Table: quality_incentive_pool_qip_program_data_year_5

py	hospital	type	number	abbreviation	title	report_status	baseline_rate	baseline_rate_annotation_code	target_rate	target_rate_annotation_code	numerator	numerator_annotation_code	denominator	denominator_annotation_code	achievement_rate	achievement_rate_annotation_code	achievement_value	overperformance_value	p4p
PY5	Alameda Health System	DPH	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Reported	0.0344	0	0.0848	None	36	0	786	0	4.6%	0	1	N/A	Yes
PY5	Alameda Health System	DPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adolescents) - informational only	Reported	None	2	N/A	None	None	1	52	0	None	1	N/A	N/A	YesS
PY5	Alameda Health System	DPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adolescents) - informational only	Reported	None	2	N/A	None	None	1	52	0	None	1	N/A	N/A	YesS
PY5	Alameda Health System	DPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adolescents) - informational only	Reported	None	2	N/A	None	20	0	52	0	38.5%	0	N/A	N/A	YesS
PY5	Alameda Health System	DPH	Q-BH2	Q-DRR-E	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	N/A	Yes
PY5	Alameda Health System	DPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adults)	Reported	0.1731	0	0.1522	None	82	0	401	0	20.5%	0	1	N/A	YesS
PY5	Alameda Health System	DPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adults)	Reported	0.2923	0	0.2609	None	135	0	401	0	33.7%	0	1	N/A	YesS
PY5	Alameda Health System	DPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adults)	Reported	0.6	0	0.6069	None	296	0	401	0	73.8%	0	1	0.5	YesS
PY5	Alameda Health System	DPH	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	0.5	Yes
PY5	Alameda Health System	DPH	Q-BH3	Q-FUA	▶ 7 Days	Reported	0.1503	0	0.1583	None	88	0	318	0	27.7%	0	1	0.5	YesS
PY5	Alameda Health System	DPH	Q-BH3	Q-FUA	▶ 30 Days	Reported	0.1933	0	0.2066	None	102	0	318	0	32.1%	0	1	0.5	YesS
PY5	Alameda Health System	DPH	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Reported	None	2	0.0269	None	11	0	772	0	1.4%	0	1	N/A	Yes
PY5	Alameda Health System	DPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Alameda Health System	DPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Alameda Health System	DPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.555	0	0.5663	None	2637	0	4503	0	58.6%	0	1	0.5	Yes
PY5	Alameda Health System	DPH	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	0.9138	0	0.9144	None	382	0	416	0	91.8%	0	1	0.5	Yes
PY5	Alameda Health System	DPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.9344	0	0.9199	None	982	0	1058	0	92.8%	0	1	N/A	Yes
PY5	Alameda Health System	DPH	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	0.9765	0	0.8775	None	503	0	510	0	98.6%	0	1	N/A	Yes
PY5	Alameda Health System	DPH	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Reported	0.7692	0	0.7761	None	4159	0	5488	0	75.8%	0	0	0	Yes
PY5	Alameda Health System	DPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	0.4344	0	0.425	None	462	0	1163	0	39.7%	0	1	0.5	YesS
PY5	Alameda Health System	DPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	0.3763	0	0.3727	None	500	0	1222	0	40.9%	0	0	0	YesS
PY5	Alameda Health System	DPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.3839	0	0.3796	None	1526	0	4079	0	37.4%	0	1	0.5	YesS
PY5	Alameda Health System	DPH	Q-CAD1	Q-HBD	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	0.6667	0	Yes
PY5	Alameda Health System	DPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Alameda Health System	DPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	233	0	928	0	25.1%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	457	0	1143	0	40.0%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	36	0	86	0	41.9%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	180	0	439	0	41.0%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	31	0	72	0	43.1%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	583	0	1397	0	41.7%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	1526	0	4079	0	37.4%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	500	0	1222	0	40.9%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	926	0	2711	0	34.2%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	100	0	146	0	68.5%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	1526	0	4079	0	37.4%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.5293	0	0.5394	None	2218	0	4079	0	54.4%	0	1	0	Yes
PY5	Alameda Health System	DPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Reported	0.6017	0	0.4676	None	2111	0	3553	0	59.4%	0	1	N/A	Yes
PY5	Alameda Health System	DPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Reported	0.8313	0	0.8319	None	427	0	505	0	84.6%	0	1	0.5	Yes
PY5	Alameda Health System	DPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Alameda Health System	DPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Alameda Health System	DPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Reported	0.9786	0	0.78	None	1931	0	1956	0	98.7%	0	1	N/A	Yes
PY5	Alameda Health System	DPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Alameda Health System	DPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Alameda Health System	DPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	1	0.5	Yes
PY5	Alameda Health System	DPH	Q-IHE1	Q-IHE1	▶ Childhood Immunization Status (CIS 10) - -Black/African American	Reported	0.2967	0	0.3207	None	35	0	91	0	38.5%	0	1	0.5	YesS
PY5	Alameda Health System	DPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Reported	None	None	N/A	3	N/A	3	N/A	3	N/A	3	1	0.5	Yes
PY5	Alameda Health System	DPH	Q-IHE2	Q-IHE2	▶ Exclusive Breast Milk Feeding (PC-05) - -Asian	Reported	0.6304	0	0.6436	None	39	0	59	0	66.1%	0	1	0.5	YesS
PY5	Alameda Health System	DPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Reported	0.1381	0	0.22	None	69	0	376	0	18.4%	0	1	N/A	Yes
PY5	Alameda Health System	DPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Reported	0.694	0	0.7008	None	718	0	992	0	72.4%	0	1	0.5	Yes
PY5	Alameda Health System	DPH	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Reported	0.7496	0	0.7583	None	489	0	613	0	79.8%	0	1	1	Yes
PY5	Alameda Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Alameda Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	Reported	N/A	3	N/A	3	59	0	64	0	92.2%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	Reported	N/A	3	N/A	3	107	0	137	0	78.1%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Alameda Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Race : White	Reported	N/A	3	N/A	3	47	0	60	0	78.3%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Alameda Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	259	0	322	0	80.4%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	Reported	N/A	3	N/A	3	489	0	613	0	79.8%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	222	0	268	0	82.8%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	255	0	314	0	81.2%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	12	0	31	0	38.7%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	489	0	613	0	79.8%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Reported	0.7979	0	0.8103	None	479	0	613	0	78.1%	0	0	0	Yes
PY5	Alameda Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Alameda Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Asian	Reported	N/A	3	N/A	3	48	0	64	0	75.0%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Black or African American	Reported	N/A	3	N/A	3	113	0	137	0	82.5%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	11	0	None	4	None	4	N/A	None	None
PY5	Alameda Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : White	Reported	N/A	3	N/A	3	46	0	60	0	76.7%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Alameda Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	252	0	322	0	78.3%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Total	Reported	N/A	3	N/A	3	479	0	613	0	78.1%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	220	0	268	0	82.1%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	251	0	314	0	79.9%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	31	0	None	1	N/A	None	None
PY5	Alameda Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	479	0	613	0	78.1%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Reported	0.454	0	0.4544	None	259	0	603	0	43.0%	0	0	0	Yes
PY5	Alameda Health System	DPH	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Reported	0.9805	0	0.9434	None	875	0	898	0	97.4%	0	1	N/A	Yes
PY5	Alameda Health System	DPH	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	None
PY5	Alameda Health System	DPH	Q-OA3	Q-QPP415	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older	Reported	0.9433	0	0.9199	None	563	0	601	0	93.7%	0	1	N/A	Yes
PY5	Alameda Health System	DPH	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	None
PY5	Alameda Health System	DPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.4642	0	0.4816	None	2680	0	5547	0	48.3%	0	1	0	Yes
PY5	Alameda Health System	DPH	Q-PC10	Q-LSC	Lead Screening in Children	Reported	0.6044	0	0.6279	None	409	0	575	0	71.1%	0	1	0	Yes
PY5	Alameda Health System	DPH	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	None
PY5	Alameda Health System	DPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Reported	0.6795	0	0.6834	None	16086	0	20506	0	78.5%	0	1	0.5	Yes
PY5	Alameda Health System	DPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.7017	0	0.7214	None	15950	0	21335	0	74.8%	0	1	1	Yes
PY5	Alameda Health System	DPH	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	None
PY5	Alameda Health System	DPH	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	N/A	Yes
PY5	Alameda Health System	DPH	Q-PC15	Q-WCC	▶ Counseling for Physical Activity	Reported	0.7709	0	0.7731	None	5637	0	6070	0	92.9%	0	1	0.5	YesS
PY5	Alameda Health System	DPH	Q-PC15	Q-WCC	▶ Counseling for Nutrition	Reported	0.7744	0	0.7794	None	5614	0	6070	0	92.5%	0	1	0.5	YesS
PY5	Alameda Health System	DPH	Q-PC15	Q-WCC	▶ BMI	Reported	0.9125	0	0.8718	None	5492	0	6070	0	90.5%	0	1	N/A	YesS
PY5	Alameda Health System	DPH	Q-PC16	Q-W30	▶ First 15 Months	Reported	0.5938	0	0.6028	None	None	1	None	4	None	1	N/A	N/A	YesS
PY5	Alameda Health System	DPH	Q-PC16	Q-W30	▶ 15 Months-30 Months	Reported	0.6153	0	0.6643	None	393	0	557	0	70.6%	0	1	0	YesS
PY5	Alameda Health System	DPH	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	0	Yes
PY5	Alameda Health System	DPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Alameda Health System	DPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.4437	0	0.4613	None	5257	0	12578	0	41.8%	0	0	0	Yes
PY5	Alameda Health System	DPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	538	0	1314	0	40.9%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	533	0	1483	0	35.9%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	47	0	134	0	35.1%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	178	0	513	0	34.7%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	71	0	147	0	48.3%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	3881	0	8963	0	43.3%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	5257	0	12578	0	41.8%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	3451	0	7198	0	47.9%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	1622	0	3919	0	41.4%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	184	0	1461	0	12.6%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	5257	0	12578	0	41.8%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Reported	0.4478	0	0.4567	None	316	0	558	0	56.6%	0	1	1	Yes
PY5	Alameda Health System	DPH	Q-PC4	Q-CIS	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC4	Q-CIS	▶ Race : Asian	Reported	N/A	3	N/A	3	37	0	57	0	64.9%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC4	Q-CIS	▶ Race : Black or African American	Reported	N/A	3	N/A	3	34	0	87	0	39.1%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC4	Q-CIS	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC4	Q-CIS	▶ Race : White	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC4	Q-CIS	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC4	Q-CIS	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	225	0	375	0	60.0%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC4	Q-CIS	▶ Race : Total	Reported	N/A	3	N/A	3	316	0	558	0	56.6%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	200	0	304	0	65.8%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	114	0	226	0	50.4%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	316	0	558	0	56.6%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Reported	0.6695	0	0.6615	None	1145	0	1648	0	69.5%	0	1	1	Yes
PY5	Alameda Health System	DPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.5915	0	0.5928	None	7411	0	12271	0	60.4%	0	1	0.5	Yes
PY5	Alameda Health System	DPH	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Reported	0.4363	0	0.3665	None	799	0	1207	0	66.2%	0	1	1	Yes
PY5	Alameda Health System	DPH	Q-PC8	Q-CMS349	HIV Screening Measure	Reported	0.6846	0	0.6263	None	15882	0	21709	0	73.2%	0	1	N/A	Yes
PY5	Alameda Health System	DPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Reported	0.3608	0	0.3753	None	281	0	584	0	48.1%	0	1	1	Yes
PY5	Alameda Health System	DPH	Q-PC9	Q-IMA	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC9	Q-IMA	▶ Race : Asian	Reported	N/A	3	N/A	3	23	0	53	0	43.4%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC9	Q-IMA	▶ Race : Black or African American	Reported	N/A	3	N/A	3	23	0	60	0	38.3%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC9	Q-IMA	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC9	Q-IMA	▶ Race : White	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC9	Q-IMA	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC9	Q-IMA	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	219	0	429	0	51.1%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC9	Q-IMA	▶ Race : Total	Reported	N/A	3	N/A	3	281	0	584	0	48.1%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	203	0	362	0	56.1%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	63	0	162	0	38.9%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	15	0	60	0	25.0%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	281	0	584	0	48.1%	0	N/A	None	None
PY5	Alameda Health System	DPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Reported	0.9718	0	0.9918	None	140	0	140	0	100.0%	0	1	0.5	Yes
PY5	Alameda Health System	DPH	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	None
PY5	Alameda Health System	DPH	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Reported	0.5713	0	0.6062	None	647	0	1012	0	63.9%	0	1	0	Yes
PY5	Alameda Health System	DPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Reported	0.6139	0	0	None	20	0	41.706	0	0.4795	0	1	N/A	Yes
PY5	Alameda Health System	DPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Reported	2.3771	0	0	None	28	0	12.437	0	2.2513	0	0	N/A	Yes
PY5	Antelope Valley Hospital	DMPH	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	None
PY5	Antelope Valley Hospital	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Antelope Valley Hospital	DMPH	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	None
PY5	Antelope Valley Hospital	DMPH	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	None
PY5	Antelope Valley Hospital	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Antelope Valley Hospital	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Antelope Valley Hospital	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Antelope Valley Hospital	DMPH	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	None
PY5	Antelope Valley Hospital	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Antelope Valley Hospital	DMPH	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	0.8922	0	0.8775	None	113	0	121	0	93.4%	0	1	N/A	Yes
PY5	Antelope Valley Hospital	DMPH	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	None
PY5	Antelope Valley Hospital	DMPH	Q-CAD1	Q-HBD	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Antelope Valley Hospital	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Antelope Valley Hospital	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Antelope Valley Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Antelope Valley Hospital	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Antelope Valley Hospital	DMPH	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	N/A	None	No
PY5	Antelope Valley Hospital	DMPH	Q-CAR2	Q-PCE	▶ Systemic Corticosteroid	Reported	0.7636	0	0.7681	None	107	0	121	0	88.4%	0	N/A	N/A	NoS
PY5	Antelope Valley Hospital	DMPH	Q-CAR2	Q-PCE	▶ Bronchodilator	Reported	0.9091	0	0.9057	None	115	0	121	0	95.0%	0	N/A	N/A	NoS
PY5	Antelope Valley Hospital	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Antelope Valley Hospital	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Antelope Valley Hospital	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Reported	0.5222	0	0.562	None	165	0	207	0	79.7%	0	1	0.5	Yes
PY5	Antelope Valley Hospital	DMPH	Q-IHE1	Q-IHE1	▶ Exclusive Breast Milk Feeding (PC-05) - -Black/African American	Reported	0.5077	0	0.5331	None	40	0	68	0	58.8%	0	0	0	Yes
PY5	Antelope Valley Hospital	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	0	0	Yes
PY5	Antelope Valley Hospital	DMPH	Q-IHE2	Q-IHE2	▶ Cesarean Birth (PC02-CH) - -Black/African American	Reported	0.2571	0	0.2481	None	22	0	93	0	23.7%	0	0	0	Yes
PY5	Antelope Valley Hospital	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	0	0	Yes
PY5	Antelope Valley Hospital	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Reported	0.2439	0	0.2415	None	46	0	204	0	22.6%	0	1	0.5	Yes
PY5	Antelope Valley Hospital	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Reported	0.5269	0	0.5504	None	198	0	299	0	66.2%	0	1	0.5	Yes
PY5	Antelope Valley Hospital	DMPH	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	None
PY5	Antelope Valley Hospital	DMPH	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	None
PY5	Antelope Valley Hospital	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Antelope Valley Hospital	DMPH	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Reported	0.0525	0	0.8634	None	282	0	307	0	91.9%	0	N/A	N/A	No
PY5	Antelope Valley Hospital	DMPH	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Reported	None	2	0.4762	None	133	0	147	0	90.5%	0	N/A	N/A	No
PY5	Antelope Valley Hospital	DMPH	Q-OA3	Q-QPP415	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older	Reported	0.8119	0	0.8227	None	177	0	205	0	86.3%	0	1	0	Yes
PY5	Antelope Valley Hospital	DMPH	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Reported	0.3231	0	0.7133	None	273	0	944	0	28.9%	0	N/A	N/A	No
PY5	Antelope Valley Hospital	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Antelope Valley Hospital	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Antelope Valley Hospital	DMPH	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	None
PY5	Antelope Valley Hospital	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Antelope Valley Hospital	DMPH	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	None
PY5	Antelope Valley Hospital	DMPH	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	None
PY5	Antelope Valley Hospital	DMPH	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	None
PY5	Antelope Valley Hospital	DMPH	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	None
PY5	Antelope Valley Hospital	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Antelope Valley Hospital	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Antelope Valley Hospital	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Antelope Valley Hospital	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Antelope Valley Hospital	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Antelope Valley Hospital	DMPH	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	None
PY5	Antelope Valley Hospital	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Antelope Valley Hospital	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Antelope Valley Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Reported	0.9954	0	0.9959	None	169	0	169	0	100.0%	0	1	0.5	Yes
PY5	Antelope Valley Hospital	DMPH	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	None
PY5	Antelope Valley Hospital	DMPH	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Reported	0.6617	0	0.6875	None	82	0	570	0	14.4%	0	0	0	Yes
PY5	Antelope Valley Hospital	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Reported	0.6617	0	0	None	0.58	0	53.469	0	0.0108	0	N/A	N/A	No
PY5	Antelope Valley Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Reported	0.6391	0	0	None	0	0	11.387	0	0	0	1	N/A	Yes
PY5	Arrowhead Regional Medical Center	DPH	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Reported	0.0491	0	0.0848	None	54	0	1240	0	4.4%	0	1	N/A	Yes
PY5	Arrowhead Regional Medical Center	DPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Arrowhead Regional Medical Center	DPH	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	None
PY5	Arrowhead Regional Medical Center	DPH	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	None
PY5	Arrowhead Regional Medical Center	DPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.418	0	0.5061	None	2542	0	4610	0	55.1%	0	1	0	Yes
PY5	Arrowhead Regional Medical Center	DPH	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	0.217	0	0.6978	None	137	0	186	0	73.7%	0	1	0	Yes
PY5	Arrowhead Regional Medical Center	DPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.3617	0	0.7637	None	682	0	806	0	84.6%	0	1	0.5	Yes
PY5	Arrowhead Regional Medical Center	DPH	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	0.7455	0	0.7587	None	21	0	None	4	None	4	0	0	Yes
PY5	Arrowhead Regional Medical Center	DPH	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Reported	0.5367	0	0.6667	None	2916	0	3550	0	82.1%	0	1	0.5	Yes
PY5	Arrowhead Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	0.2947	0	0.3406	None	185	0	553	0	33.5%	0	1	N/A	YesS
PY5	Arrowhead Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	0.2794	0	0.3406	None	921	0	2544	0	36.2%	0	0	N/A	YesS
PY5	Arrowhead Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.282	0	0.3406	None	1429	0	3923	0	36.4%	0	0	N/A	YesS
PY5	Arrowhead Regional Medical Center	DPH	Q-CAD1	Q-HBD	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	0.3333	N/A	Yes
PY5	Arrowhead Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	16	0	33	0	48.5%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	48	0	188	0	25.5%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	185	0	553	0	33.5%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	12	0	31	0	38.7%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	471	0	1124	0	41.9%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	697	0	1994	0	35.0%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	1429	0	3923	0	36.4%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	921	0	2544	0	36.2%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	285	0	949	0	30.0%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	223	0	430	0	51.9%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	1429	0	3923	0	36.4%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Reported	0.5316	0	0.4676	None	919	0	2762	0	33.3%	0	0	0	Yes
PY5	Arrowhead Regional Medical Center	DPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Reported	0.9944	0	0.78	None	108	0	111	0	97.3%	0	1	N/A	Yes
PY5	Arrowhead Regional Medical Center	DPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Reported	0.9912	0	N/A	None	187	0	2437	0	0.0767	0	0	0	Yes
PY5	Arrowhead Regional Medical Center	DPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Reported	None	None	N/A	3	N/A	3	N/A	3	N/A	3	0	0	Yes
PY5	Arrowhead Regional Medical Center	DPH	Q-IHE1	Q-IHE1	▶ Immunizations for Adolescents - -Black/African American	Reported	None	2	0.309	None	None	1	59	0	None	1	0	0	YesS
PY5	Arrowhead Regional Medical Center	DPH	Q-IHE2	Q-IHE2	▶ Child and Adolescent Well Care Visits - -Black/African American	Reported	0.4773	0	0.4915	None	441	0	1190	0	37.1%	0	0	0	YesS
PY5	Arrowhead Regional Medical Center	DPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Reported	None	None	N/A	3	N/A	3	N/A	3	N/A	3	0	0	Yes
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Reported	0.1644	0	0.22	None	117	0	600	0	19.5%	0	1	N/A	Yes
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Reported	0.7675	0	0.762	None	239	0	315	0	75.9%	0	0	0	Yes
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Reported	0.6703	0	0.7111	None	401	0	577	0	69.5%	0	0	0	Yes
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	Reported	N/A	3	N/A	3	38	0	56	0	67.9%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : White	Reported	N/A	3	N/A	3	84	0	124	0	67.7%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	266	0	380	0	70.0%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	Reported	N/A	3	N/A	3	401	0	577	0	69.5%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	246	0	343	0	71.7%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	57	0	84	0	67.9%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	98	0	150	0	65.3%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	401	0	577	0	69.5%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Reported	0.8	0	0.8122	None	367	0	577	0	63.6%	0	0	0	Yes
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Black or African American	Reported	N/A	3	N/A	3	39	0	56	0	69.6%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : White	Reported	N/A	3	N/A	3	80	0	124	0	64.5%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	240	0	380	0	63.2%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Total	Reported	N/A	3	N/A	3	367	0	577	0	63.6%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	210	0	343	0	61.2%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	50	0	84	0	59.5%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	107	0	150	0	71.3%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	367	0	577	0	63.6%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Arrowhead Regional Medical Center	DPH	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	None
PY5	Arrowhead Regional Medical Center	DPH	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	None
PY5	Arrowhead Regional Medical Center	DPH	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	None
PY5	Arrowhead Regional Medical Center	DPH	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	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.5007	0	0.5144	None	1519	0	2460	0	61.8%	0	1	0.5	Yes
PY5	Arrowhead Regional Medical Center	DPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Arrowhead Regional Medical Center	DPH	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	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Reported	0.2461	0	0.2933	None	4295	0	13225	0	32.5%	0	1	0	Yes
PY5	Arrowhead Regional Medical Center	DPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.8808	0	0.8826	None	13902	0	34900	0	39.8%	0	0	0	Yes
PY5	Arrowhead Regional Medical Center	DPH	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	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC15	Q-WCC	▶ Counseling for Physical Activity	Reported	0.6303	0	0.6466	None	2931	0	4295	0	68.2%	0	1	0.5	YesS
PY5	Arrowhead Regional Medical Center	DPH	Q-PC15	Q-WCC	▶ Counseling for Nutrition	Reported	0.6474	0	0.6651	None	2957	0	4295	0	68.9%	0	1	0	YesS
PY5	Arrowhead Regional Medical Center	DPH	Q-PC15	Q-WCC	▶ BMI	Reported	0.7461	0	0.7587	None	3407	0	4295	0	79.3%	0	1	0.5	YesS
PY5	Arrowhead Regional Medical Center	DPH	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	0	Yes
PY5	Arrowhead Regional Medical Center	DPH	Q-PC16	Q-W30	▶ First 15 Months	Reported	0.1553	0	0.4499	None	167	0	307	0	54.4%	0	1	0	YesS
PY5	Arrowhead Regional Medical Center	DPH	Q-PC16	Q-W30	▶ 15 Months-30 Months	Reported	0.6542	0	0.6716	None	393	0	645	0	60.9%	0	0	0	YesS
PY5	Arrowhead Regional Medical Center	DPH	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	0.5	0	Yes
PY5	Arrowhead Regional Medical Center	DPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.5483	0	0.5554	None	3786	0	9701	0	39.0%	0	0	0	Yes
PY5	Arrowhead Regional Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	13	0	None	4	None	4	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	105	0	246	0	42.7%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	441	0	1190	0	37.1%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	20	0	57	0	35.1%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	631	0	3190	0	19.8%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	2576	0	4995	0	51.6%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	3786	0	9701	0	39.0%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	3039	0	6361	0	47.8%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	547	0	994	0	55.0%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	200	0	2346	0	8.5%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	3786	0	9701	0	39.0%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Reported	0.2388	0	0.3187	None	45	0	309	0	14.6%	0	0	0	Yes
PY5	Arrowhead Regional Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	35	0	None	1	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : White	Reported	N/A	3	N/A	3	None	1	74	0	None	1	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	33	0	189	0	17.5%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Total	Reported	N/A	3	N/A	3	45	0	309	0	14.6%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	32	0	209	0	15.3%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	41	0	None	1	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	59	0	None	1	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	45	0	309	0	14.6%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Reported	0.617	0	0.6215	None	670	0	1160	0	57.8%	0	0	0	Yes
PY5	Arrowhead Regional Medical Center	DPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Reported	None	2	0.1765	None	594	0	1541	0	38.6%	0	1	1	Yes
PY5	Arrowhead Regional Medical Center	DPH	Q-PC8	Q-CMS349	HIV Screening Measure	Reported	0.1318	0	0.1813	None	2723	0	16952	0	16.1%	0	0.5	0	Yes
PY5	Arrowhead Regional Medical Center	DPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Reported	0.356	0	0.371	None	163	0	469	0	34.8%	0	0	0	Yes
PY5	Arrowhead Regional Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	59	0	None	1	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : White	Reported	N/A	3	N/A	3	24	0	64	0	37.5%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	128	0	333	0	38.4%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Total	Reported	N/A	3	N/A	3	163	0	469	0	34.8%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	127	0	253	0	50.2%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	40	0	None	1	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	27	0	176	0	15.3%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	163	0	469	0	34.8%	0	N/A	None	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Reported	0.8598	0	0.9918	None	109	0	109	0	100.0%	0	1	0.5	Yes
PY5	Arrowhead Regional Medical Center	DPH	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	None
PY5	Arrowhead Regional Medical Center	DPH	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	None
PY5	Arrowhead Regional Medical Center	DPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Reported	0.4177	0	0.58	None	14	0	49.336	0	0.2838	0	1	N/A	Yes
PY5	Arrowhead Regional Medical Center	DPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Reported	0.7851	0	0.795	None	11	0	13.252	0	0.8301	0	0	N/A	Yes
PY5	Bear Valley Community Hospital	DMPH	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	None
PY5	Bear Valley Community Hospital	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	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	None
PY5	Bear Valley Community Hospital	DMPH	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	None
PY5	Bear Valley Community Hospital	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	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	None
PY5	Bear Valley Community Hospital	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	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	None
PY5	Bear Valley Community Hospital	DMPH	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	None
PY5	Bear Valley Community Hospital	DMPH	Q-CAD1	Q-HBD	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	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	None
PY5	Bear Valley Community Hospital	DMPH	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	None
PY5	Bear Valley Community Hospital	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	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	None
PY5	Bear Valley Community Hospital	DMPH	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	None
PY5	Bear Valley Community Hospital	DMPH	Q-OA3	Q-QPP415	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older	Reported	0.8533	0	0.86	None	52	0	59	0	88.1%	0	1	0.5	Yes
PY5	Bear Valley Community Hospital	DMPH	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	None
PY5	Bear Valley Community Hospital	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	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	None
PY5	Bear Valley Community Hospital	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.5599	0	0.5938	None	836	0	1398	0	59.8%	0	1	0	Yes
PY5	Bear Valley Community Hospital	DMPH	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	None
PY5	Bear Valley Community Hospital	DMPH	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	None
PY5	Bear Valley Community Hospital	DMPH	Q-PC16	Q-W30	▶ 15 Months-30 Months	Reported	0.3462	0	0.6643	None	0	0	None	1	None	1	N/A	N/A	NoS
PY5	Bear Valley Community Hospital	DMPH	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	N/A	None	No
PY5	Bear Valley Community Hospital	DMPH	Q-PC16	Q-W30	▶ First 15 Months	Reported	None	2	0.4499	None	0	0	None	1	None	1	N/A	N/A	NoS
PY5	Bear Valley Community Hospital	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	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	None
PY5	Bear Valley Community Hospital	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	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	None
PY5	Bear Valley Community Hospital	DMPH	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	None
PY5	Bear Valley Community Hospital	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Bear Valley Community Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Reported	0.0514	0	0.0848	None	58	0	1451	0	4.0%	0	1	N/A	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Contra Costa Regional Medical Center	DPH	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	None
PY5	Contra Costa Regional Medical Center	DPH	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Reported	0.0161	0	0.0269	None	15	0	1179	0	1.3%	0	1	N/A	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.6503	0	0.6521	None	5327	0	8039	0	66.3%	0	1	0.5	Yes
PY5	Contra Costa Regional Medical Center	DPH	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	0.8557	0	0.8621	None	1055	0	1214	0	86.9%	0	1	0.5	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.8894	0	0.8925	None	2449	0	2740	0	89.4%	0	1	0	Yes
PY5	Contra Costa Regional Medical Center	DPH	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	0.8886	0	0.8775	None	593	0	630	0	94.1%	0	1	N/A	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Reported	0.7978	0	0.8018	None	7029	0	8670	0	81.1%	0	1	0.5	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	0.2922	0	0.3406	None	359	0	1270	0	28.3%	0	1	N/A	YesS
PY5	Contra Costa Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	0.3061	0	0.3406	None	975	0	3128	0	31.2%	0	1	N/A	YesS
PY5	Contra Costa Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.2731	0	0.3406	None	2297	0	8269	0	27.8%	0	1	N/A	YesS
PY5	Contra Costa Regional Medical Center	DPH	Q-CAD1	Q-HBD	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	N/A	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	13	0	35	0	37.1%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	271	0	1600	0	16.9%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	346	0	1225	0	28.2%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	50	0	135	0	37.0%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	529	0	1814	0	29.2%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	50	0	170	0	29.4%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	1038	0	3290	0	31.6%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	2297	0	8269	0	27.8%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	965	0	3077	0	31.4%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	1064	0	4173	0	25.5%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	268	0	1019	0	26.3%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	2297	0	8269	0	27.8%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.6504	0	0.6302	None	5114	0	8269	0	61.9%	0	0	0	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Reported	0.5953	0	0.4676	None	4989	0	8115	0	61.5%	0	1	N/A	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Reported	0.8186	0	0.8204	None	422	0	529	0	79.8%	0	0	0	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Reported	0.5719	0	0.5989	None	427	0	670	0	63.7%	0	1	0	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Reported	0.9918	0	0.78	None	3258	0	3277	0	99.4%	0	1	N/A	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-EC1	Q-QPP47	Advance Care Plan	Reported	0.4297	0	0.4799	None	5273	0	10290	0	51.2%	0	1	0	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Reported	0.1731	0	0.22	None	101	0	505	0	20.0%	0	1	N/A	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Reported	0.766	0	0.762	None	1218	0	1598	0	76.2%	0	1	N/A	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Reported	0.9018	0	0.837	None	926	0	981	0	94.4%	0	1	1	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	Reported	N/A	3	N/A	3	104	0	108	0	96.3%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	Reported	N/A	3	N/A	3	110	0	123	0	89.4%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	12	0	None	4	None	4	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : White	Reported	N/A	3	N/A	3	179	0	190	0	94.2%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	20	0	None	4	None	4	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	499	0	521	0	95.8%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	Reported	N/A	3	N/A	3	926	0	981	0	94.4%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	506	0	527	0	96.0%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	379	0	408	0	92.9%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	41	0	46	0	89.1%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	926	0	981	0	94.4%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Reported	0.9176	0	0.9181	None	917	0	981	0	93.5%	0	1	1	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Asian	Reported	N/A	3	N/A	3	100	0	108	0	92.6%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Black or African American	Reported	N/A	3	N/A	3	114	0	123	0	92.7%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	13	0	None	4	None	4	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : White	Reported	N/A	3	N/A	3	174	0	190	0	91.6%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	21	0	None	4	None	4	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	493	0	521	0	94.6%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Total	Reported	N/A	3	N/A	3	917	0	981	0	93.5%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	501	0	527	0	95.1%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	377	0	408	0	92.4%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	39	0	46	0	84.8%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	917	0	981	0	93.5%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Reported	0.5379	0	0.4576	None	548	0	1032	0	53.1%	0	1	N/A	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Reported	0.9549	0	0.9434	None	1696	0	1734	0	97.8%	0	1	N/A	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Reported	0.6991	0	0.6996	None	149	0	188	0	79.3%	0	1	0.5	Yes
PY5	Contra Costa Regional Medical Center	DPH	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	None
PY5	Contra Costa Regional Medical Center	DPH	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Reported	0.8289	0	0.8282	None	1162	0	1418	0	82.0%	0	0	0	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.6477	0	0.6377	None	6323	0	9422	0	67.1%	0	1	N/A	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-PC10	Q-LSC	Lead Screening in Children	Reported	0.5688	0	0.6131	None	1008	0	1563	0	64.5%	0	1	0	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Reported	0.5232	0	0.5638	None	26878	0	47513	0	56.6%	0	1	0	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Reported	0.86	0	0.7182	None	27878	0	30336	0	91.9%	0	1	N/A	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.9742	0	0.8988	None	30973	0	31838	0	97.3%	0	1	1	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 1 (informational only)	Reported	0.9613	0	0	None	42328	0	42677	0	99.2%	0	N/A	N/A	YesI
PY5	Contra Costa Regional Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 2	Reported	0.4826	0	0.5263	None	3696	0	6570	0	56.3%	0	1	0	YesS
PY5	Contra Costa Regional Medical Center	DPH	Q-PC14	Q-CMS138	Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention	Reported	None	None	N/A	3	N/A	3	N/A	3	N/A	3	1	0	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 3	Reported	0.879	0	0.8864	None	39476	0	42677	0	92.5%	0	1	0.5	YesS
PY5	Contra Costa Regional Medical Center	DPH	Q-PC15	Q-WCC	▶ Counseling for Nutrition	Reported	0.8524	0	0.8248	None	15199	0	17753	0	85.6%	0	1	N/A	YesS
PY5	Contra Costa Regional Medical Center	DPH	Q-PC15	Q-WCC	▶ Counseling for Physical Activity	Reported	0.8528	0	0.7932	None	15152	0	17753	0	85.4%	0	1	N/A	YesS
PY5	Contra Costa Regional Medical Center	DPH	Q-PC15	Q-WCC	▶ BMI	Reported	0.9154	0	0.8718	None	16602	0	17753	0	93.5%	0	1	N/A	YesS
PY5	Contra Costa Regional Medical Center	DPH	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	N/A	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-PC16	Q-W30	▶ 15 Months-30 Months	Reported	0.6883	0	0.7023	None	1203	0	1608	0	74.8%	0	1	1	YesS
PY5	Contra Costa Regional Medical Center	DPH	Q-PC16	Q-W30	▶ First 15 Months	Reported	0.7797	0	0.6833	None	551	0	696	0	79.2%	0	1	1	YesS
PY5	Contra Costa Regional Medical Center	DPH	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	1	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Reported	0.6262	0	0.6316	None	16904	0	26735	0	63.2%	0	1	0	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.5633	0	0.5689	None	17492	0	30701	0	57.0%	0	1	0	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	32	0	58	0	55.2%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	1559	0	2562	0	60.9%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	1877	0	3719	0	50.5%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	146	0	326	0	44.8%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	2522	0	4361	0	57.8%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	552	0	1028	0	53.7%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	10804	0	18647	0	57.9%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	17492	0	30701	0	57.0%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	10841	0	17587	0	61.6%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	5459	0	9508	0	57.4%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	1192	0	3606	0	33.1%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	17492	0	30701	0	57.0%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Reported	0.4373	0	0.4472	None	630	0	1548	0	40.7%	0	0	0	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Asian	Reported	N/A	3	N/A	3	80	0	143	0	55.9%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Black or African American	Reported	N/A	3	N/A	3	33	0	166	0	19.9%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : White	Reported	N/A	3	N/A	3	69	0	192	0	35.9%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	15	0	42	0	35.7%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	429	0	988	0	43.4%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Total	Reported	N/A	3	N/A	3	630	0	1548	0	40.7%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	392	0	818	0	47.9%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	189	0	536	0	35.3%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	49	0	194	0	25.3%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	630	0	1548	0	40.7%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Reported	0.6672	0	0.6615	None	2321	0	3343	0	69.4%	0	1	1	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.5601	0	0.5646	None	12419	0	22656	0	54.8%	0	0	0	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Reported	0.6909	0	0.3665	None	2963	0	3787	0	78.2%	0	1	1	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-PC8	Q-CMS349	HIV Screening Measure	Reported	0.821	0	0.6263	None	30749	0	35150	0	87.5%	0	1	N/A	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Reported	0.4834	0	0.4857	None	948	0	1593	0	59.5%	0	1	1	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Asian	Reported	N/A	3	N/A	3	70	0	110	0	63.6%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Black or African American	Reported	N/A	3	N/A	3	74	0	191	0	38.7%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : White	Reported	N/A	3	N/A	3	123	0	220	0	55.9%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	20	0	36	0	55.6%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	654	0	1021	0	64.1%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Total	Reported	N/A	3	N/A	3	948	0	1593	0	59.5%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	669	0	997	0	67.1%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	230	0	439	0	52.4%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	49	0	157	0	31.2%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	948	0	1593	0	59.5%	0	N/A	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Reported	0.9853	0	0.92	None	691	0	695	0	99.4%	0	1	N/A	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Reported	0.9842	0	0.92	None	148	0	154	0	96.1%	0	1	N/A	Yes
