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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	1	None	4	None	1	N/A	None
PY4	DPH	Alameda Health System	Q-BH2	Q-DRR	? Depression Remission (Adolescents) - informational only	Reported	0.00%	0	4.80%	0	None	1	None	4	None	1	N/A	None
PY4	DPH	Alameda Health System	Q-BH2	Q-DRR	? Depression Response (Adolescents) - informational only	Reported	0.00%	0	9.50%	0	None	1	None	4	None	1	N/A	None
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	None	1	623	0	None	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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None
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	None	1	1632	0	None	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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	Arrowhead Regional Medical Center	Q-PC15	Q-WCC	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	1	None	1	None	1	N/A	None
PY4	DPH	Arrowhead Regional Medical Center	Q-BH2	Q-DRR	? Depression Remission (Adolescents) - informational only	Reported	0.00%	0	4.80%	0	None	1	None	1	None	1	N/A	None
PY4	DPH	Arrowhead Regional Medical Center	Q-BH2	Q-DRR	? Depression Response (Adolescents) - informational only	Reported	0.00%	0	9.50%	0	None	1	None	1	None	1	N/A	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	Contra Costa Regional Medical Center	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	Kern Medical Center	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	Kern Medical Center	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	Kern Medical Center	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None
PY4	DPH	Los Angeles County Health System	Q-BH2	Q-DRR	? Depression Remission (Adolescents) - informational only	Reported	0.00%	0	4.80%	0	None	1	59	0	None	1	1	None
PY4	DPH	Los Angeles County Health System	Q-BH2	Q-DRR	? Depression Response (Adolescents) - informational only	Reported	0.00%	0	9.50%	0	None	1	59	0	None	1	1	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	Los Angeles County Health System	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
PY4	DPH	Natividad Medical Center	Q-BH2	Q-DRR	? Depression Remission (Adolescents) - informational only	Reported	0.00%	0	4.80%	0	None	1	48	0	None	1	0	None
PY4	DPH	Natividad Medical Center	Q-BH2	Q-DRR	? Depression Response (Adolescents) - informational only	Reported	0.00%	0	9.50%	0	None	1	48	0	None	1	0	None
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	None	1	201	0	None	1	1	NoS
PY4	DPH	Natividad Medical Center	Q-BH3	Q-FUA	? 7 Days	Reported	0.00%	0	7.10%	0	None	1	201	0	None	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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	Natividad Medical Center	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	Natividad Medical Center	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
PY4	DPH	Riverside University Health System	Q-BH2	Q-DRR	? Depression Remission (Adolescents) - informational only	Reported	0.00%	0	4.80%	0	None	1	66	0	None	1	1	None
PY4	DPH	Riverside University Health System	Q-BH2	Q-DRR	? Depression Response (Adolescents) - informational only	Reported	0.00%	0	9.50%	0	None	1	66	0	None	1	1	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None
PY4	DPH	San Francisco General Hospital	Q-BH2	Q-DRR	? Depression Response (Adolescents) - informational only	Reported	0.00%	0	9.50%	0	None	1	55	0	None	1	N/A	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	San Francisco General Hospital	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	San Francisco General Hospital	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	San Francisco General Hospital	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	San Joaquin General Hospital	Q-CC2	Q-TRC	Medication Reconciliation Post Discharge (MRP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	1	176	0	None	1	1	NoS
PY4	DPH	San Joaquin General Hospital	Q-BH2	Q-DRR	? Depression Response (Adults)	Reported	0.00%	0	9.60%	0	None	1	176	0	None	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	None	1	None	1	1	None
PY4	DPH	San Joaquin General Hospital	Q-BH2	Q-DRR	? Depression Remission (Adolescents) - informational only	Reported	0.00%	0	4.80%	0	0	0	None	1	None	1	1	None
PY4	DPH	San Joaquin General Hospital	Q-BH2	Q-DRR	? Depression Response (Adolescents) - informational only	Reported	0.00%	0	9.50%	0	0	0	None	1	None	1	1	None
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	None	1	77	0	None	1	1	NoS
PY4	DPH	San Joaquin General Hospital	Q-BH3	Q-FUA	? 7 Days	Reported	0.00%	0	7.10%	0	None	1	77	0	None	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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None
PY4	DPH	Santa Clara Valley Medical Center	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
PY4	DPH	San Mateo Medical Center	Q-BH2	Q-DRR	? Depression Remission (Adolescents) - informational only	Reported	0.00%	0	4.80%	0	None	1	125	0	None	1	N/A	None
PY4	DPH	San Mateo Medical Center	Q-BH2	Q-DRR	? Depression Response (Adolescents) - informational only	Reported	0.00%	0	9.50%	0	None	1	125	0	None	1	N/A	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	Santa Clara Valley Medical Center	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	Santa Clara Valley Medical Center	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	Santa Clara Valley Medical Center	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	Santa Clara Valley Medical Center	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	4	None	4	1	NoS
PY4	DPH	San Mateo Medical Center	Q-CAR2	Q-PCE	? Bronchodilator	Reported	0.00%	0	78.70%	0	None	1	None	4	None	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	None	1	None	1	None	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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	1	4933	0	None	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	None
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	None
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	None	1	None	1	0	None
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	None	1	None	1	0	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	San Mateo Medical Center	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	1	None	1	0	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	San Mateo Medical Center	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	San Mateo Medical Center	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	San Mateo Medical Center	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	1	36	0	None	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	None	1	114	0	None	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	None	1	38	0	None	1	1	NoS
