'0'	'79.30%%'	'0'	'335'	'0'	'445'	'0'	'75.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Reported'	'0.00%%'	'0'	'18.70%%'	'0'	'3988'	'0'	'7750'	'0'	'51.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'11615'	'0'	'11950'	'0'	'97.20%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Irvine Medical Center'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Reported'	'0.00%%'	'0'	'44.00%%'	'0'	'30'	'0'	'30'	'0'	'100.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'0'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	''	'1'	''	'1'	''	'1'	'0'	'NoS'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	''	'1'	''	'4'	''	'1'	'0'	'NoS'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Colorectal Cancer Screening - -Native Hawaiian/Pacific Islander'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	''	'1'	'33'	'0'	''	'1'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'52'	'0'	'98'	'0'	'53.10%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'129'	'0'	'234'	'0'	'55.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'2054'	'0'	'3907'	'0'	'52.60%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	'75'	'0'	'189'	'0'	'39.70%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Reported'	'0.00%%'	'0'	'48.30%%'	'0'	'86'	'0'	'156'	'0'	'55.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'4282'	'0'	'12745'	'0'	'33.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Reported'	'0.00%%'	'0'	'15.10%%'	'0'	'67'	'0'	'399'	'0'	'16.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Reported'	'0.00%%'	'0'	'9.40%%'	'0'	'459'	'0'	'1084'	'0'	'42.30%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Reported'	'0.00%%'	'0'	'30.90%%'	'0'	'83'	'0'	'233'	'0'	'35.60%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Reported'	'0.00%%'	'0'	'61.30%%'	'0'	'95'	'0'	'189'	'0'	'50.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'49.60%%'	'0'	'9767'	'0'	'26501'	'0'	'36.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Reported'	'0.00%%'	'0'	'19.20%%'	'0'	'11857'	'0'	'24465'	'0'	'48.50%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'8256'	'0'	'32188'	'0'	'25.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'22952'	'0'	'24301'	'0'	'94.50%%'	'0'	'N/A'	''
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'438'	'0'	'1463'	'0'	'29.90%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'21606'	'0'	'23980'	'0'	'90.10%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PC15'	'Q-WCC'	'? BMI'	'Reported'	'0.00%%'	'0'	'69.20%%'	'0'	'756'	'0'	'2377'	'0'	'31.80%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PC15'	'Q-WCC'	'? Counseling for Nutrition'	'Reported'	'0.00%%'	'0'	'61.10%%'	'0'	'405'	'0'	'2377'	'0'	'17.00%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PC15'	'Q-WCC'	'? Counseling for Physical Activity'	'Reported'	'0.00%%'	'0'	'55.80%%'	'0'	'412'	'0'	'2377'	'0'	'17.30%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'Reported'	'0.00%%'	'0'	'66.40%%'	'0'	'107'	'0'	'180'	'0'	'59.40%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'21'	'0'	'39'	'0'	'53.90%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'56'	'0'	'79'	'0'	'70.90%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Reported'	'0.00%%'	'0'	'66.90%%'	'0'	'649'	'0'	'804'	'0'	'80.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Reported'	'0.00%%'	'0'	'71.40%%'	'0'	'1538'	'0'	'1755'	'0'	'87.60%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Reported'	'0.00%%'	'0'	'60.40%%'	'0'	'334'	'0'	'405'	'0'	'82.50%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Reported'	'0.00%%'	'0'	'66.70%%'	'0'	'51'	'0'	'80'	'0'	'63.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'15'	'0'	'51'	'0'	'29.40%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'19'	'0'	'51'	'0'	'37.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Reported'	'0.00%%'	'0'	'88.30%%'	'0'	'44'	'0'	'51'	'0'	'86.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Reported'	'0.00%%'	'0'	'77.10%%'	'0'	'207'	'0'	'325'	'0'	'63.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Reported'	'0.00%%'	'0'	'59.90%%'	'0'	'57'	'0'	'80'	'0'	'71.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Reported'	'0.00%%'	'0'	'86.30%%'	'0'	'92'	'0'	'94'	'0'	'97.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Reported'	'0.00%%'	'0'	'77.00%%'	'0'	'428'	'0'	'466'	'0'	'91.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Reported'	'0.00%%'	'0'	'24.80%%'	'0'	'35'	'0'	'129'	'0'	'27.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Reported'	'0.00%%'	'0'	'19.70%%'	'0'	'125'	'0'	'795'	'0'	'15.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Reported'	'0.00%%'	'0'	'47.80%%'	'0'	'164'	'0'	'334'	'0'	'49.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Reported'	'0.00%%'	'0'	'71.10%%'	'0'	''	'1'	''	'1'	''	'1'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Reported'	'0.00%%'	'0'	'79.30%%'	'0'	''	'1'	''	'1'	''	'1'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Reported'	'0.00%%'	'0'	'18.70%%'	'0'	'6271'	'0'	'13482'	'0'	'46.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'13292'	'0'	'20346'	'0'	'65.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Reported'	'0.00%%'	'0'	'44.90%%'	'0'	'3427'	'0'	'6856'	'0'	'50.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Reported'	'0'	'0'	'1.07'	'0'	'27.933'	'0'	'2088'	'0'	'0.0134'	'0'	'1'	'No'
'PY4'	'DPH'	'UC Los Angeles Medical Center'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Reported'	'0.00%%'	'0'	'79.00%%'	'0'	'141'	'0'	'157.089'	'0'	'0.898'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Reported'	'0.00%%'	'0'	'44.00%%'	'0'	'136'	'0'	'136'	'0'	'100.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	''	'1'	''	'4'	''	'1'	'N/A'	'NoS'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	''	'1'	'39'	'0'	''	'1'	'1'	'NoS'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'121'	'0'	'204'	'0'	'59.30%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'458'	'0'	'768'	'0'	'59.60%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'595'	'0'	'1275'	'0'	'46.70%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	'26'	'0'	'164'	'0'	'15.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Reported'	'0.00%%'	'0'	'48.30%%'	'0'	'19'	'0'	'34'	'0'	'55.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'1512'	'0'	'2009'	'0'	'75.30%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Reported'	'0.00%%'	'0'	'15.10%%'	'0'	'142'	'0'	'329'	'0'	'43.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Reported'	'0.00%%'	'0'	'9.40%%'	'0'	'600'	'0'	'1085'	'0'	'55.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Reported'	'0.00%%'	'0'	'30.90%%'	'0'	''	'1'	'40'	'0'	''	'1'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'49.60%%'	'0'	'2535'	'0'	'4432'	'0'	'57.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Reported'	'0.00%%'	'0'	'19.20%%'	'0'	'12046'	'0'	'23502'	'0'	'51.30%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'1799'	'0'	'2716'	'0'	'66.20%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'31354'	'0'	'33597'	'0'	'93.30%%'	'0'	'N/A'	''
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'1613'	'0'	'3712'	'0'	'43.50%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'28765'	'0'	'33107'	'0'	'86.90%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PC15'	'Q-WCC'	'? BMI'	'Reported'	'0.00%%'	'0'	'69.20%%'	'0'	'411'	'0'	'631'	'0'	'65.10%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PC15'	'Q-WCC'	'? Counseling for Nutrition'	'Reported'	'0.00%%'	'0'	'61.10%%'	'0'	'388'	'0'	'631'	'0'	'61.50%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PC15'	'Q-WCC'	'? Counseling for Physical Activity'	'Reported'	'0.00%%'	'0'	'55.80%%'	'0'	'379'	'0'	'631'	'0'	'60.10%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'Reported'	'0.00%%'	'0'	'66.40%%'	'0'	'70'	'0'	'108'	'0'	'64.80%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'22'	'0'	'53'	'0'	'41.50%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'162'	'0'	'246'	'0'	'65.90%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Reported'	'0.00%%'	'0'	'66.90%%'	'0'	'49'	'0'	'56'	'0'	'87.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Reported'	'0.00%%'	'0'	'71.40%%'	'0'	'100'	'0'	'116'	'0'	'86.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Reported'	'0.00%%'	'0'	'60.40%%'	'0'	'43'	'0'	'43'	'0'	'100.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Reported'	'0.00%%'	'0'	'66.70%%'	'0'	'286'	'0'	'462'	'0'	'61.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'40'	'0'	'174'	'0'	'23.00%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'102'	'0'	'174'	'0'	'58.60%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Reported'	'0.00%%'	'0'	'88.30%%'	'0'	'156'	'0'	'174'	'0'	'89.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Reported'	'0.00%%'	'0'	'77.10%%'	'0'	'123'	'0'	'153'	'0'	'80.40%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Reported'	'0.00%%'	'0'	'59.90%%'	'0'	'39'	'0'	'46'	'0'	'84.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Reported'	'0.00%%'	'0'	'77.00%%'	'0'	'415'	'0'	'936'	'0'	'44.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Reported'	'0.00%%'	'0'	'71.30%%'	'0'	''	'1'	'42'	'0'	''	'1'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Reported'	'0.00%%'	'0'	'24.80%%'	'0'	'108'	'0'	'436'	'0'	'24.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Reported'	'0.00%%'	'0'	'19.70%%'	'0'	'152'	'0'	'556'	'0'	'27.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Reported'	'0.00%%'	'0'	'47.80%%'	'0'	'789'	'0'	'1095'	'0'	'72.