PY5	Contra Costa Regional Medical Center	DPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Contra Costa Regional Medical Center	DPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	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	None
PY5	Eastern Plumas Health Care	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	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	None
PY5	Eastern Plumas Health Care	DMPH	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	None
PY5	Eastern Plumas Health Care	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	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	None
PY5	Eastern Plumas Health Care	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	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	None
PY5	Eastern Plumas Health Care	DMPH	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	None
PY5	Eastern Plumas Health Care	DMPH	Q-CAD1	Q-HBD	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	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	None
PY5	Eastern Plumas Health Care	DMPH	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	None
PY5	Eastern Plumas Health Care	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	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	None
PY5	Eastern Plumas Health Care	DMPH	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	None
PY5	Eastern Plumas Health Care	DMPH	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	None
PY5	Eastern Plumas Health Care	DMPH	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	None
PY5	Eastern Plumas Health Care	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	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	None
PY5	Eastern Plumas Health Care	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.2727	0	0.5004	None	105	0	530	0	19.8%	0	N/A	N/A	No
PY5	Eastern Plumas Health Care	DMPH	Q-PC14	Q-CMS138	▶ Rate 2	Reported	0.7698	0	0.7848	None	108	0	135	0	80.0%	0	1	0.5	YesS
PY5	Eastern Plumas Health Care	DMPH	Q-PC14	Q-CMS138	▶ Rate 3	Reported	0.8843	0	0.8911	None	484	0	533	0	90.8%	0	1	0.5	YesS
PY5	Eastern Plumas Health Care	DMPH	Q-PC14	Q-CMS138	▶ Rate 1 (informational only)	Reported	0.944	0	0	None	511	0	533	0	95.9%	0	N/A	N/A	None
PY5	Eastern Plumas Health Care	DMPH	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	0.5	Yes
PY5	Eastern Plumas Health Care	DMPH	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	None
PY5	Eastern Plumas Health Care	DMPH	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	None
PY5	Eastern Plumas Health Care	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	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	None
PY5	Eastern Plumas Health Care	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	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	None
PY5	Eastern Plumas Health Care	DMPH	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	None
PY5	Eastern Plumas Health Care	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Eastern Plumas Health Care	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Camino Hospital	DMPH	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	None
PY5	El Camino Hospital	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Camino Hospital	DMPH	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	None
PY5	El Camino Hospital	DMPH	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	None
PY5	El Camino Hospital	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Camino Hospital	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Camino Hospital	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Camino Hospital	DMPH	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	None
PY5	El Camino Hospital	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Camino Hospital	DMPH	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	None
PY5	El Camino Hospital	DMPH	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	None
PY5	El Camino Hospital	DMPH	Q-CAD1	Q-HBD	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Camino Hospital	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Camino Hospital	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Camino Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Camino Hospital	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Camino Hospital	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Camino Hospital	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Camino Hospital	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Camino Hospital	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Camino Hospital	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Camino Hospital	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	0	0	Yes
PY5	El Camino Hospital	DMPH	Q-IHE2	Q-IHE2	▶ Exclusive Breast Milk Feeding (PC-05) - -Asian	Reported	None	2	0.4776	None	21	0	46	0	45.7%	0	0	0	Yes
PY5	El Camino Hospital	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Reported	0.287	0	0.2481	None	20	0	114	0	17.5%	0	1	0.5	Yes
PY5	El Camino Hospital	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Reported	0.43	0	0.4776	None	165	0	341	0	48.4%	0	1	0	Yes
PY5	El Camino Hospital	DMPH	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Reported	1	0	0.837	None	40	0	43	0	93.0%	0	1	1	Yes
PY5	El Camino Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	El Camino Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	El Camino Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	El Camino Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	El Camino Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : White	Reported	N/A	3	N/A	3	24	0	None	4	None	4	N/A	None	None
PY5	El Camino Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	El Camino Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	12	0	None	4	None	4	N/A	None	None
PY5	El Camino Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	Reported	N/A	3	N/A	3	40	0	43	0	93.0%	0	N/A	None	None
PY5	El Camino Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	34	0	36	0	94.4%	0	N/A	None	None
PY5	El Camino Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	El Camino Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	El Camino Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	40	0	43	0	93.0%	0	N/A	None	None
PY5	El Camino Hospital	DMPH	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Reported	0.7	0	0.7932	None	33	0	43	0	76.7%	0	N/A	N/A	No
PY5	El Camino Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	El Camino Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	El Camino Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	El Camino Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	El Camino Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : White	Reported	N/A	3	N/A	3	22	0	None	4	None	4	N/A	None	None
PY5	El Camino Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	El Camino Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	El Camino Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Total	Reported	N/A	3	N/A	3	33	0	43	0	76.7%	0	N/A	None	None
PY5	El Camino Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	28	0	36	0	77.8%	0	N/A	None	None
PY5	El Camino Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	El Camino Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	El Camino Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	33	0	43	0	76.7%	0	N/A	None	None
PY5	El Camino Hospital	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Reported	None	2	0.2258	None	None	1	34	0	None	1	N/A	N/A	No
PY5	El Camino Hospital	DMPH	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	None
PY5	El Camino Hospital	DMPH	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	None
PY5	El Camino Hospital	DMPH	Q-OA3	Q-QPP415	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older	Reported	0.7684	0	0.7983	None	69	0	73	0	94.5%	0	1	0.5	Yes
PY5	El Camino Hospital	DMPH	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	None
PY5	El Camino Hospital	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Camino Hospital	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Camino Hospital	DMPH	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	None
PY5	El Camino Hospital	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Camino Hospital	DMPH	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	None
PY5	El Camino Hospital	DMPH	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	None
PY5	El Camino Hospital	DMPH	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	None
PY5	El Camino Hospital	DMPH	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	None
PY5	El Camino Hospital	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Camino Hospital	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Camino Hospital	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Camino Hospital	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Camino Hospital	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Camino Hospital	DMPH	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	None
PY5	El Camino Hospital	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Camino Hospital	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Camino Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Reported	1	0	1	None	83	0	83	0	100.0%	0	1	N/A	Yes
PY5	El Camino Hospital	DMPH	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	None
PY5	El Camino Hospital	DMPH	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	None
PY5	El Camino Hospital	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Reported	0.4589	0	0	None	43	0	65.16	0	0.6599	0	N/A	N/A	No
PY5	El Camino Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Reported	0.3912	0	0	None	9	0	14.851	0	0.606	0	1	N/A	Yes
PY5	El Centro Regional Medical Center	DMPH	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	None
PY5	El Centro Regional Medical Center	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Centro Regional Medical Center	DMPH	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	None
PY5	El Centro Regional Medical Center	DMPH	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	None
PY5	El Centro Regional Medical Center	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.6941	0	0.6679	None	678	0	921	0	73.6%	0	1	N/A	Yes
PY5	El Centro Regional Medical Center	DMPH	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	None
PY5	El Centro Regional Medical Center	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.4211	0	0.7637	None	120	0	155	0	77.4%	0	1	0	Yes
PY5	El Centro Regional Medical Center	DMPH	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	None
PY5	El Centro Regional Medical Center	DMPH	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	None
PY5	El Centro Regional Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	0.6667	0	N/A	None	None	1	None	1	None	1	N/A	N/A	NoS
PY5	El Centro Regional Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	0.2707	0	0.3406	None	173	0	617	0	28.0%	0	1	N/A	YesS
PY5	El Centro Regional Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.2793	0	0.3406	None	177	0	658	0	26.9%	0	1	N/A	YesS
PY5	El Centro Regional Medical Center	DMPH	Q-CAD1	Q-HBD	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	N/A	Yes
PY5	El Centro Regional Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	173	0	621	0	27.9%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	177	0	658	0	26.9%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	173	0	617	0	28.0%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	37	0	None	1	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	177	0	658	0	26.9%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.1277	0	0.4501	None	304	0	658	0	46.2%	0	N/A	N/A	No
PY5	El Centro Regional Medical Center	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Centro Regional Medical Center	DMPH	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	None
PY5	El Centro Regional Medical Center	DMPH	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	None
PY5	El Centro Regional Medical Center	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Centro Regional Medical Center	DMPH	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	None
PY5	El Centro Regional Medical Center	DMPH	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	None
PY5	El Centro Regional Medical Center	DMPH	Q-OA3	Q-QPP415	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older	Reported	0.4857	0	0.7983	None	125	0	173	0	72.3%	0	N/A	N/A	No
PY5	El Centro Regional Medical Center	DMPH	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	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.6106	0	0.6133	None	425	0	657	0	64.7%	0	1	0.5	Yes
PY5	El Centro Regional Medical Center	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Reported	0.7536	0	0.7622	None	38	0	63	0	60.3%	0	N/A	N/A	No
PY5	El Centro Regional Medical Center	DMPH	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Reported	0.6918	0	0.7155	None	2809	0	3866	0	72.7%	0	1	0	Yes
PY5	El Centro Regional Medical Center	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Reported	0.2731	0	0.3176	None	1914	0	5988	0	32.0%	0	1	0	Yes
PY5	El Centro Regional Medical Center	DMPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.8583	0	0.8624	None	5292	0	6013	0	88.0%	0	1	1	Yes
PY5	El Centro Regional Medical Center	DMPH	Q-PC14	Q-CMS138	▶ Rate 1 (informational only)	Reported	0.9401	0	0	None	2790	0	2975	0	93.8%	0	N/A	N/A	NoI
PY5	El Centro Regional Medical Center	DMPH	Q-PC14	Q-CMS138	▶ Rate 2	Reported	0.6287	0	0.6578	None	59	0	281	0	21.0%	0	N/A	N/A	NoS
PY5	El Centro Regional Medical Center	DMPH	Q-PC14	Q-CMS138	▶ Rate 3	Reported	0.9019	0	0.907	None	2627	0	2975	0	88.3%	0	N/A	N/A	NoS
PY5	El Centro Regional Medical Center	DMPH	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	N/A	None	No
PY5	El Centro Regional Medical Center	DMPH	Q-PC15	Q-WCC	▶ Counseling for Nutrition	Reported	0.8927	0	0.8248	None	1332	0	1611	0	82.7%	0	1	N/A	YesS
PY5	El Centro Regional Medical Center	DMPH	Q-PC15	Q-WCC	▶ Counseling for Physical Activity	Reported	0.8927	0	0.7932	None	1320	0	1611	0	81.9%	0	1	N/A	YesS
PY5	El Centro Regional Medical Center	DMPH	Q-PC15	Q-WCC	▶ BMI	Reported	0.899	0	0.8718	None	1569	0	1611	0	97.4%	0	1	N/A	YesS
PY5	El Centro Regional Medical Center	DMPH	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	N/A	Yes
PY5	El Centro Regional Medical Center	DMPH	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	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Reported	0.2248	0	0.518	None	1174	0	1704	0	68.9%	0	1	0.5	Yes
PY5	El Centro Regional Medical Center	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.5294	0	0.5384	None	1435	0	1950	0	73.6%	0	1	1	Yes
PY5	El Centro Regional Medical Center	DMPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	22	0	31	0	71.0%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	1405	0	1908	0	73.6%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	1435	0	1950	0	73.6%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	1367	0	1846	0	74.1%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	43	0	49	0	87.8%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	25	0	55	0	45.5%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	1435	0	1950	0	73.6%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Reported	0.2459	0	0.3187	None	24	0	74	0	32.4%	0	1	0	Yes
PY5	El Centro Regional Medical Center	DMPH	Q-PC4	Q-CIS	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC4	Q-CIS	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC4	Q-CIS	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC4	Q-CIS	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC4	Q-CIS	▶ Race : White	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC4	Q-CIS	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC4	Q-CIS	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	22	0	72	0	30.6%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC4	Q-CIS	▶ Race : Total	Reported	N/A	3	N/A	3	24	0	74	0	32.4%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	22	0	68	0	32.4%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	24	0	74	0	32.4%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Reported	0.5079	0	0.5233	None	54	0	130	0	41.5%	0	N/A	N/A	No
PY5	El Centro Regional Medical Center	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.3265	0	0.3543	None	710	0	1921	0	37.0%	0	1	0	Yes
PY5	El Centro Regional Medical Center	DMPH	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	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Reported	0.3619	0	0.3763	None	58	0	138	0	42.0%	0	1	1	Yes
PY5	El Centro Regional Medical Center	DMPH	Q-PC9	Q-IMA	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC9	Q-IMA	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC9	Q-IMA	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC9	Q-IMA	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC9	Q-IMA	▶ Race : White	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC9	Q-IMA	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC9	Q-IMA	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	58	0	136	0	42.7%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC9	Q-IMA	▶ Race : Total	Reported	N/A	3	N/A	3	58	0	138	0	42.0%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	58	0	134	0	43.3%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	58	0	138	0	42.0%	0	N/A	None	None
PY5	El Centro Regional Medical Center	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	El Centro Regional Medical Center	DMPH	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	None
PY5	El Centro Regional Medical Center	DMPH	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Reported	0.7755	0	0.79	None	146	0	178	0	82.0%	0	N/A	N/A	No
PY5	El Centro Regional Medical Center	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Reported	0.3955	0	0	None	13	0	18	0	0.7222	0	N/A	N/A	No
PY5	El Centro Regional Medical Center	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	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	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	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	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	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	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.6406	0	0.6433	None	148	0	220	0	67.3%	0	N/A	N/A	No
PY5	Hazel Hawkins Memorial Hospital	DMPH	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	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	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	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	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	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	None	2	N/A	None	0	0	0	0	0.0%	0	N/A	N/A	NoS
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	0.3403	0	0.3406	None	49	0	157	0	31.2%	0	N/A	N/A	NoS
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.3636	0	0.3613	None	64	0	205	0	31.2%	0	N/A	N/A	NoS
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-CAD1	Q-HBD	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	N/A	None	No
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	16	0	54	0	29.6%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	47	0	144	0	32.6%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	64	0	205	0	31.2%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	49	0	158	0	31.0%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	15	0	47	0	31.9%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	64	0	205	0	31.2%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Reported	0.2368	0	0.2351	None	11	0	69	0	15.9%	0	1	0.5	Yes
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Reported	0.7114	0	0.7165	None	196	0	270	0	72.6%	0	1	0.5	Yes
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Reported	0.8	0	0.8037	None	81	0	95	0	85.3%	0	1	1	Yes
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : White	Reported	N/A	3	N/A	3	24	0	None	4	None	4	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	56	0	63	0	88.9%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	Reported	N/A	3	N/A	3	81	0	95	0	85.3%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	66	0	76	0	86.8%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	14	0	None	4	None	4	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	81	0	95	0	85.3%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Reported	0.8824	0	0.8864	None	83	0	91	0	91.2%	0	N/A	N/A	No
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : White	Reported	N/A	3	N/A	3	27	0	None	4	None	4	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	55	0	59	0	93.2%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Total	Reported	N/A	3	N/A	3	83	0	91	0	91.2%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	63	0	71	0	88.7%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	19	0	None	4	None	4	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	83	0	91	0	91.2%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	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	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	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	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	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	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	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	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.4328	0	0.4807	None	87	0	145	0	60.0%	0	1	0.5	Yes
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	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	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	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	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	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	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	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	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	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	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	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	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Reported	0.2759	0	0.309	None	25	0	54	0	46.3%	0	1	1	Yes
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-PC9	Q-IMA	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-PC9	Q-IMA	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-PC9	Q-IMA	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-PC9	Q-IMA	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-PC9	Q-IMA	▶ Race : White	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-PC9	Q-IMA	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	18	0	34	0	52.9%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-PC9	Q-IMA	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-PC9	Q-IMA	▶ Race : Total	Reported	N/A	3	N/A	3	25	0	54	0	46.3%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	22	0	43	0	51.2%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	25	0	54	0	46.3%	0	N/A	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	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	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	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	None
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Reported	1.8138	0	0.58	None	1	0	3.281	0	0.3048	0	1	N/A	Yes
PY5	Hazel Hawkins Memorial Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	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	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	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	None
PY5	Jerold Phelps Community Hospital	DMPH	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	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	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	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	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	None
PY5	Jerold Phelps Community Hospital	DMPH	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	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-CAD1	Q-HBD	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	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	None
PY5	Jerold Phelps Community Hospital	DMPH	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	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	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	None
PY5	Jerold Phelps Community Hospital	DMPH	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	None
PY5	Jerold Phelps Community Hospital	DMPH	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	None
PY5	Jerold Phelps Community Hospital	DMPH	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	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.2321	0	0.4807	None	20	0	43	0	46.5%	0	0	0	Yes
PY5	Jerold Phelps Community Hospital	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Reported	0.3875	0	0.4955	None	114	0	300	0	38.0%	0	N/A	N/A	No
PY5	Jerold Phelps Community Hospital	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	None	2	0.5004	None	76	0	265	0	28.7%	0	N/A	N/A	No
PY5	Jerold Phelps Community Hospital	DMPH	Q-PC14	Q-CMS138	▶ Rate 1 (informational only)	Reported	0.9834	0	0	None	167	0	167	0	100.0%	0	N/A	N/A	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-PC14	Q-CMS138	▶ Rate 2	Reported	0.8	0	0.812	None	40	0	49	0	81.6%	0	1	0	YesS
PY5	Jerold Phelps Community Hospital	DMPH	Q-PC14	Q-CMS138	▶ Rate 3	Reported	0.9129	0	0.9169	None	158	0	167	0	94.6%	0	1	0.5	YesS
PY5	Jerold Phelps Community Hospital	DMPH	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	0	Yes
PY5	Jerold Phelps Community Hospital	DMPH	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	None
PY5	Jerold Phelps Community Hospital	DMPH	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	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Reported	0.3846	0	0.518	None	91	0	251	0	36.3%	0	0	0	Yes
PY5	Jerold Phelps Community Hospital	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.4322	0	0.4494	None	63	0	202	0	31.2%	0	0	0	Yes
PY5	Jerold Phelps Community Hospital	DMPH	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	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	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	None
PY5	Jerold Phelps Community Hospital	DMPH	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	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Jerold Phelps Community Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	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	None
PY5	John C. Fremont Healthcare District	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	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	None
PY5	John C. Fremont Healthcare District	DMPH	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	None
PY5	John C. Fremont Healthcare District	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.4861	0	0.5061	None	95	0	163	0	58.3%	0	1	0.5	Yes
PY5	John C. Fremont Healthcare District	DMPH	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	None
PY5	John C. Fremont Healthcare District	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	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	None
PY5	John C. Fremont Healthcare District	DMPH	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	None
PY5	John C. Fremont Healthcare District	DMPH	Q-CAD1	Q-HBD	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	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	None
PY5	John C. Fremont Healthcare District	DMPH	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	None
PY5	John C. Fremont Healthcare District	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	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	None
PY5	John C. Fremont Healthcare District	DMPH	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	None
PY5	John C. Fremont Healthcare District	DMPH	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	None
PY5	John C. Fremont Healthcare District	DMPH	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	None
PY5	John C. Fremont Healthcare District	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	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	None
PY5	John C. Fremont Healthcare District	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	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	None
PY5	John C. Fremont Healthcare District	DMPH	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	None
PY5	John C. Fremont Healthcare District	DMPH	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	None
PY5	John C. Fremont Healthcare District	DMPH	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	None
PY5	John C. Fremont Healthcare District	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Reported	0.2581	0	0.518	None	166	0	575	0	28.9%	0	N/A	N/A	No
PY5	John C. Fremont Healthcare District	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.1741	0	0.3941	None	155	0	624	0	24.8%	0	N/A	N/A	No
PY5	John C. Fremont Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	12	0	None	4	None	4	N/A	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	93	0	307	0	30.3%	0	N/A	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	49	0	281	0	17.4%	0	N/A	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	155	0	624	0	24.8%	0	N/A	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	30	0	79	0	38.0%	0	N/A	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	45	0	174	0	25.9%	0	N/A	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	80	0	371	0	21.6%	0	N/A	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	155	0	624	0	24.8%	0	N/A	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Reported	None	2	N/A	None	20	0	31	0	64.5%	0	0	0	Yes
PY5	John C. Fremont Healthcare District	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Reported	0	0	0.1765	None	0	0	43	0	0.0%	0	0	0	Yes
PY5	John C. Fremont Healthcare District	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Reported	0.1167	0	0.1677	None	116	0	572	0	20.3%	0	1	0	Yes
PY5	John C. Fremont Healthcare District	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	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	None
PY5	John C. Fremont Healthcare District	DMPH	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	None
PY5	John C. Fremont Healthcare District	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	John C. Fremont Healthcare District	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Reported	0.1384	0	0.133	None	47	0	383	0	12.3%	0	1	0.5	Yes
PY5	Kaweah Delta Health Care District	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kaweah Delta Health Care District	DMPH	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	0	Yes
PY5	Kaweah Delta Health Care District	DMPH	Q-BH3	Q-FUA	▶ 30 Days	Reported	None	2	0.1075	None	None	1	54	0	None	1	1	0	YesS
PY5	Kaweah Delta Health Care District	DMPH	Q-BH3	Q-FUA	▶ 7 Days	Reported	None	2	0.157	None	None	1	54	0	None	1	0	0	YesS
PY5	Kaweah Delta Health Care District	DMPH	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	None
PY5	Kaweah Delta Health Care District	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.7547	0	0.6679	None	656	0	1005	0	65.3%	0	0	0	Yes
PY5	Kaweah Delta Health Care District	DMPH	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	None
PY5	Kaweah Delta Health Care District	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kaweah Delta Health Care District	DMPH	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	None
PY5	Kaweah Delta Health Care District	DMPH	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Reported	0.6436	0	0.6667	None	684	0	1116	0	61.3%	0	N/A	N/A	No
PY5	Kaweah Delta Health Care District	DMPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	None	2	N/A	None	None	1	None	4	None	1	N/A	N/A	NoS
PY5	Kaweah Delta Health Care District	DMPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	0.3617	0	0.3596	None	163	0	567	0	28.8%	0	1	0.5	YesS
PY5	Kaweah Delta Health Care District	DMPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.3492	None	0.3483	None	263	0	877	0	30.0%	0	1	0.5	YesS
PY5	Kaweah Delta Health Care District	DMPH	Q-CAD1	Q-HBD	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	0.5	Yes
PY5	Kaweah Delta Health Care District	DMPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	204	0	724	0	28.2%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	34	0	90	0	37.8%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	263	0	877	0	30.0%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	163	0	567	0	28.8%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	90	0	285	0	31.6%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	263	0	877	0	30.0%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Reported	0.292	0	0.3096	None	230	0	855	0	26.9%	0	N/A	N/A	No
PY5	Kaweah Delta Health Care District	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Reported	0.7224	0	0.7422	None	3210	0	4968	0	64.6%	0	N/A	N/A	No
PY5	Kaweah Delta Health Care District	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Reported	0.8406	0	0.837	None	190	0	230	0	82.6%	0	N/A	N/A	No
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : White	Reported	N/A	3	N/A	3	165	0	201	0	82.1%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	21	0	None	4	None	4	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	Reported	N/A	3	N/A	3	190	0	230	0	82.6%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	151	0	175	0	86.3%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	34	0	48	0	70.8%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	190	0	230	0	82.6%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Reported	0.8207	0	0.8308	None	195	0	230	0	84.8%	0	1	0	Yes
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : White	Reported	N/A	3	N/A	3	177	0	201	0	88.1%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	13	0	None	4	None	4	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Total	Reported	N/A	3	N/A	3	195	0	230	0	84.8%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	152	0	175	0	86.9%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	37	0	48	0	77.1%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	195	0	230	0	84.8%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kaweah Delta Health Care District	DMPH	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	None
PY5	Kaweah Delta Health Care District	DMPH	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	None
PY5	Kaweah Delta Health Care District	DMPH	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	None
PY5	Kaweah Delta Health Care District	DMPH	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	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.5106	0	0.5233	None	307	0	622	0	49.4%	0	0	0	Yes
PY5	Kaweah Delta Health Care District	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kaweah Delta Health Care District	DMPH	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	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kaweah Delta Health Care District	DMPH	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	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC14	Q-CMS138	▶ Rate 2	Reported	0.0378	0	0.126	None	108	0	1985	0	5.4%	0	0	0	YesS
PY5	Kaweah Delta Health Care District	DMPH	Q-PC14	Q-CMS138	▶ Rate 1 (informational only)	Reported	0.9591	0	0	None	13313	0	13894	0	95.8%	0	N/A	N/A	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC14	Q-CMS138	▶ Rate 3	Reported	0.8176	0	0.8311	None	11438	0	13894	0	82.3%	0	0	0	YesS
PY5	Kaweah Delta Health Care District	DMPH	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	0	0	Yes
PY5	Kaweah Delta Health Care District	DMPH	Q-PC15	Q-WCC	▶ Counseling for Physical Activity	Reported	0.303	0	0.5579	None	1489	0	4154	0	35.8%	0	0	0	YesS
PY5	Kaweah Delta Health Care District	DMPH	Q-PC15	Q-WCC	▶ Counseling for Nutrition	Reported	0.3174	0	0.6107	None	1444	0	4154	0	34.8%	0	0	0	YesS
PY5	Kaweah Delta Health Care District	DMPH	Q-PC15	Q-WCC	▶ BMI	Reported	0.6697	0	0.6919	None	2952	0	4154	0	71.1%	0	1	0	YesS
PY5	Kaweah Delta Health Care District	DMPH	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	0.3333	0	Yes
PY5	Kaweah Delta Health Care District	DMPH	Q-PC16	Q-W30	▶ First 15 Months	Reported	0.63	0	0.6353	None	115	0	164	0	70.1%	0	1	1	YesS
PY5	Kaweah Delta Health Care District	DMPH	Q-PC16	Q-W30	▶ 15 Months-30 Months	Reported	0.6851	0	0.6994	None	130	0	164	0	79.3%	0	1	1	YesS
PY5	Kaweah Delta Health Care District	DMPH	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	1	Yes
PY5	Kaweah Delta Health Care District	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Reported	0.5445	0	0.558	None	1699	0	3217	0	52.8%	0	0	0	Yes
PY5	Kaweah Delta Health Care District	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.6061	0	0.6075	None	2750	0	5118	0	53.7%	0	N/A	N/A	No
PY5	Kaweah Delta Health Care District	DMPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	22	0	41	0	53.7%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	50	0	96	0	52.1%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	22	0	49	0	44.9%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	1415	0	2913	0	48.6%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	1236	0	2008	0	61.6%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	2750	0	5118	0	53.7%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	2144	0	3891	0	55.1%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	351	0	778	0	45.1%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	255	0	449	0	56.8%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	2750	0	5118	0	53.7%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Reported	0.2911	0	0.3187	None	63	0	319	0	19.8%	0	N/A	N/A	No
PY5	Kaweah Delta Health Care District	DMPH	Q-PC4	Q-CIS	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC4	Q-CIS	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC4	Q-CIS	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC4	Q-CIS	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC4	Q-CIS	▶ Race : White	Reported	N/A	3	N/A	3	31	0	182	0	17.0%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC4	Q-CIS	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC4	Q-CIS	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	28	0	120	0	23.3%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC4	Q-CIS	▶ Race : Total	Reported	N/A	3	N/A	3	63	0	319	0	19.8%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	55	0	254	0	21.7%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	39	0	None	1	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	63	0	319	0	19.8%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Reported	0.3033	0	0.4829	None	148	0	470	0	31.5%	0	0	0	Yes
PY5	Kaweah Delta Health Care District	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.2168	0	0.2738	None	1023	0	3347	0	30.6%	0	1	0	Yes
PY5	Kaweah Delta Health Care District	DMPH	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	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Reported	0.2616	0	0.2981	None	1908	0	5689	0	33.5%	0	1	0.5	Yes
PY5	Kaweah Delta Health Care District	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Reported	0.3678	0	0.3816	None	96	0	315	0	30.5%	0	N/A	N/A	No
PY5	Kaweah Delta Health Care District	DMPH	Q-PC9	Q-IMA	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC9	Q-IMA	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC9	Q-IMA	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC9	Q-IMA	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC9	Q-IMA	▶ Race : White	Reported	N/A	3	N/A	3	42	0	154	0	27.3%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC9	Q-IMA	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC9	Q-IMA	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	51	0	151	0	33.8%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC9	Q-IMA	▶ Race : Total	Reported	N/A	3	N/A	3	96	0	315	0	30.5%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	82	0	238	0	34.5%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	35	0	None	1	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	42	0	None	1	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	96	0	315	0	30.5%	0	N/A	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kaweah Delta Health Care District	DMPH	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	None
PY5	Kaweah Delta Health Care District	DMPH	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	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kaweah Delta Health Care District	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Medical Center	DPH	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Reported	0.0275	0	0.0848	None	22	0	543	0	4.1%	0	1	N/A	Yes
PY5	Kern Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adults)	Reported	0.0924	0	0.0984	None	71	0	308	0	23.1%	0	1	0.5	YesS
PY5	Kern Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adults)	Reported	0.1338	0	0.1465	None	97	0	308	0	31.5%	0	1	0.5	YesS
PY5	Kern Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adults)	Reported	0.3535	0	0.3851	None	206	0	308	0	66.9%	0	1	0.5	YesS
PY5	Kern Medical Center	DPH	Q-BH2	Q-DRR-E	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	0.5	Yes
PY5	Kern Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adolescents) - informational only	Reported	None	2	N/A	None	None	1	50	0	None	1	N/A	N/A	YesS
PY5	Kern Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adolescents) - informational only	Reported	None	2	N/A	None	12	0	50	0	24.0%	0	N/A	N/A	YesS
PY5	Kern Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adolescents) - informational only	Reported	None	2	N/A	None	24	0	50	0	48.0%	0	N/A	N/A	YesS
PY5	Kern Medical Center	DPH	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	None
PY5	Kern Medical Center	DPH	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Reported	0	0	0.0269	None	None	1	446	0	None	1	1	N/A	Yes
PY5	Kern Medical Center	DPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Medical Center	DPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Medical Center	DPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.564	0	0.5744	None	1690	0	2925	0	57.8%	0	1	0	Yes
PY5	Kern Medical Center	DPH	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	0.8817	0	0.8855	None	193	0	217	0	88.9%	0	1	0.5	Yes
PY5	Kern Medical Center	DPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.8908	0	0.8937	None	324	0	350	0	92.6%	0	1	0.5	Yes
PY5	Kern Medical Center	DPH	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	0.9855	0	0.8775	None	67	0	67	0	100.0%	0	1	N/A	Yes
PY5	Kern Medical Center	DPH	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Reported	0.7383	0	0.7483	None	1984	0	2653	0	74.8%	0	0.75	0	Yes
PY5	Kern Medical Center	DPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	0.4396	0	0.4297	None	89	0	240	0	37.1%	0	1	0.5	YesS
PY5	Kern Medical Center	DPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	0.4227	0	0.4145	None	616	0	1669	0	36.9%	0	1	0.5	YesS
PY5	Kern Medical Center	DPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.4467	None	0.4361	None	1119	0	2724	0	41.1%	0	1	0.5	YesS
PY5	Kern Medical Center	DPH	Q-CAD1	Q-HBD	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	0.5	Yes
PY5	Kern Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Kern Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	20	0	80	0	25.0%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	85	0	226	0	37.6%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kern Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	762	0	2141	0	35.6%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	242	0	257	0	94.2%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	1119	0	2724	0	41.1%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	616	0	1669	0	36.9%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	267	0	811	0	32.9%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	236	0	244	0	96.7%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	1119	0	2724	0	41.1%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.2919	0	0.4501	None	1307	0	2724	0	48.0%	0	1	0	Yes