PY4	DPH	UC Davis Medical Center	Q-BH2	Q-DRR	? Depression Response (Adults)	Reported	0.00%	0	9.60%	0	None	1	38	0	None	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	None	1	None	1	N/A	None
PY4	DPH	UC Davis Medical Center	Q-BH2	Q-DRR	? Depression Remission (Adolescents) - informational only	Reported	0.00%	0	4.80%	0	0	0	None	1	None	1	N/A	None
PY4	DPH	UC Davis Medical Center	Q-BH2	Q-DRR	? Depression Response (Adolescents) - informational only	Reported	0.00%	0	9.50%	0	0	0	None	1	None	1	N/A	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	1	93	0	None	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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	UC Davis Medical Center	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	UC Davis Medical Center	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	1	35	0	None	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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	1	None	4	None	1	1	None
PY4	DPH	UC Irvine Medical Center	Q-BH2	Q-DRR	? Depression Remission (Adolescents) - informational only	Reported	0.00%	0	4.80%	0	None	1	None	4	None	1	1	None
PY4	DPH	UC Irvine Medical Center	Q-BH2	Q-DRR	? Depression Response (Adolescents) - informational only	Reported	0.00%	0	9.50%	0	None	1	None	4	None	1	1	None
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	None	1	35	0	None	1	1	NoS
PY4	DPH	UC Irvine Medical Center	Q-BH3	Q-FUA	? 7 Days	Reported	0.00%	0	7.10%	0	None	1	35	0	None	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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	UC Irvine Medical Center	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	UC Irvine Medical Center	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	1	None	1	None	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	None	1	None	4	None	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	None	1	33	0	None	1	1	No
PY4	DPH	UC Los Angeles Medical Center	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	UC Los Angeles Medical Center	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	1	None	1	None	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	None	1	None	1	None	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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	1	None	4	None	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	None	1	39	0	None	1	1	NoS
PY4	DPH	UC San Diego Medical Center	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	1	40	0	None	1	1	No
PY4	DPH	UC San Diego Medical Center	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	UC San Diego Medical Center	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	UC San Diego Medical Center	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	UC San Diego Medical Center	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	1	42	0	None	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	None	4	None	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	None	4	None	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	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	1	None	4	None	1	N/A	None
PY4	DPH	UC San Francisco Medical Center	Q-BH2	Q-DRR	? Depression Remission (Adolescents) - informational only	Reported	0.00%	0	4.80%	0	None	1	None	4	None	1	N/A	None
PY4	DPH	UC San Francisco Medical Center	Q-BH2	Q-DRR	? Depression Response (Adolescents) - informational only	Reported	0.00%	0	9.50%	0	None	1	None	4	None	1	N/A	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	UC San Francisco Medical Center	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	Ventura County Medical Center	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DPH	Ventura County Medical Center	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Black/African American	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Hispanic/Latino	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-PC4	Q-CIS10	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-PC14	Q-CMS138	Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-PC15	Q-WCC	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-PC16	Q-W30	Well-Child Visits in the First 30 Months of Life (W30)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-CAD1	Q-CDC-H9	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-CAD2	Q-CDC-E	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	1	66	0	None	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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Antelope Valley Hospital	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-IHE1	Q-IHE1	Improving Health Equity 1	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PC4	Q-CIS10	Childhood Immunization Status (CIS 10)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PC6	Q-CMS130	Colorectal Cancer Screening	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PC8	Q-CMS349	HIV Screening Measure	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PC9	Q-IMA	Immunizations for Adolescents	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PC10	Q-LSC	Lead Screening in Children	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PC14	Q-CMS138	Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PC14	Q-CMS138	? Rate 1 (informational only)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PC14	Q-CMS138	? Rate 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PC14	Q-CMS138	? Rate 3	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PC15	Q-WCC	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PC15	Q-WCC	? BMI	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PC15	Q-WCC	? Counseling for Nutrition	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PC15	Q-WCC	? Counseling for Physical Activity	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PC16	Q-W30	Well-Child Visits in the First 30 Months of Life (W30)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PC16	Q-W30	? 15 Months-30 Months	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PC16	Q-W30	? First 15 Months	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-BH2	Q-DRR	? Follow-Up PHQ-9 (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-BH2	Q-DRR	? Depression Remission (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-BH2	Q-DRR	? Depression Response (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-BH2	Q-DRR	? Follow-Up PHQ-9 (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-BH2	Q-DRR	? Depression Remission (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-BH2	Q-DRR	? Depression Response (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-BH3	Q-FUA	? 