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Reported'	'0.00%%'	'0'	'71.10%%'	'0'	'16'	'0'	''	'4'	''	'4'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Reported'	'0.00%%'	'0'	'79.30%%'	'0'	'13'	'0'	''	'4'	''	'4'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Reported'	'0.00%%'	'0'	'18.70%%'	'0'	'3858'	'0'	'9242'	'0'	'41.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Reported'	'0.00%%'	'0'	'99.20%%'	'0'	'655'	'0'	'709'	'0'	'92.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'16259'	'0'	'16691'	'0'	'97.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Reported'	'0.00%%'	'0'	'44.90%%'	'0'	'3945'	'0'	'6619'	'0'	'59.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Reported'	'0'	'0'	'1.07'	'0'	'30'	'0'	'46.024'	'0'	'0.6518'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Diego Medical Center'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Reported'	'0.00%%'	'0'	'79.00%%'	'0'	'127'	'0'	'145.81'	'0'	'0.871'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Reported'	'0.00%%'	'0'	'44.00%%'	'0'	'626'	'0'	'626'	'0'	'100.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Reported'	'0.00%%'	'0'	'100.00%%'	'0'	'44'	'0'	'43.758'	'0'	'1.006'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'51'	'0'	'173'	'0'	'29.50%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'32'	'0'	'113'	'0'	'28.30%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-IHE2'	'Q-IHE2'	'? Controlling High Blood Pressure (CBP) - -Black/African American'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'131'	'0'	'239'	'0'	'54.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'681'	'0'	'1229'	'0'	'55.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'2312'	'0'	'3583'	'0'	'64.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'2428'	'0'	'3840'	'0'	'63.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	'131'	'0'	'258'	'0'	'50.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Reported'	'0.00%%'	'0'	'48.30%%'	'0'	'172'	'0'	'334'	'0'	'51.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'2923'	'0'	'4386'	'0'	'66.60%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Reported'	'0.00%%'	'0'	'15.10%%'	'0'	'340'	'0'	'618'	'0'	'55.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Reported'	'0.00%%'	'0'	'9.40%%'	'0'	'3795'	'0'	'5269'	'0'	'72.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Reported'	'0.00%%'	'0'	'30.90%%'	'0'	'94'	'0'	'266'	'0'	'35.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Reported'	'0.00%%'	'0'	'19.20%%'	'0'	'17796'	'0'	'27647'	'0'	'64.40%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'4753'	'0'	'8022'	'0'	'59.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'25125'	'0'	'25747'	'0'	'97.60%%'	'0'	'N/A'	''
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'1100'	'0'	'2473'	'0'	'44.50%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'23423'	'0'	'25418'	'0'	'92.20%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'Reported'	'0.00%%'	'0'	'66.40%%'	'0'	'161'	'0'	'233'	'0'	'69.10%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'67'	'0'	'105'	'0'	'63.80%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'Yes'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adults)'	'Reported'	'0.00%%'	'0'	'36.10%%'	'0'	'170'	'0'	'324'	'0'	'52.50%%'	'0'	'1'	'YesS'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adults)'	'Reported'	'0.00%%'	'0'	'4.10%%'	'0'	'32'	'0'	'324'	'0'	'9.90%%'	'0'	'1'	'YesS'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adults)'	'Reported'	'0.00%%'	'0'	'9.60%%'	'0'	'55'	'0'	'324'	'0'	'17.00%%'	'0'	'1'	'YesS'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'30.00%%'	'0'	''	'1'	''	'4'	''	'1'	'N/A'	''
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'4.80%%'	'0'	''	'1'	''	'4'	''	'1'	'N/A'	''
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'9.50%%'	'0'	''	'1'	''	'4'	''	'1'	'N/A'	''
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'643'	'0'	'1042'	'0'	'61.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Reported'	'0.00%%'	'0'	'66.90%%'	'0'	'182'	'0'	'194'	'0'	'93.80%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Reported'	'0.00%%'	'0'	'71.40%%'	'0'	'320'	'0'	'332'	'0'	'96.40%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Reported'	'0.00%%'	'0'	'60.40%%'	'0'	'105'	'0'	'108'	'0'	'97.20%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Reported'	'0.00%%'	'0'	'66.70%%'	'0'	'1006'	'0'	'1371'	'0'	'73.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'202'	'0'	'816'	'0'	'24.80%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'451'	'0'	'804'	'0'	'56.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Reported'	'0.00%%'	'0'	'88.30%%'	'0'	'738'	'0'	'815'	'0'	'90.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Reported'	'0.00%%'	'0'	'77.10%%'	'0'	'498'	'0'	'552'	'0'	'90.20%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Reported'	'0.00%%'	'0'	'59.90%%'	'0'	'136'	'0'	'225'	'0'	'60.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Reported'	'0.00%%'	'0'	'86.30%%'	'0'	'207'	'0'	'211'	'0'	'98.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Reported'	'0.00%%'	'0'	'24.80%%'	'0'	'29'	'0'	'124'	'0'	'23.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Reported'	'0.00%%'	'0'	'19.70%%'	'0'	'881'	'0'	'2860'	'0'	'30.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Reported'	'0.00%%'	'0'	'47.80%%'	'0'	'153'	'0'	'242'	'0'	'63.20%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Reported'	'0.00%%'	'0'	'71.10%%'	'0'	'117'	'0'	'145'	'0'	'80.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Reported'	'0.00%%'	'0'	'79.30%%'	'0'	'81'	'0'	'145'	'0'	'55.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Reported'	'0.00%%'	'0'	'18.70%%'	'0'	'8686'	'0'	'11040'	'0'	'78.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Reported'	'0.00%%'	'0'	'99.20%%'	'0'	'357'	'0'	'357'	'0'	'100.00%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'12716'	'0'	'12873'	'0'	'98.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Reported'	'0.00%%'	'0'	'44.90%%'	'0'	'4533'	'0'	'4958'	'0'	'91.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Reported'	'0'	'0'	'1.07'	'0'	'37'	'0'	'56.886'	'0'	'0.6504'	'0'	'1'	'No'
'PY4'	'DPH'	'UC San Francisco Medical Center'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Reported'	'0.00%%'	'0'	'79.00%%'	'0'	'101'	'0'	'108.54'	'0'	'0.931'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Reported'	'0.00%%'	'0'	'44.00%%'	'0'	'1453'	'0'	'1529'	'0'	'95.00%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'24'	'0'	'63'	'0'	'38.10%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'695'	'0'	'1894'	'0'	'36.70%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'1881'	'0'	'3524'	'0'	'53.40%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'8461'	'0'	'15995'	'0'	'52.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'13925'	'0'	'35545'	'0'	'39.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	'637'	'0'	'1687'	'0'	'37.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Reported'	'0.00%%'	'0'	'48.30%%'	'0'	'1393'	'0'	'2717'	'0'	'51.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'4447'	'0'	'9615'	'0'	'46.30%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Reported'	'0.00%%'	'0'	'15.10%%'	'0'	'1415'	'0'	'3411'	'0'	'41.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Reported'	'0.00%%'	'0'	'9.40%%'	'0'	'13348'	'0'	'26007'	'0'	'51.30%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Reported'	'0.00%%'	'0'	'30.90%%'	'0'	'714'	'0'	'2188'	'0'	'32.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Reported'	'0.00%%'	'0'	'61.30%%'	'0'	'823'	'0'	'1695'	'0'	'48.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'49.60%%'	'0'	'18226'	'0'	'31358'	'0'	'58.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Reported'	'0.00%%'	'0'	'19.20%%'	'0'	'16076'	'0'	'29653'	'0'	'54.20%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'16538'	'0'	'30020'	'0'	'55.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'Yes'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'26581'	'0'	'26761'	'0'	'99.30%%'	'0'	'N/A'	''
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'1153'	'0'	'2231'	'0'	'51.70%%'	'0'	'1'	'YesS'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'25359'	'0'	'26760'	'0'	'94.80%%'	'0'	'1'	'YesS'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'Reported'	'0.00%%'	'0'	'66.40%%'	'0'	'1104'	'0'	'1659'	'0'	'66.60%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'242'	'0'	'334'	'0'	'72.50%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adults)'	'Reported'	'0.00%%'	'0'	'36.10%%'	'0'	'270'	'0'	'714'	'0'	'37.80%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adults)'	'Reported'	'0.00%%'	'0'	'4.10%%'	'0'	'62'	'0'	'714'	'0'	'8.70%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adults)'	'Reported'	'0.00%%'	'0'	'9.60%%'	'0'	'108'	'0'	'714'	'0'	'15.10%%'	'0'	'1'	'NoS'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'30.00%%'	'0'	'44'	'0'	'170'	'0'	'25.90%%'	'0'	'N/A'	''
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'4.80%%'	'0'	'11'	'0'	'170'	'0'	'6.50%%'	'0'	'N/A'	''
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adolescents) - informational only'	'Reported'	'0.00%%'	'0'	'9.50%%'	'0'	'20'	'0'	'170'	'0'	'11.80%%'	'0'	'N/A'	''