PY5	Kern Medical Center	DPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Reported	0.5292	0	0.4676	None	1285	0	2660	0	48.3%	0	1	N/A	Yes
PY5	Kern Medical Center	DPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Medical Center	DPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Reported	0.4727	0	0.5989	None	131	0	183	0	71.6%	0	1	0.5	Yes
PY5	Kern Medical Center	DPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Medical Center	DPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Reported	0.8534	0	0.78	None	961	0	1098	0	87.5%	0	1	N/A	Yes
PY5	Kern Medical Center	DPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Reported	1.0146	0	0.998	None	28	0	34.9038	0	0.8022	0	1	N/A	Yes
PY5	Kern Medical Center	DPH	Q-EC1	Q-QPP47	Advance Care Plan	Reported	0.8717	0	0.8765	None	1370	0	1376	0	99.6%	0	1	0.5	Yes
PY5	Kern Medical Center	DPH	Q-IHE1	Q-IHE1	▶ Controlling High Blood Pressure (CBP) - -Black/African American	Reported	0.5138	0	0.5292	None	157	0	295	0	53.2%	0	1	0	YesS
PY5	Kern Medical Center	DPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	1	0	Yes
PY5	Kern Medical Center	DPH	Q-IHE2	Q-IHE2	▶ Exclusive Breast Milk Feeding (PC-05) - -Black/African American	Reported	0.4878	0	0.5152	None	49	0	84	0	58.3%	0	1	0.5	YesS
PY5	Kern Medical Center	DPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	1	0.5	Yes
PY5	Kern Medical Center	DPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Medical Center	DPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Reported	0.6639	0	0.6737	None	1154	0	1634	0	70.6%	0	1	0.5	Yes
PY5	Kern Medical Center	DPH	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Reported	0.2971	0	0.7111	None	484	0	678	0	71.4%	0	1	0	Yes
PY5	Kern Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kern Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kern Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	Reported	N/A	3	N/A	3	18	0	None	4	None	4	N/A	None	None
PY5	Kern Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kern Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : White	Reported	N/A	3	N/A	3	183	0	252	0	72.6%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	279	0	393	0	71.0%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	Reported	N/A	3	N/A	3	484	0	678	0	71.4%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	157	0	209	0	75.1%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	46	0	75	0	61.3%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	281	0	394	0	71.3%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	484	0	678	0	71.4%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Reported	0.3037	0	0.7932	None	331	0	678	0	48.8%	0	0	0	Yes
PY5	Kern Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kern Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kern Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Black or African American	Reported	N/A	3	N/A	3	14	0	None	4	None	4	N/A	None	None
PY5	Kern Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kern Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : White	Reported	N/A	3	N/A	3	154	0	252	0	61.1%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	158	0	393	0	40.2%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Total	Reported	N/A	3	N/A	3	331	0	678	0	48.8%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	129	0	209	0	61.7%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	43	0	75	0	57.3%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	159	0	394	0	40.4%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	331	0	678	0	48.8%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Medical Center	DPH	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Reported	0.9925	0	0.9434	None	100	0	104	0	96.2%	0	1	N/A	Yes
PY5	Kern Medical Center	DPH	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	None
PY5	Kern Medical Center	DPH	Q-OA3	Q-QPP415	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older	Reported	0.8755	0	0.8799	None	235	0	238	0	98.7%	0	1	0.5	Yes
PY5	Kern Medical Center	DPH	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Reported	0.6919	0	0.7133	None	78	0	93	0	83.9%	0	1	0.5	Yes
PY5	Kern Medical Center	DPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.4485	0	0.4807	None	1172	0	2165	0	54.1%	0	1	0.5	Yes
PY5	Kern Medical Center	DPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Medical Center	DPH	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Reported	0.4808	0	0.5256	None	3565	0	10959	0	32.5%	0	0	0	Yes
PY5	Kern Medical Center	DPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Medical Center	DPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.6296	0	0.6565	None	7377	0	10281	0	71.8%	0	1	1	Yes
PY5	Kern Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 1 (informational only)	Reported	0.9821	0	0	None	14447	0	14658	0	98.6%	0	N/A	N/A	YesI
PY5	Kern Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 2	Reported	0.2906	0	0.3535	None	547	0	2082	0	26.3%	0	0	0	YesS
PY5	Kern Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 3	Reported	0.8684	0	0.8768	None	12963	0	14658	0	88.4%	0	1	0.25	YesS
PY5	Kern Medical Center	DPH	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	0.5	0	Yes
PY5	Kern Medical Center	DPH	Q-PC15	Q-WCC	▶ Counseling for Physical Activity	Reported	0.1248	0	0.5579	None	846	0	4396	0	19.2%	0	0	0	YesS
PY5	Kern Medical Center	DPH	Q-PC15	Q-WCC	▶ Counseling for Nutrition	Reported	0.152	0	0.6107	None	946	0	4396	0	21.5%	0	0	0	YesS
PY5	Kern Medical Center	DPH	Q-PC15	Q-WCC	▶ BMI	Reported	0.9721	0	0.8718	None	4339	0	4396	0	98.7%	0	1	N/A	YesS
PY5	Kern Medical Center	DPH	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	0.3333	N/A	Yes
PY5	Kern Medical Center	DPH	Q-PC16	Q-W30	▶ 15 Months-30 Months	Reported	0.3363	0	0.6643	None	240	0	635	0	37.8%	0	0	0	YesS
PY5	Kern Medical Center	DPH	Q-PC16	Q-W30	▶ First 15 Months	Reported	0.3989	0	0.4499	None	36	0	662	0	5.4%	0	0	0	YesS
PY5	Kern Medical Center	DPH	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	0	0	Yes
PY5	Kern Medical Center	DPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Medical Center	DPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.3358	0	0.3941	None	4437	0	14694	0	30.2%	0	0	0	Yes
PY5	Kern Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	81	0	132	0	61.4%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	270	0	673	0	40.1%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	3632	0	7922	0	45.9%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	443	0	5938	0	7.5%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	4437	0	14694	0	30.2%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	3343	0	7196	0	46.5%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	695	0	1693	0	41.1%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	399	0	5805	0	6.9%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	4437	0	14694	0	30.2%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Reported	0.2326	0	0.3187	None	53	0	487	0	10.9%	0	0	0	Yes
PY5	Kern Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : White	Reported	N/A	3	N/A	3	33	0	89	0	37.1%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	18	0	389	0	4.6%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Total	Reported	N/A	3	N/A	3	53	0	487	0	10.9%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	32	0	82	0	39.0%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	18	0	389	0	4.6%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	53	0	487	0	10.9%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Reported	0.3707	0	0.4829	None	623	0	1556	0	40.0%	0	0	0	Yes
PY5	Kern Medical Center	DPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.4515	0	0.4668	None	2357	0	4984	0	47.3%	0	1	0	Yes
PY5	Kern Medical Center	DPH	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Reported	0.0313	0	0.1765	None	602	0	2542	0	23.7%	0	1	1	Yes
PY5	Kern Medical Center	DPH	Q-PC8	Q-CMS349	HIV Screening Measure	Reported	0.4195	0	0.4402	None	7034	0	14037	0	50.1%	0	1	0.5	Yes
PY5	Kern Medical Center	DPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Reported	0.152	0	0.309	None	62	0	682	0	9.1%	0	0	0	Yes
PY5	Kern Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : White	Reported	N/A	3	N/A	3	16	0	81	0	19.8%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	43	0	592	0	7.3%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Total	Reported	N/A	3	N/A	3	62	0	682	0	9.1%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	16	0	76	0	21.1%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	42	0	590	0	7.1%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	62	0	682	0	9.1%	0	N/A	None	None
PY5	Kern Medical Center	DPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Reported	1	0	1	None	92	0	92	0	100.0%	0	1	0	Yes
PY5	Kern Medical Center	DPH	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Reported	0.9051	0	0.9066	None	1211	0	1296	0	93.4%	0	1	0.5	Yes
PY5	Kern Medical Center	DPH	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Reported	0.8977	0	0.8999	None	515	0	568	0	90.7%	0	1	0.5	Yes
PY5	Kern Medical Center	DPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Medical Center	DPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Reported	0.4842	0	0.795	None	6	0	8.736	0	0.6868	0	1	N/A	Yes
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH2	Q-DRR-E	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	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH3	Q-FUA	▶ 30 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH3	Q-FUA	▶ 7 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH3	Q-FUA	▶ 30 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH3	Q-FUA	▶ 30 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH3	Q-FUA	▶ 30 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH3	Q-FUA	▶ 7 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH3	Q-FUA	▶ 7 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH3	Q-FUA	▶ 7 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH5	Q-FUI	▶ 30 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH5	Q-FUI	▶ 7 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH5	Q-FUI	▶ 30 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH5	Q-FUI	▶ 30 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH5	Q-FUI	▶ 30 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH5	Q-FUI	▶ 7 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH5	Q-FUI	▶ 7 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH5	Q-FUI	▶ 7 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	None	2	0.3406	None	0	0	0	0	0.0%	0	N/A	N/A	NoS
PY5	Kern Valley Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	0.2917	0	0.3406	None	None	1	None	1	None	1	N/A	N/A	NoS
PY5	Kern Valley Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.3056	0	0.3406	None	20	0	78	0	25.6%	0	1	N/A	YesS
PY5	Kern Valley Healthcare District	DMPH	Q-CAD1	Q-HBD	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	N/A	Yes
PY5	Kern Valley Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	17	0	69	0	24.6%	0	N/A	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	20	0	78	0	25.6%	0	N/A	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	13	0	60	0	21.7%	0	N/A	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	20	0	78	0	25.6%	0	N/A	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAR2	Q-PCE	▶ Systemic Corticosteroid	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAR2	Q-PCE	▶ Bronchodilator	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAR2	Q-PCE	▶ Systemic Corticosteroid	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAR2	Q-PCE	▶ Systemic Corticosteroid	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAR2	Q-PCE	▶ Systemic Corticosteroid	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAR2	Q-PCE	▶ Bronchodilator	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAR2	Q-PCE	▶ Bronchodilator	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CAR2	Q-PCE	▶ Bronchodilator	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.2857	0	0.4807	None	100	0	214	0	46.7%	0	0	0	Yes
PY5	Kern Valley Healthcare District	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Reported	0.2469	0	0.4955	None	397	0	758	0	52.4%	0	1	0	Yes
PY5	Kern Valley Healthcare District	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	Q-PC15	Q-WCC	▶ Counseling for Physical Activity	Reported	0.2033	0	0.5579	None	243	0	404	0	60.2%	0	N/A	N/A	NoS
PY5	Kern Valley Healthcare District	DMPH	Q-PC15	Q-WCC	▶ Counseling for Nutrition	Reported	0.4856	0	0.6107	None	289	0	404	0	71.5%	0	N/A	N/A	NoS
PY5	Kern Valley Healthcare District	DMPH	Q-PC15	Q-WCC	▶ BMI	Reported	0.9211	0	0.8718	None	297	0	404	0	73.5%	0	N/A	N/A	NoS
PY5	Kern Valley Healthcare District	DMPH	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	N/A	None	No
PY5	Kern Valley Healthcare District	DMPH	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	N/A	None	No
PY5	Kern Valley Healthcare District	DMPH	Q-PC16	Q-W30	▶ 15 Months-30 Months	Reported	None	2	0.6643	None	13	0	30	0	43.3%	0	N/A	N/A	NoS
PY5	Kern Valley Healthcare District	DMPH	Q-PC16	Q-W30	▶ First 15 Months	Reported	None	2	0.4499	None	23	0	44	0	52.3%	0	N/A	N/A	NoS
PY5	Kern Valley Healthcare District	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.2743	0	0.3073	None	176	0	453	0	38.9%	0	1	0.5	Yes
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	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	None
PY5	Kern Valley Healthcare District	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Kern Valley Healthcare District	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Lompoc Valley Medical Center	DMPH	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	None
PY5	Lompoc Valley Medical Center	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Lompoc Valley Medical Center	DMPH	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	None
PY5	Lompoc Valley Medical Center	DMPH	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	None
PY5	Lompoc Valley Medical Center	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.6162	0	0.6214	None	204	0	371	0	55.0%	0	N/A	N/A	No
PY5	Lompoc Valley Medical Center	DMPH	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	None
PY5	Lompoc Valley Medical Center	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Lompoc Valley Medical Center	DMPH	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	None
PY5	Lompoc Valley Medical Center	DMPH	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	None
PY5	Lompoc Valley Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	None	2	N/A	None	None	1	None	1	None	1	N/A	N/A	NoS
PY5	Lompoc Valley Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	0.3218	0	0.3406	None	28	0	101	0	27.7%	0	1	N/A	YesS
PY5	Lompoc Valley Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.3429	0	0.3427	None	47	0	189	0	24.9%	0	1	0.5	YesS
PY5	Lompoc Valley Medical Center	DMPH	Q-CAD1	Q-HBD	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	N/A	Yes
PY5	Lompoc Valley Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	25	0	81	0	30.9%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	19	0	98	0	19.4%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	47	0	189	0	24.9%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	28	0	101	0	27.7%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	45	0	None	1	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	11	0	43	0	25.6%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	47	0	189	0	24.9%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Reported	0.2179	0	0.2687	None	71	0	245	0	29.0%	0	1	0	Yes
PY5	Lompoc Valley Medical Center	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Reported	0.3404	0	0.2481	None	12	0	52	0	23.1%	0	1	0.5	Yes
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Reported	0.5938	0	0.7111	None	38	0	48	0	79.2%	0	1	1	Yes
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : White	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	27	0	31	0	87.1%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	Reported	N/A	3	N/A	3	38	0	48	0	79.2%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	25	0	30	0	83.3%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	38	0	48	0	79.2%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : White	Reported	N/A	3	N/A	3	14	0	None	4	None	4	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	21	0	None	4	None	4	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Total	Reported	N/A	3	N/A	3	37	0	41	0	90.2%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	21	0	None	4	None	4	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	37	0	41	0	90.2%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Reported	None	2	0.7932	None	37	0	41	0	90.2%	0	1	1	Yes
PY5	Lompoc Valley Medical Center	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Lompoc Valley Medical Center	DMPH	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	None
PY5	Lompoc Valley Medical Center	DMPH	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	None
PY5	Lompoc Valley Medical Center	DMPH	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	None
PY5	Lompoc Valley Medical Center	DMPH	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	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.5	0	0.5138	None	196	0	307	0	63.8%	0	1	0.5	Yes
PY5	Lompoc Valley Medical Center	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Reported	0.3272	0	0.6131	None	50	0	175	0	28.6%	0	N/A	N/A	No
PY5	Lompoc Valley Medical Center	DMPH	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Reported	0.2526	0	0.4955	None	399	0	763	0	52.3%	0	1	0	Yes
PY5	Lompoc Valley Medical Center	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Reported	0.1967	0	0.2671	None	623	0	2322	0	26.8%	0	1	0	Yes
PY5	Lompoc Valley Medical Center	DMPH	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	None
PY5	Lompoc Valley Medical Center	DMPH	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	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC15	Q-WCC	▶ Counseling for Physical Activity	Reported	0.082	0	0.5579	None	1352	0	1898	0	71.2%	0	1	0.5	YesS
PY5	Lompoc Valley Medical Center	DMPH	Q-PC15	Q-WCC	▶ Counseling for Nutrition	Reported	0.2123	0	0.6107	None	1354	0	1898	0	71.3%	0	1	0.5	YesS
PY5	Lompoc Valley Medical Center	DMPH	Q-PC15	Q-WCC	▶ BMI	Reported	0.7805	0	0.7896	None	1780	0	1898	0	93.8%	0	1	0.5	YesS
PY5	Lompoc Valley Medical Center	DMPH	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	0.5	Yes
PY5	Lompoc Valley Medical Center	DMPH	Q-PC16	Q-W30	▶ First 15 Months	Reported	0.85	0	0.6833	None	140	0	179	0	78.2%	0	N/A	N/A	NoS
PY5	Lompoc Valley Medical Center	DMPH	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	N/A	None	No
PY5	Lompoc Valley Medical Center	DMPH	Q-PC16	Q-W30	▶ 15 Months-30 Months	Reported	None	2	N/A	None	144	0	193	0	74.6%	0	N/A	N/A	NoS
PY5	Lompoc Valley Medical Center	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Reported	0.4063	0	0.518	None	512	0	1060	0	48.3%	0	N/A	N/A	No
PY5	Lompoc Valley Medical Center	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.5349	0	0.5434	None	1424	0	2692	0	52.9%	0	N/A	N/A	No
PY5	Lompoc Valley Medical Center	DMPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	17	0	32	0	53.1%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	13	0	30	0	43.3%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	37	0	70	0	52.9%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	685	0	1240	0	55.2%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	670	0	1312	0	51.1%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	1424	0	2692	0	52.9%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	1007	0	1740	0	57.9%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	178	0	368	0	48.4%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	239	0	584	0	40.9%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	1424	0	2692	0	52.9%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Reported	0.2901	0	0.3187	None	34	0	175	0	19.4%	0	N/A	N/A	No
PY5	Lompoc Valley Medical Center	DMPH	Q-PC4	Q-CIS	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC4	Q-CIS	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC4	Q-CIS	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC4	Q-CIS	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC4	Q-CIS	▶ Race : White	Reported	N/A	3	N/A	3	15	0	88	0	17.1%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC4	Q-CIS	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC4	Q-CIS	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	18	0	76	0	23.7%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC4	Q-CIS	▶ Race : Total	Reported	N/A	3	N/A	3	34	0	175	0	19.4%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	26	0	121	0	21.5%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	34	0	175	0	19.4%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Reported	0.3885	0	0.4829	None	26	0	195	0	13.3%	0	N/A	N/A	No
PY5	Lompoc Valley Medical Center	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Reported	0.5711	0	0.3665	None	265	0	408	0	65.0%	0	1	1	Yes
PY5	Lompoc Valley Medical Center	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Reported	0.2425	0	0.2809	None	590	0	1985	0	29.7%	0	1	0	Yes
PY5	Lompoc Valley Medical Center	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Reported	0.25	0	0.309	None	45	0	137	0	32.9%	0	1	0	Yes
PY5	Lompoc Valley Medical Center	DMPH	Q-PC9	Q-IMA	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC9	Q-IMA	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC9	Q-IMA	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC9	Q-IMA	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC9	Q-IMA	▶ Race : White	Reported	N/A	3	N/A	3	28	0	68	0	41.2%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC9	Q-IMA	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC9	Q-IMA	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	17	0	59	0	28.8%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC9	Q-IMA	▶ Race : Total	Reported	N/A	3	N/A	3	45	0	137	0	32.9%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	36	0	94	0	38.3%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	45	0	137	0	32.9%	0	N/A	None	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Lompoc Valley Medical Center	DMPH	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	None
PY5	Lompoc Valley Medical Center	DMPH	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	None
PY5	Lompoc Valley Medical Center	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Reported	0.907	0	0	None	2	0	4.75	0	0.4211	0	1	N/A	Yes
PY5	Lompoc Valley Medical Center	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Los Angeles County Health System	DPH	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Reported	0.0688	0	0.0848	None	132	0	2039	0	6.5%	0	1	N/A	Yes
PY5	Los Angeles County Health System	DPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adults)	Reported	0.1412	0	0.1423	None	156	0	1098	0	14.2%	0	0.75	0	YesS
PY5	Los Angeles County Health System	DPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adults)	Reported	0.2034	0	0.2092	None	205	0	1098	0	18.7%	0	0	0	YesS
PY5	Los Angeles County Health System	DPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adolescents) - informational only	Reported	None	2	0	None	12	0	71	0	16.9%	0	N/A	N/A	YesS
PY5	Los Angeles County Health System	DPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adolescents) - informational only	Reported	None	2	0	None	15	0	71	0	21.1%	0	N/A	N/A	YesS
PY5	Los Angeles County Health System	DPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adolescents) - informational only	Reported	0.3729	0	0	None	37	0	71	0	52.1%	0	N/A	N/A	YesS
PY5	Los Angeles County Health System	DPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adults)	Reported	0.4896	0	0.5076	None	454	0	1098	0	41.4%	0	0	0	YesS
PY5	Los Angeles County Health System	DPH	Q-BH2	Q-DRR-E	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	0.25	0	Yes
PY5	Los Angeles County Health System	DPH	Q-BH3	Q-FUA	▶ 7 Days	Reported	0.1533	0	0.161	None	64	0	407	0	15.7%	0	0.5	0	YesS
PY5	Los Angeles County Health System	DPH	Q-BH3	Q-FUA	▶ 30 Days	Reported	0.2403	0	0.2489	None	112	0	407	0	27.5%	0	1	0.5	YesS
PY5	Los Angeles County Health System	DPH	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	0.75	0	Yes
PY5	Los Angeles County Health System	DPH	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	None
PY5	Los Angeles County Health System	DPH	Q-BH5	Q-FUI	▶ 30 Days	Reported	0.3522	None	0.3894	None	73	0	152	0	48.0%	0	1	0	YesS
PY5	Los Angeles County Health System	DPH	Q-BH5	Q-FUI	▶ 7 Days	Reported	0.2264	None	0.2529	None	53	0	152	0	34.9%	0	1	0.5	YesS
PY5	Los Angeles County Health System	DPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	1	0	Yes
PY5	Los Angeles County Health System	DPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Los Angeles County Health System	DPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.5395	0	0.5523	None	11431	0	19609	0	58.3%	0	1	0.5	Yes
PY5	Los Angeles County Health System	DPH	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	0.9248	0	0.9199	None	4365	0	4660	0	93.7%	0	1	N/A	Yes
PY5	Los Angeles County Health System	DPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.8946	0	0.8971	None	7190	0	8006	0	89.8%	0	1	0	Yes
PY5	Los Angeles County Health System	DPH	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	0.9534	0	0.8775	None	4126	0	4280	0	96.4%	0	1	N/A	Yes
PY5	Los Angeles County Health System	DPH	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Reported	0.7685	0	0.7755	None	17183	0	21520	0	79.9%	0	1	0.5	Yes
PY5	Los Angeles County Health System	DPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	0.3772	0	0.3735	None	984	0	2622	0	37.5%	0	0.5	0	YesS
PY5	Los Angeles County Health System	DPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	0.3875	0	0.3828	None	4657	0	12342	0	37.7%	0	1	0.5	YesS
PY5	Los Angeles County Health System	DPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.3821	0	0.378	None	7475	0	19677	0	38.0%	0	0.5	0	YesS
PY5	Los Angeles County Health System	DPH	Q-CAD1	Q-HBD	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	0.6667	0	Yes
PY5	Los Angeles County Health System	DPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	48	0	124	0	38.7%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	356	0	1368	0	26.0%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	966	0	2573	0	37.5%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	29	0	63	0	46.0%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	312	0	785	0	39.8%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	56	0	142	0	39.4%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	5708	0	14622	0	39.0%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	7475	0	19677	0	38.0%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	4657	0	12342	0	37.7%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	2280	0	6543	0	34.9%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	538	0	792	0	67.9%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	7475	0	19677	0	38.0%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.5369	0	0.5462	None	10783	0	19677	0	54.8%	0	1	0	Yes
PY5	Los Angeles County Health System	DPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Reported	0.6025	0	0.4676	None	9788	0	18562	0	52.7%	0	1	N/A	Yes
PY5	Los Angeles County Health System	DPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Reported	0.8341	0	0.8344	None	3339	0	3997	0	83.5%	0	1	0.5	Yes
PY5	Los Angeles County Health System	DPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Los Angeles County Health System	DPH	Q-CAR2	Q-PCE	▶ Systemic Corticosteroid	Reported	0.5604	0	0.636	None	40	0	62	0	64.5%	0	1	0	YesS
PY5	Los Angeles County Health System	DPH	Q-CAR2	Q-PCE	▶ Bronchodilator	Reported	0.7473	0	0.7872	None	55	0	62	0	88.7%	0	1	0.5	YesS
PY5	Los Angeles County Health System	DPH	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	0	Yes
PY5	Los Angeles County Health System	DPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Reported	0.865	0	0.78	None	9261	0	10177	0	91.0%	0	1	N/A	Yes
PY5	Los Angeles County Health System	DPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Los Angeles County Health System	DPH	Q-EC1	Q-QPP47	Advance Care Plan	Reported	0.9348	0	0.9199	None	28939	0	30612	0	94.5%	0	1	N/A	Yes
PY5	Los Angeles County Health System	DPH	Q-IHE1	Q-IHE1	▶ Developmental Screening in the First Three Years of Life - -Black/African American	Reported	0.305	0	0.3112	None	267	0	692	0	38.6%	0	1	0.5	YesS
PY5	Los Angeles County Health System	DPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	1	0.5	Yes
PY5	Los Angeles County Health System	DPH	Q-IHE2	Q-IHE2	▶ Chlamydia Screening in Women (CHL) - -Asian	Reported	0.5486	0	0.5599	None	108	0	164	0	65.9%	0	1	0.5	YesS
PY5	Los Angeles County Health System	DPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	1	0.5	Yes
PY5	Los Angeles County Health System	DPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Reported	0.2601	0	0.2481	None	213	0	948	0	22.5%	0	1	0.5	Yes
PY5	Los Angeles County Health System	DPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Reported	0.5978	0	0.6142	None	1175	0	2067	0	56.9%	0	0	0	Yes
PY5	Los Angeles County Health System	DPH	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Reported	0.7522	0	0.7607	None	1479	0	1812	0	81.6%	0	1	1	Yes
PY5	Los Angeles County Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	Reported	N/A	3	N/A	3	46	0	50	0	92.0%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	Reported	N/A	3	N/A	3	230	0	301	0	76.4%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Race : White	Reported	N/A	3	N/A	3	53	0	71	0	74.7%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	23	0	32	0	71.9%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	1124	0	1353	0	83.1%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	Reported	N/A	3	N/A	3	1479	0	1812	0	81.6%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	958	0	1119	0	85.6%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	470	0	606	0	77.6%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	51	0	87	0	58.6%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	1479	0	1812	0	81.6%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Reported	0.8447	0	0.8524	None	1491	0	1812	0	82.3%	0	0	0	Yes
PY5	Los Angeles County Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Asian	Reported	N/A	3	N/A	3	43	0	50	0	86.0%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Black or African American	Reported	N/A	3	N/A	3	243	0	301	0	80.7%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : White	Reported	N/A	3	N/A	3	53	0	71	0	74.7%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	24	0	32	0	75.0%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	1123	0	1353	0	83.0%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Total	Reported	N/A	3	N/A	3	1491	0	1812	0	82.3%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	961	0	1119	0	85.9%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	490	0	606	0	80.9%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	40	0	87	0	46.0%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	1491	0	1812	0	82.3%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Los Angeles County Health System	DPH	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Reported	0.9905	0	0.9434	None	3835	0	3877	0	98.9%	0	1	N/A	Yes
PY5	Los Angeles County Health System	DPH	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Reported	0.9286	0	0.7039	None	180	0	198	0	90.9%	0	1	N/A	Yes
PY5	Los Angeles County Health System	DPH	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	None
PY5	Los Angeles County Health System	DPH	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Reported	0.8431	0	0.8282	None	1991	0	2240	0	88.9%	0	1	N/A	Yes
PY5	Los Angeles County Health System	DPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.5396	0	0.5494	None	10827	0	19190	0	56.4%	0	1	0.5	Yes
PY5	Los Angeles County Health System	DPH	Q-PC10	Q-LSC	Lead Screening in Children	Reported	0.5752	0	0.6131	None	1172	0	1889	0	62.0%	0	1	0	Yes
PY5	Los Angeles County Health System	DPH	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	None
PY5	Los Angeles County Health System	DPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Los Angeles County Health System	DPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.9245	0	0.8988	None	99174	0	108964	0	91.0%	0	1	1	Yes
PY5	Los Angeles County Health System	DPH	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	None
PY5	Los Angeles County Health System	DPH	Q-PC15	Q-WCC	▶ Counseling for Physical Activity	Reported	0.7218	0	0.7289	None	13657	0	17950	0	76.1%	0	1	0.5	YesS
PY5	Los Angeles County Health System	DPH	Q-PC15	Q-WCC	▶ Counseling for Nutrition	Reported	0.7324	0	0.7416	None	13926	0	17950	0	77.6%	0	1	0.5	YesS
PY5	Los Angeles County Health System	DPH	Q-PC15	Q-WCC	▶ BMI	Reported	0.8205	0	0.8256	None	16347	0	17950	0	91.1%	0	1	0.5	YesS
PY5	Los Angeles County Health System	DPH	Q-PC15	Q-WCC	Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents	Reported	N/A	3	N/A	N/A	N/A	3	N/A	3	N/A	3	1	0.5	Yes
PY5	Los Angeles County Health System	DPH	Q-PC16	Q-W30	▶ 15 Months-30 Months	Reported	0.6261	0	0.6643	None	1191	0	1792	0	66.5%	0	1	0	YesS
PY5	Los Angeles County Health System	DPH	Q-PC16	Q-W30	▶ First 15 Months	Reported	0.6532	0	0.6562	None	566	0	840	0	67.4%	0	1	1	YesS
PY5	Los Angeles County Health System	DPH	Q-PC16	Q-W30	Well-Child Visits in the First 30 Months of Life (W30)	Reported	N/A	3	N/A	N/A	N/A	3	N/A	3	N/A	3	1	0	Yes
PY5	Los Angeles County Health System	DPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Los Angeles County Health System	DPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.3834	0	0.407	None	16320	0	38233	0	42.7%	0	1	0	Yes
PY5	Los Angeles County Health System	DPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	31	0	70	0	44.3%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	426	0	1208	0	35.3%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	1326	0	3889	0	34.1%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	22	0	72	0	30.6%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	236	0	1034	0	22.8%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	159	0	351	0	45.3%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	14120	0	31609	0	44.7%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	16320	0	38233	0	42.7%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	12589	0	26377	0	47.7%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	3003	0	7087	0	42.4%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	728	0	4769	0	15.3%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	16320	0	38233	0	42.7%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Reported	0.4644	0	0.4716	None	717	0	1836	0	39.1%	0	0	0	Yes
PY5	Los Angeles County Health System	DPH	Q-PC4	Q-CIS	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC4	Q-CIS	▶ Race : Asian	Reported	N/A	3	N/A	3	31	0	55	0	56.4%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC4	Q-CIS	▶ Race : Black or African American	Reported	N/A	3	N/A	3	57	0	242	0	23.6%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC4	Q-CIS	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC4	Q-CIS	▶ Race : White	Reported	N/A	3	N/A	3	26	0	64	0	40.6%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC4	Q-CIS	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC4	Q-CIS	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	597	0	1449	0	41.2%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC4	Q-CIS	▶ Race : Total	Reported	N/A	3	N/A	3	717	0	1836	0	39.1%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	501	0	1164	0	43.0%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	147	0	455	0	32.3%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	69	0	217	0	31.8%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	717	0	1836	0	39.1%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Reported	0.5977	0	0.6041	None	3768	0	5629	0	66.9%	0	1	1	Yes
PY5	Los Angeles County Health System	DPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.5865	0	0.5883	None	44746	0	80641	0	55.5%	0	0	0	Yes
PY5	Los Angeles County Health System	DPH	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Reported	0.5426	0	0.3665	None	2015	0	4533	0	44.5%	0	1	1	Yes
PY5	Los Angeles County Health System	DPH	Q-PC8	Q-CMS349	HIV Screening Measure	Reported	0.5489	0	0.5566	None	51582	0	86124	0	59.9%	0	1	0.5	Yes
PY5	Los Angeles County Health System	DPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Reported	0.3901	0	0.4017	None	135	0	323	0	41.8%	0	1	1	Yes
PY5	Los Angeles County Health System	DPH	Q-PC9	Q-IMA	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC9	Q-IMA	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC9	Q-IMA	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC9	Q-IMA	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC9	Q-IMA	▶ Race : White	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC9	Q-IMA	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC9	Q-IMA	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	123	0	279	0	44.1%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC9	Q-IMA	▶ Race : Total	Reported	N/A	3	N/A	3	135	0	323	0	41.8%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	106	0	229	0	46.3%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	20	0	61	0	32.8%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	33	0	None	1	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	135	0	323	0	41.8%	0	N/A	None	None
PY5	Los Angeles County Health System	DPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Los Angeles County Health System	DPH	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Reported	0.9316	0	0.92	None	7646	0	8026	0	95.3%	0	1	N/A	Yes
PY5	Los Angeles County Health System	DPH	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	None
PY5	Los Angeles County Health System	DPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Reported	0.5836	0	0	None	117	0	183.619	0	0.6372	0	0	N/A	Yes
PY5	Los Angeles County Health System	DPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Reported	0.418	0	0	None	27	0	39.583	0	0.6821	0	1	N/A	Yes
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.5507	0	0.5624	None	47	0	72	0	65.3%	0	1	0.5	Yes
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Reported	0.6667	0	0.6838	None	48	0	66	0	72.7%	0	1	0	Yes
PY5	Mammoth Hospital	DMPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	0	0	N/A	None	0	0	0	0	0.0%	0	N/A	N/A	NoS
PY5	Mammoth Hospital	DMPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	None	2	0.3406	None	16	0	61	0	26.2%	0	1	N/A	YesS
PY5	Mammoth Hospital	DMPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.2459	0	0.3406	None	26	0	90	0	28.9%	0	1	N/A	YesS
PY5	Mammoth Hospital	DMPH	Q-CAD1	Q-HBD	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	N/A	Yes
PY5	Mammoth Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	14	0	43	0	32.6%	0	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	45	0	None	1	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	26	0	90	0	28.9%	0	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	16	0	61	0	26.2%	0	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	26	0	90	0	28.9%	0	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	Q-CAR2	Q-PCE	▶ Systemic Corticosteroid	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CAR2	Q-PCE	▶ Bronchodilator	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CAR2	Q-PCE	▶ Systemic Corticosteroid	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CAR2	Q-PCE	▶ Systemic Corticosteroid	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CAR2	Q-PCE	▶ Systemic Corticosteroid	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CAR2	Q-PCE	▶ Bronchodilator	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CAR2	Q-PCE	▶ Bronchodilator	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CAR2	Q-PCE	▶ Bronchodilator	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : White	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : American Indian or Alaska Native	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Asian	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Black or African American	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Native Hawaiian or Other Pacific Islander	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : White	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Two or More Races	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Other/Declined/Unknown	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Total	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Hispanic or Latino	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Not Hispanic or Latino	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Declined/Unknown	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Total	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.4775	0	0.4935	None	74	0	124	0	59.7%	0	1	0.5	Yes
PY5	Mammoth Hospital	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Reported	0.5241	0	0.5646	None	473	0	930	0	50.9%	0	N/A	N/A	No
PY5	Mammoth Hospital	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.6699	0	0.6928	None	757	0	879	0	86.1%	0	N/A	N/A	No
PY5	Mammoth Hospital	DMPH	Q-PC14	Q-CMS138	▶ Rate 2	Reported	0.1892	0	0.2623	None	29	0	89	0	32.6%	0	N/A	N/A	NoS
PY5	Mammoth Hospital	DMPH	Q-PC14	Q-CMS138	▶ Rate 1 (informational only)	Reported	0.9787	0	0	None	821	0	833	0	98.6%	0	N/A	N/A	NoI
PY5	Mammoth Hospital	DMPH	Q-PC14	Q-CMS138	▶ Rate 3	Reported	0.8953	0	0.901	None	1028	0	1106	0	93.0%	0	N/A	N/A	NoS
PY5	Mammoth Hospital	DMPH	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	N/A	None	No
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Reported	0.488	0	0.518	None	266	0	481	0	55.3%	0	1	0	Yes
PY5	Mammoth Hospital	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.3914	0	0.4142	None	513	0	1015	0	50.5%	0	1	1	Yes
PY5	Mammoth Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	431	0	758	0	56.9%	0	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	68	0	230	0	29.6%	0	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	513	0	1015	0	50.5%	0	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	400	0	699	0	57.2%	0	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	110	0	263	0	41.8%	0	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	53	0	None	1	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	513	0	1015	0	50.5%	0	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Reported	0.7813	0	0.5366	None	27	0	39	0	69.2%	0	1	1	Yes
PY5	Mammoth Hospital	DMPH	Q-PC4	Q-CIS	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-PC4	Q-CIS	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-PC4	Q-CIS	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-PC4	Q-CIS	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-PC4	Q-CIS	▶ Race : White	Reported	N/A	3	N/A	3	27	0	38	0	71.1%	0	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-PC4	Q-CIS	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-PC4	Q-CIS	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-PC4	Q-CIS	▶ Race : Total	Reported	N/A	3	N/A	3	27	0	39	0	69.2%	0	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	20	0	None	4	None	4	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	27	0	39	0	69.2%	0	N/A	None	None
PY5	Mammoth Hospital	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Reported	0.5472	0	0.5586	None	40	0	85	0	47.1%	0	N/A	N/A	No
PY5	Mammoth Hospital	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.4484	0	0.464	None	170	0	285	0	59.7%	0	1	0.5	Yes
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	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	None
PY5	Mammoth Hospital	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mammoth Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Marin General Hospital	DMPH	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	None
PY5	Marin General Hospital	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Marin General Hospital	DMPH	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	None
PY5	Marin General Hospital	DMPH	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	None
PY5	Marin General Hospital	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Marin General Hospital	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Marin General Hospital	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Marin General Hospital	DMPH	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	None
PY5	Marin General Hospital	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Marin General Hospital	DMPH	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	None
PY5	Marin General Hospital	DMPH	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	None
PY5	Marin General Hospital	DMPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	None	2	N/A	None	None	1	None	4	None	1	N/A	N/A	NoS
PY5	Marin General Hospital	DMPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	0.3503	0	0.3493	None	94	0	303	0	31.0%	0	1	0.5	YesS