30 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-BH3	Q-FUA	? 7 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-CAD1	Q-CDC-H9	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-CAD2	Q-CDC-E	Comprehensive Diabetes Care: Eye Exam (CDC-E)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-CAR2	Q-PCE	? Systemic Corticosteroid	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-CAR2	Q-PCE	? Bronchodilator	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-EC1	Q-QPP47	Advance Care Plan	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Bear Valley Community Hospital	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-CC2	Q-TRC	Medication Reconciliation Post Discharge (MRP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Hispanic/Latino	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-PC4	Q-CIS10	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-PC15	Q-WCC	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-PC16	Q-W30	Well-Child Visits in the First 30 Months of Life (W30)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-CAD1	Q-CDC-H9	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-CAD2	Q-CDC-E	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Eastern Plumas Health Care	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-CC2	Q-TRC	Medication Reconciliation Post Discharge (MRP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Black/African American	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Hispanic/Latino	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-PC4	Q-CIS10	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-PC14	Q-CMS138	Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-PC15	Q-WCC	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-PC16	Q-W30	Well-Child Visits in the First 30 Months of Life (W30)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-CAD1	Q-CDC-H9	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-CAD2	Q-CDC-E	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Camino Hospital	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Centro Regional Medical Center	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	1	None	1	None	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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Centro Regional Medical Center	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Centro Regional Medical Center	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Centro Regional Medical Center	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Centro Regional Medical Center	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Centro Regional Medical Center	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Centro Regional Medical Center	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Centro Regional Medical Center	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Centro Regional Medical Center	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Centro Regional Medical Center	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Centro Regional Medical Center	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Centro Regional Medical Center	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Centro Regional Medical Center	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Centro Regional Medical Center	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Centro Regional Medical Center	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Centro Regional Medical Center	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	El Centro Regional Medical Center	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Hispanic/Latino	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-PC14	Q-CMS138	Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-PC15	Q-WCC	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-PC16	Q-W30	Well-Child Visits in the First 30 Months of Life (W30)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Hazel Hawkins Memorial Hospital	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-CC2	Q-TRC	Medication Reconciliation Post Discharge (MRP)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-IHE1	Q-IHE1	Improving Health Equity 1	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Hispanic/Latino	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PC4	Q-CIS10	Childhood Immunization Status (CIS 10)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PC6	Q-CMS130	Colorectal Cancer Screening	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PC8	Q-CMS349	HIV Screening Measure	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PC9	Q-IMA	Immunizations for Adolescents	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PC10	Q-LSC	Lead Screening in Children	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PC14	Q-CMS138	Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PC14	Q-CMS138	? Rate 1 (informational only)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PC14	Q-CMS138	? Rate 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PC14	Q-CMS138	? Rate 3	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PC15	Q-WCC	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PC15	Q-WCC	? BMI	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PC15	Q-WCC	? Counseling for Nutrition	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PC15	Q-WCC	? Counseling for Physical Activity	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PC16	Q-W30	Well-Child Visits in the First 30 Months of Life (W30)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PC16	Q-W30	? 15 Months-30 Months	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PC16	Q-W30	? First 15 Months	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-BH2	Q-DRR	? Follow-Up PHQ-9 (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-BH2	Q-DRR	? Depression Remission (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-BH2	Q-DRR	? Depression Response (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-BH2	Q-DRR	? Follow-Up PHQ-9 (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-BH2	Q-DRR	? Depression Remission (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-BH2	Q-DRR	? Depression Response (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-BH3	Q-FUA	? 30 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-BH3	Q-FUA	? 