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'2206'	'0'	'4050'	'0'	'54.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Reported'	'0.00%%'	'0'	'66.90%%'	'0'	'134'	'0'	'159'	'0'	'84.30%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Reported'	'0.00%%'	'0'	'71.40%%'	'0'	'314'	'0'	'362'	'0'	'86.70%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Reported'	'0.00%%'	'0'	'60.40%%'	'0'	'47'	'0'	'49'	'0'	'95.90%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Reported'	'0.00%%'	'0'	'66.70%%'	'0'	'2378'	'0'	'3569'	'0'	'66.60%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'1103'	'0'	'3091'	'0'	'35.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'1506'	'0'	'3091'	'0'	'48.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Reported'	'0.00%%'	'0'	'88.30%%'	'0'	'2623'	'0'	'3091'	'0'	'84.90%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Reported'	'0.00%%'	'0'	'77.10%%'	'0'	'130'	'0'	'225'	'0'	'57.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Reported'	'0.00%%'	'0'	'59.90%%'	'0'	'544'	'0'	'957'	'0'	'56.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Reported'	'0.00%%'	'0'	'86.30%%'	'0'	'970'	'0'	'984'	'0'	'98.60%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'77'	'0'	'81'	'0'	'95.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Reported'	'0.00%%'	'0'	'77.00%%'	'0'	'62'	'0'	'91'	'0'	'68.10%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Reported'	'0.00%%'	'0'	'71.30%%'	'0'	'1230'	'0'	'1516'	'0'	'81.10%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Reported'	'0.00%%'	'0'	'24.80%%'	'0'	'50'	'0'	'269'	'0'	'18.60%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Reported'	'0.00%%'	'0'	'47.80%%'	'0'	'616'	'0'	'913'	'0'	'67.50%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Reported'	'0.00%%'	'0'	'71.10%%'	'0'	'655'	'0'	'831'	'0'	'78.80%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Reported'	'0.00%%'	'0'	'79.30%%'	'0'	'704'	'0'	'831'	'0'	'84.70%%'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'1874'	'0'	'1902'	'0'	'98.50%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Reported'	'0.00%%'	'0'	'44.90%%'	'0'	'125'	'0'	'250'	'0'	'50.00%%'	'0'	'1'	'Yes'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Reported'	'0'	'0'	'1.07'	'0'	'5'	'0'	'6.585'	'0'	'0.7593'	'0'	'1'	'No'
'PY4'	'DPH'	'Ventura County Medical Center'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Reported'	'0.00%%'	'0'	'79.00%%'	'0'	'13'	'0'	'12.58'	'0'	'1.033'	'0'	'1'	'No'
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Reported'	'0.00%%'	'0'	'44.00%%'	'0'	'4939'	'0'	'6806'	'0'	'72.60%%'	'0'	'0.5'	'No'
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Reported'	'0.00%%'	'0'	'100.00%%'	'0'	'262'	'0'	'221.579'	'0'	'1.182'	'0'	'0.5'	'No'
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'0.5'	'No'
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-BH3'	'Q-FUA'	'? 30 Days'	'Reported'	'0.00%%'	'0'	'10.80%%'	'0'	'64'	'0'	'339'	'0'	'18.90%%'	'0'	'0.5'	'NoS'
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-BH3'	'Q-FUA'	'? 7 Days'	'Reported'	'0.00%%'	'0'	'7.10%%'	'0'	'70'	'0'	'339'	'0'	'20.70%%'	'0'	'0.5'	'NoS'
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'0.5'	'No'
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-CAR2'	'Q-PCE'	'? Systemic Corticosteroid'	'Reported'	'0.00%%'	'0'	'63.60%%'	'0'	'126'	'0'	'165'	'0'	'76.40%%'	'0'	'0.5'	'NoS'
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-CAR2'	'Q-PCE'	'? Bronchodilator'	'Reported'	'0.00%%'	'0'	'78.70%%'	'0'	'150'	'0'	'165'	'0'	'90.90%%'	'0'	'0.5'	'NoS'
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Reported'	'0.00%%'	'0'	'86.30%%'	'0'	'16'	'0'	'305'	'0'	'5.30%%'	'0'	'0'	'Yes'
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	''	'1'	'66'	'0'	''	'1'	'0'	'Yes'
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Reported'	'0.00%%'	'0'	'77.00%%'	'0'	'177'	'0'	'218'	'0'	'81.20%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Reported'	'0.00%%'	'0'	'71.30%%'	'0'	'390'	'0'	'1207'	'0'	'32.30%%'	'0'	'0.5'	'No'
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Reported'	'0.00%%'	'0'	'24.80%%'	'0'	'151'	'0'	'619'	'0'	'24.40%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Reported'	'0.00%%'	'0'	'47.80%%'	'0'	'401'	'0'	'761'	'0'	'52.70%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Reported'	'0.00%%'	'0'	'71.10%%'	'0'	'165'	'0'	'1911'	'0'	'8.60%%'	'0'	'0.5'	'No'
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Reported'	'0.00%%'	'0'	'18.70%%'	'0'	'94'	'0'	'180'	'0'	'52.20%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Reported'	'0.00%%'	'0'	'44.90%%'	'0'	'712'	'0'	'1076'	'0'	'66.20%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Reported'	'0'	'0'	'1.07'	'0'	'10'	'0'	'15.648'	'0'	'0.6391'	'0'	'1'	'No'
'PY4'	'DMPH'	'Antelope Valley Hospital'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Reported'	'0.00%%'	'0'	'79.00%%'	'0'	'38'	'0'	'57.431'	'0'	'0.662'	'0'	'1'	'No'
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PC15'	'Q-WCC'	'? BMI'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PC15'	'Q-WCC'	'? Counseling for Nutrition'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PC15'	'Q-WCC'	'? Counseling for Physical Activity'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adults)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adults)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adults)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adolescents) - informational only'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adolescents) - informational only'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adolescents) - informational only'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-BH3'	'Q-FUA'	'? 30 Days'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-BH3'	'Q-FUA'	'? 7 Days'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-CAR2'	'Q-PCE'	'? Systemic Corticosteroid'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-CAR2'	'Q-PCE'	'? Bronchodilator'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Bear Valley Community Hospital'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'120'	'0'	'227'	'0'	'52.90%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'108'	'0'	'340'	'0'	'31.80%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Eastern Plumas Health Care'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Reported'	'0.00%%'	'0'	'77.00%%'	'0'	'73'	'0'	'95'	'0'	'76.80%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'El Camino Hospital'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Reported'	'0.00%%'	'0'	'24.80%%'	'0'	'31'	'0'	'108'	'0'	'28.70%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'El Camino Hospital'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Reported'	'0.00%%'	'0'	'47.80%%'	'0'	'126'	'0'	'293'	'0'	'43.00%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'El Camino Hospital'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Reported'	'0.00%%'	'0'	'71.10%%'	'0'	'30'	'0'	'30'	'0'	'100.00%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'El Camino Hospital'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Reported'	'0.00%%'	'0'	'79.30%%'	'0'	'21'	'0'	'30'	'0'	'70.00%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'El Camino Hospital'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Reported'	'0.00%%'	'0'	'18.70%%'	'0'	'699'	'0'	'1207'	'0'	'57.90%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'El Camino Hospital'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Reported'	'0.00%%'	'0'	'99.20%%'	'0'	'283'	'0'	'283'	'0'	'100.00%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'El Camino Hospital'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'5288'	'0'	'5366'	'0'	'98.60%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'El Camino Hospital'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Camino Hospital'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Reported'	'0'	'0'	'1.07'	'0'	'6'	'0'	'15.339'	'0'	'0.3912'	'0'	'1'	'No'
'PY4'	'DMPH'	'El Camino Hospital'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Reported'	'0.00%%'	'0'	'79.00%%'	'0'	'27'	'0'	'58.836'	'0'	'0.459'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	''	'1'	''	'1'	''	'1'	'1'	'NoS'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'196'	'0'	'724'	'0'	'27.10%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'428'	'0'	'701'	'0'	'61.10%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'488'	'0'	'2171'	'0'	'22.50%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	'15'	'0'	'61'	'0'	'24.60%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Reported'	'0.00%%'	'0'	'48.30%%'	'0'	'129'	'0'	'254'	'0'	'50.80%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'607'	'0'	'1859'	'0'	'32.70%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Reported'	'0.00%%'	'0'	'30.90%%'	'0'	'38'	'0'	'105'	'0'	'36.20%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Reported'	'0.00%%'	'0'	'61.30%%'	'0'	'52'	'0'	'69'	'0'	'75.40%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'49.60%%'	'0'	'3826'	'0'	'4011'	'0'	'95.40%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'4060'	'0'	'4417'	'0'	'91.90%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'4016'	'0'	'4272'	'0'	'94.00%%'	'0'	'N/A'	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'276'	'0'	'439'	'0'	'62.90%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'3853'	'0'	'4272'	'0'	'90.20%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PC15'	'Q-WCC'	'? BMI'	'Reported'	'0.00%%'	'0'	'69.20%%'	'0'	'1282'	'0'	'1426'	'0'	'89.90%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PC15'	'Q-WCC'	'? Counseling for Nutrition'	'Reported'	'0.00%%'	'0'	'61.10%%'	'0'	'1273'	'0'	'1426'	'0'	'89.30%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PC15'	'Q-WCC'	'? Counseling for Physical Activity'	'Reported'	'0.00%%'	'0'	'55.80%%'	'0'	'1273'	'0'	'1426'	'0'	'89.30%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'708'	'0'	'1020'	'0'	'69.40%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Reported'	'0.00%%'	'0'	'71.40%%'	'0'	'134'	'0'	'191'	'0'	'70.20%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'210'	'0'	'752'	'0'	'27.90%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'96'	'0'	'752'	'0'	'12.80%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Reported'	'0.00%%'	'0'	'77.00%%'	'0'	'34'	'0'	'70'	'0'	'48.60%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Reported'	'0.00%%'	'0'	'71.30%%'	'0'	'205'	'0'	'455'	'0'	'45.10%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Reported'	'0.00%%'	'0'	'44.90%%'	'0'	'152'	'0'	'196'	'0'	'77.60%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'El Centro Regional Medical Center'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Reported'	'0.00%%'	'0'	'79.00%%'	'0'	'7'	'0'	'17.7'	'0'	'0.396'	'0'	'1'	'No'