PY5	Marin General Hospital	DMPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.3556	0	0.3541	None	124	0	424	0	29.3%	0	1	0.5	YesS
PY5	Marin General Hospital	DMPH	Q-CAD1	Q-HBD	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	0.5	Yes
PY5	Marin General Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Marin General Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Marin General Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Marin General Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Marin General Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	18	0	60	0	30.0%	0	N/A	None	None
PY5	Marin General Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Marin General Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	97	0	322	0	30.1%	0	N/A	None	None
PY5	Marin General Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	124	0	424	0	29.3%	0	N/A	None	None
PY5	Marin General Hospital	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	94	0	303	0	31.0%	0	N/A	None	None
PY5	Marin General Hospital	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	29	0	115	0	25.2%	0	N/A	None	None
PY5	Marin General Hospital	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Marin General Hospital	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	124	0	424	0	29.3%	0	N/A	None	None
PY5	Marin General Hospital	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Marin General Hospital	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Marin General Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Marin General Hospital	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Marin General Hospital	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Marin General Hospital	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Reported	0.6491	0	0.6622	None	362	0	506	0	71.5%	0	1	0.5	Yes
PY5	Marin General Hospital	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Marin General Hospital	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Reported	0.1579	0	0.4799	None	253	0	793	0	31.9%	0	N/A	N/A	No
PY5	Marin General Hospital	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Marin General Hospital	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Marin General Hospital	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Reported	0.1667	0	0.22	None	28	0	161	0	17.4%	0	1	N/A	Yes
PY5	Marin General Hospital	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Reported	0.7597	0	0.7599	None	107	0	139	0	77.0%	0	1	0.5	Yes
PY5	Marin General Hospital	DMPH	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Reported	0.8973	0	0.837	None	271	0	303	0	89.4%	0	1	1	Yes
PY5	Marin General Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Marin General Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Marin General Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Marin General Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Marin General Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : White	Reported	N/A	3	N/A	3	14	0	None	4	None	4	N/A	None	None
PY5	Marin General Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Marin General Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	246	0	261	0	94.3%	0	N/A	None	None
PY5	Marin General Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	Reported	N/A	3	N/A	3	271	0	303	0	89.4%	0	N/A	None	None
PY5	Marin General Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	238	0	252	0	94.4%	0	N/A	None	None
PY5	Marin General Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	32	0	49	0	65.3%	0	N/A	None	None
PY5	Marin General Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Marin General Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	271	0	303	0	89.4%	0	N/A	None	None
PY5	Marin General Hospital	DMPH	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	None
PY5	Marin General Hospital	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Marin General Hospital	DMPH	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	None
PY5	Marin General Hospital	DMPH	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	None
PY5	Marin General Hospital	DMPH	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	None
PY5	Marin General Hospital	DMPH	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	None
PY5	Marin General Hospital	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.608	0	0.611	None	531	0	713	0	74.5%	0	1	0.5	Yes
PY5	Marin General Hospital	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Marin General Hospital	DMPH	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	None
PY5	Marin General Hospital	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Marin General Hospital	DMPH	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	None
PY5	Marin General Hospital	DMPH	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	None
PY5	Marin General Hospital	DMPH	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	None
PY5	Marin General Hospital	DMPH	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	None
PY5	Marin General Hospital	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Marin General Hospital	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Marin General Hospital	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Marin General Hospital	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Marin General Hospital	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Marin General Hospital	DMPH	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	None
PY5	Marin General Hospital	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Marin General Hospital	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Marin General Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Reported	0.9815	0	0.9918	None	23	0	None	4	None	4	N/A	N/A	No
PY5	Marin General Hospital	DMPH	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	None
PY5	Marin General Hospital	DMPH	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Reported	0.7184	0	0.7386	None	0	0	131	0	0.0%	0	0	0	Yes
PY5	Marin General Hospital	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Reported	0.2134	0	0	None	13	0	25.9	0	0.5019	0	N/A	N/A	No
PY5	Marin General Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	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	None
PY5	Mayers Memorial Hospital District	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	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	None
PY5	Mayers Memorial Hospital District	DMPH	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	None
PY5	Mayers Memorial Hospital District	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	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	None
PY5	Mayers Memorial Hospital District	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	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	None
PY5	Mayers Memorial Hospital District	DMPH	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	None
PY5	Mayers Memorial Hospital District	DMPH	Q-CAD1	Q-HBD	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	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	None
PY5	Mayers Memorial Hospital District	DMPH	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	None
PY5	Mayers Memorial Hospital District	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	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	None
PY5	Mayers Memorial Hospital District	DMPH	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	None
PY5	Mayers Memorial Hospital District	DMPH	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	None
PY5	Mayers Memorial Hospital District	DMPH	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	None
PY5	Mayers Memorial Hospital District	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	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	None
PY5	Mayers Memorial Hospital District	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Reported	0.8111	0	0.7182	None	70	0	167	0	41.9%	0	0	0	Yes
PY5	Mayers Memorial Hospital District	DMPH	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	None
PY5	Mayers Memorial Hospital District	DMPH	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	None
PY5	Mayers Memorial Hospital District	DMPH	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	None
PY5	Mayers Memorial Hospital District	DMPH	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	None
PY5	Mayers Memorial Hospital District	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	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	None
PY5	Mayers Memorial Hospital District	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Mayers Memorial Hospital District	DMPH	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	None
PY5	Mayers Memorial Hospital District	DMPH	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	None
PY5	Mayers Memorial Hospital District	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Reported	0	0	0	None	0	0	0.652	0	0	0	N/A	N/A	No
PY5	Mayers Memorial Hospital District	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	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	None
PY5	Modoc Medical Center	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	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	None
PY5	Modoc Medical Center	DMPH	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	None
PY5	Modoc Medical Center	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	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	None
PY5	Modoc Medical Center	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	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	None
PY5	Modoc Medical Center	DMPH	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	None
PY5	Modoc Medical Center	DMPH	Q-CAD1	Q-HBD	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	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	None
PY5	Modoc Medical Center	DMPH	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	None
PY5	Modoc Medical Center	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	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	None
PY5	Modoc Medical Center	DMPH	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	None
PY5	Modoc Medical Center	DMPH	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	None
PY5	Modoc Medical Center	DMPH	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	None
PY5	Modoc Medical Center	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	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	None
PY5	Modoc Medical Center	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.5823	0	0.614	None	518	0	709	0	73.1%	0	1	1	Yes
PY5	Modoc Medical Center	DMPH	Q-PC14	Q-CMS138	▶ Rate 1 (informational only)	Reported	0.9237	0	0	None	555	0	560	0	99.1%	0	N/A	N/A	NoI
PY5	Modoc Medical Center	DMPH	Q-PC14	Q-CMS138	▶ Rate 2	Reported	0.6996	0	0.7216	None	117	0	178	0	65.7%	0	N/A	N/A	NoS
PY5	Modoc Medical Center	DMPH	Q-PC14	Q-CMS138	▶ Rate 3	Reported	0.8261	0	0.8387	None	497	0	560	0	88.8%	0	N/A	N/A	NoS
PY5	Modoc Medical Center	DMPH	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	N/A	None	No
PY5	Modoc Medical Center	DMPH	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	None
PY5	Modoc Medical Center	DMPH	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	None
PY5	Modoc Medical Center	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	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	None
PY5	Modoc Medical Center	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	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	None
PY5	Modoc Medical Center	DMPH	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	None
PY5	Modoc Medical Center	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Modoc Medical Center	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Natividad Medical Center	DPH	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Reported	0.0387	0	0.0848	None	17	0	507	0	3.4%	0	1	N/A	Yes
PY5	Natividad Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adults)	Reported	0.0786	0	0.086	None	37	0	305	0	12.1%	0	1	0.5	YesS
PY5	Natividad Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adults)	Reported	0.1572	0	0.1676	None	72	0	305	0	23.6%	0	1	0.5	YesS
PY5	Natividad Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adolescents) - informational only	Reported	None	2	0	None	None	1	60	0	None	1	N/A	N/A	YesS
PY5	Natividad Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adolescents) - informational only	Reported	None	2	0	None	12	0	60	0	20.0%	0	N/A	N/A	YesS
PY5	Natividad Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adolescents) - informational only	Reported	0.25	0	0	None	25	0	60	0	41.7%	0	N/A	N/A	YesS
PY5	Natividad Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adults)	Reported	0.3974	0	0.4246	None	145	0	305	0	47.5%	0	1	0.5	YesS
PY5	Natividad Medical Center	DPH	Q-BH2	Q-DRR-E	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	0.5	Yes
PY5	Natividad Medical Center	DPH	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	0	Yes
PY5	Natividad Medical Center	DPH	Q-BH3	Q-FUA	▶ 30 Days	Reported	None	2	0.1075	None	29	0	138	0	21.0%	0	1	0	YesS
PY5	Natividad Medical Center	DPH	Q-BH3	Q-FUA	▶ 7 Days	Reported	None	2	0.071	None	14	0	138	0	10.1%	0	1	0	YesS
PY5	Natividad Medical Center	DPH	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	None
PY5	Natividad Medical Center	DPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Natividad Medical Center	DPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Natividad Medical Center	DPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.6144	0	0.6198	None	1339	0	2170	0	61.7%	0	0.5	0	Yes
PY5	Natividad Medical Center	DPH	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	0.7831	0	0.7968	None	137	0	168	0	81.6%	0	1	0.5	Yes
PY5	Natividad Medical Center	DPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.7805	0	0.7944	None	210	0	262	0	80.2%	0	1	0	Yes
PY5	Natividad Medical Center	DPH	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	0.8511	0	0.8537	None	43	0	49	0	87.8%	0	1	0.5	Yes
PY5	Natividad Medical Center	DPH	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Reported	0.7551	0	0.7634	None	1060	0	1379	0	76.9%	0	1	0.25	Yes
PY5	Natividad Medical Center	DPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	0.3571	0	0.3555	None	12	0	42	0	28.6%	0	1	0.5	YesS
PY5	Natividad Medical Center	DPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	0.3722	0	0.369	None	352	0	1071	0	32.9%	0	1	0.5	YesS
PY5	Natividad Medical Center	DPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.3439	0	0.3436	None	496	0	1539	0	32.2%	0	1	0.5	YesS
PY5	Natividad Medical Center	DPH	Q-CAD1	Q-HBD	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	0.5	Yes
PY5	Natividad Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	29	0	115	0	25.2%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	12	0	42	0	28.6%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	411	0	1242	0	33.1%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	36	0	122	0	29.5%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	496	0	1539	0	32.2%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	352	0	1071	0	32.9%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	106	0	332	0	31.9%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	38	0	136	0	27.9%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	496	0	1539	0	32.2%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.5735	0	0.5792	None	894	0	1539	0	58.1%	0	1	0	Yes
PY5	Natividad Medical Center	DPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Reported	0.3893	0	0.3971	None	679	0	1666	0	40.8%	0	1	0.5	Yes
PY5	Natividad Medical Center	DPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Reported	0.7939	0	0.7982	None	145	0	176	0	82.4%	0	1	0.5	Yes
PY5	Natividad Medical Center	DPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Reported	0.9945	0	0.7532	None	68	0	69	0	98.6%	0	1	N/A	Yes
PY5	Natividad Medical Center	DPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Natividad Medical Center	DPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Reported	0.3811	0	0.44	None	890	0	1075	0	82.8%	0	1	0.5	Yes
PY5	Natividad Medical Center	DPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Reported	0.3333	0	0	None	29	0	27.4682	0	1.0558	0	0	N/A	Yes
PY5	Natividad Medical Center	DPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Natividad Medical Center	DPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Natividad Medical Center	DPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Natividad Medical Center	DPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Reported	0.2009	0	0.22	None	101	0	471	0	21.4%	0	1	N/A	Yes
PY5	Natividad Medical Center	DPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Natividad Medical Center	DPH	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Reported	0.8508	0	0.837	None	350	0	387	0	90.4%	0	1	1	Yes
PY5	Natividad Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : White	Reported	N/A	3	N/A	3	327	0	357	0	91.6%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	Reported	N/A	3	N/A	3	350	0	387	0	90.4%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	319	0	345	0	92.5%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	27	0	32	0	84.4%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	350	0	387	0	90.4%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Reported	0.8011	0	0.8132	None	331	0	387	0	85.5%	0	1	0	Yes
PY5	Natividad Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : White	Reported	N/A	3	N/A	3	308	0	357	0	86.3%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Total	Reported	N/A	3	N/A	3	331	0	387	0	85.5%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	300	0	345	0	87.0%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	28	0	32	0	87.5%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	331	0	387	0	85.5%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Reported	0.5776	0	0.4576	None	355	0	613	0	57.9%	0	1	N/A	Yes
PY5	Natividad Medical Center	DPH	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Reported	0.9955	0	0.9434	None	3390	0	3432	0	98.8%	0	1	N/A	Yes
PY5	Natividad Medical Center	DPH	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Reported	1	0	0.7039	None	191	0	195	0	98.0%	0	1	N/A	Yes
PY5	Natividad Medical Center	DPH	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	None
PY5	Natividad Medical Center	DPH	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Reported	0.924	0	0.8282	None	210	0	232	0	90.5%	0	1	N/A	Yes
PY5	Natividad Medical Center	DPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.505	0	0.5183	None	1004	0	1791	0	56.1%	0	1	0.5	Yes
PY5	Natividad Medical Center	DPH	Q-PC10	Q-LSC	Lead Screening in Children	Reported	0.7693	0	0.7763	None	941	0	1142	0	82.4%	0	1	0.5	Yes
PY5	Natividad Medical Center	DPH	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Reported	0.4961	0	0.5394	None	7022	0	17207	0	40.8%	0	0	0	Yes
PY5	Natividad Medical Center	DPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Reported	0.5841	0	0.5975	None	15815	0	25296	0	62.5%	0	1	0.5	Yes
PY5	Natividad Medical Center	DPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.6496	0	0.6745	None	13387	0	17274	0	77.5%	0	1	1	Yes
PY5	Natividad Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 1 (informational only)	Reported	0.9603	0	0	None	12370	0	12780	0	96.8%	0	N/A	N/A	YesI
PY5	Natividad Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 2	Reported	0.5861	0	0.6195	None	661	0	923	0	71.6%	0	1	0.5	YesS
PY5	Natividad Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 3	Reported	0.9285	0	0.9309	None	11985	0	12643	0	94.8%	0	1	0.5	YesS
PY5	Natividad Medical Center	DPH	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	0.5	Yes
PY5	Natividad Medical Center	DPH	Q-PC15	Q-WCC	▶ Counseling for Nutrition	Reported	0.7786	0	0.7832	None	10177	0	12559	0	81.0%	0	1	0.5	YesS
PY5	Natividad Medical Center	DPH	Q-PC15	Q-WCC	▶ Counseling for Physical Activity	Reported	0.7786	0	0.7801	None	10184	0	12559	0	81.1%	0	1	0.5	YesS
PY5	Natividad Medical Center	DPH	Q-PC15	Q-WCC	▶ BMI	Reported	0.846	0	0.8486	None	11395	0	12559	0	90.7%	0	1	0.5	YesS
PY5	Natividad Medical Center	DPH	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	0.5	Yes
PY5	Natividad Medical Center	DPH	Q-PC16	Q-W30	▶ First 15 Months	Reported	0.4613	0	0.4835	None	160	0	226	0	70.8%	0	1	1	YesS
PY5	Natividad Medical Center	DPH	Q-PC16	Q-W30	▶ 15 Months-30 Months	Reported	0.5639	0	0.6643	None	839	0	1235	0	67.9%	0	1	0	YesS
PY5	Natividad Medical Center	DPH	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	0	Yes
PY5	Natividad Medical Center	DPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Reported	0.5492	0	0.5623	None	4392	0	7806	0	56.3%	0	1	0	Yes
PY5	Natividad Medical Center	DPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.4808	0	0.4947	None	14355	0	24607	0	58.3%	0	1	1	Yes
PY5	Natividad Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	47	0	71	0	66.2%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	267	0	570	0	46.8%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	180	0	426	0	42.3%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	37	0	81	0	45.7%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	12479	0	20446	0	61.0%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	1345	0	3013	0	44.6%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	14355	0	24607	0	58.3%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	13158	0	21229	0	62.0%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	1002	0	2345	0	42.7%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	195	0	1033	0	18.9%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	14355	0	24607	0	58.3%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Reported	0.5437	0	0.5366	None	620	0	1149	0	54.0%	0	1	1	Yes
PY5	Natividad Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Asian	Reported	N/A	3	N/A	3	12	0	None	4	None	4	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : White	Reported	N/A	3	N/A	3	576	0	989	0	58.2%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	27	0	112	0	24.1%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Total	Reported	N/A	3	N/A	3	620	0	1149	0	54.0%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	567	0	962	0	58.9%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	40	0	99	0	40.4%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	13	0	88	0	14.8%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	620	0	1149	0	54.0%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Reported	0.5217	0	0.5357	None	236	0	415	0	56.9%	0	1	1	Yes
PY5	Natividad Medical Center	DPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.58	0	0.5825	None	3047	0	5225	0	58.3%	0	1	0	Yes
PY5	Natividad Medical Center	DPH	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Reported	0.0075	0	0.1765	None	76	0	2665	0	2.9%	0	0	0	Yes
PY5	Natividad Medical Center	DPH	Q-PC8	Q-CMS349	HIV Screening Measure	Reported	0.5626	0	0.569	None	6878	0	11461	0	60.0%	0	1	0.5	Yes
PY5	Natividad Medical Center	DPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Reported	0.7939	0	0.5061	None	819	0	1397	0	58.6%	0	1	1	Yes
PY5	Natividad Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Asian	Reported	N/A	3	N/A	3	17	0	30	0	56.7%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : White	Reported	N/A	3	N/A	3	708	0	1162	0	60.9%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	82	0	167	0	49.1%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Total	Reported	N/A	3	N/A	3	819	0	1397	0	58.6%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	770	0	1235	0	62.4%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	43	0	127	0	33.9%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	35	0	None	1	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	819	0	1397	0	58.6%	0	N/A	None	None
PY5	Natividad Medical Center	DPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Natividad Medical Center	DPH	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Reported	0.9237	0	0.92	None	694	0	738	0	94.0%	0	1	N/A	Yes
PY5	Natividad Medical Center	DPH	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Reported	0.8782	0	0.8824	None	232	0	261	0	88.9%	0	1	0	Yes
PY5	Natividad Medical Center	DPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Natividad Medical Center	DPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	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	None
PY5	Northern Inyo Hospital	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	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	None
PY5	Northern Inyo Hospital	DMPH	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	None
PY5	Northern Inyo Hospital	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	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	None
PY5	Northern Inyo Hospital	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	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	None
PY5	Northern Inyo Hospital	DMPH	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	None
PY5	Northern Inyo Hospital	DMPH	Q-CAD1	Q-HBD	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Reported	0.6667	0	0.6762	None	73	0	90	0	81.1%	0	1	0.5	Yes
PY5	Northern Inyo Hospital	DMPH	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Reported	0.5882	0	0.7111	None	27	0	36	0	75.0%	0	1	0	Yes
PY5	Northern Inyo Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Northern Inyo Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Northern Inyo Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Northern Inyo Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Northern Inyo Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : White	Reported	N/A	3	N/A	3	20	0	None	4	None	4	N/A	None	None
PY5	Northern Inyo Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Northern Inyo Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Northern Inyo Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	Reported	N/A	3	N/A	3	27	0	36	0	75.0%	0	N/A	None	None
PY5	Northern Inyo Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Northern Inyo Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	19	0	None	4	None	4	N/A	None	None
PY5	Northern Inyo Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Northern Inyo Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	27	0	36	0	75.0%	0	N/A	None	None
PY5	Northern Inyo Hospital	DMPH	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Reported	0.5143	0	0.7932	None	31	0	36	0	86.1%	0	1	1	Yes
PY5	Northern Inyo Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Northern Inyo Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Northern Inyo Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Northern Inyo Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Northern Inyo Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : White	Reported	N/A	3	N/A	3	25	0	None	4	None	4	N/A	None	None
PY5	Northern Inyo Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Northern Inyo Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Northern Inyo Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Total	Reported	N/A	3	N/A	3	31	0	36	0	86.1%	0	N/A	None	None
PY5	Northern Inyo Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Northern Inyo Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	21	0	None	4	None	4	N/A	None	None
PY5	Northern Inyo Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Northern Inyo Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	31	0	36	0	86.1%	0	N/A	None	None
PY5	Northern Inyo Hospital	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	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	None
PY5	Northern Inyo Hospital	DMPH	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	None
PY5	Northern Inyo Hospital	DMPH	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	None
PY5	Northern Inyo Hospital	DMPH	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	None
PY5	Northern Inyo Hospital	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	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	None
PY5	Northern Inyo Hospital	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	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	None
PY5	Northern Inyo Hospital	DMPH	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	None
PY5	Northern Inyo Hospital	DMPH	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	None
PY5	Northern Inyo Hospital	DMPH	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	None
PY5	Northern Inyo Hospital	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Reported	0.5188	0	0.3665	None	55	0	130	0	42.3%	0	N/A	N/A	No
PY5	Northern Inyo Hospital	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	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	None
PY5	Northern Inyo Hospital	DMPH	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	None
PY5	Northern Inyo Hospital	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Northern Inyo Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Oak Valley Hospital District	DMPH	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	None
PY5	Oak Valley Hospital District	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Oak Valley Hospital District	DMPH	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	None
PY5	Oak Valley Hospital District	DMPH	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	None
PY5	Oak Valley Hospital District	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Oak Valley Hospital District	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Oak Valley Hospital District	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.534	0	0.5474	None	55	0	87	0	63.2%	0	1	0.5	Yes
PY5	Oak Valley Hospital District	DMPH	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	None
PY5	Oak Valley Hospital District	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.7337	0	0.7637	None	41	0	53	0	77.4%	0	1	0	Yes
PY5	Oak Valley Hospital District	DMPH	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	None
PY5	Oak Valley Hospital District	DMPH	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Reported	0.6789	0	0.6948	None	515	0	646	0	79.7%	0	1	0.5	Yes
PY5	Oak Valley Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	None	2	N/A	None	None	1	None	1	None	1	N/A	N/A	NoS
PY5	Oak Valley Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	0.2706	0	0.3406	None	33	0	129	0	25.6%	0	1	N/A	YesS
PY5	Oak Valley Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.2864	0	0.3406	None	68	0	255	0	26.7%	0	1	N/A	YesS
PY5	Oak Valley Hospital District	DMPH	Q-CAD1	Q-HBD	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	N/A	Yes
PY5	Oak Valley Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Oak Valley Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Oak Valley Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Oak Valley Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Oak Valley Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	27	0	101	0	26.7%	0	N/A	None	None
PY5	Oak Valley Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Oak Valley Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	38	0	143	0	26.6%	0	N/A	None	None
PY5	Oak Valley Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	68	0	255	0	26.7%	0	N/A	None	None
PY5	Oak Valley Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	33	0	129	0	25.6%	0	N/A	None	None
PY5	Oak Valley Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	26	0	81	0	32.1%	0	N/A	None	None
PY5	Oak Valley Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	45	0	None	1	N/A	None	None
PY5	Oak Valley Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	68	0	255	0	26.7%	0	N/A	None	None
PY5	Oak Valley Hospital District	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0	0	0.4501	None	227	0	503	0	45.1%	0	1	0	Yes
PY5	Oak Valley Hospital District	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Reported	0.7076	0	0.4676	None	73	0	271	0	26.9%	0	0	0	Yes
PY5	Oak Valley Hospital District	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Oak Valley Hospital District	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Oak Valley Hospital District	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Oak Valley Hospital District	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Oak Valley Hospital District	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Oak Valley Hospital District	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Oak Valley Hospital District	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Oak Valley Hospital District	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Oak Valley Hospital District	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Oak Valley Hospital District	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Oak Valley Hospital District	DMPH	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	None
PY5	Oak Valley Hospital District	DMPH	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	None
PY5	Oak Valley Hospital District	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Reported	0.6032	0	0.4576	None	33	0	53	0	62.3%	0	N/A	N/A	No
PY5	Oak Valley Hospital District	DMPH	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	None
PY5	Oak Valley Hospital District	DMPH	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	None
PY5	Oak Valley Hospital District	DMPH	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	None
PY5	Oak Valley Hospital District	DMPH	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	None
PY5	Oak Valley Hospital District	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.5323	0	0.5428	None	186	0	342	0	54.4%	0	1	0	Yes
PY5	Oak Valley Hospital District	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Reported	None	2	N/A	None	36	0	120	0	30.0%	0	N/A	N/A	No
PY5	Oak Valley Hospital District	DMPH	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Reported	0.1589	0	0.4955	None	2186	0	4220	0	51.8%	0	1	0	Yes
PY5	Oak Valley Hospital District	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Reported	0.2106	0	0.2671	None	754	0	3934	0	19.2%	0	N/A	N/A	No
PY5	Oak Valley Hospital District	DMPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.7667	0	0.7799	None	3065	0	4104	0	74.7%	0	N/A	N/A	No
PY5	Oak Valley Hospital District	DMPH	Q-PC14	Q-CMS138	▶ Rate 1 (informational only)	Reported	0.9758	0	0	None	3448	0	3501	0	98.5%	0	N/A	N/A	NoI
PY5	Oak Valley Hospital District	DMPH	Q-PC14	Q-CMS138	▶ Rate 2	Reported	0.8605	0	0.8664	None	395	0	478	0	82.6%	0	N/A	N/A	NoS
PY5	Oak Valley Hospital District	DMPH	Q-PC14	Q-CMS138	▶ Rate 3	Reported	0.9767	0	0.9525	None	3300	0	3501	0	94.3%	0	N/A	N/A	NoS
PY5	Oak Valley Hospital District	DMPH	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	N/A	None	No
PY5	Oak Valley Hospital District	DMPH	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	0	Yes
PY5	Oak Valley Hospital District	DMPH	Q-PC15	Q-WCC	▶ BMI	Reported	None	2	0.6919	None	1505	0	1516	0	99.3%	0	1	0.5	YesS
PY5	Oak Valley Hospital District	DMPH	Q-PC15	Q-WCC	▶ Counseling for Nutrition	Reported	None	2	0.6107	None	971	0	1516	0	64.1%	0	1	0	YesS
PY5	Oak Valley Hospital District	DMPH	Q-PC15	Q-WCC	▶ Counseling for Physical Activity	Reported	None	2	0.5579	None	1015	0	1516	0	67.0%	0	1	0.5	YesS
PY5	Oak Valley Hospital District	DMPH	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	None
PY5	Oak Valley Hospital District	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Reported	0.5446	0	0.5581	None	810	0	1437	0	56.4%	0	1	0	Yes
PY5	Oak Valley Hospital District	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.2256	0	0.3941	None	1042	0	2078	0	50.1%	0	1	1	Yes
PY5	Oak Valley Hospital District	DMPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Oak Valley Hospital District	DMPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Oak Valley Hospital District	DMPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Oak Valley Hospital District	DMPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Oak Valley Hospital District	DMPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	64	0	188	0	34.0%	0	N/A	None	None
PY5	Oak Valley Hospital District	DMPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Oak Valley Hospital District	DMPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	974	0	1879	0	51.8%	0	N/A	None	None
PY5	Oak Valley Hospital District	DMPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	1042	0	2078	0	50.1%	0	N/A	None	None
PY5	Oak Valley Hospital District	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	245	0	496	0	49.4%	0	N/A	None	None
PY5	Oak Valley Hospital District	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	70	0	202	0	34.7%	0	N/A	None	None
PY5	Oak Valley Hospital District	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	727	0	1380	0	52.7%	0	N/A	None	None
PY5	Oak Valley Hospital District	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	1042	0	2078	0	50.1%	0	N/A	None	None
PY5	Oak Valley Hospital District	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Oak Valley Hospital District	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Reported	None	2	N/A	None	83	0	200	0	41.5%	0	N/A	N/A	No
PY5	Oak Valley Hospital District	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.5543	0	0.5593	None	644	0	1145	0	56.2%	0	1	0.25	Yes
PY5	Oak Valley Hospital District	DMPH	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Reported	0	0	0.1765	None	100	0	445	0	22.5%	0	1	1	Yes
PY5	Oak Valley Hospital District	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Reported	0.267	0	0.3029	None	640	0	2506	0	25.5%	0	N/A	N/A	No
PY5	Oak Valley Hospital District	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Oak Valley Hospital District	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Oak Valley Hospital District	DMPH	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	None
PY5	Oak Valley Hospital District	DMPH	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	None
PY5	Oak Valley Hospital District	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Oak Valley Hospital District	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	Q-BH2	Q-DRR-E	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	None
PY5	Palo Verde Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	Q-BH3	Q-FUA	▶ 30 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH3	Q-FUA	▶ 7 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH3	Q-FUA	▶ 30 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH3	Q-FUA	▶ 30 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH3	Q-FUA	▶ 7 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH3	Q-FUA	▶ 7 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH5	Q-FUI	▶ 30 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH5	Q-FUI	▶ 7 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH5	Q-FUI	▶ 30 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH5	Q-FUI	▶ 30 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH5	Q-FUI	▶ 7 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH5	Q-FUI	▶ 7 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	Q-CAD1	Q-HBD	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	None
PY5	Palo Verde Hospital	DMPH	Q-CAD1	Q-HBD	▶ Black/African-American	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAD1	Q-HBD	▶ Total Population	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Asian	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : White	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Total	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAD1	Q-HBD	▶ Black/African-American	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAD1	Q-HBD	▶ Black/African-American	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAD1	Q-HBD	▶ Total Population	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAD1	Q-HBD	▶ Total Population	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	Q-CAR2	Q-PCE	▶ Systemic Corticosteroid	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAR2	Q-PCE	▶ Bronchodilator	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAR2	Q-PCE	▶ Systemic Corticosteroid	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAR2	Q-PCE	▶ Systemic Corticosteroid	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAR2	Q-PCE	▶ Bronchodilator	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CAR2	Q-PCE	▶ Bronchodilator	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Reported	0	0	0.4799	None	0	0	121	0	0.0%	0	N/A	N/A	No
PY5	Palo Verde Hospital	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : White	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : American Indian or Alaska Native	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Asian	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Black or African American	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Native Hawaiian or Other Pacific Islander	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : White	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Two or More Races	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Other/Declined/Unknown	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Total	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Hispanic or Latino	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Not Hispanic or Latino	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Declined/Unknown	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Total	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Reported	None	2	0.4955	None	102	0	503	0	20.3%	0	0	0	Yes
PY5	Palo Verde Hospital	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Reported	0.6481	0	0.6551	None	193	0	348	0	55.5%	0	0	0	Yes
PY5	Palo Verde Hospital	DMPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.2718	0	0.5004	None	140	0	505	0	27.7%	0	N/A	N/A	No
PY5	Palo Verde Hospital	DMPH	Q-PC14	Q-CMS138	▶ Rate 3	Reported	0.209	0	0.7542	None	36	0	390	0	9.2%	0	0	0	YesS
PY5	Palo Verde Hospital	DMPH	Q-PC14	Q-CMS138	▶ Rate 2	Reported	0.8	0	0.812	None	36	0	104	0	34.6%	0	0	0	YesS
PY5	Palo Verde Hospital	DMPH	Q-PC14	Q-CMS138	▶ Rate 1 (informational only)	Reported	0.9892	0	0	None	390	0	390	0	100.0%	0	N/A	N/A	None
PY5	Palo Verde Hospital	DMPH	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	0	0	Yes
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	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	None
PY5	Palo Verde Hospital	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palo Verde Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palomar Health	DMPH	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	None
PY5	Palomar Health	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palomar Health	DMPH	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	None
PY5	Palomar Health	DMPH	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	None
PY5	Palomar Health	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palomar Health	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palomar Health	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palomar Health	DMPH	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	None
PY5	Palomar Health	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palomar Health	DMPH	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	0.7778	0	0.7878	None	72	0	80	0	90.0%	0	1	0.5	Yes
PY5	Palomar Health	DMPH	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	None
PY5	Palomar Health	DMPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	None	2	N/A	None	0	0	None	1	None	1	N/A	N/A	NoS
PY5	Palomar Health	DMPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	0.2584	0	0.3406	None	38	0	145	0	26.2%	0	1	N/A	YesS
PY5	Palomar Health	DMPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.236	0	0.3406	None	71	0	264	0	26.9%	0	1	N/A	YesS
PY5	Palomar Health	DMPH	Q-CAD1	Q-HBD	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	N/A	Yes
PY5	Palomar Health	DMPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Palomar Health	DMPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Palomar Health	DMPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Palomar Health	DMPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Palomar Health	DMPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	47	0	153	0	30.7%	0	N/A	None	None
PY5	Palomar Health	DMPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Palomar Health	DMPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	21	0	84	0	25.0%	0	N/A	None	None
PY5	Palomar Health	DMPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	71	0	264	0	26.9%	0	N/A	None	None
PY5	Palomar Health	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	38	0	145	0	26.2%	0	N/A	None	None
PY5	Palomar Health	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	23	0	82	0	28.1%	0	N/A	None	None
PY5	Palomar Health	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	37	0	None	1	N/A	None	None
PY5	Palomar Health	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	71	0	264	0	26.9%	0	N/A	None	None