7 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-CAD1	Q-CDC-H9	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-CAD2	Q-CDC-E	Comprehensive Diabetes Care: Eye Exam (CDC-E)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-CAR2	Q-PCE	? Systemic Corticosteroid	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-CAR2	Q-PCE	? Bronchodilator	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-EC1	Q-QPP47	Advance Care Plan	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Healdsburg District Hospital	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-CC2	Q-TRC	Medication Reconciliation Post Discharge (MRP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Hispanic/Latino	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-PC4	Q-CIS10	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-PC16	Q-W30	Well-Child Visits in the First 30 Months of Life (W30)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-CAD1	Q-CDC-H9	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-CAD2	Q-CDC-E	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Jerold Phelps Community Hospital	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-CC2	Q-TRC	Medication Reconciliation Post Discharge (MRP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	1	43	0	None	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	None	1	134	0	None	1	1	No
PY4	DMPH	John C. Fremont Healthcare District	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-PC10	Q-LSC	Lead Screening in Children	Reported	0.00%	0	61.30%	0	None	1	45	0	None	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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-PC14	Q-CMS138	Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-PC15	Q-WCC	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-PC16	Q-W30	Well-Child Visits in the First 30 Months of Life (W30)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-CAD1	Q-CDC-H9	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-CAD2	Q-CDC-E	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	John C. Fremont Healthcare District	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kaweah Delta Health Care District	Q-CC2	Q-TRC	Medication Reconciliation Post Discharge (MRP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kaweah Delta Health Care District	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	1	None	4	None	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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kaweah Delta Health Care District	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	1	35	0	None	1	1	NoS
PY4	DMPH	Kaweah Delta Health Care District	Q-BH3	Q-FUA	? 7 Days	Reported	0.00%	0	7.10%	0	None	1	35	0	None	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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kaweah Delta Health Care District	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kaweah Delta Health Care District	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kaweah Delta Health Care District	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kaweah Delta Health Care District	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kaweah Delta Health Care District	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kaweah Delta Health Care District	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kaweah Delta Health Care District	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kaweah Delta Health Care District	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kaweah Delta Health Care District	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kaweah Delta Health Care District	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kaweah Delta Health Care District	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kaweah Delta Health Care District	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kaweah Delta Health Care District	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kaweah Delta Health Care District	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-CC2	Q-TRC	Medication Reconciliation Post Discharge (MRP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Hispanic/Latino	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-PC4	Q-CIS10	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-PC14	Q-CMS138	Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	1	39	0	None	1	1	NoS
PY4	DMPH	Kern Valley Healthcare District	Q-PC16	Q-W30	? First 15 Months	Reported	0.00%	0	45.00%	0	None	1	34	0	None	1	1	NoS
PY4	DMPH	Kern Valley Healthcare District	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-EC1	Q-QPP47	Advance Care Plan	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Kern Valley Healthcare District	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Lompoc Valley Medical Center	Q-CC2	Q-TRC	Medication Reconciliation Post Discharge (MRP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Lompoc Valley Medical Center	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	1	None	1	None	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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Lompoc Valley Medical Center	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	4	None	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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Lompoc Valley Medical Center	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Lompoc Valley Medical Center	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	4	None	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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Lompoc Valley Medical Center	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Lompoc Valley Medical Center	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Lompoc Valley Medical Center	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Lompoc Valley Medical Center	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Lompoc Valley Medical Center	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Lompoc Valley Medical Center	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Lompoc Valley Medical Center	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Lompoc Valley Medical Center	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Lompoc Valley Medical Center	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Lompoc Valley Medical Center	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Lompoc Valley Medical Center	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Lompoc Valley Medical Center	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Lompoc