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'58'	'0'	'134'	'0'	'43.30%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'612'	'0'	'1027'	'0'	'59.60%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'740'	'0'	'1753'	'0'	'42.20%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	'41'	'0'	'138'	'0'	'29.70%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'123'	'0'	'192'	'0'	'64.10%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'68'	'0'	'187'	'0'	'36.40%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Reported'	'0.00%%'	'0'	'24.80%%'	'0'	'18'	'0'	'76'	'0'	'23.70%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Reported'	'0.00%%'	'0'	'47.80%%'	'0'	'175'	'0'	'246'	'0'	'71.10%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Reported'	'0.00%%'	'0'	'71.10%%'	'0'	'68'	'0'	'85'	'0'	'80.00%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Hazel Hawkins Memorial Hospital'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PC15'	'Q-WCC'	'? BMI'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PC15'	'Q-WCC'	'? Counseling for Nutrition'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PC15'	'Q-WCC'	'? Counseling for Physical Activity'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adults)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adults)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adults)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adolescents) - informational only'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adolescents) - informational only'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adolescents) - informational only'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-BH3'	'Q-FUA'	'? 30 Days'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-BH3'	'Q-FUA'	'? 7 Days'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-CAR2'	'Q-PCE'	'? Systemic Corticosteroid'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-CAR2'	'Q-PCE'	'? Bronchodilator'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Healdsburg District Hospital'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'18'	'0'	'65'	'0'	'27.70%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'84'	'0'	'214'	'0'	'39.30%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'51'	'0'	'118'	'0'	'43.20%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'49.60%%'	'0'	'80'	'0'	'263'	'0'	'30.40%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Reported'	'0.00%%'	'0'	'19.20%%'	'0'	'31'	'0'	'216'	'0'	'14.40%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'237'	'0'	'241'	'0'	'98.30%%'	'0'	'N/A'	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'48'	'0'	'60'	'0'	'80.00%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'220'	'0'	'241'	'0'	'91.30%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Jerold Phelps Community Hospital'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'140'	'0'	'676'	'0'	'20.70%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	''	'1'	'43'	'0'	''	'1'	'1'	'No'
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Reported'	'0.00%%'	'0'	'48.30%%'	'0'	''	'1'	'134'	'0'	''	'1'	'1'	'No'
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Reported'	'0.00%%'	'0'	'15.10%%'	'0'	'22'	'0'	'114'	'0'	'19.30%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Reported'	'0.00%%'	'0'	'9.40%%'	'0'	'199'	'0'	'1705'	'0'	'11.70%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Reported'	'0.00%%'	'0'	'61.30%%'	'0'	''	'1'	'45'	'0'	''	'1'	'1'	'No'
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'John C. Fremont Healthcare District'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	''	'1'	''	'4'	''	'1'	'1'	'NoS'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'166'	'0'	'459'	'0'	'36.20%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'241'	'0'	'472'	'0'	'51.10%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'1635'	'0'	'3003'	'0'	'54.50%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	'115'	'0'	'395'	'0'	'29.10%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Reported'	'0.00%%'	'0'	'48.30%%'	'0'	'145'	'0'	'478'	'0'	'30.30%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'432'	'0'	'1993'	'0'	'21.70%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Reported'	'0.00%%'	'0'	'9.40%%'	'0'	'1395'	'0'	'5333'	'0'	'26.20%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'49.60%%'	'0'	'1370'	'0'	'7152'	'0'	'19.20%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'3016'	'0'	'6953'	'0'	'43.40%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'13779'	'0'	'14366'	'0'	'95.90%%'	'0'	'1'	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'80'	'0'	'2114'	'0'	'3.80%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'11745'	'0'	'14366'	'0'	'81.80%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PC15'	'Q-WCC'	'? BMI'	'Reported'	'0.00%%'	'0'	'69.20%%'	'0'	'2747'	'0'	'4102'	'0'	'67.00%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PC15'	'Q-WCC'	'? Counseling for Nutrition'	'Reported'	'0.00%%'	'0'	'61.10%%'	'0'	'1302'	'0'	'4102'	'0'	'31.70%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PC15'	'Q-WCC'	'? Counseling for Physical Activity'	'Reported'	'0.00%%'	'0'	'55.80%%'	'0'	'1243'	'0'	'4102'	'0'	'30.30%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'Reported'	'0.00%%'	'0'	'66.40%%'	'0'	'248'	'0'	'362'	'0'	'68.50%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'63'	'0'	'100'	'0'	'63.00%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Reported'	'0.00%%'	'0'	'14.70%%'	'0'	'44'	'0'	'318'	'0'	'13.80%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-BH3'	'Q-FUA'	'? 30 Days'	'Reported'	'0.00%%'	'0'	'10.80%%'	'0'	''	'1'	'35'	'0'	''	'1'	'1'	'NoS'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-BH3'	'Q-FUA'	'? 7 Days'	'Reported'	'0.00%%'	'0'	'7.10%%'	'0'	''	'1'	'35'	'0'	''	'1'	'1'	'NoS'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'763'	'0'	'1011'	'0'	'75.50%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'250'	'0'	'716'	'0'	'34.90%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Reported'	'0.00%%'	'0'	'88.30%%'	'0'	'410'	'0'	'716'	'0'	'57.30%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Reported'	'0.00%%'	'0'	'71.10%%'	'0'	'211'	'0'	'251'	'0'	'84.10%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Reported'	'0.00%%'	'0'	'79.30%%'	'0'	'206'	'0'	'251'	'0'	'82.10%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Reported'	'0.00%%'	'0'	'18.70%%'	'0'	'627'	'0'	'868'	'0'	'72.20%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kaweah Delta Health Care District'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'78'	'0'	'273'	'0'	'28.60%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'124'	'0'	'452'	'0'	'27.40%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'49.60%%'	'0'	'237'	'0'	'960'	'0'	'24.70%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-PC15'	'Q-WCC'	'? BMI'	'Reported'	'0.00%%'	'0'	'69.20%%'	'0'	'385'	'0'	'418'	'0'	'92.10%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-PC15'	'Q-WCC'	'? Counseling for Nutrition'	'Reported'	'0.00%%'	'0'	'61.10%%'	'0'	'203'	'0'	'418'	'0'	'48.60%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-PC15'	'Q-WCC'	'? Counseling for Physical Activity'	'Reported'	'0.00%%'	'0'	'55.80%%'	'0'	'85'	'0'	'418'	'0'	'20.30%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'Reported'	'0.00%%'	'0'	'66.40%%'	'0'	''	'1'	'39'	'0'	''	'1'	'1'	'NoS'
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	''	'1'	'34'	'0'	''	'1'	'1'	'NoS'