PY5	Palomar Health	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palomar Health	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palomar Health	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palomar Health	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palomar Health	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palomar Health	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Reported	0.3673	0	0.44	None	154	0	300	0	51.3%	0	1	0	Yes
PY5	Palomar Health	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palomar Health	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Reported	1	0	0.9199	None	304	0	325	0	93.5%	0	1	N/A	Yes
PY5	Palomar Health	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palomar Health	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palomar Health	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Reported	0.1816	0	0.22	None	119	0	670	0	17.8%	0	1	N/A	Yes
PY5	Palomar Health	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Reported	0.484	0	0.5118	None	321	0	625	0	51.4%	0	1	0	Yes
PY5	Palomar Health	DMPH	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	None
PY5	Palomar Health	DMPH	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	None
PY5	Palomar Health	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palomar Health	DMPH	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	None
PY5	Palomar Health	DMPH	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	None
PY5	Palomar Health	DMPH	Q-OA3	Q-QPP415	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older	Reported	0.8087	0	0.8198	None	228	0	271	0	84.1%	0	1	0	Yes
PY5	Palomar Health	DMPH	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	None
PY5	Palomar Health	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palomar Health	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palomar Health	DMPH	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	None
PY5	Palomar Health	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palomar Health	DMPH	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	None
PY5	Palomar Health	DMPH	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	None
PY5	Palomar Health	DMPH	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	None
PY5	Palomar Health	DMPH	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	None
PY5	Palomar Health	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palomar Health	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palomar Health	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palomar Health	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palomar Health	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.3564	0	0.3812	None	117	0	383	0	30.6%	0	N/A	N/A	No
PY5	Palomar Health	DMPH	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	None
PY5	Palomar Health	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palomar Health	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Palomar Health	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Reported	0.6129	0	0.9918	None	305	0	374	0	81.6%	0	N/A	N/A	No
PY5	Palomar Health	DMPH	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Reported	0.988	0	0.92	None	424	0	435	0	97.5%	0	1	N/A	Yes
PY5	Palomar Health	DMPH	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Reported	0.1758	0	0.4485	None	198	0	206	0	96.1%	0	1	0.5	Yes
PY5	Palomar Health	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Reported	0.3574	0	0	None	29	0	46.933	0	0.6179	0	N/A	N/A	No
PY5	Palomar Health	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Reported	0.6867	0	0	None	16	0	13.923	0	1.1492	0	N/A	N/A	No
PY5	Pioneers Memorial Healthcare District	DMPH	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	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	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	None
PY5	Pioneers Memorial Healthcare District	DMPH	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	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.4949	0	0.5122	None	311	0	606	0	51.3%	0	1	0	Yes
PY5	Pioneers Memorial Healthcare District	DMPH	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	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	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	None
PY5	Pioneers Memorial Healthcare District	DMPH	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	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	0	0	N/A	None	None	1	None	1	None	1	N/A	N/A	NoS
PY5	Pioneers Memorial Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	0.5226	0	0.5044	None	186	0	374	0	49.7%	0	N/A	N/A	NoS
PY5	Pioneers Memorial Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.5114	0	0.4943	None	234	0	447	0	52.4%	0	N/A	N/A	NoS
PY5	Pioneers Memorial Healthcare District	DMPH	Q-CAD1	Q-HBD	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	N/A	None	No
PY5	Pioneers Memorial Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	202	0	399	0	50.6%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	31	0	47	0	66.0%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	234	0	447	0	52.4%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	186	0	374	0	49.7%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	17	0	None	4	None	4	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	31	0	47	0	66.0%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	234	0	447	0	52.4%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Reported	0.1865	0	0.22	None	61	0	320	0	19.1%	0	1	N/A	Yes
PY5	Pioneers Memorial Healthcare District	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Reported	0.3409	0	0.4776	None	281	0	837	0	33.6%	0	N/A	N/A	No
PY5	Pioneers Memorial Healthcare District	DMPH	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	None
PY5	Pioneers Memorial Healthcare District	DMPH	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	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	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	None
PY5	Pioneers Memorial Healthcare District	DMPH	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	None
PY5	Pioneers Memorial Healthcare District	DMPH	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	None
PY5	Pioneers Memorial Healthcare District	DMPH	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	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.545	0	0.5543	None	216	0	372	0	58.1%	0	1	0.5	Yes
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Reported	0.1486	0	0.6131	None	43	0	93	0	46.2%	0	N/A	N/A	No
PY5	Pioneers Memorial Healthcare District	DMPH	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	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	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	None
PY5	Pioneers Memorial Healthcare District	DMPH	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	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC15	Q-WCC	▶ Counseling for Physical Activity	Reported	0.0974	0	0.5579	None	49	0	1372	0	3.6%	0	N/A	N/A	NoS
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC15	Q-WCC	▶ Counseling for Nutrition	Reported	0.2322	0	0.6107	None	179	0	1372	0	13.1%	0	N/A	N/A	NoS
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC15	Q-WCC	▶ BMI	Reported	0.6273	0	0.6919	None	694	0	1372	0	50.6%	0	N/A	N/A	NoS
PY5	Pioneers Memorial Healthcare District	DMPH	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	N/A	None	No
PY5	Pioneers Memorial Healthcare District	DMPH	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	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Reported	0.5518	0	0.5646	None	1214	0	2089	0	58.1%	0	1	0	Yes
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.3929	0	0.4156	None	998	0	2352	0	42.4%	0	1	0	Yes
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	928	0	2119	0	43.8%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	62	0	215	0	28.8%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	998	0	2352	0	42.4%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	904	0	2119	0	42.7%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	32	0	106	0	30.2%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	62	0	127	0	48.8%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	998	0	2352	0	42.4%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Reported	0.3579	0	0.3758	None	36	0	93	0	38.7%	0	1	0.5	Yes
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC4	Q-CIS	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC4	Q-CIS	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC4	Q-CIS	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC4	Q-CIS	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC4	Q-CIS	▶ Race : White	Reported	N/A	3	N/A	3	31	0	75	0	41.3%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC4	Q-CIS	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC4	Q-CIS	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC4	Q-CIS	▶ Race : Total	Reported	N/A	3	N/A	3	36	0	93	0	38.7%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	31	0	75	0	41.3%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	36	0	93	0	38.7%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Reported	0.5238	0	0.5376	None	92	0	170	0	54.1%	0	1	0	Yes
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	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	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Reported	0.3011	0	0.3216	None	32	0	98	0	32.7%	0	1	0	Yes
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC9	Q-IMA	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC9	Q-IMA	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC9	Q-IMA	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC9	Q-IMA	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC9	Q-IMA	▶ Race : White	Reported	N/A	3	N/A	3	32	0	98	0	32.7%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC9	Q-IMA	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC9	Q-IMA	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC9	Q-IMA	▶ Race : Total	Reported	N/A	3	N/A	3	32	0	98	0	32.7%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	32	0	98	0	32.7%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	32	0	98	0	32.7%	0	N/A	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	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	None
PY5	Pioneers Memorial Healthcare District	DMPH	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	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Pioneers Memorial Healthcare District	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	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	None
PY5	Plumas District Hospital	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	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	None
PY5	Plumas District Hospital	DMPH	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	None
PY5	Plumas District Hospital	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	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	None
PY5	Plumas District Hospital	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	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	None
PY5	Plumas District Hospital	DMPH	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	None
PY5	Plumas District Hospital	DMPH	Q-CAD1	Q-HBD	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	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	None
PY5	Plumas District Hospital	DMPH	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	None
PY5	Plumas District Hospital	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	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	None
PY5	Plumas District Hospital	DMPH	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	None
PY5	Plumas District Hospital	DMPH	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	None
PY5	Plumas District Hospital	DMPH	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	None
PY5	Plumas District Hospital	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	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	None
PY5	Plumas District Hospital	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	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	None
PY5	Plumas District Hospital	DMPH	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	None
PY5	Plumas District Hospital	DMPH	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	None
PY5	Plumas District Hospital	DMPH	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	None
PY5	Plumas District Hospital	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.2775	0	0.3941	None	182	0	631	0	28.8%	0	N/A	N/A	No
PY5	Plumas District Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Plumas District Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Plumas District Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Plumas District Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Plumas District Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	160	0	533	0	30.0%	0	N/A	None	None
PY5	Plumas District Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Plumas District Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	52	0	None	1	N/A	None	None
PY5	Plumas District Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	182	0	631	0	28.8%	0	N/A	None	None
PY5	Plumas District Hospital	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	14	0	43	0	32.6%	0	N/A	None	None
PY5	Plumas District Hospital	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	149	0	511	0	29.2%	0	N/A	None	None
PY5	Plumas District Hospital	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	19	0	77	0	24.7%	0	N/A	None	None
PY5	Plumas District Hospital	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	182	0	631	0	28.8%	0	N/A	None	None
PY5	Plumas District Hospital	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.3968	0	0.4176	None	142	0	337	0	42.1%	0	1	0	Yes
PY5	Plumas District Hospital	DMPH	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	None
PY5	Plumas District Hospital	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	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	None
PY5	Plumas District Hospital	DMPH	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	None
PY5	Plumas District Hospital	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Plumas District Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Riverside University Health System	DPH	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Reported	0.0545	0	0.0848	None	120	0	2440	0	4.9%	0	1	N/A	Yes
PY5	Riverside University Health System	DPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adults)	Reported	0.1145	0	0.1183	None	310	0	1363	0	22.7%	0	1	0.5	YesS
PY5	Riverside University Health System	DPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adults)	Reported	0.1761	0	0.1846	None	398	0	1363	0	29.2%	0	1	0.5	YesS
PY5	Riverside University Health System	DPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adolescents) - informational only	Reported	None	2	0	None	12	0	91	0	13.2%	0	N/A	N/A	YesS
PY5	Riverside University Health System	DPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adolescents) - informational only	Reported	None	2	0	None	15	0	91	0	16.5%	0	N/A	N/A	YesS
PY5	Riverside University Health System	DPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adolescents) - informational only	Reported	0.2727	0	0	None	25	0	91	0	27.5%	0	N/A	N/A	YesS
PY5	Riverside University Health System	DPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adults)	Reported	0.4513	0	0.4731	None	767	0	1363	0	56.3%	0	1	0.5	YesS
PY5	Riverside University Health System	DPH	Q-BH2	Q-DRR-E	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	0.5	Yes
PY5	Riverside University Health System	DPH	Q-BH3	Q-FUA	▶ 7 Days	Reported	0.3087	0	0.2298	None	57	0	166	0	34.3%	0	1	N/A	YesS
PY5	Riverside University Health System	DPH	Q-BH3	Q-FUA	▶ 30 Days	Reported	0.4027	0	0.326	None	84	0	166	0	50.6%	0	1	N/A	YesS
PY5	Riverside University Health System	DPH	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	N/A	Yes
PY5	Riverside University Health System	DPH	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Reported	0.0256	0	0.0269	None	37	0	1393	0	2.7%	0	1	N/A	Yes
PY5	Riverside University Health System	DPH	Q-BH5	Q-FUI	▶ 30 Days	Reported	0.4776	None	0.4975	None	35	0	72	0	48.6%	0	0	0	YesS
PY5	Riverside University Health System	DPH	Q-BH5	Q-FUI	▶ 7 Days	Reported	0.2537	None	0.2775	None	16	0	72	0	22.2%	0	0	0	YesS
PY5	Riverside University Health System	DPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	0	0	Yes
PY5	Riverside University Health System	DPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Riverside University Health System	DPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.6101	0	0.6159	None	255	0	407	0	62.7%	0	1	0.5	Yes
PY5	Riverside University Health System	DPH	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	0.8024	0	0.8142	None	1318	0	1535	0	85.9%	0	1	0.5	Yes
PY5	Riverside University Health System	DPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.7896	0	0.8026	None	1777	0	2259	0	78.7%	0	0	0	Yes
PY5	Riverside University Health System	DPH	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	0.8989	0	0.8775	None	521	0	586	0	88.9%	0	1	N/A	Yes
PY5	Riverside University Health System	DPH	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Reported	0.6903	0	0.7051	None	5936	0	8393	0	70.7%	0	1	0	Yes
PY5	Riverside University Health System	DPH	Q-CAD1	Q-HBD	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Riverside University Health System	DPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.5945	0	0.5981	None	4713	0	6792	0	69.4%	0	1	0.5	Yes
PY5	Riverside University Health System	DPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Reported	0.4359	0	0.4391	None	3311	0	7326	0	45.2%	0	1	0.5	Yes
PY5	Riverside University Health System	DPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Reported	0.8245	0	0.8258	None	579	0	691	0	83.8%	0	1	0.5	Yes
PY5	Riverside University Health System	DPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Riverside University Health System	DPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Riverside University Health System	DPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Reported	0.9751	0	0.78	None	2135	0	2355	0	90.7%	0	1	N/A	Yes
PY5	Riverside University Health System	DPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Riverside University Health System	DPH	Q-EC1	Q-QPP47	Advance Care Plan	Reported	0.6081	0	0.6393	None	4171	0	5748	0	72.6%	0	1	0	Yes
PY5	Riverside University Health System	DPH	Q-IHE1	Q-IHE1	▶ Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention - Rate 2 -Native Hawaiian/Pacific Islander	Reported	0.4242	0	0.4738	None	43	0	46	0	93.5%	0	1	0.5	YesS
PY5	Riverside University Health System	DPH	Q-IHE1	Q-IHE1	▶ Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention - Rate 3 -Native Hawaiian/Pacific Islander	Reported	0.7623	0	0.7813	None	193	0	204	0	94.6%	0	1	0.5	YesS
PY5	Riverside University Health System	DPH	Q-IHE1	Q-IHE1	▶ Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention - Rate 1 (informational only) -Native Hawaiian/Pacific Islander	Reported	0.877	0	0	None	200	0	204	0	98.0%	0	N/A	0	YesI
PY5	Riverside University Health System	DPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	1	0.5	Yes
PY5	Riverside University Health System	DPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Riverside University Health System	DPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Reported	0.2125	0	0.22	None	96	0	439	0	21.9%	0	1	N/A	Yes
PY5	Riverside University Health System	DPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Reported	0.6879	0	0.6953	None	862	0	1231	0	70.0%	0	1	0.25	Yes
PY5	Riverside University Health System	DPH	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Reported	0.7211	0	0.7327	None	1380	0	1763	0	78.3%	0	1	1	Yes
PY5	Riverside University Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Riverside University Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	Reported	N/A	3	N/A	3	28	0	37	0	75.7%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	Reported	N/A	3	N/A	3	97	0	145	0	66.9%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Riverside University Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Race : White	Reported	N/A	3	N/A	3	749	0	956	0	78.4%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Riverside University Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	495	0	608	0	81.4%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	Reported	N/A	3	N/A	3	1380	0	1763	0	78.3%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	906	0	1120	0	80.9%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	277	0	397	0	69.8%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	197	0	246	0	80.1%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	1380	0	1763	0	78.3%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Reported	0.6135	0	0.7932	None	1418	0	1763	0	80.4%	0	1	0	Yes
PY5	Riverside University Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Riverside University Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Asian	Reported	N/A	3	N/A	3	33	0	37	0	89.2%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Black or African American	Reported	N/A	3	N/A	3	132	0	145	0	91.0%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Riverside University Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : White	Reported	N/A	3	N/A	3	803	0	956	0	84.0%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Riverside University Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	436	0	608	0	71.7%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Total	Reported	N/A	3	N/A	3	1418	0	1763	0	80.4%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	926	0	1120	0	82.7%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	340	0	397	0	85.6%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	152	0	246	0	61.8%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	1418	0	1763	0	80.4%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Riverside University Health System	DPH	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Reported	1	0	0.9434	None	296	0	302	0	98.0%	0	1	N/A	Yes
PY5	Riverside University Health System	DPH	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Reported	0.5111	0	0.5304	None	71	0	105	0	67.6%	0	1	0.5	Yes
PY5	Riverside University Health System	DPH	Q-OA3	Q-QPP415	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older	Reported	0.5773	0	0.7983	None	415	0	498	0	83.3%	0	1	0	Yes
PY5	Riverside University Health System	DPH	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Reported	0.809	0	0.8109	None	972	0	1134	0	85.7%	0	1	0.5	Yes
PY5	Riverside University Health System	DPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Riverside University Health System	DPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Riverside University Health System	DPH	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	None
PY5	Riverside University Health System	DPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Reported	0.4832	0	0.5067	None	15725	0	26312	0	59.8%	0	1	0.5	Yes
PY5	Riverside University Health System	DPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.957	0	0.8988	None	37326	0	38828	0	96.1%	0	1	1	Yes
PY5	Riverside University Health System	DPH	Q-PC14	Q-CMS138	▶ Rate 1 (informational only)	Reported	0.8939	0	0	None	59013	0	59835	0	98.6%	0	N/A	N/A	YesI
PY5	Riverside University Health System	DPH	Q-PC14	Q-CMS138	▶ Rate 2	Reported	0.6231	0	0.6528	None	8402	0	9239	0	90.9%	0	1	0.5	YesS
PY5	Riverside University Health System	DPH	Q-PC14	Q-CMS138	▶ Rate 3	Reported	0.8541	0	0.8639	None	57171	0	59552	0	96.0%	0	1	0.5	YesS
PY5	Riverside University Health System	DPH	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	0.5	Yes
PY5	Riverside University Health System	DPH	Q-PC15	Q-WCC	▶ Counseling for Nutrition	Reported	0.7751	0	0.7801	None	4803	0	5990	0	80.2%	0	1	0.5	YesS
PY5	Riverside University Health System	DPH	Q-PC15	Q-WCC	▶ Counseling for Physical Activity	Reported	0.7767	0	0.7784	None	4803	0	5990	0	80.2%	0	1	0.5	YesS
PY5	Riverside University Health System	DPH	Q-PC15	Q-WCC	▶ BMI	Reported	0.8677	0	0.8681	None	5212	0	5990	0	87.0%	0	1	0.5	YesS
PY5	Riverside University Health System	DPH	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	0.5	Yes
PY5	Riverside University Health System	DPH	Q-PC16	Q-W30	▶ First 15 Months	Reported	0.2376	0	0.4499	None	58	0	196	0	29.6%	0	0	0	YesS
PY5	Riverside University Health System	DPH	Q-PC16	Q-W30	▶ 15 Months-30 Months	Reported	0.4934	0	0.6643	None	320	0	655	0	48.9%	0	0	0	YesS
PY5	Riverside University Health System	DPH	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	0	0	Yes
PY5	Riverside University Health System	DPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Riverside University Health System	DPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.3384	0	0.3941	None	4762	0	18467	0	25.8%	0	0	0	Yes
PY5	Riverside University Health System	DPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	14	0	33	0	42.4%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	167	0	477	0	35.0%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	490	0	1626	0	30.1%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	19	0	65	0	29.2%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	3322	0	10161	0	32.7%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	13	0	46	0	28.3%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	737	0	6059	0	12.2%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	4762	0	18467	0	25.8%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	3598	0	10408	0	34.6%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	1023	0	3831	0	26.7%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	141	0	4228	0	3.3%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	4762	0	18467	0	25.8%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Reported	0.1761	0	0.3187	None	97	0	300	0	32.3%	0	1	0	Yes
PY5	Riverside University Health System	DPH	Q-PC4	Q-CIS	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC4	Q-CIS	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC4	Q-CIS	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC4	Q-CIS	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC4	Q-CIS	▶ Race : White	Reported	N/A	3	N/A	3	54	0	165	0	32.7%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC4	Q-CIS	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC4	Q-CIS	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	34	0	104	0	32.7%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC4	Q-CIS	▶ Race : Total	Reported	N/A	3	N/A	3	97	0	300	0	32.3%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	75	0	195	0	38.5%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	17	0	63	0	27.0%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	42	0	None	1	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	97	0	300	0	32.3%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Reported	0.6986	0	0.6615	None	2215	0	3266	0	67.8%	0	1	1	Yes
PY5	Riverside University Health System	DPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.4586	0	0.4732	None	10726	0	21813	0	49.2%	0	1	0.5	Yes
PY5	Riverside University Health System	DPH	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Reported	0.2894	0	0.2971	None	628	0	1611	0	39.0%	0	1	1	Yes
PY5	Riverside University Health System	DPH	Q-PC8	Q-CMS349	HIV Screening Measure	Reported	0.7286	0	0.6263	None	26374	0	39970	0	66.0%	0	1	N/A	Yes
PY5	Riverside University Health System	DPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Reported	0.2052	0	0.309	None	170	0	709	0	24.0%	0	0	0	Yes
PY5	Riverside University Health System	DPH	Q-PC9	Q-IMA	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC9	Q-IMA	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC9	Q-IMA	▶ Race : Black or African American	Reported	N/A	3	N/A	3	15	0	75	0	20.0%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC9	Q-IMA	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC9	Q-IMA	▶ Race : White	Reported	N/A	3	N/A	3	113	0	426	0	26.5%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC9	Q-IMA	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC9	Q-IMA	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	37	0	182	0	20.3%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC9	Q-IMA	▶ Race : Total	Reported	N/A	3	N/A	3	170	0	709	0	24.0%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	139	0	433	0	32.1%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	24	0	162	0	14.8%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	114	0	None	1	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	170	0	709	0	24.0%	0	N/A	None	None
PY5	Riverside University Health System	DPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Reported	1	0	1	None	63	0	63	0	100.0%	0	1	N/A	Yes
PY5	Riverside University Health System	DPH	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Reported	0.9844	0	0.92	None	598	0	615	0	97.2%	0	1	N/A	Yes
PY5	Riverside University Health System	DPH	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	None
PY5	Riverside University Health System	DPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Reported	0.5548	0	0.58	None	25	0	50.942	0	0.4908	0	1	N/A	Yes
PY5	Riverside University Health System	DPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Reported	0.1834	0	0.795	None	3	0	14.494	0	0.207	0	1	N/A	Yes
PY5	Salinas Valley Memorial Healthcare System	DMPH	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	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	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	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	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	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	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	0.8939	0	0.8965	None	521	0	560	0	93.0%	0	1	0.5	Yes
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.8646	0	0.8701	None	1815	0	2055	0	88.3%	0	1	0.5	Yes
PY5	Salinas Valley Memorial Healthcare System	DMPH	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	0.7814	0	0.791	None	262	0	329	0	79.6%	0	1	0.25	Yes
PY5	Salinas Valley Memorial Healthcare System	DMPH	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	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-CAD1	Q-HBD	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Reported	0.3481	0	0.44	None	180	0	360	0	50.0%	0	1	0	Yes
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Reported	0.7135	0	0.7259	None	176	0	197	0	89.3%	0	1	1	Yes
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	Reported	N/A	3	N/A	3	14	0	None	4	None	4	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : White	Reported	N/A	3	N/A	3	60	0	69	0	87.0%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	91	0	101	0	90.1%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	Reported	N/A	3	N/A	3	176	0	197	0	89.3%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	153	0	172	0	89.0%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	23	0	None	4	None	4	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	176	0	197	0	89.3%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Reported	0.7344	0	0.7932	None	154	0	201	0	76.6%	0	N/A	N/A	No
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Asian	Reported	N/A	3	N/A	3	13	0	None	4	None	4	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : White	Reported	N/A	3	N/A	3	54	0	71	0	76.1%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	79	0	103	0	76.7%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Total	Reported	N/A	3	N/A	3	154	0	201	0	76.6%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	137	0	176	0	77.8%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	17	0	None	4	None	4	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	154	0	201	0	76.6%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Reported	0.922	0	0.9241	None	690	0	745	0	92.6%	0	1	0.25	Yes
PY5	Salinas Valley Memorial Healthcare System	DMPH	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	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	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	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	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	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.4755	0	0.4917	None	901	0	1347	0	66.9%	0	1	0.5	Yes
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Reported	0.284	0	0.4955	None	8047	0	21844	0	36.8%	0	N/A	N/A	No
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Reported	0.4517	0	0.4784	None	8941	0	21052	0	42.5%	0	N/A	N/A	No
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.1288	0	0.5004	None	7230	0	21006	0	34.4%	0	N/A	N/A	No
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC14	Q-CMS138	▶ Rate 2	Reported	0.2031	0	0.2748	None	493	0	1879	0	26.2%	0	N/A	N/A	NoS
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC14	Q-CMS138	▶ Rate 1 (informational only)	Reported	0.9034	0	0	None	19393	0	20924	0	92.7%	0	N/A	N/A	NoI
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC14	Q-CMS138	▶ Rate 3	Reported	0.8213	0	0.8344	None	18007	0	20924	0	86.1%	0	N/A	N/A	NoS
PY5	Salinas Valley Memorial Healthcare System	DMPH	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	N/A	None	No
PY5	Salinas Valley Memorial Healthcare System	DMPH	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	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC16	Q-W30	▶ First 15 Months	Reported	0.4052	0	0.4499	None	51	0	108	0	47.2%	0	1	0	YesS
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC16	Q-W30	▶ 15 Months-30 Months	Reported	0.6691	0	0.685	None	119	0	160	0	74.4%	0	1	1	YesS
PY5	Salinas Valley Memorial Healthcare System	DMPH	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	0	Yes
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Reported	0.5685	0	0.5796	None	4611	0	7234	0	63.7%	0	1	0.5	Yes
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.4279	0	0.4471	None	1968	0	4063	0	48.4%	0	1	1	Yes
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	137	0	334	0	41.0%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	11	0	59	0	18.6%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	588	0	1245	0	47.2%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	148	0	259	0	57.1%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	1078	0	2141	0	50.4%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	1968	0	4063	0	48.4%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	1558	0	2890	0	53.9%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	376	0	1063	0	35.4%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	34	0	110	0	30.9%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	1968	0	4063	0	48.4%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Reported	0.3212	0	0.3427	None	39	0	126	0	31.0%	0	N/A	N/A	No
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC4	Q-CIS	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC4	Q-CIS	▶ Race : Asian	Reported	N/A	3	N/A	3	11	0	38	0	29.0%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC4	Q-CIS	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC4	Q-CIS	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC4	Q-CIS	▶ Race : White	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC4	Q-CIS	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC4	Q-CIS	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	11	0	44	0	25.0%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC4	Q-CIS	▶ Race : Total	Reported	N/A	3	N/A	3	39	0	126	0	31.0%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	34	0	105	0	32.4%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	39	0	126	0	31.0%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Reported	0.6291	0	0.6323	None	708	0	1385	0	51.1%	0	N/A	N/A	No
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.3241	0	0.3522	None	2878	0	7233	0	39.8%	0	1	0.5	Yes
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Reported	0.21	0	0.2257	None	159	0	289	0	55.0%	0	1	1	Yes
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Reported	0.3457	0	0.3617	None	82	0	197	0	41.6%	0	1	1	Yes
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC9	Q-IMA	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC9	Q-IMA	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC9	Q-IMA	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC9	Q-IMA	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC9	Q-IMA	▶ Race : White	Reported	N/A	3	N/A	3	17	0	56	0	30.4%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC9	Q-IMA	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC9	Q-IMA	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	62	0	115	0	53.9%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC9	Q-IMA	▶ Race : Total	Reported	N/A	3	N/A	3	82	0	197	0	41.6%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	75	0	133	0	56.4%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	60	0	None	1	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	82	0	197	0	41.6%	0	N/A	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	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	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	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	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Salinas Valley Memorial Healthcare System	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	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	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	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	None
PY5	San Bernardino Mountains Community Hospital	DMPH	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	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.5825	0	0.591	None	79	0	138	0	57.3%	0	N/A	N/A	No
PY5	San Bernardino Mountains Community Hospital	DMPH	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	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	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	None
PY5	San Bernardino Mountains Community Hospital	DMPH	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	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-CAD1	Q-HBD	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	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	None
PY5	San Bernardino Mountains Community Hospital	DMPH	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	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	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	None
PY5	San Bernardino Mountains Community Hospital	DMPH	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	None
PY5	San Bernardino Mountains Community Hospital	DMPH	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	None
PY5	San Bernardino Mountains Community Hospital	DMPH	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	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.5304	0	0.5411	None	65	0	119	0	54.6%	0	1	0	Yes
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Reported	0.6575	0	0.6847	None	884	0	1289	0	68.6%	0	N/A	N/A	No
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.5188	0	0.5568	None	1109	0	1330	0	83.4%	0	1	1	Yes
PY5	San Bernardino Mountains Community Hospital	DMPH	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	None
PY5	San Bernardino Mountains Community Hospital	DMPH	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	None
PY5	San Bernardino Mountains Community Hospital	DMPH	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	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.373	0	0.3962	None	281	0	571	0	49.2%	0	1	0.5	Yes
PY5	San Bernardino Mountains Community Hospital	DMPH	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	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	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	None
PY5	San Bernardino Mountains Community Hospital	DMPH	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	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Bernardino Mountains Community Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Francisco General Hospital	DPH	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Reported	0.0875	0	0.0872	None	35	0	509	0	6.9%	0	1	0.5	Yes
PY5	San Francisco General Hospital	DPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adults)	Reported	0.0324	0	0.0444	None	50	0	877	0	5.7%	0	1	0	YesS
PY5	San Francisco General Hospital	DPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adults)	Reported	0.0576	0	0.0962	None	107	0	877	0	12.2%	0	1	0	YesS
PY5	San Francisco General Hospital	DPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adults)	Reported	0.3022	0	0.3605	None	341	0	877	0	38.9%	0	1	0	YesS
PY5	San Francisco General Hospital	DPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adolescents) - informational only	Reported	0	0	0	None	0	0	55	0	0.0%	0	N/A	N/A	YesS
PY5	San Francisco General Hospital	DPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adolescents) - informational only	Reported	None	2	0	None	None	1	55	0	None	1	N/A	N/A	YesS
PY5	San Francisco General Hospital	DPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adolescents) - informational only	Reported	0.2182	0	0	None	11	0	55	0	20.0%	0	N/A	N/A	YesS
PY5	San Francisco General Hospital	DPH	Q-BH2	Q-DRR-E	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	0	Yes
PY5	San Francisco General Hospital	DPH	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	None
PY5	San Francisco General Hospital	DPH	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	None
PY5	San Francisco General Hospital	DPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Francisco General Hospital	DPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Francisco General Hospital	DPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.568	0	0.578	None	3149	0	5211	0	60.4%	0	1	0.5	Yes
PY5	San Francisco General Hospital	DPH	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	0.8817	0	0.8855	None	859	0	959	0	89.6%	0	1	0.5	Yes
PY5	San Francisco General Hospital	DPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.8627	0	0.8684	None	1703	0	1942	0	87.7%	0	1	0.5	Yes
PY5	San Francisco General Hospital	DPH	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	0.8992	0	0.8775	None	749	0	816	0	91.8%	0	1	N/A	Yes
PY5	San Francisco General Hospital	DPH	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Reported	0.7627	0	0.7702	None	4027	0	4996	0	80.6%	0	1	0.5	Yes
PY5	San Francisco General Hospital	DPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	0.3112	0	0.3406	None	276	0	815	0	33.9%	0	1	N/A	YesS
PY5	San Francisco General Hospital	DPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	0.3643	0	0.3619	None	441	0	1272	0	34.7%	0	1	0.5	YesS
PY5	San Francisco General Hospital	DPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.2931	0	0.3406	None	1180	0	4050	0	29.1%	0	1	N/A	YesS
PY5	San Francisco General Hospital	DPH	Q-CAD1	Q-HBD	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	N/A	Yes
PY5	San Francisco General Hospital	DPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	197	0	1149	0	17.2%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	276	0	815	0	33.9%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	32	0	87	0	36.8%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	152	0	492	0	30.9%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	74	0	215	0	34.4%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	445	0	1276	0	34.9%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	1180	0	4050	0	29.1%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	441	0	1272	0	34.7%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	734	0	2757	0	26.6%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	1180	0	4050	0	29.1%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.5643	0	0.5709	None	2495	0	4050	0	61.6%	0	1	0.5	Yes
PY5	San Francisco General Hospital	DPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Reported	0.6451	0	0.4676	None	2572	0	4033	0	63.8%	0	1	N/A	Yes
PY5	San Francisco General Hospital	DPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Reported	0.8446	0	0.837	None	1846	0	2170	0	85.1%	0	1	N/A	Yes
PY5	San Francisco General Hospital	DPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Reported	0.4641	0	0.5989	None	213	0	437	0	48.7%	0	0	0	Yes
PY5	San Francisco General Hospital	DPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Francisco General Hospital	DPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Reported	0.9878	0	0.78	None	2794	0	2836	0	98.5%	0	1	N/A	Yes
PY5	San Francisco General Hospital	DPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Francisco General Hospital	DPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Francisco General Hospital	DPH	Q-IHE1	Q-IHE1	▶ Breast Cancer Screening (BCS) - -Black/African American	Reported	0.435	0	0.4807	None	459	0	932	0	49.3%	0	1	0	YesS
PY5	San Francisco General Hospital	DPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	1	0	Yes
PY5	San Francisco General Hospital	DPH	Q-IHE2	Q-IHE2	▶ Controlling High Blood Pressure (CBP) - -Black/African American	Reported	0.5093	0	0.5252	None	669	0	1257	0	53.2%	0	1	0	YesS