Valley Medical Center	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Lompoc Valley Medical Center	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Lompoc Valley Medical Center	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Black/African American	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Hispanic/Latino	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-PC16	Q-W30	Well-Child Visits in the First 30 Months of Life (W30)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-BH3	Q-FUA	Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mammoth Hospital	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	1	None	4	None	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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-PC4	Q-CIS10	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-PC14	Q-CMS138	Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-PC15	Q-WCC	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-PC16	Q-W30	Well-Child Visits in the First 30 Months of Life (W30)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Marin General Hospital	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Hispanic/Latino	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-PC4	Q-CIS10	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-PC14	Q-CMS138	Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-PC15	Q-WCC	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-PC16	Q-W30	Well-Child Visits in the First 30 Months of Life (W30)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-CAD1	Q-CDC-H9	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-CAD2	Q-CDC-E	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mayers Memorial Hospital District	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	1	None	1	None	1	1	No
PY4	DMPH	Mayers Memorial Hospital District	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Black/African American	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Hispanic/Latino	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-PC4	Q-CIS10	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-PC16	Q-W30	Well-Child Visits in the First 30 Months of Life (W30)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-CAD1	Q-CDC-H9	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-CAD2	Q-CDC-E	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Modoc Medical Center	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-CC2	Q-TRC	Medication Reconciliation Post Discharge (MRP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Black/African American	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Hispanic/Latino	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-PC4	Q-CIS10	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-PC14	Q-CMS138	Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-PC15	Q-WCC	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-PC16	Q-W30	Well-Child Visits in the First 30 Months of Life (W30)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-CAD2	Q-CDC-E	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Northern Inyo Hospital	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	1	None	1	None	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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	4	None	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	None	1	None	4	None	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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Oak Valley Hospital District	Q-PC9	Q-IMA	Immunizations for Adolescents	Reported	0.00%	0	30.90%	0	0	0	None	1	None	1	1	No
PY4	DMPH	Oak Valley Hospital District	Q-PC10	Q-LSC	Lead Screening in Children	Reported	0.00%	0	61.30%	0	None	1	None	4	None	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	None
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	None	1	1256	0	None	1	1	NoS
PY4	DMPH	Oak Valley Hospital District	Q-PC15	Q-WCC	? Counseling for Nutrition	Reported	0.00%	0	61.10%	0	None	1	1256	0	None	1	1	NoS
PY4	DMPH	Oak Valley Hospital District	Q-PC15	Q-WCC	? Counseling for Physical Activity	Reported	0.00%	0	55.80%	0	None	1	1256	0	None	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	None	1	None	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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Oak Valley Hospital District	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Oak Valley Hospital District	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Oak Valley Hospital District	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Oak Valley Hospital District	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Oak Valley Hospital District	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Oak Valley Hospital District	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Oak Valley Hospital District	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Oak Valley Hospital District	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Oak Valley Hospital District	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Oak Valley Hospital District	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Oak Valley Hospital District	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Oak Valley Hospital District	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Oak Valley Hospital District	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Oak Valley Hospital District	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Oak Valley Hospital District	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Oak Valley Hospital District	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Oak Valley Hospital District	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Oak Valley Hospital District	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Oak Valley Hospital District	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Oak Valley Hospital District	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	1	None	4	None	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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Palomar Health	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Palomar Health	Q-PC4	Q-CIS10	Childhood Immunization Status (CIS 10)	Reported	0.00%	0	31.90%	0	None	1	None	1	None	1	1	No