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'22'	'0'	'72'	'0'	'30.60%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Kern Valley Healthcare District'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	''	'1'	''	'1'	''	'1'	'N/A'	'NoS'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'20'	'0'	'60'	'0'	'33.30%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'114'	'0'	'228'	'0'	'50.00%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'374'	'0'	'705'	'0'	'53.10%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'1150'	'0'	'2150'	'0'	'53.50%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Reported'	'0.00%%'	'0'	'48.30%%'	'0'	'54'	'0'	'139'	'0'	'38.90%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'148'	'0'	'1006'	'0'	'14.70%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Reported'	'0.00%%'	'0'	'30.90%%'	'0'	'28'	'0'	'112'	'0'	'25.00%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Reported'	'0.00%%'	'0'	'61.30%%'	'0'	'53'	'0'	'162'	'0'	'32.70%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'49.60%%'	'0'	'1171'	'0'	'3713'	'0'	'31.50%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Reported'	'0.00%%'	'0'	'19.20%%'	'0'	'765'	'0'	'3881'	'0'	'19.70%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'178'	'0'	'4362'	'0'	'4.10%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'1899'	'0'	'2453'	'0'	'77.40%%'	'0'	'N/A'	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'112'	'0'	'255'	'0'	'43.90%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'1654'	'0'	'2453'	'0'	'67.40%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PC15'	'Q-WCC'	'? BMI'	'Reported'	'0.00%%'	'0'	'69.20%%'	'0'	'1419'	'0'	'1818'	'0'	'78.10%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PC15'	'Q-WCC'	'? Counseling for Nutrition'	'Reported'	'0.00%%'	'0'	'61.10%%'	'0'	'386'	'0'	'1818'	'0'	'21.20%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PC15'	'Q-WCC'	'? Counseling for Physical Activity'	'Reported'	'0.00%%'	'0'	'55.80%%'	'0'	'149'	'0'	'1818'	'0'	'8.20%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'Reported'	'0.00%%'	'0'	'66.40%%'	'0'	'13'	'0'	''	'4'	''	'4'	'1'	'NoS'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'34'	'0'	'40'	'0'	'85.00%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'167'	'0'	'271'	'0'	'61.60%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Reported'	'0.00%%'	'0'	'66.90%%'	'0'	'15'	'0'	''	'4'	''	'4'	'1'	'No'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Reported'	'0.00%%'	'0'	'71.40%%'	'0'	'24'	'0'	'33'	'0'	'72.70%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Reported'	'0.00%%'	'0'	'66.70%%'	'0'	'180'	'0'	'307'	'0'	'58.60%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'30'	'0'	'133'	'0'	'22.60%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Reported'	'0.00%%'	'0'	'99.20%%'	'0'	'50'	'0'	'53'	'0'	'94.30%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Lompoc Valley Medical Center'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Reported'	'0.00%%'	'0'	'79.00%%'	'0'	'4'	'0'	'4.41'	'0'	'0.907'	'0'	'1'	'No'
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'53'	'0'	'111'	'0'	'47.80%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'203'	'0'	'416'	'0'	'48.80%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'375'	'0'	'958'	'0'	'39.10%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	'25'	'0'	'32'	'0'	'78.10%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Reported'	'0.00%%'	'0'	'48.30%%'	'0'	'29'	'0'	'53'	'0'	'54.70%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'178'	'0'	'397'	'0'	'44.80%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'49.60%%'	'0'	'459'	'0'	'1295'	'0'	'35.40%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'659'	'0'	'1399'	'0'	'47.10%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'1056'	'0'	'1079'	'0'	'97.90%%'	'0'	'1'	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'21'	'0'	'111'	'0'	'18.90%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'966'	'0'	'1079'	'0'	'89.50%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'38'	'0'	'69'	'0'	'55.10%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Reported'	'0.00%%'	'0'	'66.70%%'	'0'	'40'	'0'	'60'	'0'	'66.70%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'15'	'0'	'61'	'0'	'24.60%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mammoth Hospital'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Reported'	'0.00%%'	'0'	'44.00%%'	'0'	'246'	'0'	'379'	'0'	'64.90%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Marin General Hospital'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Marin General Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	''	'1'	''	'4'	''	'1'	'1'	'NoS'
'PY4'	'DMPH'	'Marin General Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'61'	'0'	'177'	'0'	'34.50%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Marin General Hospital'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'183'	'0'	'301'	'0'	'60.80%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Marin General Hospital'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'96'	'0'	'270'	'0'	'35.60%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Marin General Hospital'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Reported'	'0.00%%'	'0'	'24.80%%'	'0'	'30'	'0'	'180'	'0'	'16.70%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Marin General Hospital'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Reported'	'0.00%%'	'0'	'47.80%%'	'0'	'98'	'0'	'129'	'0'	'76.00%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Marin General Hospital'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Reported'	'0.00%%'	'0'	'18.70%%'	'0'	'302'	'0'	'1912'	'0'	'15.80%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Marin General Hospital'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Reported'	'0.00%%'	'0'	'99.20%%'	'0'	'106'	'0'	'108'	'0'	'98.20%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Marin General Hospital'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Reported'	'0.00%%'	'0'	'44.90%%'	'0'	'528'	'0'	'735'	'0'	'71.80%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Marin General Hospital'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Marin General Hospital'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Reported'	'0.00%%'	'0'	'79.00%%'	'0'	'5'	'0'	'23.431'	'0'	'0.213'	'0'	'1'	'No'
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Reported'	'0.00%%'	'0'	'44.90%%'	'0'	''	'1'	''	'1'	''	'1'	'1'	'No'
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mayers Memorial Hospital District'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Reported'	'0.00%%'	'0'	'79.00%%'	'0'	'0'	'0'	'0.485'	'0'	'0'	'0'	'1'	'No'
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'495'	'0'	'878'	'0'	'56.40%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'666'	'0'	'721'	'0'	'92.40%%'	'0'	'1'	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'163'	'0'	'233'	'0'	'70.00%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'594'	'0'	'719'	'0'	'82.60%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Modoc Medical Center'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Reported'	'0.00%%'	'0'	'15.10%%'	'0'	'83'	'0'	'160'	'0'	'51.90%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Reported'	'0.00%%'	'0'	'19.20%%'	'0'	'798'	'0'	'1652'	'0'	'48.30%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Reported'	'0.00%%'	'0'	'66.70%%'	'0'	'68'	'0'	'94'	'0'	'72.30%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Reported'	'0.00%%'	'0'	'47.80%%'	'0'	'46'	'0'	'69'	'0'	'66.70%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Northern Inyo Hospital'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Reported'	'0.00%%'	'0'	'44.00%%'	'0'	'2790'	'0'	'2790'	'0'	'100.00%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	''	'1'	''	'1'	''	'1'	'1'	'NoS'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'59'	'0'	'218'	'0'	'27.10%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'66'	'0'	'124'	'0'	'53.20%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'171'	'0'	'314'	'0'	'54.50%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'353'	'0'	'1564'	'0'	'22.60%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	'0'	'0'	''	'4'	''	'4'	'1'	'No'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Reported'	'0.00%%'	'0'	'48.30%%'	'0'	''	'1'	''	'4'	''	'1'	'1'	'No'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'965'	'0'	'1741'	'0'	'55.40%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Reported'	'0.00%%'	'0'	'15.10%%'	'0'	'0'	'0'	'36'	'0'	'0.00%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Reported'	'0.00%%'	'0'	'30.90%%'	'0'	'0'	'0'	''	'1'	''	'1'	'1'	'No'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Reported'	'0.00%%'	'0'	'61.30%%'	'0'	''	'1'	''	'4'	''	'1'	'1'	'No'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'49.60%%'	'0'	'512'	'0'	'2875'	'0'	'17.80%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Reported'	'0.00%%'	'0'	'19.20%%'	'0'	'658'	'0'	'2062'	'0'	'31.90%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'181'	'0'	'353'	'0'	'51.30%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'1414'	'0'	'1449'	'0'	'97.60%%'	'0'	'1'	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'185'	'0'	'215'	'0'	'86.10%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'1381'	'0'	'1414'	'0'	'97.70%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PC15'	'Q-WCC'	'? BMI'	'Reported'	'0.00%%'	'0'	'69.20%%'	'0'	''	'1'	'1256'	'0'	''	'1'	'1'	'NoS'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PC15'	'Q-WCC'	'? Counseling for Nutrition'	'Reported'	'0.00%%'	'0'	'61.10%%'	'0'	''	'1'	'1256'	'0'	''	'1'	'1'	'NoS'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PC15'	'Q-WCC'	'? Counseling for Physical Activity'	'Reported'	'0.00%%'	'0'	'55.80%%'	'0'	''	'1'	'1256'	'0'	''	'1'	'1'	'NoS'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'Reported'	'0.00%%'	'0'	'66.40%%'	'0'	'0'	'0'	''	'1'	''	'1'	'1'	'NoS'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'0'	'0'	'0'	'0'	'0.00%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Reported'	'0.00%%'	'0'	'66.70%%'	'0'	'406'	'0'	'598'	'0'	'67.90%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'0'	'0'	'388'	'0'	'0.00%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Reported'	'0.00%%'	'0'	'88.30%%'	'0'	'344'	'0'	'388'	'0'	'88.70%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Oak Valley Hospital District'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Reported'	'0.00%%'	'0'	'44.00%%'	'0'	'119'	'0'	'324'	'0'	'36.70%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Palomar Health'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DMPH'	'Palomar Health'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Palomar Health'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	''	'1'	''	'4'	''	'1'	'N/A'	'NoS'