PY5	San Francisco General Hospital	DPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	1	0	Yes
PY5	San Francisco General Hospital	DPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Reported	0.2	0	0.22	None	57	0	347	0	16.4%	0	1	N/A	Yes
PY5	San Francisco General Hospital	DPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Reported	0.8288	0	0.762	None	694	0	852	0	81.5%	0	1	N/A	Yes
PY5	San Francisco General Hospital	DPH	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Reported	0.8714	0	0.837	None	315	0	370	0	85.1%	0	1	1	Yes
PY5	San Francisco General Hospital	DPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	Reported	N/A	3	N/A	3	26	0	None	4	None	4	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	Reported	N/A	3	N/A	3	51	0	69	0	73.9%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-MPH4	Q-PPC-PST	▶ Race : White	Reported	N/A	3	N/A	3	24	0	31	0	77.4%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	11	0	None	4	None	4	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	197	0	222	0	88.7%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	Reported	N/A	3	N/A	3	315	0	370	0	85.1%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	176	0	195	0	90.3%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	138	0	172	0	80.2%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	315	0	370	0	85.1%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Reported	0.8457	0	0.8533	None	321	0	370	0	86.8%	0	1	1	Yes
PY5	San Francisco General Hospital	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Asian	Reported	N/A	3	N/A	3	24	0	None	4	None	4	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Black or African American	Reported	N/A	3	N/A	3	58	0	69	0	84.1%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : White	Reported	N/A	3	N/A	3	24	0	31	0	77.4%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	197	0	222	0	88.7%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Total	Reported	N/A	3	N/A	3	321	0	370	0	86.8%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	175	0	195	0	89.7%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	144	0	172	0	83.7%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	321	0	370	0	86.8%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Reported	0.5433	0	0.4576	None	214	0	397	0	53.9%	0	1	N/A	Yes
PY5	San Francisco General Hospital	DPH	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Reported	0.9831	0	0.9434	None	1103	0	1120	0	98.5%	0	1	N/A	Yes
PY5	San Francisco General Hospital	DPH	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Reported	1	0	0.7039	None	42	0	47	0	89.4%	0	1	N/A	Yes
PY5	San Francisco General Hospital	DPH	Q-OA3	Q-QPP415	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older	Reported	0.8932	0	0.8959	None	460	0	513	0	89.7%	0	1	0	Yes
PY5	San Francisco General Hospital	DPH	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Reported	0.8439	0	0.8282	None	288	0	347	0	83.0%	0	1	N/A	Yes
PY5	San Francisco General Hospital	DPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.5055	0	0.5187	None	3053	0	5444	0	56.1%	0	1	0.5	Yes
PY5	San Francisco General Hospital	DPH	Q-PC10	Q-LSC	Lead Screening in Children	Reported	0.8075	0	0.8107	None	439	0	516	0	85.1%	0	1	0.5	Yes
PY5	San Francisco General Hospital	DPH	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	None
PY5	San Francisco General Hospital	DPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Reported	0.7053	0	0.7066	None	20698	0	27589	0	75.0%	0	1	0.5	Yes
PY5	San Francisco General Hospital	DPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.6114	0	0.6401	None	12488	0	20803	0	60.0%	0	0	0	Yes
PY5	San Francisco General Hospital	DPH	Q-PC14	Q-CMS138	▶ Rate 1 (informational only)	Reported	0.9756	0	0	None	33412	0	34227	0	97.6%	0	N/A	N/A	YesI
PY5	San Francisco General Hospital	DPH	Q-PC14	Q-CMS138	▶ Rate 2	Reported	0.7618	0	0.7776	None	5843	0	7410	0	78.9%	0	1	0.25	YesS
PY5	San Francisco General Hospital	DPH	Q-PC14	Q-CMS138	▶ Rate 3	Reported	0.923	0	0.926	None	31845	0	34227	0	93.0%	0	1	0.5	YesS
PY5	San Francisco General Hospital	DPH	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	0.25	Yes
PY5	San Francisco General Hospital	DPH	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	None
PY5	San Francisco General Hospital	DPH	Q-PC16	Q-W30	▶ First 15 Months	Reported	0.6995	0	0.6833	None	200	0	271	0	73.8%	0	1	1	YesS
PY5	San Francisco General Hospital	DPH	Q-PC16	Q-W30	▶ 15 Months-30 Months	Reported	0.877	0	0.8282	None	384	0	558	0	68.8%	0	0	0	YesS
PY5	San Francisco General Hospital	DPH	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	0.5	0	Yes
PY5	San Francisco General Hospital	DPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Reported	0.4762	0	0.518	None	6238	0	13089	0	47.7%	0	0	0	Yes
PY5	San Francisco General Hospital	DPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.4728	0	0.4875	None	4703	0	10095	0	46.6%	0	0	0	Yes
PY5	San Francisco General Hospital	DPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	18	0	41	0	43.9%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	331	0	770	0	43.0%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	419	0	1052	0	39.8%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	51	0	130	0	39.2%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	138	0	344	0	40.1%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	263	0	541	0	48.6%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	3483	0	7217	0	48.3%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	4703	0	10095	0	46.6%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	3473	0	6992	0	49.7%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	1188	0	2919	0	40.7%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	42	0	184	0	22.8%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	4703	0	10095	0	46.6%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Reported	0.4567	0	0.4647	None	290	0	545	0	53.2%	0	1	1	Yes
PY5	San Francisco General Hospital	DPH	Q-PC4	Q-CIS	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC4	Q-CIS	▶ Race : Asian	Reported	N/A	3	N/A	3	23	0	34	0	67.7%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC4	Q-CIS	▶ Race : Black or African American	Reported	N/A	3	N/A	3	11	0	57	0	19.3%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC4	Q-CIS	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC4	Q-CIS	▶ Race : White	Reported	N/A	3	N/A	3	11	0	None	4	None	4	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC4	Q-CIS	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC4	Q-CIS	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	235	0	406	0	57.9%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC4	Q-CIS	▶ Race : Total	Reported	N/A	3	N/A	3	290	0	545	0	53.2%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	225	0	379	0	59.4%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	63	0	157	0	40.1%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	290	0	545	0	53.2%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Reported	0.7419	0	0.6615	None	740	0	993	0	74.5%	0	1	1	Yes
PY5	San Francisco General Hospital	DPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.6015	0	0.6018	None	9459	0	15682	0	60.3%	0	1	0.5	Yes
PY5	San Francisco General Hospital	DPH	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Reported	0.5666	0	0.3665	None	1089	0	1576	0	69.1%	0	1	1	Yes
PY5	San Francisco General Hospital	DPH	Q-PC8	Q-CMS349	HIV Screening Measure	Reported	0.8064	0	0.6263	None	14469	0	17263	0	83.8%	0	1	N/A	Yes
PY5	San Francisco General Hospital	DPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Reported	0.5854	0	0.5061	None	319	0	536	0	59.5%	0	1	1	Yes
PY5	San Francisco General Hospital	DPH	Q-PC9	Q-IMA	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC9	Q-IMA	▶ Race : Asian	Reported	N/A	3	N/A	3	21	0	31	0	67.7%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC9	Q-IMA	▶ Race : Black or African American	Reported	N/A	3	N/A	3	23	0	68	0	33.8%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC9	Q-IMA	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC9	Q-IMA	▶ Race : White	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC9	Q-IMA	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	16	0	None	4	None	4	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC9	Q-IMA	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	251	0	394	0	63.7%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC9	Q-IMA	▶ Race : Total	Reported	N/A	3	N/A	3	319	0	536	0	59.5%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	254	0	381	0	66.7%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	62	0	149	0	41.6%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	319	0	536	0	59.5%	0	N/A	None	None
PY5	San Francisco General Hospital	DPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Reported	1	0	1	None	162	0	162	0	100.0%	0	1	N/A	Yes
PY5	San Francisco General Hospital	DPH	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	None
PY5	San Francisco General Hospital	DPH	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Reported	0.8652	0	0.8707	None	918	0	1017	0	90.3%	0	1	0	Yes
PY5	San Francisco General Hospital	DPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Francisco General Hospital	DPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	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	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	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	None
PY5	San Gorgonio Memorial Hospital	DMPH	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	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	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	0.8235	0	0.8331	None	46	0	47	0	97.9%	0	1	0.5	Yes
PY5	San Gorgonio Memorial Hospital	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	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	None
PY5	San Gorgonio Memorial Hospital	DMPH	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	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-CAD1	Q-HBD	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	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	None
PY5	San Gorgonio Memorial Hospital	DMPH	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	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	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	None
PY5	San Gorgonio Memorial Hospital	DMPH	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	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-OA3	Q-QPP415	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older	Reported	0.9425	0	0.9199	None	58	0	59	0	98.3%	0	1	N/A	Yes
PY5	San Gorgonio Memorial Hospital	DMPH	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	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	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	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	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	None
PY5	San Gorgonio Memorial Hospital	DMPH	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	None
PY5	San Gorgonio Memorial Hospital	DMPH	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	None
PY5	San Gorgonio Memorial Hospital	DMPH	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	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	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	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Reported	1	0	1	None	0	0	0	0	0.0%	0	N/A	N/A	No
PY5	San Gorgonio Memorial Hospital	DMPH	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Reported	1	0	0.92	None	217	0	219	0	99.1%	0	N/A	N/A	No
PY5	San Gorgonio Memorial Hospital	DMPH	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	None
PY5	San Gorgonio Memorial Hospital	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Reported	0.8512	0	0	None	4	0	7.538	0	0.5306	0	0	N/A	Yes
PY5	San Gorgonio Memorial Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Joaquin General Hospital	DPH	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Reported	0.0507	0	0.0848	None	11	0	533	0	2.1%	0	1	N/A	Yes
PY5	San Joaquin General Hospital	DPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adults)	Reported	0.0966	0	0.3605	None	53	0	402	0	13.2%	0	0	0	YesS
PY5	San Joaquin General Hospital	DPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adolescents) - informational only	Reported	None	2	N/A	None	0	0	None	1	None	1	N/A	N/A	YesS
PY5	San Joaquin General Hospital	DPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adolescents) - informational only	Reported	None	2	N/A	None	0	0	None	1	None	1	N/A	N/A	YesS
PY5	San Joaquin General Hospital	DPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adolescents) - informational only	Reported	None	2	N/A	None	0	0	None	1	None	1	N/A	N/A	YesS
PY5	San Joaquin General Hospital	DPH	Q-BH2	Q-DRR-E	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	0	0	Yes
PY5	San Joaquin General Hospital	DPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adults)	Reported	None	2	0.0408	None	None	1	402	0	None	1	0	0	YesS
PY5	San Joaquin General Hospital	DPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adults)	Reported	None	2	0.0962	None	19	0	402	0	4.7%	0	0	0	YesS
PY5	San Joaquin General Hospital	DPH	Q-BH3	Q-FUA	▶ 7 Days	Reported	0.1194	0	0.1304	None	None	1	83	0	None	1	0	0	YesS
PY5	San Joaquin General Hospital	DPH	Q-BH3	Q-FUA	▶ 30 Days	Reported	0.2836	0	0.2878	None	16	0	83	0	19.3%	0	0	0	YesS
PY5	San Joaquin General Hospital	DPH	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	0	Yes
PY5	San Joaquin General Hospital	DPH	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	None
PY5	San Joaquin General Hospital	DPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Joaquin General Hospital	DPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Joaquin General Hospital	DPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.3855	0	0.5061	None	1462	0	2533	0	57.7%	0	1	0.5	Yes
PY5	San Joaquin General Hospital	DPH	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	None
PY5	San Joaquin General Hospital	DPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.7988	0	0.8109	None	844	0	1035	0	81.6%	0	1	0	Yes
PY5	San Joaquin General Hospital	DPH	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	None
PY5	San Joaquin General Hospital	DPH	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Reported	0.7875	0	0.7926	None	1797	0	2255	0	79.7%	0	1	0.25	Yes
PY5	San Joaquin General Hospital	DPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	0.4954	0	0.4799	None	119	0	259	0	46.0%	0	1	0	YesS
PY5	San Joaquin General Hospital	DPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	0.4986	0	0.4828	None	369	0	848	0	43.5%	0	1	0	YesS
PY5	San Joaquin General Hospital	DPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.4383	0	0.4285	None	887	0	2265	0	39.2%	0	1	0.5	YesS
PY5	San Joaquin General Hospital	DPH	Q-CAD1	Q-HBD	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	0	Yes
PY5	San Joaquin General Hospital	DPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	124	0	498	0	24.9%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	119	0	259	0	46.0%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	197	0	439	0	44.9%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	428	0	1021	0	41.9%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	887	0	2265	0	39.2%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	369	0	848	0	43.5%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	462	0	1277	0	36.2%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	56	0	140	0	40.0%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	887	0	2265	0	39.2%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.3382	0	0.4501	None	1039	0	2265	0	45.9%	0	1	0	Yes
PY5	San Joaquin General Hospital	DPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Joaquin General Hospital	DPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Reported	0.4783	0	0.773	None	67	0	118	0	56.8%	0	0	0	Yes
PY5	San Joaquin General Hospital	DPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Reported	0.564	0	0.5989	None	111	0	171	0	64.9%	0	1	0.5	Yes
PY5	San Joaquin General Hospital	DPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Joaquin General Hospital	DPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Joaquin General Hospital	DPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Reported	0.1404	0	0	None	36	0	35.8662	0	1.0037	0	0	N/A	Yes
PY5	San Joaquin General Hospital	DPH	Q-EC1	Q-QPP47	Advance Care Plan	Reported	0.2185	0	0.4799	None	304	0	2617	0	11.6%	0	0	0	Yes
PY5	San Joaquin General Hospital	DPH	Q-IHE1	Q-IHE1	▶ Asthma Medication Ratio (AMR) - -White	Reported	0.5122	0	0.5989	None	26	0	36	0	72.2%	0	1	0.5	YesS
PY5	San Joaquin General Hospital	DPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	1	0.5	Yes
PY5	San Joaquin General Hospital	DPH	Q-IHE2	Q-IHE2	▶ Prenatal and Postpartum Care: Postpartum Care (PPC-PST) - -Black/African American	Reported	0.5	0	0.7111	None	35	0	49	0	71.4%	0	1	0	YesS
PY5	San Joaquin General Hospital	DPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	1	0	Yes
PY5	San Joaquin General Hospital	DPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Reported	0.1975	0	0.22	None	77	0	482	0	16.0%	0	1	N/A	Yes
PY5	San Joaquin General Hospital	DPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Reported	0.7005	0	0.7067	None	1056	0	1404	0	75.2%	0	1	0.5	Yes
PY5	San Joaquin General Hospital	DPH	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Reported	0.6084	0	0.7111	None	266	0	341	0	78.0%	0	1	1	Yes
PY5	San Joaquin General Hospital	DPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	Reported	N/A	3	N/A	3	33	0	38	0	86.8%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	Reported	N/A	3	N/A	3	35	0	49	0	71.4%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-MPH4	Q-PPC-PST	▶ Race : White	Reported	N/A	3	N/A	3	38	0	46	0	82.6%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	156	0	201	0	77.6%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	Reported	N/A	3	N/A	3	266	0	341	0	78.0%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	148	0	189	0	78.3%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	109	0	141	0	77.3%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	266	0	341	0	78.0%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Reported	0.7203	0	0.7932	None	290	0	341	0	85.0%	0	1	0	Yes
PY5	San Joaquin General Hospital	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Asian	Reported	N/A	3	N/A	3	37	0	38	0	97.4%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Black or African American	Reported	N/A	3	N/A	3	44	0	49	0	89.8%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : White	Reported	N/A	3	N/A	3	34	0	46	0	73.9%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	171	0	201	0	85.1%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Total	Reported	N/A	3	N/A	3	290	0	341	0	85.0%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	161	0	189	0	85.2%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	122	0	141	0	86.5%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	290	0	341	0	85.0%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Joaquin General Hospital	DPH	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Reported	0.9559	0	0.9434	None	2227	0	2252	0	98.9%	0	1	N/A	Yes
PY5	San Joaquin General Hospital	DPH	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	None
PY5	San Joaquin General Hospital	DPH	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	None
PY5	San Joaquin General Hospital	DPH	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Reported	0.1912	0	0.7133	None	593	0	689	0	86.1%	0	1	0.5	Yes
PY5	San Joaquin General Hospital	DPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.421	0	0.4807	None	1068	0	2462	0	43.4%	0	0	0	Yes
PY5	San Joaquin General Hospital	DPH	Q-PC10	Q-LSC	Lead Screening in Children	Reported	0.5773	0	0.6131	None	359	0	515	0	69.7%	0	1	0	Yes
PY5	San Joaquin General Hospital	DPH	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Reported	0.2128	0	0.4955	None	4016	0	17216	0	23.3%	0	0	0	Yes
PY5	San Joaquin General Hospital	DPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Reported	0.4738	0	0.4982	None	4927	0	21089	0	23.4%	0	0	0	Yes
PY5	San Joaquin General Hospital	DPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.3785	0	0.5004	None	9537	0	19031	0	50.1%	0	1	0	Yes
PY5	San Joaquin General Hospital	DPH	Q-PC14	Q-CMS138	▶ Rate 1 (informational only)	Reported	0.9221	0	0	None	15673	0	16171	0	96.9%	0	N/A	N/A	YesI
PY5	San Joaquin General Hospital	DPH	Q-PC14	Q-CMS138	▶ Rate 2	Reported	0.4503	0	0.4973	None	1144	0	2260	0	50.6%	0	1	0	YesS
PY5	San Joaquin General Hospital	DPH	Q-PC14	Q-CMS138	▶ Rate 3	Reported	0.835	0	0.8468	None	14557	0	16171	0	90.0%	0	1	0.5	YesS
PY5	San Joaquin General Hospital	DPH	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	0	Yes
PY5	San Joaquin General Hospital	DPH	Q-PC15	Q-WCC	▶ Counseling for Nutrition	Reported	0.7413	0	0.7497	None	4193	0	5477	0	76.6%	0	1	0.5	YesS
PY5	San Joaquin General Hospital	DPH	Q-PC15	Q-WCC	▶ Counseling for Physical Activity	Reported	0.746	0	0.7507	None	4234	0	5477	0	77.3%	0	1	0.5	YesS
PY5	San Joaquin General Hospital	DPH	Q-PC15	Q-WCC	▶ BMI	Reported	0.9181	0	0.8718	None	5171	0	5477	0	94.4%	0	1	N/A	YesS
PY5	San Joaquin General Hospital	DPH	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	N/A	Yes
PY5	San Joaquin General Hospital	DPH	Q-PC16	Q-W30	▶ 15 Months-30 Months	Reported	0.4614	0	0.6643	None	314	0	533	0	58.9%	0	0	0	YesS
PY5	San Joaquin General Hospital	DPH	Q-PC16	Q-W30	▶ First 15 Months	Reported	0.4931	0	0.5121	None	30	0	40	0	75.0%	0	1	1	YesS
PY5	San Joaquin General Hospital	DPH	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	0.5	0	Yes
PY5	San Joaquin General Hospital	DPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Reported	0.2874	0	0.518	None	4912	0	12441	0	39.5%	0	0	0	Yes
PY5	San Joaquin General Hospital	DPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.3859	0	0.4093	None	5082	0	12308	0	41.3%	0	1	0	Yes
PY5	San Joaquin General Hospital	DPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	30	0	46	0	65.2%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	467	0	888	0	52.6%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	683	0	1414	0	48.3%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	12	0	31	0	38.7%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	599	0	1304	0	45.9%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	96	0	194	0	49.5%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	3195	0	8431	0	37.9%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	5082	0	12308	0	41.3%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	2247	0	4111	0	54.7%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	2183	0	4545	0	48.0%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	652	0	3652	0	17.9%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	5082	0	12308	0	41.3%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Reported	0.2274	0	0.3187	None	193	0	515	0	37.5%	0	1	0	Yes
PY5	San Joaquin General Hospital	DPH	Q-PC4	Q-CIS	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC4	Q-CIS	▶ Race : Asian	Reported	N/A	3	N/A	3	23	0	42	0	54.8%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC4	Q-CIS	▶ Race : Black or African American	Reported	N/A	3	N/A	3	18	0	66	0	27.3%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC4	Q-CIS	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC4	Q-CIS	▶ Race : White	Reported	N/A	3	N/A	3	21	0	63	0	33.3%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC4	Q-CIS	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC4	Q-CIS	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	123	0	320	0	38.4%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC4	Q-CIS	▶ Race : Total	Reported	N/A	3	N/A	3	193	0	515	0	37.5%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	113	0	252	0	44.8%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	50	0	156	0	32.1%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	30	0	107	0	28.0%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	193	0	515	0	37.5%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Reported	0.5359	0	0.5485	None	393	0	715	0	55.0%	0	1	0	Yes
PY5	San Joaquin General Hospital	DPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.5221	0	0.5304	None	2631	0	7359	0	35.8%	0	0	0	Yes
PY5	San Joaquin General Hospital	DPH	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Reported	0.6496	0	0.3665	None	351	0	1183	0	29.7%	0	0	0	Yes
PY5	San Joaquin General Hospital	DPH	Q-PC8	Q-CMS349	HIV Screening Measure	Reported	0.3325	0	0.3619	None	5849	0	11582	0	50.5%	0	1	0.5	Yes
PY5	San Joaquin General Hospital	DPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Reported	0.3855	0	0.3976	None	232	0	624	0	37.2%	0	0	0	Yes
PY5	San Joaquin General Hospital	DPH	Q-PC9	Q-IMA	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC9	Q-IMA	▶ Race : Asian	Reported	N/A	3	N/A	3	17	0	55	0	30.9%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC9	Q-IMA	▶ Race : Black or African American	Reported	N/A	3	N/A	3	24	0	67	0	35.8%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC9	Q-IMA	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC9	Q-IMA	▶ Race : White	Reported	N/A	3	N/A	3	25	0	66	0	37.9%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC9	Q-IMA	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC9	Q-IMA	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	163	0	427	0	38.2%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC9	Q-IMA	▶ Race : Total	Reported	N/A	3	N/A	3	232	0	624	0	37.2%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	87	0	181	0	48.1%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	94	0	247	0	38.1%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	51	0	196	0	26.0%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	232	0	624	0	37.2%	0	N/A	None	None
PY5	San Joaquin General Hospital	DPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Reported	1	0	1	None	59	0	59	0	100.0%	0	1	N/A	Yes
PY5	San Joaquin General Hospital	DPH	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Reported	0.8802	0	0.8842	None	220	0	239	0	92.1%	0	1	0.5	Yes
PY5	San Joaquin General Hospital	DPH	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	None
PY5	San Joaquin General Hospital	DPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Reported	0.3941	0	0	None	8	0	20.039	0	0.3992	0	1	N/A	Yes
PY5	San Joaquin General Hospital	DPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Reported	1.6829	0	0	None	24	0	20.554	0	1.1677	0	0	N/A	Yes
PY5	San Mateo Medical Center	DPH	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Reported	0.1025	0	0.1007	None	22	0	247	0	8.9%	0	1	0.5	Yes
PY5	San Mateo Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adults)	Reported	0.0724	0	0.0804	None	29	0	576	0	5.0%	0	0	0	YesS
PY5	San Mateo Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adults)	Reported	0.1095	0	0.1246	None	60	0	576	0	10.4%	0	0	0	YesS
PY5	San Mateo Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adults)	Reported	0.2783	0	0.3605	None	174	0	576	0	30.2%	0	0	0	YesS
PY5	San Mateo Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adolescents) - informational only	Reported	None	2	0	None	None	1	125	0	None	1	N/A	0	YesI
PY5	San Mateo Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adolescents) - informational only	Reported	None	2	0	None	None	1	125	0	None	1	N/A	0	YesI
PY5	San Mateo Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adolescents) - informational only	Reported	0.176	0	0	None	17	0	125	0	13.6%	0	N/A	0	YesI
PY5	San Mateo Medical Center	DPH	Q-BH2	Q-DRR-E	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	0	0	Yes
PY5	San Mateo Medical Center	DPH	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	None
PY5	San Mateo Medical Center	DPH	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	None
PY5	San Mateo Medical Center	DPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Mateo Medical Center	DPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Mateo Medical Center	DPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.5187	0	0.5336	None	1728	0	2794	0	61.9%	0	1	0.5	Yes
PY5	San Mateo Medical Center	DPH	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	0.8521	0	0.8589	None	257	0	288	0	89.2%	0	1	0.5	Yes
PY5	San Mateo Medical Center	DPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.9568	0	0.9199	None	516	0	546	0	94.5%	0	1	N/A	Yes
PY5	San Mateo Medical Center	DPH	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	0.8529	0	0.8554	None	32	0	32	0	100.0%	0	1	0.5	Yes
PY5	San Mateo Medical Center	DPH	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Reported	0.7612	0	0.7689	None	2824	0	3533	0	79.9%	0	1	0.5	Yes
PY5	San Mateo Medical Center	DPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	0.337	None	0.3406	None	31	0	95	0	32.6%	0	1	N/A	YesS
PY5	San Mateo Medical Center	DPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	0.3357	None	0.3406	None	290	0	878	0	33.0%	0	1	N/A	YesS
PY5	San Mateo Medical Center	DPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.2857	None	0.3406	None	587	0	2012	0	29.2%	0	1	N/A	YesS
PY5	San Mateo Medical Center	DPH	Q-CAD1	Q-HBD	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	N/A	Yes
PY5	San Mateo Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	14	0	45	0	31.1%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	48	0	254	0	18.9%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	31	0	95	0	32.6%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	27	0	80	0	33.8%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	229	0	754	0	30.4%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	238	0	783	0	30.4%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	587	0	2012	0	29.2%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	290	0	878	0	33.0%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	246	0	951	0	25.9%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	51	0	183	0	27.9%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	587	0	2012	0	29.2%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.6178	0	0.619	None	1260	0	2012	0	62.6%	0	1	0.5	Yes
PY5	San Mateo Medical Center	DPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Reported	0.6319	0	0.4676	None	1323	0	2196	0	60.3%	0	1	N/A	Yes
PY5	San Mateo Medical Center	DPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Reported	0.7665	0	0.7736	None	268	0	325	0	82.5%	0	1	0.5	Yes
PY5	San Mateo Medical Center	DPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Reported	0.8571	0	0.7532	None	45	0	52	0	86.5%	0	1	N/A	Yes
PY5	San Mateo Medical Center	DPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Mateo Medical Center	DPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Reported	0.5452	0	0.5687	None	193	0	327	0	59.0%	0	1	0.25	Yes
PY5	San Mateo Medical Center	DPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Reported	0.639	0	0	None	12	0	19.5411	0	0.6141	0	1	N/A	Yes
PY5	San Mateo Medical Center	DPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Mateo Medical Center	DPH	Q-IHE1	Q-IHE1	▶ Breast Cancer Screening (BCS) - -Black/African American	Reported	0.587	0	0.5921	None	34	0	57	0	59.7%	0	1	0.25	YesS
PY5	San Mateo Medical Center	DPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	1	0.25	Yes
PY5	San Mateo Medical Center	DPH	Q-IHE2	Q-IHE2	▶ Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention - Rate 2 -Black/African American	Reported	0.6083	0	None	None	76	0	114	0	66.7%	0	0	0	YesS
PY5	San Mateo Medical Center	DPH	Q-IHE2	Q-IHE2	▶ Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention - Rate 3 -Black/African American	Reported	0.8595	0	None	None	296	0	338	0	87.6%	0	1	0.25	YesS
PY5	San Mateo Medical Center	DPH	Q-IHE2	Q-IHE2	▶ Preventative Care and Screening: Tobacco Use - Screening and Cessation Intervention - Rate 1 (informational only) -Black/African American	Reported	0.989	0	0	None	336	0	341	0	98.5%	0	N/A	0	YesS
PY5	San Mateo Medical Center	DPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	0.5	0	Yes
PY5	San Mateo Medical Center	DPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Mateo Medical Center	DPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Mateo Medical Center	DPH	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Reported	0.9457	0	0.837	None	247	0	265	0	93.2%	0	1	1	Yes
PY5	San Mateo Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : White	Reported	N/A	3	N/A	3	126	0	131	0	96.2%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	100	0	112	0	89.3%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	Reported	N/A	3	N/A	3	247	0	265	0	93.2%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	177	0	191	0	92.7%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	38	0	41	0	92.7%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	32	0	33	0	97.0%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	247	0	265	0	93.2%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Reported	0.8806	0	0.8848	None	198	0	218	0	90.8%	0	1	1	Yes
PY5	San Mateo Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : White	Reported	N/A	3	N/A	3	96	0	108	0	88.9%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	88	0	95	0	92.6%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Total	Reported	N/A	3	N/A	3	198	0	218	0	90.8%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	149	0	162	0	92.0%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	27	0	30	0	90.0%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	22	0	None	4	None	4	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	198	0	218	0	90.8%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Reported	0.5556	0	0.4576	None	45	0	79	0	57.0%	0	1	N/A	Yes
PY5	San Mateo Medical Center	DPH	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Reported	1	0	0.9434	None	788	0	788	0	100.0%	0	1	N/A	Yes
PY5	San Mateo Medical Center	DPH	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	None
PY5	San Mateo Medical Center	DPH	Q-OA3	Q-QPP415	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older	Reported	0.8268	0	0.8361	None	114	0	127	0	89.8%	0	1	0.5	Yes
PY5	San Mateo Medical Center	DPH	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Reported	0.9096	0	0.8282	None	88	0	99	0	88.9%	0	1	N/A	Yes
PY5	San Mateo Medical Center	DPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.7123	0	0.6377	None	1181	0	1848	0	63.9%	0	1	N/A	Yes
PY5	San Mateo Medical Center	DPH	Q-PC10	Q-LSC	Lead Screening in Children	Reported	0.9371	0	0.8394	None	244	0	350	0	69.7%	0	0	0	Yes
PY5	San Mateo Medical Center	DPH	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Reported	0.3104	0	0.4955	None	9809	0	21694	0	45.2%	0	0	0	Yes
PY5	San Mateo Medical Center	DPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Reported	0.644	0	0.6514	None	9024	0	13867	0	65.1%	0	0.75	0	Yes
PY5	San Mateo Medical Center	DPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.5884	0	0.6194	None	13173	0	22271	0	59.2%	0	0	0	Yes
PY5	San Mateo Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 1 (informational only)	Reported	0.9928	0	0	None	11610	0	11698	0	99.3%	0	N/A	N/A	YesI
PY5	San Mateo Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 2	Reported	0.4665	0	0.5118	None	977	0	1596	0	61.2%	0	1	0	YesS
PY5	San Mateo Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 3	Reported	0.9137	0	0.9176	None	10980	0	11698	0	93.9%	0	1	0.5	YesS
PY5	San Mateo Medical Center	DPH	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	0	Yes
PY5	San Mateo Medical Center	DPH	Q-PC15	Q-WCC	▶ Counseling for Physical Activity	Reported	0.1699	0	0.5579	None	6056	0	7357	0	82.3%	0	1	0.5	YesS
PY5	San Mateo Medical Center	DPH	Q-PC15	Q-WCC	▶ Counseling for Nutrition	Reported	0.8675	0	0.8248	None	6177	0	7357	0	84.0%	0	1	N/A	YesS
PY5	San Mateo Medical Center	DPH	Q-PC15	Q-WCC	▶ BMI	Reported	0.8943	0	0.8718	None	6580	0	7357	0	89.4%	0	1	N/A	YesS
PY5	San Mateo Medical Center	DPH	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	N/A	Yes
PY5	San Mateo Medical Center	DPH	Q-PC16	Q-W30	▶ First 15 Months	Reported	0.622	0	0.6281	None	118	0	155	0	76.1%	0	1	1	YesS
PY5	San Mateo Medical Center	DPH	Q-PC16	Q-W30	▶ 15 Months-30 Months	Reported	0.8542	0	0.8282	None	356	0	443	0	80.4%	0	0	0	YesS
PY5	San Mateo Medical Center	DPH	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	0.5	0	Yes
PY5	San Mateo Medical Center	DPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Reported	0.692	0	0.6799	None	3301	0	5650	0	58.4%	0	0	0	Yes
PY5	San Mateo Medical Center	DPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.7747	0	0.6197	None	7079	0	12292	0	57.6%	0	0	0	Yes
PY5	San Mateo Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	50	0	104	0	48.1%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	209	0	347	0	60.2%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	45	0	78	0	57.7%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	72	0	131	0	55.0%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	3654	0	6019	0	60.7%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	3040	0	5600	0	54.3%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	7079	0	12292	0	57.6%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	5764	0	9791	0	58.9%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	767	0	1371	0	55.9%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	548	0	1130	0	48.5%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	7079	0	12292	0	57.6%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Reported	0.7016	0	0.5366	None	211	0	350	0	60.3%	0	1	1	Yes
PY5	San Mateo Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : White	Reported	N/A	3	N/A	3	50	0	86	0	58.1%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	158	0	254	0	62.2%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Total	Reported	N/A	3	N/A	3	211	0	350	0	60.3%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	118	0	179	0	65.9%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	18	0	None	4	None	4	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	75	0	142	0	52.8%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	211	0	350	0	60.3%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Reported	0.798	0	0.6615	None	1023	0	1333	0	76.7%	0	1	1	Yes
PY5	San Mateo Medical Center	DPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.5774	0	0.5801	None	5116	0	8534	0	60.0%	0	1	0.5	Yes
PY5	San Mateo Medical Center	DPH	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Reported	0.6369	0	0.3665	None	619	0	843	0	73.4%	0	1	1	Yes
PY5	San Mateo Medical Center	DPH	Q-PC8	Q-CMS349	HIV Screening Measure	Reported	0.6769	0	0.6263	None	7005	0	9799	0	71.5%	0	1	N/A	Yes
PY5	San Mateo Medical Center	DPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Reported	0.5663	0	0.5061	None	344	0	663	0	51.9%	0	1	1	Yes
PY5	San Mateo Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : White	Reported	N/A	3	N/A	3	114	0	231	0	49.4%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	211	0	409	0	51.6%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Total	Reported	N/A	3	N/A	3	344	0	663	0	51.9%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	287	0	546	0	52.6%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	35	0	65	0	53.9%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	22	0	52	0	42.3%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	344	0	663	0	51.9%	0	N/A	None	None
PY5	San Mateo Medical Center	DPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Mateo Medical Center	DPH	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Reported	0.9947	0	0.92	None	409	0	409	0	100.0%	0	1	N/A	Yes
PY5	San Mateo Medical Center	DPH	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Reported	0.6933	0	0.716	None	60	0	66	0	90.9%	0	1	0.5	Yes
PY5	San Mateo Medical Center	DPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	San Mateo Medical Center	DPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Reported	0.0955	0	0.0944	None	78	0	803	0	9.7%	0	0	0	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adults)	Reported	0.0575	0	0.067	None	30	0	575	0	5.2%	0	0	0	YesS
PY5	Santa Clara Valley Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adults)	Reported	0.0887	0	0.1059	None	64	0	575	0	11.1%	0	1	0	YesS
PY5	Santa Clara Valley Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adults)	Reported	0.2397	0	0.3605	None	223	0	575	0	38.8%	0	1	0	YesS
PY5	Santa Clara Valley Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adolescents) - informational only	Reported	None	2	N/A	None	0	0	None	4	None	4	N/A	N/A	YesS
PY5	Santa Clara Valley Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adolescents) - informational only	Reported	None	2	N/A	None	0	0	None	4	None	4	N/A	N/A	YesS
PY5	Santa Clara Valley Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adolescents) - informational only	Reported	None	2	N/A	None	None	1	None	4	None	1	N/A	N/A	YesS
PY5	Santa Clara Valley Medical Center	DPH	Q-BH2	Q-DRR-E	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	0.6667	0	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-BH3	Q-FUA	▶ 7 Days	Reported	0.0981	0	0.1113	None	60	0	410	0	14.6%	0	1	0.5	YesS
PY5	Santa Clara Valley Medical Center	DPH	Q-BH3	Q-FUA	▶ 30 Days	Reported	0.2344	0	0.2436	None	116	0	410	0	28.3%	0	1	0.5	YesS
PY5	Santa Clara Valley Medical Center	DPH	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	0.5	Yes
PY5	Santa Clara Valley Medical Center	DPH	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	None
PY5	Santa Clara Valley Medical Center	DPH	Q-BH5	Q-FUI	▶ 30 Days	Reported	0.3669	0	0.3979	None	58	0	162	0	35.8%	0	0	0	YesS
PY5	Santa Clara Valley Medical Center	DPH	Q-BH5	Q-FUI	▶ 7 Days	Reported	0.3669	0	0.3793	None	19	0	162	0	11.7%	0	0	0	YesS
PY5	Santa Clara Valley Medical Center	DPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	0	0	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.4671	0	0.5061	None	3768	0	7357	0	51.2%	0	1	0	Yes
PY5	Santa Clara Valley Medical Center	DPH	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	None
PY5	Santa Clara Valley Medical Center	DPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Santa Clara Valley Medical Center	DPH	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	None
PY5	Santa Clara Valley Medical Center	DPH	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Reported	0.6836	0	0.6991	None	4957	0	6995	0	70.9%	0	1	0	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	0.3612	0	0.3591	None	154	0	476	0	32.4%	0	1	0.5	YesS
PY5	Santa Clara Valley Medical Center	DPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	0.422	0	0.4139	None	1196	0	3203	0	37.3%	0	1	0.5	YesS
PY5	Santa Clara Valley Medical Center	DPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.3426	0	0.3424	None	2285	0	7429	0	30.8%	0	1	0.5	YesS
PY5	Santa Clara Valley Medical Center	DPH	Q-CAD1	Q-HBD	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	0.5	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	38	0	None	1	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	420	0	2134	0	19.7%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	145	0	455	0	31.9%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	20	0	65	0	30.8%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	1528	0	4320	0	35.4%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	63	0	199	0	31.7%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	99	0	218	0	45.4%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	2285	0	7429	0	30.8%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	1198	0	3211	0	37.3%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	1026	0	4091	0	25.1%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	61	0	127	0	48.0%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	2285	0	7429	0	30.8%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Reported	0.4834	0	0.4676	None	4323	0	7467	0	57.9%	0	1	N/A	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Reported	0.8176	0	0.8195	None	772	0	880	0	87.7%	0	1	0.5	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-CAR2	Q-PCE	▶ Systemic Corticosteroid	Reported	0.6203	0	0.6391	None	84	0	122	0	68.9%	0	1	0	YesS
PY5	Santa Clara Valley Medical Center	DPH	Q-CAR2	Q-PCE	▶ Bronchodilator	Reported	0.8354	0	0.8424	None	111	0	122	0	91.0%	0	1	0.5	YesS
PY5	Santa Clara Valley Medical Center	DPH	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	0	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Reported	0.9789	0	0.78	None	4503	0	4505	0	100.0%	0	1	N/A	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-IHE1	Q-IHE1	▶ Prenatal and Postpartum Care: Postpartum Care (PPC-PST) - -Black/African American	Reported	0.661	0	0.7111	None	51	0	66	0	77.3%	0	1	0.5	YesS
PY5	Santa Clara Valley Medical Center	DPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	1	0.5	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-IHE2	Q-IHE2	▶ Colorectal Cancer Screening - -Black/African American	Reported	0.5152	0	0.5241	None	650	0	1183	0	55.0%	0	1	0.5	YesS