PY4	DMPH	Palomar Health	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Palomar Health	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Palomar Health	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Palomar Health	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Palomar Health	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Palomar Health	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Palomar Health	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Palomar Health	Q-PC14	Q-CMS138	Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Palomar Health	Q-PC15	Q-WCC	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Palomar Health	Q-PC16	Q-W30	Well-Child Visits in the First 30 Months of Life (W30)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Palomar Health	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Palomar Health	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Palomar Health	Q-BH3	Q-FUA	Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Palomar Health	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Palomar Health	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Palomar Health	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Palomar Health	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Palomar Health	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Palomar Health	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Palomar Health	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	4	None	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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Hispanic/Latino	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Pioneers Memorial Healthcare District	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-CC2	Q-TRC	Medication Reconciliation Post Discharge (MRP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Black/African American	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Hispanic/Latino	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-PC4	Q-CIS10	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-PC15	Q-WCC	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-PC16	Q-W30	Well-Child Visits in the First 30 Months of Life (W30)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-CAD1	Q-CDC-H9	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-CAD2	Q-CDC-E	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Plumas District Hospital	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Salinas Valley Memorial Healthcare System	Q-CC2	Q-TRC	Medication Reconciliation Post Discharge (MRP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Salinas Valley Memorial Healthcare System	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Salinas Valley Memorial Healthcare System	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Salinas Valley Memorial Healthcare System	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Salinas Valley Memorial Healthcare System	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Salinas Valley Memorial Healthcare System	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	1	1416	0	None	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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Salinas Valley Memorial Healthcare System	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Salinas Valley Memorial Healthcare System	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Salinas Valley Memorial Healthcare System	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Salinas Valley Memorial Healthcare System	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Salinas Valley Memorial Healthcare System	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Salinas Valley Memorial Healthcare System	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Salinas Valley Memorial Healthcare System	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Salinas Valley Memorial Healthcare System	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Salinas Valley Memorial Healthcare System	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Salinas Valley Memorial Healthcare System	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Salinas Valley Memorial Healthcare System	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Salinas Valley Memorial Healthcare System	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Salinas Valley Memorial Healthcare System	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Salinas Valley Memorial Healthcare System	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Salinas Valley Memorial Healthcare System	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-CC2	Q-TRC	Medication Reconciliation Post Discharge (MRP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-PC4	Q-CIS10	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-PC15	Q-WCC	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-PC16	Q-W30	Well-Child Visits in the First 30 Months of Life (W30)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-CAD1	Q-CDC-H9	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-CAD2	Q-CDC-E	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	4	None	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	None	4	None	4	1	No
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Mountains Community Hospital, Lake Arrowhead	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Hispanic/Latino	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-PC4	Q-CIS10	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-PC14	Q-CMS138	Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-PC15	Q-WCC	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-PC16	Q-W30	Well-Child Visits in the First 30 Months of Life (W30)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-CAD1	Q-CDC-H9	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-CAD2	Q-CDC-E	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Gorgonio Memorial Hospital	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	1	52	0	None	1	1	No
PY4	DMPH	San Gorgonio Memorial Hospital	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Black/African American	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Hispanic/Latino	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-PC4	Q-CIS10	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.00%	0	27.40%	0	None	1	69	0	None	1	1	No