'PY4'	'DMPH'	'Palomar Health'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'46'	'0'	'178'	'0'	'25.80%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Palomar Health'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'33'	'0'	'52'	'0'	'63.50%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Palomar Health'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	''	'1'	''	'1'	''	'1'	'1'	'No'
'PY4'	'DMPH'	'Palomar Health'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'36'	'0'	'101'	'0'	'35.60%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Palomar Health'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Reported'	'0.00%%'	'0'	'60.40%%'	'0'	'28'	'0'	'31'	'0'	'90.30%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Palomar Health'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'97'	'0'	'411'	'0'	'23.60%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Palomar Health'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Reported'	'0.00%%'	'0'	'59.90%%'	'0'	'37'	'0'	'53'	'0'	'69.80%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Palomar Health'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Reported'	'0.00%%'	'0'	'77.00%%'	'0'	'317'	'0'	'392'	'0'	'80.90%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Palomar Health'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Reported'	'0.00%%'	'0'	'24.80%%'	'0'	'73'	'0'	'402'	'0'	'18.20%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Palomar Health'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Reported'	'0.00%%'	'0'	'47.80%%'	'0'	'196'	'0'	'405'	'0'	'48.40%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Palomar Health'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Palomar Health'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Reported'	'0.00%%'	'0'	'79.30%%'	'0'	'25'	'0'	''	'4'	''	'4'	'1'	'No'
'PY4'	'DMPH'	'Palomar Health'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Reported'	'0.00%%'	'0'	'18.70%%'	'0'	'204'	'0'	'204'	'0'	'100.00%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Palomar Health'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Reported'	'0.00%%'	'0'	'99.20%%'	'0'	'228'	'0'	'372'	'0'	'61.30%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Palomar Health'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'2311'	'0'	'2339'	'0'	'98.80%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Palomar Health'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Reported'	'0.00%%'	'0'	'44.90%%'	'0'	'115'	'0'	'654'	'0'	'17.60%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Palomar Health'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Reported'	'0'	'0'	'1.07'	'0'	'10'	'0'	'14.562'	'0'	'0.6867'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Palomar Health'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Reported'	'0.00%%'	'0'	'79.00%%'	'0'	'17'	'0'	'47.563'	'0'	'0.357'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'1107'	'0'	'2006'	'0'	'55.20%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'754'	'0'	'1919'	'0'	'39.30%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	'34'	'0'	'95'	'0'	'35.80%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Reported'	'0.00%%'	'0'	'48.30%%'	'0'	'99'	'0'	'189'	'0'	'52.40%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'0'	'0'	'2323'	'0'	'0.00%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-PC15'	'Q-WCC'	'? BMI'	'Reported'	'0.00%%'	'0'	'69.20%%'	'0'	'786'	'0'	'1253'	'0'	'62.70%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-PC15'	'Q-WCC'	'? Counseling for Nutrition'	'Reported'	'0.00%%'	'0'	'61.10%%'	'0'	'291'	'0'	'1253'	'0'	'23.20%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-PC15'	'Q-WCC'	'? Counseling for Physical Activity'	'Reported'	'0.00%%'	'0'	'55.80%%'	'0'	'122'	'0'	'1253'	'0'	'9.70%%'	'0'	'1'	'Nos'
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'Reported'	'0.00%%'	'0'	'N/A'	'0'	'106'	'0'	'170'	'0'	'62.40%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'Reported'	'0.00%%'	'0'	'N/A'	'0'	'34'	'0'	'66'	'0'	'51.50%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'343'	'0'	'693'	'0'	'49.50%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'246'	'0'	'481'	'0'	'51.10%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'254'	'0'	'481'	'0'	'52.80%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Reported'	'0.00%%'	'0'	'71.10%%'	'0'	'79'	'0'	'127'	'0'	'62.20%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Reported'	'0.00%%'	'0'	'79.30%%'	'0'	'93'	'0'	'127'	'0'	'73.20%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Pioneers Memorial Healthcare District'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Reported'	'0.00%%'	'0'	'19.20%%'	'0'	'206'	'0'	'1189'	'0'	'17.30%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'750'	'0'	'1057'	'0'	'71.00%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Plumas District Hospital'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'466'	'0'	'980'	'0'	'47.60%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'3322'	'0'	'5843'	'0'	'56.90%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'1389'	'0'	'3246'	'0'	'42.80%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	'44'	'0'	'137'	'0'	'32.10%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Reported'	'0.00%%'	'0'	'48.30%%'	'0'	'134'	'0'	'213'	'0'	'62.90%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'1521'	'0'	'4693'	'0'	'32.40%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Reported'	'0.00%%'	'0'	'30.90%%'	'0'	'56'	'0'	'162'	'0'	'34.60%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'49.60%%'	'0'	'4111'	'0'	'16364'	'0'	'25.10%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Reported'	'0.00%%'	'0'	'19.20%%'	'0'	'5064'	'0'	'14816'	'0'	'34.20%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'1671'	'0'	'15164'	'0'	'11.00%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'12955'	'0'	'14340'	'0'	'90.30%%'	'0'	'N/A'	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'300'	'0'	'1477'	'0'	'20.30%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'11778'	'0'	'14340'	'0'	'82.10%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PC15'	'Q-WCC'	'? BMI'	'Reported'	'0.00%%'	'0'	'69.20%%'	'0'	'185'	'0'	'1416'	'0'	'13.10%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PC15'	'Q-WCC'	'? Counseling for Nutrition'	'Reported'	'0.00%%'	'0'	'61.10%%'	'0'	''	'1'	'1416'	'0'	''	'1'	'1'	'NoS'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PC15'	'Q-WCC'	'? Counseling for Physical Activity'	'Reported'	'0.00%%'	'0'	'55.80%%'	'0'	'37'	'0'	'1416'	'0'	'2.60%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'Reported'	'0.00%%'	'0'	'66.40%%'	'0'	'93'	'0'	'139'	'0'	'66.90%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'47'	'0'	'116'	'0'	'40.50%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'530'	'0'	'1017'	'0'	'52.10%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Reported'	'0.00%%'	'0'	'66.90%%'	'0'	'151'	'0'	'163'	'0'	'92.60%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Reported'	'0.00%%'	'0'	'71.40%%'	'0'	'250'	'0'	'290'	'0'	'86.20%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'309'	'0'	'858'	'0'	'36.00%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Reported'	'0.00%%'	'0'	'86.30%%'	'0'	'260'	'0'	'282'	'0'	'92.20%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Reported'	'0.00%%'	'0'	'71.10%%'	'0'	'137'	'0'	'192'	'0'	'71.40%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Reported'	'0.00%%'	'0'	'79.30%%'	'0'	'141'	'0'	'192'	'0'	'73.40%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Salinas Valley Memorial Healthcare System'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Reported'	'0.00%%'	'0'	'100.00%%'	'0'	'0'	'0'	'16'	'0'	'0'	'0'	'1'	'No'
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'61'	'0'	'115'	'0'	'53.00%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'254'	'0'	'681'	'0'	'37.30%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'49.60%%'	'0'	'883'	'0'	'1365'	'0'	'64.70%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'758'	'0'	'1461'	'0'	'51.90%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'60'	'0'	'103'	'0'	'58.30%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'17'	'0'	''	'4'	''	'4'	'1'	'No'
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Reported'	'0.00%%'	'0'	'44.90%%'	'0'	'18'	'0'	''	'4'	''	'4'	'1'	'No'
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Mountains Community Hospital, Lake Arrowhead'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Reported'	'0.00%%'	'0'	'44.00%%'	'0'	'653'	'0'	'845'	'0'	'77.30%%'	'0'	'0.5'	'No'
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Reported'	'0.00%%'	'0'	'100.00%%'	'0'	'35'	'0'	'12.876'	'0'	'2.718'	'0'	'0.5'	'No'
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'0.5'	'No'
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-CAR2'	'Q-PCE'	'? Systemic Corticosteroid'	'Reported'	'0.00%%'	'0'	'63.60%%'	'0'	'34'	'0'	'40'	'0'	'85.00%%'	'0'	'0'	'NoS'
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-CAR2'	'Q-PCE'	'? Bronchodilator'	'Reported'	'0.00%%'	'0'	'78.70%%'	'0'	'35'	'0'	'40'	'0'	'87.50%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Reported'	'0.00%%'	'0'	'86.30%%'	'0'	'542'	'0'	'558'	'0'	'97.10%%'	'0'	'0'	'Yes'
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Reported'	'0.00%%'	'0'	'71.30%%'	'0'	'82'	'0'	'124'	'0'	'66.10%%'	'0'	'0.5'	'No'