PY5	Santa Clara Valley Medical Center	DPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	1	0.5	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Reported	0.2033	0	0.22	None	207	0	1078	0	19.2%	0	1	N/A	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Reported	0.7036	0	0.7094	None	2216	0	3189	0	69.5%	0	0	0	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Reported	0.7613	0	0.7689	None	803	0	1022	0	78.6%	0	1	1	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	Reported	N/A	3	N/A	3	108	0	120	0	90.0%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	Reported	N/A	3	N/A	3	44	0	58	0	75.9%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : White	Reported	N/A	3	N/A	3	611	0	784	0	77.9%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	21	0	None	4	None	4	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	Reported	N/A	3	N/A	3	803	0	1022	0	78.6%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	558	0	709	0	78.7%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	237	0	294	0	80.6%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	803	0	1022	0	78.6%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Reported	0.821	0	0.8311	None	853	0	1022	0	83.5%	0	1	0	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Asian	Reported	N/A	3	N/A	3	106	0	120	0	88.3%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Black or African American	Reported	N/A	3	N/A	3	45	0	58	0	77.6%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : White	Reported	N/A	3	N/A	3	661	0	784	0	84.3%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	22	0	None	4	None	4	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	12	0	None	4	None	4	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Total	Reported	N/A	3	N/A	3	853	0	1022	0	83.5%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	602	0	709	0	84.9%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	243	0	294	0	82.7%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	853	0	1022	0	83.5%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Reported	0.5723	0	0.4576	None	557	0	984	0	56.6%	0	1	N/A	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Reported	0.9779	0	0.9434	None	6424	0	6608	0	97.2%	0	1	N/A	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Reported	0.7901	0	0.7039	None	279	0	335	0	83.3%	0	1	N/A	Yes
PY5	Santa Clara Valley Medical Center	DPH	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	None
PY5	Santa Clara Valley Medical Center	DPH	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	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.5574	0	0.5654	None	3399	0	5825	0	58.4%	0	1	0.5	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-PC10	Q-LSC	Lead Screening in Children	Reported	0.7484	0	0.7575	None	1656	0	2040	0	81.2%	0	1	0.5	Yes
PY5	Santa Clara Valley Medical Center	DPH	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	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Reported	0.4962	0	0.5184	None	30204	0	58197	0	51.9%	0	1	0	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.394	0	0.5004	None	18748	0	32126	0	58.4%	0	1	0	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 2	Reported	0.3506	0	0.4075	None	2077	0	6420	0	32.4%	0	0	0	YesS
PY5	Santa Clara Valley Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 1 (informational only)	Reported	0.9713	0	0	None	46772	0	47406	0	98.7%	0	N/A	N/A	YesI
PY5	Santa Clara Valley Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 3	Reported	0.8722	0	0.8802	None	42429	0	47406	0	89.5%	0	1	0.5	YesS
PY5	Santa Clara Valley Medical Center	DPH	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	0.5	0	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-PC15	Q-WCC	▶ Counseling for Physical Activity	Reported	0.6795	0	0.6909	None	14161	0	16667	0	85.0%	0	1	0.5	YesS
PY5	Santa Clara Valley Medical Center	DPH	Q-PC15	Q-WCC	▶ Counseling for Nutrition	Reported	0.699	0	0.7116	None	14476	0	16667	0	86.9%	0	1	0.5	YesS
PY5	Santa Clara Valley Medical Center	DPH	Q-PC15	Q-WCC	▶ BMI	Reported	0.8298	0	0.834	None	15899	0	16667	0	95.4%	0	1	0.5	YesS
PY5	Santa Clara Valley Medical Center	DPH	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	0.5	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-PC16	Q-W30	▶ First 15 Months	Reported	0.6477	0	0.6513	None	545	0	704	0	77.4%	0	1	1	YesS
PY5	Santa Clara Valley Medical Center	DPH	Q-PC16	Q-W30	▶ 15 Months-30 Months	Reported	0.6941	0	0.7075	None	1513	0	2036	0	74.3%	0	1	1	YesS
PY5	Santa Clara Valley Medical Center	DPH	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	1	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Reported	0.5063	0	0.5237	None	8281	0	17006	0	48.7%	0	0	0	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.4537	0	0.4703	None	16378	0	32868	0	49.8%	0	1	1	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	15	0	32	0	46.9%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	1661	0	3078	0	54.0%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	594	0	1232	0	48.2%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	46	0	142	0	32.4%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	13073	0	25751	0	50.8%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	508	0	1031	0	49.3%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	481	0	1602	0	30.0%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	16378	0	32868	0	49.8%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	12920	0	25416	0	50.8%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	3305	0	6597	0	50.1%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	153	0	855	0	17.9%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	16378	0	32868	0	49.8%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Reported	0.5929	0	0.5366	None	1117	0	1859	0	60.1%	0	1	1	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Asian	Reported	N/A	3	N/A	3	181	0	230	0	78.7%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Black or African American	Reported	N/A	3	N/A	3	28	0	79	0	35.4%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : White	Reported	N/A	3	N/A	3	844	0	1414	0	59.7%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	48	0	77	0	62.3%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	44	0	None	1	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Total	Reported	N/A	3	N/A	3	1117	0	1859	0	60.1%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	845	0	1397	0	60.5%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	260	0	416	0	62.5%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	12	0	46	0	26.1%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	1117	0	1859	0	60.1%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Reported	0.6059	0	0.6115	None	2055	0	3351	0	61.3%	0	1	0	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.5771	0	0.5799	None	13029	0	21075	0	61.8%	0	1	0.5	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Reported	0.7308	0	0.3665	None	3304	0	4269	0	77.4%	0	1	1	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-PC8	Q-CMS349	HIV Screening Measure	Reported	0.6888	0	0.6263	None	23404	0	31600	0	74.1%	0	1	N/A	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Reported	0.3037	0	0.3239	None	701	0	2057	0	34.1%	0	1	0	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Asian	Reported	N/A	3	N/A	3	57	0	172	0	33.1%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Black or African American	Reported	N/A	3	N/A	3	16	0	71	0	22.5%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : White	Reported	N/A	3	N/A	3	591	0	1676	0	35.3%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	20	0	53	0	37.7%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	14	0	77	0	18.2%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Total	Reported	N/A	3	N/A	3	701	0	2057	0	34.1%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	580	0	1624	0	35.7%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	113	0	379	0	29.8%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	54	0	None	1	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	701	0	2057	0	34.1%	0	N/A	None	None
PY5	Santa Clara Valley Medical Center	DPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Reported	1	0	1	None	175	0	175	0	100.0%	0	1	N/A	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Reported	0.9974	0	0.92	None	2820	0	2833	0	99.5%	0	1	N/A	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Reported	0.7375	0	0.7558	None	613	0	615	0	99.7%	0	1	0.5	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Reported	0.6431	0	0	None	46	0	124.75	0	0.3687	0	1	N/A	Yes
PY5	Santa Clara Valley Medical Center	DPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Reported	1.8686	0	0	None	25	0	17.498	0	1.4287	0	0	N/A	Yes
PY5	Seneca Healthcare District	DMPH	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	None
PY5	Seneca Healthcare District	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	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	None
PY5	Seneca Healthcare District	DMPH	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	None
PY5	Seneca Healthcare District	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	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	None
PY5	Seneca Healthcare District	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	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	None
PY5	Seneca Healthcare District	DMPH	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	None
PY5	Seneca Healthcare District	DMPH	Q-CAD1	Q-HBD	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	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	None
PY5	Seneca Healthcare District	DMPH	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	None
PY5	Seneca Healthcare District	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	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	None
PY5	Seneca Healthcare District	DMPH	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	None
PY5	Seneca Healthcare District	DMPH	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	None
PY5	Seneca Healthcare District	DMPH	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	None
PY5	Seneca Healthcare District	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	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	None
PY5	Seneca Healthcare District	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0	0	0.5004	None	57	0	443	0	12.9%	0	N/A	N/A	No
PY5	Seneca Healthcare District	DMPH	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	None
PY5	Seneca Healthcare District	DMPH	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	None
PY5	Seneca Healthcare District	DMPH	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	None
PY5	Seneca Healthcare District	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	None	2	0.2738	None	39	0	131	0	29.8%	0	1	0	Yes
PY5	Seneca Healthcare District	DMPH	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	None
PY5	Seneca Healthcare District	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	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	None
PY5	Seneca Healthcare District	DMPH	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	None
PY5	Seneca Healthcare District	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Seneca Healthcare District	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sierra View District Hospital	DMPH	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	None
PY5	Sierra View District Hospital	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sierra View District Hospital	DMPH	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	None
PY5	Sierra View District Hospital	DMPH	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	None
PY5	Sierra View District Hospital	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sierra View District Hospital	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sierra View District Hospital	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sierra View District Hospital	DMPH	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	None
PY5	Sierra View District Hospital	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sierra View District Hospital	DMPH	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	None
PY5	Sierra View District Hospital	DMPH	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	None
PY5	Sierra View District Hospital	DMPH	Q-CAD1	Q-HBD	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sierra View District Hospital	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sierra View District Hospital	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sierra View District Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sierra View District Hospital	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sierra View District Hospital	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sierra View District Hospital	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sierra View District Hospital	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sierra View District Hospital	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Reported	0.752	0	0.7688	None	64	0	65	0	98.5%	0	1	0.5	Yes
PY5	Sierra View District Hospital	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sierra View District Hospital	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sierra View District Hospital	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Reported	0.2337	0	0.2323	None	74	0	254	0	29.1%	0	0	0	Yes
PY5	Sierra View District Hospital	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Reported	0.5172	0	0.5417	None	79	0	178	0	44.4%	0	0	0	Yes
PY5	Sierra View District Hospital	DMPH	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	None
PY5	Sierra View District Hospital	DMPH	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	None
PY5	Sierra View District Hospital	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sierra View District Hospital	DMPH	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	None
PY5	Sierra View District Hospital	DMPH	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	None
PY5	Sierra View District Hospital	DMPH	Q-OA3	Q-QPP415	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older	Reported	0.1077	0	0.7983	None	85	0	101	0	84.2%	0	1	0	Yes
PY5	Sierra View District Hospital	DMPH	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	None
PY5	Sierra View District Hospital	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sierra View District Hospital	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sierra View District Hospital	DMPH	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	None
PY5	Sierra View District Hospital	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Reported	0.0562	0	0.2671	None	646	0	8585	0	7.5%	0	N/A	N/A	No
PY5	Sierra View District Hospital	DMPH	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	None
PY5	Sierra View District Hospital	DMPH	Q-PC14	Q-CMS138	▶ Rate 3	Reported	0.0072	0	0.7542	None	312	0	10048	0	3.1%	0	N/A	N/A	NoS
PY5	Sierra View District Hospital	DMPH	Q-PC14	Q-CMS138	▶ Rate 2	Reported	0.0193	0	0.1094	None	40	0	917	0	4.4%	0	N/A	N/A	NoS
PY5	Sierra View District Hospital	DMPH	Q-PC14	Q-CMS138	▶ Rate 1 (informational only)	Reported	0.9527	0	0	None	9115	0	10208	0	89.3%	0	N/A	N/A	NoS
PY5	Sierra View District Hospital	DMPH	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	N/A	None	No
PY5	Sierra View District Hospital	DMPH	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	None
PY5	Sierra View District Hospital	DMPH	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	None
PY5	Sierra View District Hospital	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sierra View District Hospital	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sierra View District Hospital	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sierra View District Hospital	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sierra View District Hospital	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sierra View District Hospital	DMPH	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	None
PY5	Sierra View District Hospital	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sierra View District Hospital	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sierra View District Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Reported	0.9694	0	0.9918	None	61	0	61	0	100.0%	0	1	0.5	Yes
PY5	Sierra View District Hospital	DMPH	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Reported	0.9599	0	0.92	None	252	0	279	0	90.3%	0	0	0	Yes
PY5	Sierra View District Hospital	DMPH	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Reported	0.5514	0	0.5883	None	70	0	107	0	65.4%	0	1	0	Yes
PY5	Sierra View District Hospital	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Reported	0.7533	0	0	None	3	0	10.431	0	0.2876	0	N/A	N/A	No
PY5	Sierra View District Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	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	None
PY5	Sonoma Valley Hospital	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	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	None
PY5	Sonoma Valley Hospital	DMPH	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	None
PY5	Sonoma Valley Hospital	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	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	None
PY5	Sonoma Valley Hospital	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	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	None
PY5	Sonoma Valley Hospital	DMPH	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	None
PY5	Sonoma Valley Hospital	DMPH	Q-CAD1	Q-HBD	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	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	None
PY5	Sonoma Valley Hospital	DMPH	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	None
PY5	Sonoma Valley Hospital	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	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	None
PY5	Sonoma Valley Hospital	DMPH	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	None
PY5	Sonoma Valley Hospital	DMPH	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	None
PY5	Sonoma Valley Hospital	DMPH	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	None
PY5	Sonoma Valley Hospital	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	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	None
PY5	Sonoma Valley Hospital	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	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	None
PY5	Sonoma Valley Hospital	DMPH	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	None
PY5	Sonoma Valley Hospital	DMPH	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	None
PY5	Sonoma Valley Hospital	DMPH	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	None
PY5	Sonoma Valley Hospital	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	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	None
PY5	Sonoma Valley Hospital	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Sonoma Valley Hospital	DMPH	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	None
PY5	Sonoma Valley Hospital	DMPH	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	None
PY5	Sonoma Valley Hospital	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Reported	1.7986	0	0	None	1	0	2.136	0	0.4682	0	1	N/A	Yes
PY5	Sonoma Valley Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Reported	0	0	0	None	0	0	0.124	0	0	0	N/A	N/A	No
PY5	Southern Inyo Hospital	DMPH	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	None
PY5	Southern Inyo Hospital	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	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	None
PY5	Southern Inyo Hospital	DMPH	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	None
PY5	Southern Inyo Hospital	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	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	None
PY5	Southern Inyo Hospital	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	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	None
PY5	Southern Inyo Hospital	DMPH	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	None
PY5	Southern Inyo Hospital	DMPH	Q-CAD1	Q-HBD	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	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	None
PY5	Southern Inyo Hospital	DMPH	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	None
PY5	Southern Inyo Hospital	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	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	None
PY5	Southern Inyo Hospital	DMPH	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	None
PY5	Southern Inyo Hospital	DMPH	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	None
PY5	Southern Inyo Hospital	DMPH	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	None
PY5	Southern Inyo Hospital	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	None	2	N/A	None	14	0	None	4	None	4	N/A	N/A	No
PY5	Southern Inyo Hospital	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	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	None
PY5	Southern Inyo Hospital	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	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	None
PY5	Southern Inyo Hospital	DMPH	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	None
PY5	Southern Inyo Hospital	DMPH	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	None
PY5	Southern Inyo Hospital	DMPH	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	None
PY5	Southern Inyo Hospital	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.5348	0	0.5433	None	26	0	51	0	51.0%	0	0	0	Yes
PY5	Southern Inyo Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Southern Inyo Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Southern Inyo Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Southern Inyo Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Southern Inyo Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Southern Inyo Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Southern Inyo Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	19	0	37	0	51.4%	0	N/A	None	None
PY5	Southern Inyo Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	26	0	51	0	51.0%	0	N/A	None	None
PY5	Southern Inyo Hospital	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	20	0	37	0	54.1%	0	N/A	None	None
PY5	Southern Inyo Hospital	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Southern Inyo Hospital	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Southern Inyo Hospital	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	26	0	51	0	51.0%	0	N/A	None	None
PY5	Southern Inyo Hospital	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	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	None
PY5	Southern Inyo Hospital	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	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	None
PY5	Southern Inyo Hospital	DMPH	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	None
PY5	Southern Inyo Hospital	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Southern Inyo Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH2	Q-DRR-E	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	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adults)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adolescents) - informational only	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH3	Q-FUA	▶ 30 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH3	Q-FUA	▶ 7 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH3	Q-FUA	▶ 30 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH3	Q-FUA	▶ 30 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH3	Q-FUA	▶ 7 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH3	Q-FUA	▶ 7 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH5	Q-FUI	▶ 30 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH5	Q-FUI	▶ 7 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH5	Q-FUI	▶ 30 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH5	Q-FUI	▶ 30 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH5	Q-FUI	▶ 7 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH5	Q-FUI	▶ 7 Days	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD1	Q-HBD	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	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD1	Q-HBD	▶ Black/African-American	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD1	Q-HBD	▶ Total Population	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Asian	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : White	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD1	Q-HBD	▶ Race : Total	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD1	Q-HBD	▶ Black/African-American	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD1	Q-HBD	▶ Black/African-American	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD1	Q-HBD	▶ Total Population	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD1	Q-HBD	▶ Total Population	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAR2	Q-PCE	▶ Systemic Corticosteroid	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAR2	Q-PCE	▶ Bronchodilator	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAR2	Q-PCE	▶ Systemic Corticosteroid	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAR2	Q-PCE	▶ Systemic Corticosteroid	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAR2	Q-PCE	▶ Bronchodilator	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CAR2	Q-PCE	▶ Bronchodilator	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : White	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : American Indian or Alaska Native	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Asian	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Black or African American	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Native Hawaiian or Other Pacific Islander	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : White	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Two or More Races	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Other/Declined/Unknown	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Race : Total	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Hispanic or Latino	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Not Hispanic or Latino	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Declined/Unknown	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Total	No Data Entered	N/A	3	N/A	None	None	None	None	None	None	None	N/A	None	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0	0	0.5004	None	17	0	288	0	5.9%	0	N/A	N/A	No
PY5	Surprise Valley Community Hospital	DMPH	Q-PC14	Q-CMS138	▶ Rate 2	Reported	0.0992	0	0.1813	None	30	0	42	0	71.4%	0	1	0.5	YesS
PY5	Surprise Valley Community Hospital	DMPH	Q-PC14	Q-CMS138	▶ Rate 1 (informational only)	Reported	0.5171	0	N/A	None	119	0	128	0	93.0%	0	N/A	N/A	None
PY5	Surprise Valley Community Hospital	DMPH	Q-PC14	Q-CMS138	▶ Rate 3	Reported	0.5684	0	0.7542	None	24	0	128	0	18.8%	0	0	0	YesS
PY5	Surprise Valley Community Hospital	DMPH	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	0.5	0	Yes
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	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	None
PY5	Surprise Valley Community Hospital	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Surprise Valley Community Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tahoe Forest Hospital District	DMPH	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	None
PY5	Tahoe Forest Hospital District	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-BH3	Q-FUA	▶ 7 Days	Reported	0.2143	0	0.2159	None	None	1	51	0	None	1	0	0	YesS
PY5	Tahoe Forest Hospital District	DMPH	Q-BH3	Q-FUA	▶ 30 Days	Reported	0.3036	0	0.3058	None	12	0	51	0	23.5%	0	0	0	YesS
PY5	Tahoe Forest Hospital District	DMPH	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	0	Yes
PY5	Tahoe Forest Hospital District	DMPH	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	None
PY5	Tahoe Forest Hospital District	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.6373	0	0.6404	None	88	0	146	0	60.3%	0	N/A	N/A	No
PY5	Tahoe Forest Hospital District	DMPH	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	None
PY5	Tahoe Forest Hospital District	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tahoe Forest Hospital District	DMPH	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	None
PY5	Tahoe Forest Hospital District	DMPH	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	None
PY5	Tahoe Forest Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	0	0	N/A	None	0	0	0	0	0.0%	0	N/A	N/A	NoS
PY5	Tahoe Forest Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	None	2	0.3406	None	None	1	50	0	None	1	1	N/A	YesS
PY5	Tahoe Forest Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.2182	0	0.3406	None	19	0	93	0	20.4%	0	1	N/A	YesS
PY5	Tahoe Forest Hospital District	DMPH	Q-CAD1	Q-HBD	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	N/A	Yes
PY5	Tahoe Forest Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	14	0	59	0	23.7%	0	N/A	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	31	0	None	1	N/A	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	19	0	93	0	20.4%	0	N/A	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	50	0	None	1	N/A	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	11	0	43	0	25.6%	0	N/A	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	19	0	93	0	20.4%	0	N/A	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Reported	0.5686	0	0.5897	None	59	0	100	0	59.0%	0	1	0	Yes
PY5	Tahoe Forest Hospital District	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Reported	0.6885	0	0.6959	None	144	0	155	0	92.9%	0	1	0.5	Yes
PY5	Tahoe Forest Hospital District	DMPH	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	None
PY5	Tahoe Forest Hospital District	DMPH	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	None
PY5	Tahoe Forest Hospital District	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tahoe Forest Hospital District	DMPH	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	None
PY5	Tahoe Forest Hospital District	DMPH	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	None
PY5	Tahoe Forest Hospital District	DMPH	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	None
PY5	Tahoe Forest Hospital District	DMPH	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	None
PY5	Tahoe Forest Hospital District	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.6202	0	0.622	None	108	0	174	0	62.1%	0	N/A	N/A	No
PY5	Tahoe Forest Hospital District	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tahoe Forest Hospital District	DMPH	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	None
PY5	Tahoe Forest Hospital District	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.4195	0	0.5004	None	778	0	1589	0	49.0%	0	0	0	Yes
PY5	Tahoe Forest Hospital District	DMPH	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	None
PY5	Tahoe Forest Hospital District	DMPH	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	None
PY5	Tahoe Forest Hospital District	DMPH	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	None
PY5	Tahoe Forest Hospital District	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Reported	0.6053	0	0.6128	None	571	0	928	0	61.5%	0	1	0	Yes
PY5	Tahoe Forest Hospital District	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tahoe Forest Hospital District	DMPH	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	None
PY5	Tahoe Forest Hospital District	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Reported	0.2472	0	0.309	None	18	0	87	0	20.7%	0	N/A	N/A	No
PY5	Tahoe Forest Hospital District	DMPH	Q-PC9	Q-IMA	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-PC9	Q-IMA	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-PC9	Q-IMA	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-PC9	Q-IMA	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-PC9	Q-IMA	▶ Race : White	Reported	N/A	3	N/A	3	15	0	70	0	21.4%	0	N/A	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-PC9	Q-IMA	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-PC9	Q-IMA	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-PC9	Q-IMA	▶ Race : Total	Reported	N/A	3	N/A	3	18	0	87	0	20.7%	0	N/A	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	13	0	45	0	28.9%	0	N/A	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	40	0	None	1	N/A	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	18	0	87	0	20.7%	0	N/A	None	None
PY5	Tahoe Forest Hospital District	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tahoe Forest Hospital District	DMPH	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	None
PY5	Tahoe Forest Hospital District	DMPH	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	None
PY5	Tahoe Forest Hospital District	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Reported	0.7396	0	0.58	None	0	0	2.555	0	0	0	1	N/A	Yes
PY5	Tahoe Forest Hospital District	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tri-City Medical Center	DMPH	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Reported	0	0	N/A	None	0	0	0	0	0.0%	0	0	0	Yes
PY5	Tri-City Medical Center	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tri-City Medical Center	DMPH	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	None
PY5	Tri-City Medical Center	DMPH	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Reported	0	0	N/A	None	0	0	0	0	0.0%	0	0	0	Yes
PY5	Tri-City Medical Center	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	N/A	None	No
PY5	Tri-City Medical Center	DMPH	Q-BH5	Q-FUI	▶ 30 Days	Reported	None	2	0.3894	None	None	1	478	0	None	1	N/A	N/A	NoS
PY5	Tri-City Medical Center	DMPH	Q-BH5	Q-FUI	▶ 7 Days	Reported	None	2	0.234	None	None	1	477	0	None	1	N/A	N/A	NoS
PY5	Tri-City Medical Center	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Reported	0	0	N/A	None	0	0	0	0	0.0%	0	0	0	Yes
PY5	Tri-City Medical Center	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tri-City Medical Center	DMPH	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	None
PY5	Tri-City Medical Center	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tri-City Medical Center	DMPH	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	0	N/A	3	84	0	103	0	81.6%	0	0	0	Yes
PY5	Tri-City Medical Center	DMPH	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	None
PY5	Tri-City Medical Center	DMPH	Q-CAD1	Q-HBD	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tri-City Medical Center	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tri-City Medical Center	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tri-City Medical Center	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tri-City Medical Center	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tri-City Medical Center	DMPH	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	0	Yes
PY5	Tri-City Medical Center	DMPH	Q-CAR2	Q-PCE	▶ Bronchodilator	Reported	None	2	N/A	None	0	0	0	0	0.0%	0	0	0	YesS
PY5	Tri-City Medical Center	DMPH	Q-CAR2	Q-PCE	▶ Systemic Corticosteroid	Reported	None	2	N/A	None	0	0	0	0	0.0%	0	0	0	YesS
PY5	Tri-City Medical Center	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Reported	0.54	0	0.564	None	0	0	0	0	0.0%	0	0	0	Yes
PY5	Tri-City Medical Center	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tri-City Medical Center	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Reported	0	0	N/A	None	32	0	33	0	97.0%	0	0	0	Yes
PY5	Tri-City Medical Center	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tri-City Medical Center	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	No Data Entered	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tri-City Medical Center	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Reported	0.2111	0	0.22	None	46	0	250	0	18.4%	0	1	N/A	Yes
PY5	Tri-City Medical Center	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Reported	0.4545	0	0.4853	None	164	0	333	0	49.3%	0	1	0	Yes
PY5	Tri-City Medical Center	DMPH	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	None
PY5	Tri-City Medical Center	DMPH	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	None
PY5	Tri-City Medical Center	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Reported	None	2	0.1696	None	None	1	303	0	None	1	N/A	N/A	No
PY5	Tri-City Medical Center	DMPH	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	None
PY5	Tri-City Medical Center	DMPH	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	None
PY5	Tri-City Medical Center	DMPH	Q-OA3	Q-QPP415	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older	Reported	0.8611	0	0.867	None	23	0	None	4	None	4	0	0	Yes
PY5	Tri-City Medical Center	DMPH	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	None
PY5	Tri-City Medical Center	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tri-City Medical Center	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tri-City Medical Center	DMPH	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	None
PY5	Tri-City Medical Center	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Reported	0.8819	0	0.7182	None	397	0	1206	0	32.9%	0	N/A	N/A	No
PY5	Tri-City Medical Center	DMPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.0215	0	0.5004	None	517	0	17691	0	2.9%	0	N/A	N/A	No
PY5	Tri-City Medical Center	DMPH	Q-PC14	Q-CMS138	▶ Rate 3	Reported	0.0068	0	0.7542	None	63	0	6877	0	0.9%	0	N/A	N/A	NoS
PY5	Tri-City Medical Center	DMPH	Q-PC14	Q-CMS138	▶ Rate 2	Reported	0.0192	0	0.1093	None	63	0	2272	0	2.8%	0	N/A	N/A	NoS
PY5	Tri-City Medical Center	DMPH	Q-PC14	Q-CMS138	▶ Rate 1 (informational only)	Reported	0.9489	0	0	None	6545	0	6877	0	95.2%	0	N/A	N/A	NoI
PY5	Tri-City Medical Center	DMPH	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	N/A	None	No
PY5	Tri-City Medical Center	DMPH	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	None
PY5	Tri-City Medical Center	DMPH	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	None
PY5	Tri-City Medical Center	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tri-City Medical Center	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tri-City Medical Center	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tri-City Medical Center	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tri-City Medical Center	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tri-City Medical Center	DMPH	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	None
PY5	Tri-City Medical Center	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tri-City Medical Center	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Tri-City Medical Center	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Reported	1	0	1	None	43	0	43	0	100.0%	0	1	N/A	Yes
PY5	Tri-City Medical Center	DMPH	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Reported	0.7312	0	0.7501	None	169	0	169	0	100.0%	0	1	0.5	Yes
PY5	Tri-City Medical Center	DMPH	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Reported	0.9701	0	0.92	None	None	1	393	0	None	1	0	0	Yes
PY5	Tri-City Medical Center	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Reported	0.8817	0	0	None	19	0	25.897	0	0.7337	0	N/A	N/A	No
PY5	Tri-City Medical Center	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Reported	1.1952	0	0	None	4	0	2.754	0	1.4524	0	N/A	N/A	No
PY5	Trinity Hospital	DMPH	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	None
PY5	Trinity Hospital	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	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	None
PY5	Trinity Hospital	DMPH	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	None
PY5	Trinity Hospital	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	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	None
PY5	Trinity Hospital	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	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	None
PY5	Trinity Hospital	DMPH	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	None
PY5	Trinity Hospital	DMPH	Q-CAD1	Q-HBD	Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) (CDC-H9)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	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	None
PY5	Trinity Hospital	DMPH	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	None
PY5	Trinity Hospital	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	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	None
PY5	Trinity Hospital	DMPH	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	None
PY5	Trinity Hospital	DMPH	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	None
PY5	Trinity Hospital	DMPH	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	None
PY5	Trinity Hospital	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	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	None
PY5	Trinity Hospital	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	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	None
PY5	Trinity Hospital	DMPH	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	None
PY5	Trinity Hospital	DMPH	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	None
PY5	Trinity Hospital	DMPH	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	None
PY5	Trinity Hospital	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Reported	0.1661	0	0.518	None	222	0	603	0	36.8%	0	N/A	N/A	No
PY5	Trinity Hospital	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.3013	0	0.3941	None	262	0	730	0	35.9%	0	0	0	Yes
PY5	Trinity Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Trinity Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	29	0	78	0	37.2%	0	N/A	None	None
PY5	Trinity Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Trinity Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Trinity Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	232	0	638	0	36.4%	0	N/A	None	None
PY5	Trinity Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Trinity Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Trinity Hospital	DMPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	262	0	730	0	35.9%	0	N/A	None	None
PY5	Trinity Hospital	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Trinity Hospital	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	260	0	713	0	36.5%	0	N/A	None	None
PY5	Trinity Hospital	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Trinity Hospital	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	262	0	730	0	35.9%	0	N/A	None	None
PY5	Trinity Hospital	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	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	None
PY5	Trinity Hospital	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	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	None
PY5	Trinity Hospital	DMPH	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	None
PY5	Trinity Hospital	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Trinity Hospital	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Davis Medical Center	DPH	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Reported	None	2	0.0848	None	None	1	124	0	None	1	1	N/A	Yes
PY5	UC Davis Medical Center	DPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Davis Medical Center	DPH	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	None
PY5	UC Davis Medical Center	DPH	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Reported	None	2	0.0318	None	None	1	86	0	None	1	1	0.5	Yes
PY5	UC Davis Medical Center	DPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Davis Medical Center	DPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Davis Medical Center	DPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.6279	0	0.6319	None	141	0	209	0	67.5%	0	1	0.5	Yes
PY5	UC Davis Medical Center	DPH	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	0.8143	0	0.8249	None	765	0	914	0	83.7%	0	1	0.5	Yes
PY5	UC Davis Medical Center	DPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Davis Medical Center	DPH	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	None
PY5	UC Davis Medical Center	DPH	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	None
PY5	UC Davis Medical Center	DPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	0.3939	0	0.3886	None	28	0	67	0	41.8%	0	0	0	YesS
PY5	UC Davis Medical Center	DPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	0.4	0	0.3941	None	34	0	96	0	35.4%	0	1	0.5	YesS
PY5	UC Davis Medical Center	DPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.3322	0	0.3406	None	110	0	325	0	33.9%	0	1	N/A	YesS
PY5	UC Davis Medical Center	DPH	Q-CAD1	Q-HBD	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	0.6667	N/A	Yes
PY5	UC Davis Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	31	0	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	28	0	67	0	41.8%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	21	0	79	0	26.6%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	45	0	128	0	35.2%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	110	0	325	0	33.9%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	34	0	96	0	35.4%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	64	0	200	0	32.0%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	12	0	None	4	None	4	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	110	0	325	0	33.9%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.6784	0	0.6302	None	213	0	325	0	65.5%	0	1	N/A	Yes