PY4	DMPH	Seneca Healthcare District	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-PC15	Q-WCC	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-PC16	Q-W30	Well-Child Visits in the First 30 Months of Life (W30)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-CAD1	Q-CDC-H9	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-CAD2	Q-CDC-E	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Seneca Healthcare District	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-CC2	Q-TRC	Medication Reconciliation Post Discharge (MRP)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-IHE1	Q-IHE1	Improving Health Equity 1	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-PC4	Q-CIS10	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-PC16	Q-W30	Well-Child Visits in the First 30 Months of Life (W30)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-BH2	Q-DRR	? Follow-Up PHQ-9 (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-BH2	Q-DRR	? Depression Remission (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-BH2	Q-DRR	? Depression Response (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-BH2	Q-DRR	? Follow-Up PHQ-9 (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-BH2	Q-DRR	? Depression Remission (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-BH2	Q-DRR	? Depression Response (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-BH3	Q-FUA	? 30 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-BH3	Q-FUA	? 7 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-CAD1	Q-CDC-H9	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-CAD2	Q-CDC-E	Comprehensive Diabetes Care: Eye Exam (CDC-E)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-CAR2	Q-PCE	? Systemic Corticosteroid	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-CAR2	Q-PCE	? Bronchodilator	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sierra View District Hospital	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Black/African American	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Hispanic/Latino	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-PC4	Q-CIS10	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-PC14	Q-CMS138	Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-PC15	Q-WCC	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-PC16	Q-W30	Well-Child Visits in the First 30 Months of Life (W30)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-CAD1	Q-CDC-H9	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-CAD2	Q-CDC-E	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Reported	0.00%	0	99.20%	0	24	0	None	4	None	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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Sonoma Valley Hospital	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-CC2	Q-TRC	Medication Reconciliation Post Discharge (MRP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Black/African American	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Hispanic/Latino	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-PC4	Q-CIS10	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-PC14	Q-CMS138	Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-PC15	Q-WCC	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-PC16	Q-W30	Well-Child Visits in the First 30 Months of Life (W30)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-CAD1	Q-CDC-H9	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-CAD2	Q-CDC-E	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Southern Inyo Hospital	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-CC2	Q-TRC	Medication Reconciliation Post Discharge (MRP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Hispanic/Latino	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-PC4	Q-CIS10	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-PC16	Q-W30	Well-Child Visits in the First 30 Months of Life (W30)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-CAD1	Q-CDC-H9	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-CAD2	Q-CDC-E	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Surprise Valley Community Hospital	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-CC2	Q-TRC	Medication Reconciliation Post Discharge (MRP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Hispanic/Latino	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-PC16	Q-W30	Well-Child Visits in the First 30 Months of Life (W30)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tahoe Forest Hospital District	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None
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	None
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	None	1	None	1	None	1	0	None
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	None	4	None	4	0	None
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	None
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	None	4	None	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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tri-City Medical Center	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tri-City Medical Center	Q-PC4	Q-CIS10	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tri-City Medical Center	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tri-City Medical Center	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tri-City Medical Center	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tri-City Medical Center	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tri-City Medical Center	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tri-City Medical Center	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tri-City Medical Center	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tri-City Medical Center	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tri-City Medical Center	Q-PC14	Q-CMS138	Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tri-City Medical Center	Q-PC15	Q-WCC	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tri-City Medical Center	Q-PC16	Q-W30	Well-Child Visits in the First 30 Months of Life (W30)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tri-City Medical Center	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tri-City Medical Center	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	1	124	0	None	1	1	NoS
PY4	DMPH	Tri-City Medical Center	Q-BH3	Q-FUA	? 7 Days	Reported	0.00%	0	7.10%	0	None	1	124	0	None	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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tri-City Medical Center	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tri-City Medical Center	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tri-City Medical Center	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tri-City Medical Center	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tri-City Medical Center	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Reported	0.00%	0	59.90%	0	None	1	31	0	None	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	None	1	None	1	None	1	1	NoS