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Reported'	'0.00%%'	'0'	'24.80%%'	'0'	'12'	'0'	'30'	'0'	'40.00%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Reported'	'0.00%%'	'0'	'47.80%%'	'0'	'21'	'0'	'73'	'0'	'28.80%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'193'	'0'	'193'	'0'	'100.00%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Reported'	'0.00%%'	'0'	'44.90%%'	'0'	''	'1'	'52'	'0'	''	'1'	'1'	'No'
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Gorgonio Memorial Hospital'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Reported'	'0.00%%'	'0'	'79.00%%'	'0'	'6'	'0'	'7.049'	'0'	'0.851'	'0'	'1'	'No'
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	''	'1'	'69'	'0'	''	'1'	'1'	'No'
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'0'	'0'	'130'	'0'	'0.00%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Seneca Healthcare District'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Reported'	'0.00%%'	'0'	'19.20%%'	'0'	'257'	'0'	'4570'	'0'	'5.60%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'4869'	'0'	'5111'	'0'	'95.30%%'	'0'	'N/A'	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'13'	'0'	'672'	'0'	'1.90%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'37'	'0'	'5111'	'0'	'0.70%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adults)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adults)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adults)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adolescents) - informational only'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adolescents) - informational only'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adolescents) - informational only'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-BH3'	'Q-FUA'	'? 30 Days'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-BH3'	'Q-FUA'	'? 7 Days'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-CAR2'	'Q-PCE'	'? Systemic Corticosteroid'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-CAR2'	'Q-PCE'	'? Bronchodilator'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Reported'	'0.00%%'	'0'	'77.00%%'	'0'	'14'	'0'	'130'	'0'	'10.80%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Reported'	'0.00%%'	'0'	'24.80%%'	'0'	'43'	'0'	'184'	'0'	'23.40%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Reported'	'0.00%%'	'0'	'47.80%%'	'0'	'60'	'0'	'116'	'0'	'51.70%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Reported'	'0.00%%'	'0'	'18.70%%'	'0'	'94'	'0'	'125'	'0'	'75.20%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Reported'	'0.00%%'	'0'	'99.20%%'	'0'	'95'	'0'	'98'	'0'	'96.90%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'431'	'0'	'449'	'0'	'96.00%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Reported'	'0.00%%'	'0'	'44.90%%'	'0'	'59'	'0'	'107'	'0'	'55.10%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sierra View District Hospital'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Reported'	'0.00%%'	'0'	'79.00%%'	'0'	'9'	'0'	'11.948'	'0'	'0.753'	'0'	'1'	'No'
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Reported'	'0.00%%'	'0'	'99.20%%'	'0'	'24'	'0'	''	'4'	''	'4'	'1'	'No'
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'455'	'0'	'497'	'0'	'91.60%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Sonoma Valley Hospital'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'141'	'0'	'798'	'0'	'17.70%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'57'	'0'	'204'	'0'	'27.90%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Southern Inyo Hospital'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'30'	'0'	'289'	'0'	'10.40%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'121'	'0'	'234'	'0'	'51.70%%'	'0'	'0'	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'12'	'0'	'121'	'0'	'9.90%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'133'	'0'	'234'	'0'	'56.80%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Surprise Valley Community Hospital'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'454'	'0'	'750'	'0'	'60.50%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'749'	'0'	'1749'	'0'	'42.80%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Reported'	'0.00%%'	'0'	'19.20%%'	'0'	'1233'	'0'	'3270'	'0'	'37.70%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Reported'	'0.00%%'	'0'	'50.00%%'	'0'	'733'	'0'	'2079'	'0'	'35.30%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'Reported'	'0.00%%'	'0'	'0.00%%'	'0'	'2306'	'0'	'2322'	'0'	'99.30%%'	'0'	'N/A'	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'Reported'	'0.00%%'	'0'	'6.70%%'	'0'	'177'	'0'	'306'	'0'	'57.80%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'Reported'	'0.00%%'	'0'	'75.40%%'	'0'	'2164'	'0'	'2322'	'0'	'93.20%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'65'	'0'	'102'	'0'	'63.70%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'12'	'0'	'55'	'0'	'21.80%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'26'	'0'	'55'	'0'	'47.30%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Reported'	'0.00%%'	'0'	'88.30%%'	'0'	'51'	'0'	'55'	'0'	'92.70%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Reported'	'0.00%%'	'0'	'47.80%%'	'0'	'84'	'0'	'122'	'0'	'68.90%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tahoe Forest Hospital District'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Reported'	'0.00%%'	'0'	'44.00%%'	'0'	'506'	'0'	'937'	'0'	'54.00%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'0'	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	''	'1'	''	'1'	''	'1'	'0'	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'12'	'0'	''	'4'	''	'4'	'0'	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-IHE1'	'Q-IHE1'	'Breast Cancer Screening (BCS)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Breast Cancer Screening (BCS) - -Black/African American'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'22'	'0'	'44'	'0'	'50.00%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-IHE1'	'Q-IHE1'	'? Breast Cancer Screening (BCS) - -White'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'322'	'0'	'502'	'0'	'64.10%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-IHE2'	'Q-IHE2'	'? Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE) - -Black/African American'	'Reported'	'0.00%%'	'0'	'79.30%%'	'0'	'13'	'0'	''	'4'	''	'4'	'1'	'No'
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'507'	'0'	'798'	'0'	'63.50%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-BH3'	'Q-FUA'	'? 30 Days'	'Reported'	'0.00%%'	'0'	'10.80%%'	'0'	''	'1'	'124'	'0'	''	'1'	'1'	'NoS'
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-BH3'	'Q-FUA'	'? 7 Days'	'Reported'	'0.00%%'	'0'	'7.10%%'	'0'	''	'1'	'124'	'0'	''	'1'	'1'	'NoS'
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Reported'	'0.00%%'	'0'	'71.40%%'	'0'	'145'	'0'	'227'	'0'	'63.90%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'27'	'0'	'68'	'0'	'39.70%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Reported'	'0.00%%'	'0'	'59.90%%'	'0'	''	'1'	'31'	'0'	''	'1'	'1'	'No'
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-CAR2'	'Q-PCE'	'? Systemic Corticosteroid'	'Reported'	'0.00%%'	'0'	'63.60%%'	'0'	''	'1'	''	'1'	''	'1'	'1'	'NoS'
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-CAR2'	'Q-PCE'	'? Bronchodilator'	'Reported'	'0.00%%'	'0'	'78.70%%'	'0'	''	'1'	''	'1'	''	'1'	'1'	'NoS'
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Reported'	'0.00%%'	'0'	'77.00%%'	'0'	'31'	'0'	'36'	'0'	'86.10%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Reported'	'0.00%%'	'0'	'71.30%%'	'0'	'380'	'0'	'634'	'0'	'59.90%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Reported'	'0.00%%'	'0'	'24.80%%'	'0'	'76'	'0'	'360'	'0'	'21.10%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Reported'	'0.00%%'	'0'	'47.80%%'	'0'	'405'	'0'	'891'	'0'	'45.50%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Reported'	'0.00%%'	'0'	'71.10%%'	'0'	'284'	'0'	'459'	'0'	'61.90%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Reported'	'0.00%%'	'0'	'79.30%%'	'0'	'356'	'0'	'459'	'0'	'77.60%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Reported'	'0.00%%'	'0'	'99.20%%'	'0'	'197'	'0'	'197'	'0'	'100.00%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Reported'	'0.00%%'	'0'	'47.60%%'	'0'	'1159'	'0'	'1585'	'0'	'73.10%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Reported'	'0.00%%'	'0'	'44.90%%'	'0'	'65'	'0'	'67'	'0'	'97.00%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Reported'	'0'	'0'	'1.07'	'0'	'7'	'0'	'5.857'	'0'	'1.1952'	'0'	'1'	'No'
'PY4'	'DMPH'	'Tri-City Medical Center'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Reported'	'0.00%%'	'0'	'79.00%%'	'0'	'33'	'0'	'37.429'	'0'	'0.882'	'0'	'1'	'No'
'PY4'	'DMPH'	'Trinity Hospital'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'50'	'0'	'218'	'0'	'22.90%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Trinity Hospital'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'106'	'0'	'638'	'0'	'16.60%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Trinity Hospital'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Trinity Hospital'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'Reported'	'0.00%%'	'0'	'48.10%%'	'0'	'132'	'0'	'204'	'0'	'64.70%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'Reported'	'0.00%%'	'0'	'51.80%%'	'0'	'333'	'0'	'499'	'0'	'66.70%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'Reported'	'0.00%%'	'0'	'39.40%%'	'0'	'556'	'0'	'1005'	'0'	'55.30%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'Reported'	'0.00%%'	'0'	'31.90%%'	'0'	'12'	'0'	'40'	'0'	'30.00%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'Reported'	'0.00%%'	'0'	'48.30%%'	'0'	'43'	'0'	'66'	'0'	'65.20%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'Reported'	'0.00%%'	'0'	'27.40%%'	'0'	'424'	'0'	'894'	'0'	'47.40%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'Reported'	'0.00%%'	'0'	'15.10%%'	'0'	'21'	'0'	'77'	'0'	'27.30%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'Reported'	'0.00%%'	'0'	'30.90%%'	'0'	'13'	'0'	'48'	'0'	'27.10%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'Reported'	'0.00%%'	'0'	'19.20%%'	'0'	'1622'	'0'	'3856'	'0'	'42.10%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-PC15'	'Q-WCC'	'? BMI'	'Reported'	'0.00%%'	'0'	'69.20%%'	'0'	'523'	'0'	'586'	'0'	'89.30%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-PC15'	'Q-WCC'	'? Counseling for Nutrition'	'Reported'	'0.00%%'	'0'	'61.10%%'	'0'	'476'	'0'	'586'	'0'	'81.20%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-PC15'	'Q-WCC'	'? Counseling for Physical Activity'	'Reported'	'0.00%%'	'0'	'55.80%%'	'0'	'472'	'0'	'586'	'0'	'80.60%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'Reported'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'N/A'	'3'	'1'	'No'