PY4	DMPH	Tri-City Medical Center	Q-CAR2	Q-PCE	? Bronchodilator	Reported	0.00%	0	78.70%	0	None	1	None	1	None	1	1	NoS
PY4	DMPH	Tri-City Medical Center	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Tri-City Medical Center	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Black/African American	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Hispanic/Latino	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-PC4	Q-CIS10	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-PC14	Q-CMS138	Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-PC15	Q-WCC	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-PC16	Q-W30	Well-Child Visits in the First 30 Months of Life (W30)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-BH3	Q-FUA	Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-CAD1	Q-CDC-H9	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-CAD2	Q-CDC-E	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Trinity Hospital	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Washington Hospital Healthcare District	Q-CC2	Q-TRC	Medication Reconciliation Post Discharge (MRP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Washington Hospital Healthcare District	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Washington Hospital Healthcare District	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Washington Hospital Healthcare District	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Washington Hospital Healthcare District	Q-IHE1	Q-IHE1	? Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9) - -Hispanic/Latino	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Washington Hospital Healthcare District	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Washington Hospital Healthcare District	Q-PC14	Q-CMS138	Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	1	None	4	None	1	1	NOs
PY4	DMPH	Washington Hospital Healthcare District	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Washington Hospital Healthcare District	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Washington Hospital Healthcare District	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Washington Hospital Healthcare District	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Washington Hospital Healthcare District	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Washington Hospital Healthcare District	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Washington Hospital Healthcare District	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Washington Hospital Healthcare District	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Washington Hospital Healthcare District	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Washington Hospital Healthcare District	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Reported	0.00%	0	24.80%	0	None	1	39	0	None	1	1	Yes
PY4	DMPH	Washington Hospital Healthcare District	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Washington Hospital Healthcare District	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Washington Hospital Healthcare District	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Washington Hospital Healthcare District	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	Washington Hospital Healthcare District	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-CC4	Q-PCR	Plan All-Cause Readmissions (PCR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-IHE1	Q-IHE1	Improving Health Equity 1	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-IHE1	Q-IHE1	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-PC4	Q-CIS10	Childhood Immunization Status (CIS 10)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-PC6	Q-CMS130	Colorectal Cancer Screening	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-PC8	Q-CMS349	HIV Screening Measure	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-PC9	Q-IMA	Immunizations for Adolescents	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-PC10	Q-LSC	Lead Screening in Children	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-PC14	Q-CMS138	Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-PC14	Q-CMS138	? Rate 1 (informational only)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-PC14	Q-CMS138	? Rate 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-PC14	Q-CMS138	? Rate 3	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-PC15	Q-WCC	? BMI	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-PC15	Q-WCC	? Counseling for Nutrition	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-PC15	Q-WCC	? Counseling for Physical Activity	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-PC16	Q-W30	? 15 Months-30 Months	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-PC16	Q-W30	? First 15 Months	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-BH2	Q-DRR	Depression Remission or Response for Adolescents and Adults (DRR-E)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-BH2	Q-DRR	? Follow-Up PHQ-9 (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-BH2	Q-DRR	? Depression Remission (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-BH2	Q-DRR	? Depression Response (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-BH2	Q-DRR	? Follow-Up PHQ-9 (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-BH2	Q-DRR	? Depression Remission (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-BH2	Q-DRR	? Depression Response (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-BH3	Q-FUA	? 30 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-BH3	Q-FUA	? 7 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-CAD2	Q-CDC-E	Comprehensive Diabetes Care: Eye Exam (CDC-E)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-CAD3	Q-CDC-N	Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC-MN)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-CAR2	Q-PCE	? Systemic Corticosteroid	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-CAR2	Q-PCE	? Bronchodilator	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-MPH2	Q-CCW	Contraceptive Care - All Women Ages 15-44	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-EC1	Q-QPP47	Advance Care Plan	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
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	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None
PY4	DMPH	San Bernardino Mountains Community Hospital	Q-PS6	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None