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'Reported'	'0.00%%'	'0'	'66.40%%'	'0'	'21'	'0'	'31'	'0'	'67.70%%'	'0'	'1'	'NoS'
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	''	'1'	''	'4'	''	'1'	'1'	'NOs'
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'Reported'	'0.00%%'	'0'	'50.60%%'	'0'	'214'	'0'	'299'	'0'	'71.60%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'Reported'	'0.00%%'	'0'	'71.40%%'	'0'	'81'	'0'	'85'	'0'	'95.30%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'Reported'	'0.00%%'	'0'	'51.90%%'	'0'	'35'	'0'	'165'	'0'	'21.20%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'Reported'	'0.00%%'	'0'	'45.00%%'	'0'	'91'	'0'	'165'	'0'	'55.20%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'Reported'	'0.00%%'	'0'	'88.30%%'	'0'	'146'	'0'	'165'	'0'	'88.50%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'Reported'	'0.00%%'	'0'	'24.80%%'	'0'	''	'1'	'39'	'0'	''	'1'	'1'	'Yes'
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'Reported'	'0.00%%'	'0'	'47.80%%'	'0'	'73'	'0'	'110'	'0'	'66.40%%'	'0'	'1'	'Yes'
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'Reported'	'0.00%%'	'0'	'99.20%%'	'0'	'147'	'0'	'147'	'0'	'100.00%%'	'0'	'1'	'No'
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'Not Reported'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'Washington Hospital Healthcare District'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'Reported'	'0.00%%'	'0'	'79.00%%'	'0'	'6'	'0'	'38.172'	'0'	'0.157'	'0'	'1'	'No'
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-CC2'	'Q-TRC'	'Medication Reconciliation Post Discharge (MRP)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-CC4'	'Q-PCR'	'Plan All-Cause Readmissions (PCR)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-IHE1'	'Q-IHE1'	'Improving Health Equity 1'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-IHE1'	'Q-IHE1'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Black/African American'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-IHE1'	'Q-IHE1'	'? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9) - -Hispanic/Latino'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-IHE2'	'Q-IHE2'	'Improving Health Equity 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PC1'	'Q-BCS'	'Breast Cancer Screening (BCS)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PC2'	'Q-CCS'	'Cervical Cancer Screening (CCS)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PC3'	'Q-WCV'	'Child and Adolescent Well Care Visits'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PC4'	'Q-CIS10'	'Childhood Immunization Status (CIS 10)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PC5'	'Q-CHL'	'Chlamydia Screening in Women (CHL)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PC6'	'Q-CMS130'	'Colorectal Cancer Screening'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PC7'	'Q-DEV'	'Developmental Screening in the First Three Years of Life'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PC8'	'Q-CMS349'	'HIV Screening Measure'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PC9'	'Q-IMA'	'Immunizations for Adolescents'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PC10'	'Q-LSC'	'Lead Screening in Children'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PC11'	'Q-CMS69'	'Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PC12'	'Q-CMS147'	'Preventive Care and Screening: Influenza Immunization'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PC13'	'Q-CMS2'	'Preventive Care and Screening: Screening for Depression and Follow-Up Plan'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PC14'	'Q-CMS138'	'Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 1 (informational only)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 2'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PC14'	'Q-CMS138'	'? Rate 3'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PC15'	'Q-WCC'	'Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PC15'	'Q-WCC'	'? BMI'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PC15'	'Q-WCC'	'? Counseling for Nutrition'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PC15'	'Q-WCC'	'? Counseling for Physical Activity'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PC16'	'Q-W30'	'Well-Child Visits in the First 30 Months of Life (W30)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PC16'	'Q-W30'	'? 15 Months-30 Months'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PC16'	'Q-W30'	'? First 15 Months'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-BH1'	'Q-COB'	'Concurrent Use of Opioids and Benzodiazepines (COB-AD)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-BH2'	'Q-DRR'	'Depression Remission or Response for Adolescents and Adults (DRR-E)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adults)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adults)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adults)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-BH2'	'Q-DRR'	'? Follow-Up PHQ-9 (Adolescents) - informational only'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-BH2'	'Q-DRR'	'? Depression Remission (Adolescents) - informational only'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-BH2'	'Q-DRR'	'? Depression Response (Adolescents) - informational only'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-BH3'	'Q-FUA'	'Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-BH3'	'Q-FUA'	'? 30 Days'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-BH3'	'Q-FUA'	'? 7 Days'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-BH4'	'Q-OHD'	'Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-CAC1'	'Q-CBP'	'Controlling High Blood Pressure (CBP)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-CAC2'	'Q-QPP118'	'Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVSD < 40%%)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-CAC3'	'Q-QPP6'	'Coronary Artery Disease (CAD): Antiplatelet Therapy'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-CAC4'	'Q-CMS135'	'Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-CAC5'	'Q-CMS347'	'Statin Therapy for the Prevention and Treatment of Cardiovascular Disease'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-CAD1'	'Q-CDC-H9'	'Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%%) (CDC-H9)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-CAD2'	'Q-CDC-E'	'Comprehensive Diabetes Care: Eye Exam (CDC-E)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-CAD3'	'Q-CDC-N'	'Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-CAH1'	'Q-HVL'	'HIV Viral Suppression (HVL-AD)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-CAR1'	'Q-AMR'	'Asthma Medication Ratio (AMR)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-CAR2'	'Q-PCE'	'Pharmacotherapy Management of COPD Exacerbation (PCE)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-CAR2'	'Q-PCE'	'? Systemic Corticosteroid'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-CAR2'	'Q-PCE'	'? Bronchodilator'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-OA1'	'Q-URI'	'Appropriate Treatment for Upper Respiratory Infection (URI)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-OA2'	'Q-AAB'	'Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-OA3'	'Q-QPP415'	'Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-OA4'	'Q-LBP'	'Use of Imaging Studies for Low Back Pain (LBP)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-MPH1'	'Q-PC02'	'Cesarean Birth (PC02-CH)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-MPH2'	'Q-CCW'	'Contraceptive Care - All Women Ages 15-44'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-MPH3'	'Q-PC05'	'Exclusive Breast Milk Feeding (PC-05)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-MPH4'	'Q-PPC-PST'	'Prenatal and Postpartum Care: Postpartum Care (PPC-PST)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-MPH5'	'Q-PPC-PRE'	'Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-EC1'	'Q-QPP47'	'Advance Care Plan'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PS1'	'Q-STK-2'	'Discharged on Antithrombotic Therapy'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PS2'	'Q-QPP23'	'Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PS3'	'Q-QPP76'	'Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PS5'	'Q-SSI'	'Surgical Site Infection (SSI)'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''
'PY4'	'DMPH'	'San Bernardino Mountains Community Hospital'	'Q-PS6'	'Q-CDI'	'Reduction in Hospital Acquired Clostridium Difficile Infections'	'No Data Entered'	''	''	''	''	''	''	''	''	''	''	''	''