PY5	UC Davis Medical Center	DPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Davis Medical Center	DPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Davis Medical Center	DPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Reported	0.5854	0	0.6022	None	46	0	71	0	64.8%	0	1	0.5	Yes
PY5	UC Davis Medical Center	DPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Davis Medical Center	DPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Reported	0.9965	0	0.78	None	252	0	257	0	98.1%	0	1	N/A	Yes
PY5	UC Davis Medical Center	DPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Reported	0.7588	0	0	None	18	0	17.5607	0	1.025	0	0	N/A	Yes
PY5	UC Davis Medical Center	DPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Davis Medical Center	DPH	Q-IHE1	Q-IHE1	▶ Controlling High Blood Pressure (CBP) - -Black/African American	Reported	0.5769	0	0.586	None	27	0	44	0	61.4%	0	1	0.5	YesS
PY5	UC Davis Medical Center	DPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	1	0.5	Yes
PY5	UC Davis Medical Center	DPH	Q-IHE2	Q-IHE2	▶ Exclusive Breast Milk Feeding (PC-05) - -Black/African American	Reported	0.4267	0	0.4776	None	19	0	37	0	51.4%	0	1	0	YesS
PY5	UC Davis Medical Center	DPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	1	0	Yes
PY5	UC Davis Medical Center	DPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Davis Medical Center	DPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Reported	0.5101	0	0.5353	None	169	0	310	0	54.5%	0	1	0	Yes
PY5	UC Davis Medical Center	DPH	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Reported	0.7222	0	0.7337	None	38	0	51	0	74.5%	0	1	0	Yes
PY5	UC Davis Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : White	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	18	0	None	4	None	4	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	Reported	N/A	3	N/A	3	38	0	51	0	74.5%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	13	0	None	4	None	4	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	22	0	31	0	71.0%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	38	0	51	0	74.5%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Reported	0.7593	0	0.7932	None	46	0	51	0	90.2%	0	1	1	Yes
PY5	UC Davis Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : White	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	22	0	None	4	None	4	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Total	Reported	N/A	3	N/A	3	46	0	51	0	90.2%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	14	0	None	4	None	4	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	28	0	31	0	90.3%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	46	0	51	0	90.2%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Reported	0.549	0	0.4576	None	25	0	50	0	50.0%	0	1	N/A	Yes
PY5	UC Davis Medical Center	DPH	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	None
PY5	UC Davis Medical Center	DPH	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	None
PY5	UC Davis Medical Center	DPH	Q-OA3	Q-QPP415	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older	Reported	0.9169	0	0.9172	None	728	0	792	0	91.9%	0	1	0.5	Yes
PY5	UC Davis Medical Center	DPH	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Reported	0.8444	0	0.8282	None	59	0	67	0	88.1%	0	1	N/A	Yes
PY5	UC Davis Medical Center	DPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.5372	0	0.5473	None	172	0	309	0	55.7%	0	1	0.25	Yes
PY5	UC Davis Medical Center	DPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Davis Medical Center	DPH	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	None
PY5	UC Davis Medical Center	DPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Davis Medical Center	DPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.4645	0	0.5079	None	2603	0	4388	0	59.3%	0	1	0	Yes
PY5	UC Davis Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 2	Reported	0.4267	0	0.476	None	1571	0	2384	0	65.9%	0	1	0	YesS
PY5	UC Davis Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 3	Reported	0.8451	0	0.8558	None	15566	0	17731	0	87.8%	0	1	0.5	YesS
PY5	UC Davis Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 1 (informational only)	Reported	0.9262	0	0	None	16416	0	17768	0	92.4%	0	N/A	N/A	YesI
PY5	UC Davis Medical Center	DPH	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	0	Yes
PY5	UC Davis Medical Center	DPH	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	None
PY5	UC Davis Medical Center	DPH	Q-PC16	Q-W30	▶ 15 Months-30 Months	Reported	0.3167	0	0.6643	None	35	0	116	0	30.2%	0	0	0	YesS
PY5	UC Davis Medical Center	DPH	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	0	0	Yes
PY5	UC Davis Medical Center	DPH	Q-PC16	Q-W30	▶ First 15 Months	Reported	None	2	0.4499	None	None	1	None	4	None	1	N/A	N/A	YesS
PY5	UC Davis Medical Center	DPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Davis Medical Center	DPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.2723	0	0.3941	None	497	0	1863	0	26.7%	0	0	0	Yes
PY5	UC Davis Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	31	0	85	0	36.5%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	85	0	198	0	42.9%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	67	0	230	0	29.1%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	37	0	92	0	40.2%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	273	0	1245	0	21.9%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	497	0	1863	0	26.7%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	159	0	396	0	40.2%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	218	0	598	0	36.5%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	120	0	869	0	13.8%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	497	0	1863	0	26.7%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Reported	0.195	0	0.3187	None	14	0	55	0	25.5%	0	0	0	Yes
PY5	UC Davis Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : White	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Total	Reported	N/A	3	N/A	3	14	0	55	0	25.5%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	14	0	55	0	25.5%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Reported	0.6111	0	0.6161	None	38	0	80	0	47.5%	0	0	0	Yes
PY5	UC Davis Medical Center	DPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.4433	0	0.4594	None	1641	0	3000	0	54.7%	0	1	0.5	Yes
PY5	UC Davis Medical Center	DPH	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Reported	0.079	0	0.1765	None	39	0	152	0	25.7%	0	1	1	Yes
PY5	UC Davis Medical Center	DPH	Q-PC8	Q-CMS349	HIV Screening Measure	Reported	0.7977	0	0.6263	None	1194	0	1464	0	81.6%	0	1	N/A	Yes
PY5	UC Davis Medical Center	DPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Reported	0.2308	0	0.309	None	21	0	105	0	20.0%	0	0	0	Yes
PY5	UC Davis Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : White	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	17	0	69	0	24.6%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Total	Reported	N/A	3	N/A	3	21	0	105	0	20.0%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	35	0	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	47	0	None	1	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	21	0	105	0	20.0%	0	N/A	None	None
PY5	UC Davis Medical Center	DPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Reported	0.9307	0	0.9918	None	128	0	128	0	100.0%	0	1	0.5	Yes
PY5	UC Davis Medical Center	DPH	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Reported	0.9772	0	0.92	None	4273	0	4398	0	97.2%	0	1	N/A	Yes
PY5	UC Davis Medical Center	DPH	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	None
PY5	UC Davis Medical Center	DPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Davis Medical Center	DPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Irvine Medical Center	DPH	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Reported	0.0548	0	0.0848	None	16	0	269	0	6.0%	0	1	N/A	Yes
PY5	UC Irvine Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adults)	Reported	0.1392	0	0.1405	None	45	0	298	0	15.1%	0	1	0.5	YesS
PY5	UC Irvine Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adults)	Reported	0.1701	0	0.1792	None	55	0	298	0	18.5%	0	1	0.25	YesS
PY5	UC Irvine Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adults)	Reported	0.299	0	0.3605	None	107	0	298	0	35.9%	0	0	0	YesS
PY5	UC Irvine Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adolescents) - informational only	Reported	None	2	N/A	None	0	0	None	4	None	4	N/A	N/A	YesI
PY5	UC Irvine Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adolescents) - informational only	Reported	None	2	N/A	None	None	1	None	4	None	1	N/A	N/A	YesI
PY5	UC Irvine Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adolescents) - informational only	Reported	None	2	N/A	None	None	1	None	4	None	1	N/A	N/A	YesI
PY5	UC Irvine Medical Center	DPH	Q-BH2	Q-DRR-E	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	0.6667	0	Yes
PY5	UC Irvine Medical Center	DPH	Q-BH3	Q-FUA	▶ 30 Days	Reported	0.1348	0	0.1539	None	33	0	119	0	27.7%	0	1	0.5	YesS
PY5	UC Irvine Medical Center	DPH	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	0.5	Yes
PY5	UC Irvine Medical Center	DPH	Q-BH3	Q-FUA	▶ 7 Days	Reported	None	2	0.0938	None	17	0	119	0	14.3%	0	1	0.5	YesS
PY5	UC Irvine Medical Center	DPH	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	None
PY5	UC Irvine Medical Center	DPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Irvine Medical Center	DPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Irvine Medical Center	DPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.5797	0	0.5885	None	918	0	1423	0	64.5%	0	1	0.5	Yes
PY5	UC Irvine Medical Center	DPH	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	0.8271	0	0.8364	None	960	0	1163	0	82.6%	0	0	0	Yes
PY5	UC Irvine Medical Center	DPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.8467	0	0.854	None	1832	0	2176	0	84.2%	0	0	0	Yes
PY5	UC Irvine Medical Center	DPH	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	0.8367	0	0.8408	None	554	0	665	0	83.3%	0	0	0	Yes
PY5	UC Irvine Medical Center	DPH	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Reported	0.7243	0	0.7357	None	1451	0	2019	0	71.9%	0	0	0	Yes
PY5	UC Irvine Medical Center	DPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	None	2	0.3406	None	12	0	42	0	28.6%	0	1	N/A	YesS
PY5	UC Irvine Medical Center	DPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	0.3216	0	0.3406	None	420	0	1275	0	32.9%	0	1	N/A	YesS
PY5	UC Irvine Medical Center	DPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.32	0	0.3406	None	564	0	1686	0	33.5%	0	1	N/A	YesS
PY5	UC Irvine Medical Center	DPH	Q-CAD1	Q-HBD	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	N/A	Yes
PY5	UC Irvine Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	32	0	126	0	25.4%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	11	0	40	0	27.5%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	399	0	1185	0	33.7%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	35	0	94	0	37.2%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	79	0	222	0	35.6%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	564	0	1686	0	33.5%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	420	0	1275	0	32.9%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	141	0	404	0	34.9%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	564	0	1686	0	33.5%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.3129	0	0.4501	None	403	0	1688	0	23.9%	0	0	0	Yes
PY5	UC Irvine Medical Center	DPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Reported	0.6056	0	0.4676	None	831	0	1577	0	52.7%	0	1	N/A	Yes
PY5	UC Irvine Medical Center	DPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Reported	0.7382	0	0.773	None	233	0	344	0	67.7%	0	0	0	Yes
PY5	UC Irvine Medical Center	DPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Reported	0.7052	0	0.71	None	143	0	172	0	83.1%	0	1	0.5	Yes
PY5	UC Irvine Medical Center	DPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Irvine Medical Center	DPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Reported	0.999	0	0.78	None	1192	0	1206	0	98.8%	0	1	N/A	Yes
PY5	UC Irvine Medical Center	DPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Reported	0.8281	0	0	None	40	0	52.74	0	0.7584	0	1	N/A	Yes
PY5	UC Irvine Medical Center	DPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Irvine Medical Center	DPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Irvine Medical Center	DPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Irvine Medical Center	DPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Reported	0.1756	0	0.22	None	47	0	285	0	16.5%	0	1	N/A	Yes
PY5	UC Irvine Medical Center	DPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Reported	0.6059	0	0.6215	None	126	0	173	0	72.8%	0	1	0.5	Yes
PY5	UC Irvine Medical Center	DPH	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Reported	0.8225	0	0.824	None	388	0	472	0	82.2%	0	0	0	Yes
PY5	UC Irvine Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	Reported	N/A	3	N/A	3	23	0	30	0	76.7%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : White	Reported	N/A	3	N/A	3	269	0	326	0	82.5%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	22	0	None	4	None	4	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	64	0	80	0	80.0%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	Reported	N/A	3	N/A	3	388	0	472	0	82.2%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	278	0	338	0	82.3%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	105	0	129	0	81.4%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	388	0	472	0	82.2%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Reported	0.7528	0	0.7932	None	368	0	472	0	78.0%	0	0	0	Yes
PY5	UC Irvine Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Asian	Reported	N/A	3	N/A	3	26	0	30	0	86.7%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : White	Reported	N/A	3	N/A	3	254	0	326	0	77.9%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	22	0	None	4	None	4	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	55	0	80	0	68.8%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Total	Reported	N/A	3	N/A	3	368	0	472	0	78.0%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	261	0	338	0	77.2%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	106	0	129	0	82.2%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	368	0	472	0	78.0%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Reported	0.4863	0	0.4576	None	199	0	483	0	41.2%	0	0	0	Yes
PY5	UC Irvine Medical Center	DPH	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Reported	0.9809	0	0.9434	None	1092	0	1117	0	97.8%	0	1	N/A	Yes
PY5	UC Irvine Medical Center	DPH	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	None
PY5	UC Irvine Medical Center	DPH	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	None
PY5	UC Irvine Medical Center	DPH	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Reported	0.9337	0	0.8282	None	494	0	522	0	94.6%	0	1	N/A	Yes
PY5	UC Irvine Medical Center	DPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.5255	0	0.5367	None	723	0	1287	0	56.2%	0	1	0.5	Yes
PY5	UC Irvine Medical Center	DPH	Q-PC10	Q-LSC	Lead Screening in Children	Reported	0.4602	0	0.6131	None	210	0	393	0	53.4%	0	0	0	Yes
PY5	UC Irvine Medical Center	DPH	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Reported	0.4411	0	0.4955	None	7198	0	17318	0	41.6%	0	0	0	Yes
PY5	UC Irvine Medical Center	DPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.5575	0	0.5916	None	8997	0	15939	0	56.5%	0	0	0	Yes
PY5	UC Irvine Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 2	Reported	0.3246	0	0.3841	None	620	0	1748	0	35.5%	0	0.5	0	YesS
PY5	UC Irvine Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 3	Reported	0.9157	0	0.9194	None	22906	0	24868	0	92.1%	0	1	0	YesS
PY5	UC Irvine Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 1 (informational only)	Reported	0.967	0	0	None	24298	0	25132	0	96.7%	0	N/A	N/A	YesI
PY5	UC Irvine Medical Center	DPH	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	0.75	0	Yes
PY5	UC Irvine Medical Center	DPH	Q-PC15	Q-WCC	▶ Counseling for Physical Activity	Reported	0.8142	0	0.7932	None	2935	0	3669	0	80.0%	0	1	N/A	YesS
PY5	UC Irvine Medical Center	DPH	Q-PC15	Q-WCC	▶ Counseling for Nutrition	Reported	0.816	0	0.8169	None	2940	0	3669	0	80.1%	0	0	0	YesS
PY5	UC Irvine Medical Center	DPH	Q-PC15	Q-WCC	▶ BMI	Reported	0.9838	0	0.8718	None	3641	0	3669	0	99.2%	0	1	N/A	YesS
PY5	UC Irvine Medical Center	DPH	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	0.6667	N/A	Yes
PY5	UC Irvine Medical Center	DPH	Q-PC16	Q-W30	▶ First 15 Months	Reported	0.6339	0	0.6388	None	160	0	199	0	80.4%	0	1	1	YesS
PY5	UC Irvine Medical Center	DPH	Q-PC16	Q-W30	▶ 15 Months-30 Months	Reported	0.6485	0	0.6665	None	306	0	417	0	73.4%	0	1	1	YesS
PY5	UC Irvine Medical Center	DPH	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	1	Yes
PY5	UC Irvine Medical Center	DPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Reported	0.5345	0	0.549	None	3829	0	6930	0	55.3%	0	1	0	Yes
PY5	UC Irvine Medical Center	DPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.4494	0	0.4664	None	3128	0	6921	0	45.2%	0	0	0	Yes
PY5	UC Irvine Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	159	0	298	0	53.4%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	73	0	144	0	50.7%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	12	0	None	4	None	4	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	2357	0	4771	0	49.4%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	40	0	108	0	37.0%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	483	0	1564	0	30.9%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	3128	0	6921	0	45.2%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	2527	0	5088	0	49.7%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	582	0	1216	0	47.9%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	19	0	617	0	3.1%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	3128	0	6921	0	45.2%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Reported	0.5505	0	0.5366	None	201	0	391	0	51.4%	0	0	0	Yes
PY5	UC Irvine Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Asian	Reported	N/A	3	N/A	3	12	0	None	4	None	4	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : White	Reported	N/A	3	N/A	3	129	0	246	0	52.4%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	46	0	99	0	46.5%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Total	Reported	N/A	3	N/A	3	201	0	391	0	51.4%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	149	0	283	0	52.7%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	50	0	88	0	56.8%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	201	0	391	0	51.4%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Reported	0.6414	0	0.6434	None	543	0	825	0	65.8%	0	1	1	Yes
PY5	UC Irvine Medical Center	DPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.5214	0	0.5297	None	3129	0	6693	0	46.8%	0	0	0	Yes
PY5	UC Irvine Medical Center	DPH	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Reported	0.4443	0	0.3665	None	585	0	981	0	59.6%	0	1	1	Yes
PY5	UC Irvine Medical Center	DPH	Q-PC8	Q-CMS349	HIV Screening Measure	Reported	0.5896	0	0.5933	None	6732	0	9457	0	71.2%	0	1	0.5	Yes
PY5	UC Irvine Medical Center	DPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Reported	0.3902	0	0.4018	None	92	0	292	0	31.5%	0	0	0	Yes
PY5	UC Irvine Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : White	Reported	N/A	3	N/A	3	73	0	205	0	35.6%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	17	0	68	0	25.0%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Total	Reported	N/A	3	N/A	3	92	0	292	0	31.5%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	79	0	218	0	36.2%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	13	0	50	0	26.0%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	0	0	None	4	None	4	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	92	0	292	0	31.5%	0	N/A	None	None
PY5	UC Irvine Medical Center	DPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Reported	0.936	0	0.9918	None	215	0	227	0	94.7%	0	0	0	Yes
PY5	UC Irvine Medical Center	DPH	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Reported	0.972	0	0.92	None	4066	0	4122	0	98.6%	0	1	N/A	Yes
PY5	UC Irvine Medical Center	DPH	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	None
PY5	UC Irvine Medical Center	DPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Irvine Medical Center	DPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Reported	0.8666	0	0	None	22	0	36.524	0	0.6023	0	1	N/A	Yes
PY5	UC Los Angeles Medical Center	DPH	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	None
PY5	UC Los Angeles Medical Center	DPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Los Angeles Medical Center	DPH	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	None
PY5	UC Los Angeles Medical Center	DPH	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	None
PY5	UC Los Angeles Medical Center	DPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.7089	0	0.6679	None	55	0	78	0	70.5%	0	1	N/A	Yes
PY5	UC Los Angeles Medical Center	DPH	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	0.8045	0	0.816	None	1400	0	1717	0	81.5%	0	0.75	0	Yes
PY5	UC Los Angeles Medical Center	DPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Los Angeles Medical Center	DPH	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	0.5909	0	0.6969	None	587	0	736	0	79.8%	0	1	0.5	Yes
PY5	UC Los Angeles Medical Center	DPH	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	None
PY5	UC Los Angeles Medical Center	DPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	None	2	N/A	None	None	1	None	1	None	1	N/A	N/A	YesS
PY5	UC Los Angeles Medical Center	DPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	None	2	N/A	None	None	1	None	4	None	1	N/A	N/A	YesS
PY5	UC Los Angeles Medical Center	DPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.2941	None	0.3406	None	15	0	46	0	32.6%	0	1	N/A	YesS
PY5	UC Los Angeles Medical Center	DPH	Q-CAD1	Q-HBD	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	N/A	Yes
PY5	UC Los Angeles Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	15	0	46	0	32.6%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	15	0	46	0	32.6%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.5513	0	0.4501	None	19	0	46	0	41.3%	0	0	0	Yes
PY5	UC Los Angeles Medical Center	DPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Reported	0.4783	0	0.4676	None	23	0	43	0	53.5%	0	1	N/A	Yes
PY5	UC Los Angeles Medical Center	DPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Reported	1	0	0.78	None	42	0	42	0	100.0%	0	1	N/A	Yes
PY5	UC Los Angeles Medical Center	DPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	0.336	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	1	0	Yes
PY5	UC Los Angeles Medical Center	DPH	Q-IHE1	Q-IHE1	▶ Colorectal Cancer Screening - -Native Hawaiian/Pacific Islander	Reported	None	2	0.3059	None	14	0	38	0	36.8%	0	1	0	YesS
PY5	UC Los Angeles Medical Center	DPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Reported	0.2713	0	0.2481	None	33	0	168	0	19.6%	0	1	0.5	Yes
PY5	UC Los Angeles Medical Center	DPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Reported	0.491	0	0.5181	None	167	0	343	0	48.7%	0	0	0	Yes
PY5	UC Los Angeles Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : White	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Reported	None	2	N/A	None	None	1	None	1	None	1	0	0	Yes
PY5	UC Los Angeles Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : White	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Total	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Reported	None	2	N/A	None	None	1	None	1	None	1	0	0	Yes
PY5	UC Los Angeles Medical Center	DPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Reported	0.9787	0	0.9434	None	397	0	411	0	96.6%	0	1	N/A	Yes
PY5	UC Los Angeles Medical Center	DPH	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	None
PY5	UC Los Angeles Medical Center	DPH	Q-OA3	Q-QPP415	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older	Reported	0.9185	0	0.9186	None	321	0	377	0	85.2%	0	0	0	Yes
PY5	UC Los Angeles Medical Center	DPH	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	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.5306	0	0.5413	None	48	0	93	0	51.6%	0	0	0	Yes
PY5	UC Los Angeles Medical Center	DPH	Q-PC10	Q-LSC	Lead Screening in Children	Reported	0.5026	0	0.6131	None	94	0	181	0	51.9%	0	0	0	Yes
PY5	UC Los Angeles Medical Center	DPH	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	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.1924	0	0.5004	None	5873	0	30834	0	19.1%	0	0	0	Yes
PY5	UC Los Angeles Medical Center	DPH	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	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC15	Q-WCC	▶ Counseling for Nutrition	Reported	0.1704	0	0.6107	None	1671	0	2806	0	59.6%	0	0	0	YesS
PY5	UC Los Angeles Medical Center	DPH	Q-PC15	Q-WCC	▶ Counseling for Physical Activity	Reported	0.1733	0	0.5579	None	1384	0	2806	0	49.3%	0	0	0	YesS
PY5	UC Los Angeles Medical Center	DPH	Q-PC15	Q-WCC	▶ BMI	Reported	0.318	0	0.6919	None	2601	0	2806	0	92.7%	0	1	0.5	YesS
PY5	UC Los Angeles Medical Center	DPH	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	0.3333	0	Yes
PY5	UC Los Angeles Medical Center	DPH	Q-PC16	Q-W30	▶ First 15 Months	Reported	0.5385	0	0.553	None	27	0	41	0	65.9%	0	1	1	YesS
PY5	UC Los Angeles Medical Center	DPH	Q-PC16	Q-W30	▶ 15 Months-30 Months	Reported	0.5944	0	0.6643	None	150	0	209	0	71.8%	0	1	1	YesS
PY5	UC Los Angeles Medical Center	DPH	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	1	Yes
PY5	UC Los Angeles Medical Center	DPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Reported	0.5513	0	0.5642	None	121	0	248	0	48.8%	0	0	0	Yes
PY5	UC Los Angeles Medical Center	DPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.5257	0	0.5351	None	2260	0	4339	0	52.1%	0	0	0	Yes
PY5	UC Los Angeles Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	12	0	33	0	36.4%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	106	0	186	0	57.0%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	185	0	355	0	52.1%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	712	0	1445	0	49.3%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	154	0	259	0	59.5%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	1085	0	2051	0	52.9%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	2260	0	4339	0	52.1%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	1295	0	2343	0	55.3%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	797	0	1576	0	50.6%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	168	0	420	0	40.0%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	2260	0	4339	0	52.1%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Reported	0.3968	0	0.4108	None	84	0	177	0	47.5%	0	1	1	Yes
PY5	UC Los Angeles Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : White	Reported	N/A	3	N/A	3	11	0	None	4	None	4	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	53	0	112	0	47.3%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Total	Reported	N/A	3	N/A	3	84	0	177	0	47.5%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	50	0	93	0	53.8%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	29	0	74	0	39.2%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	84	0	177	0	47.5%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Reported	0.5513	0	0.5623	None	89	0	175	0	50.9%	0	0	0	Yes
PY5	UC Los Angeles Medical Center	DPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.336	0	0.3629	None	4977	0	14750	0	33.7%	0	0	0	Yes
PY5	UC Los Angeles Medical Center	DPH	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Reported	0.1679	0	0.1878	None	87	0	455	0	19.1%	0	1	0	Yes
PY5	UC Los Angeles Medical Center	DPH	Q-PC8	Q-CMS349	HIV Screening Measure	Reported	0.4234	0	0.4437	None	499	0	1144	0	43.6%	0	0.5	0	Yes
PY5	UC Los Angeles Medical Center	DPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Reported	0.3562	0	0.3712	None	96	0	257	0	37.4%	0	1	0	Yes
PY5	UC Los Angeles Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : White	Reported	N/A	3	N/A	3	39	0	121	0	32.2%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	41	0	93	0	44.1%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Total	Reported	N/A	3	N/A	3	96	0	257	0	37.4%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	62	0	143	0	43.4%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	28	0	95	0	29.5%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	96	0	257	0	37.4%	0	N/A	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC Los Angeles Medical Center	DPH	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Reported	0.6533	0	0.68	None	2890	0	3467	0	83.4%	0	1	0	Yes
PY5	UC Los Angeles Medical Center	DPH	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Reported	0.4999	0	0.5419	None	1660	0	2780	0	59.7%	0	1	0	Yes
PY5	UC Los Angeles Medical Center	DPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Reported	0.8976	0	0	None	62	0	108.75	0	0.5701	0	0	N/A	Yes
PY5	UC Los Angeles Medical Center	DPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC San Diego Medical Center	DPH	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Reported	0.1927	0	0.1415	None	11	0	99	0	11.1%	0	1	0.5	Yes
PY5	UC San Diego Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adolescents) - informational only	Reported	0	0	N/A	None	0	0	None	1	None	1	N/A	N/A	YesI
PY5	UC San Diego Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adolescents) - informational only	Reported	0	0	N/A	None	0	0	None	1	None	1	N/A	N/A	YesI
PY5	UC San Diego Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adolescents) - informational only	Reported	0	0	N/A	None	None	1	None	1	None	1	N/A	N/A	YesI
PY5	UC San Diego Medical Center	DPH	Q-BH2	Q-DRR-E	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	0	0	Yes
PY5	UC San Diego Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adults)	Reported	None	2	N/A	None	11	0	87	0	12.6%	0	0	0	YesS
PY5	UC San Diego Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adults)	Reported	None	2	N/A	None	18	0	87	0	20.7%	0	0	0	YesS
PY5	UC San Diego Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adults)	Reported	None	2	N/A	None	52	0	87	0	59.8%	0	0	0	YesS
PY5	UC San Diego Medical Center	DPH	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	None
PY5	UC San Diego Medical Center	DPH	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Reported	None	2	0.0397	None	None	1	82	0	None	1	0	0	Yes
PY5	UC San Diego Medical Center	DPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC San Diego Medical Center	DPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Reported	None	2	N/A	None	None	1	None	1	None	1	0	0	Yes
PY5	UC San Diego Medical Center	DPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.6585	0	0.6594	None	187	0	277	0	67.5%	0	1	0.5	Yes
PY5	UC San Diego Medical Center	DPH	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	0.7972	0	0.8095	None	1028	0	1265	0	81.3%	0	1	0	Yes
PY5	UC San Diego Medical Center	DPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.8422	0	0.85	None	2504	0	2996	0	83.6%	0	0	0	Yes
PY5	UC San Diego Medical Center	DPH	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	0.766	0	0.7772	None	893	0	1130	0	79.0%	0	1	0.5	Yes
PY5	UC San Diego Medical Center	DPH	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Reported	0.619	0	0.6667	None	287	0	385	0	74.6%	0	1	0.5	Yes
PY5	UC San Diego Medical Center	DPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	None	2	N/A	None	None	1	None	4	None	1	N/A	N/A	YesS
PY5	UC San Diego Medical Center	DPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	None	2	0.3406	None	None	1	39	0	None	1	1	N/A	YesS
PY5	UC San Diego Medical Center	DPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.2299	0	0.3406	None	38	0	188	0	20.2%	0	1	N/A	YesS
PY5	UC San Diego Medical Center	DPH	Q-CAD1	Q-HBD	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	N/A	Yes
PY5	UC San Diego Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	17	0	80	0	21.3%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	13	0	55	0	23.6%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	38	0	188	0	20.2%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	38	0	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	27	0	146	0	18.5%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	38	0	188	0	20.2%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.5862	0	0.5906	None	113	0	188	0	60.1%	0	1	0.5	Yes
PY5	UC San Diego Medical Center	DPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Reported	0.5754	0	0.4676	None	112	0	193	0	58.0%	0	1	N/A	Yes
PY5	UC San Diego Medical Center	DPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Reported	0.8039	0	0.8072	None	114	0	129	0	88.4%	0	1	0.5	Yes
PY5	UC San Diego Medical Center	DPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Reported	0.8478	0	0.7532	None	28	0	33	0	84.9%	0	1	N/A	Yes
PY5	UC San Diego Medical Center	DPH	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	0	Yes
PY5	UC San Diego Medical Center	DPH	Q-CAR2	Q-PCE	▶ Bronchodilator	Reported	None	2	N/A	None	None	1	None	1	None	1	0	0	YesS
PY5	UC San Diego Medical Center	DPH	Q-CAR2	Q-PCE	▶ Systemic Corticosteroid	Reported	None	2	N/A	None	None	1	None	1	None	1	0	0	YesS
PY5	UC San Diego Medical Center	DPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Reported	1	0	0.78	None	128	0	128	0	100.0%	0	1	N/A	Yes
PY5	UC San Diego Medical Center	DPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Reported	0.698	0	0	None	8	0	9.079	0	0.8812	0	1	N/A	Yes
PY5	UC San Diego Medical Center	DPH	Q-EC1	Q-QPP47	Advance Care Plan	Reported	0.4174	0	0.4799	None	5432	0	10574	0	51.4%	0	1	0	Yes
PY5	UC San Diego Medical Center	DPH	Q-IHE1	Q-IHE1	▶ Child and Adolescent Well Care Visits - -Black/African American	Reported	0.3611	0	0.3941	None	42	0	95	0	44.2%	0	1	0	YesS
PY5	UC San Diego Medical Center	DPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	1	0	Yes
PY5	UC San Diego Medical Center	DPH	Q-IHE2	Q-IHE2	▶ HIV Viral Suppression (HVL-AD) - -Hispanic/Latino	Reported	0.7692	0	0.776	None	30	0	35	0	85.7%	0	1	0.5	YesS
PY5	UC San Diego Medical Center	DPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	1	0.5	Yes
PY5	UC San Diego Medical Center	DPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC San Diego Medical Center	DPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Reported	0.7205	0	0.7247	None	892	0	1193	0	74.8%	0	1	0.5	Yes
PY5	UC San Diego Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : White	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Reported	None	2	N/A	None	None	1	None	4	None	1	0	0	Yes
PY5	UC San Diego Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Asian	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : White	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Total	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Reported	None	2	N/A	None	None	1	None	4	None	1	0	0	Yes
PY5	UC San Diego Medical Center	DPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC San Diego Medical Center	DPH	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	None
PY5	UC San Diego Medical Center	DPH	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	None
PY5	UC San Diego Medical Center	DPH	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	None
PY5	UC San Diego Medical Center	DPH	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	None
PY5	UC San Diego Medical Center	DPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.5931	0	0.5976	None	228	0	329	0	69.3%	0	1	0.5	Yes
PY5	UC San Diego Medical Center	DPH	Q-PC10	Q-LSC	Lead Screening in Children	Reported	0.5732	0	0.6131	None	125	0	170	0	73.5%	0	1	0.5	Yes
PY5	UC San Diego Medical Center	DPH	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Reported	0.4581	0	0.5052	None	1777	0	4406	0	40.3%	0	0	0	Yes
PY5	UC San Diego Medical Center	DPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.6633	0	0.6869	None	1787	0	2492	0	71.7%	0	1	1	Yes
PY5	UC San Diego Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 2	Reported	0.4345	0	0.483	None	1289	0	2325	0	55.4%	0	1	0	YesS
PY5	UC San Diego Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 3	Reported	0.8688	0	0.8772	None	22302	0	24439	0	91.3%	0	1	0.5	YesS
PY5	UC San Diego Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 1 (informational only)	Reported	0.9332	0	0	None	23743	0	24844	0	95.6%	0	N/A	N/A	YesI
PY5	UC San Diego Medical Center	DPH	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	0	Yes
PY5	UC San Diego Medical Center	DPH	Q-PC15	Q-WCC	▶ Counseling for Physical Activity	Reported	0.6006	0	0.6199	None	622	0	947	0	65.7%	0	1	0	YesS
PY5	UC San Diego Medical Center	DPH	Q-PC15	Q-WCC	▶ Counseling for Nutrition	Reported	0.6149	0	0.6359	None	638	0	947	0	67.4%	0	1	0	YesS
PY5	UC San Diego Medical Center	DPH	Q-PC15	Q-WCC	▶ BMI	Reported	0.6513	0	0.6919	None	748	0	947	0	79.0%	0	1	0.5	YesS
PY5	UC San Diego Medical Center	DPH	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	0	Yes
PY5	UC San Diego Medical Center	DPH	Q-PC16	Q-W30	▶ First 15 Months	Reported	0.4151	0	0.4499	None	25	0	34	0	73.5%	0	1	1	YesS
PY5	UC San Diego Medical Center	DPH	Q-PC16	Q-W30	▶ 15 Months-30 Months	Reported	0.6481	0	0.6661	None	128	0	181	0	70.7%	0	1	1	YesS
PY5	UC San Diego Medical Center	DPH	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	1	Yes
PY5	UC San Diego Medical Center	DPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Reported	0.5964	0	0.6048	None	493	0	791	0	62.3%	0	1	0.5	Yes
PY5	UC San Diego Medical Center	DPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.4667	0	0.482	None	764	0	1539	0	49.6%	0	1	0.5	Yes
PY5	UC San Diego Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	54	0	99	0	54.6%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	42	0	95	0	44.2%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	248	0	462	0	53.7%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	20	0	37	0	54.1%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	393	0	835	0	47.1%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	764	0	1539	0	49.6%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	245	0	463	0	52.9%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	349	0	674	0	51.8%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	170	0	402	0	42.3%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	764	0	1539	0	49.6%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Reported	0.1585	0	0.3187	None	70	0	169	0	41.4%	0	1	1	Yes
PY5	UC San Diego Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Asian	Reported	N/A	3	N/A	3	12	0	None	4	None	4	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : White	Reported	N/A	3	N/A	3	30	0	66	0	45.5%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	19	0	65	0	29.2%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Total	Reported	N/A	3	N/A	3	70	0	169	0	41.4%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	24	0	59	0	40.7%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	44	0	92	0	47.8%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	70	0	169	0	41.4%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Reported	0.5588	0	0.5691	None	25	0	55	0	45.5%	0	0	0	Yes
PY5	UC San Diego Medical Center	DPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.7526	0	0.6046	None	1587	0	2096	0	75.7%	0	1	N/A	Yes
PY5	UC San Diego Medical Center	DPH	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Reported	0.4316	0	0.3665	None	251	0	384	0	65.4%	0	1	1	Yes
PY5	UC San Diego Medical Center	DPH	Q-PC8	Q-CMS349	HIV Screening Measure	Reported	0.553	0	0.5603	None	696	0	1092	0	63.7%	0	1	0.5	Yes
PY5	UC San Diego Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : White	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	13	0	38	0	34.2%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Total	Reported	N/A	3	N/A	3	21	0	60	0	35.0%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	21	0	60	0	35.0%	0	N/A	None	None
PY5	UC San Diego Medical Center	DPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Reported	None	2	0.309	None	21	0	60	0	35.0%	0	1	0	Yes
PY5	UC San Diego Medical Center	DPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC San Diego Medical Center	DPH	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Reported	0.9741	0	0.92	None	5628	0	5765	0	97.6%	0	1	N/A	Yes
PY5	UC San Diego Medical Center	DPH	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Reported	0.596	0	0.6284	None	2346	0	3035	0	77.3%	0	1	0	Yes
PY5	UC San Diego Medical Center	DPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC San Diego Medical Center	DPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC San Francisco Medical Center	DPH	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Reported	0.1474	0	0.1411	None	45	0	367	0	12.3%	0	1	0.5	Yes
PY5	UC San Francisco Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adults)	Reported	0.0988	0	0.1041	None	37	0	345	0	10.7%	0	1	0.25	YesS
PY5	UC San Francisco Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adults)	Reported	0.1698	0	0.1789	None	59	0	345	0	17.1%	0	0	0	YesS
PY5	UC San Francisco Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adults)	Reported	0.5247	0	0.5391	None	195	0	345	0	56.5%	0	1	0.5	YesS
PY5	UC San Francisco Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Remission (Adolescents) - informational only	Reported	None	2	N/A	None	0	0	None	4	None	4	N/A	N/A	YesI
PY5	UC San Francisco Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Depression Response (Adolescents) - informational only	Reported	None	2	N/A	None	0	0	None	4	None	4	N/A	N/A	YesI
PY5	UC San Francisco Medical Center	DPH	Q-BH2	Q-DRR-E	▶ Follow-Up PHQ-9 (Adolescents) - informational only	Reported	None	2	N/A	None	None	1	None	4	None	1	N/A	N/A	YesI
PY5	UC San Francisco Medical Center	DPH	Q-BH2	Q-DRR-E	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	0.6667	0	Yes
PY5	UC San Francisco Medical Center	DPH	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	0.5	Yes
PY5	UC San Francisco Medical Center	DPH	Q-BH3	Q-FUA	▶ 30 Days	Reported	None	2	0.2057	None	14	0	42	0	33.3%	0	1	0.5	YesS
PY5	UC San Francisco Medical Center	DPH	Q-BH3	Q-FUA	▶ 7 Days	Reported	None	2	0.0749	None	None	1	42	0	None	1	1	0.5	YesS
PY5	UC San Francisco Medical Center	DPH	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	None
PY5	UC San Francisco Medical Center	DPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC San Francisco Medical Center	DPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC San Francisco Medical Center	DPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.6171	0	0.6222	None	919	0	1398	0	65.7%	0	1	0.5	Yes
PY5	UC San Francisco Medical Center	DPH	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	0.8214	0	0.8313	None	854	0	1019	0	83.8%	0	1	0.25	Yes
PY5	UC San Francisco Medical Center	DPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC San Francisco Medical Center	DPH	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	0.8549	0	0.8572	None	578	0	661	0	87.4%	0	1	0.5	Yes
PY5	UC San Francisco Medical Center	DPH	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Reported	0.7338	0	0.7442	None	1210	0	1605	0	75.4%	0	1	0.25	Yes
PY5	UC San Francisco Medical Center	DPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	0.2948	0	0.3406	None	59	0	221	0	26.7%	0	1	N/A	YesS
PY5	UC San Francisco Medical Center	DPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	0.2832	0	0.3406	None	28	0	131	0	21.4%	0	1	N/A	YesS
PY5	UC San Francisco Medical Center	DPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.2475	0	0.3406	None	210	0	933	0	22.5%	0	1	N/A	YesS
PY5	UC San Francisco Medical Center	DPH	Q-CAD1	Q-HBD	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	N/A	Yes
PY5	UC San Francisco Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	52	0	311	0	16.7%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	55	0	201	0	27.4%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	42	0	149	0	28.2%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	11	0	49	0	22.5%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	43	0	201	0	21.4%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	210	0	933	0	22.5%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	28	0	131	0	21.4%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	172	0	786	0	21.9%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	210	0	933	0	22.5%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.5609	0	0.5678	None	551	0	935	0	58.9%	0	1	0.5	Yes
PY5	UC San Francisco Medical Center	DPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Reported	0.6039	0	0.4676	None	617	0	950	0	65.0%	0	1	N/A	Yes
PY5	UC San Francisco Medical Center	DPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Reported	0.9022	0	0.837	None	473	0	544	0	87.0%	0	1	N/A	Yes
PY5	UC San Francisco Medical Center	DPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Reported	0.6044	0	0.6193	None	113	0	198	0	57.1%	0	0	0	Yes
PY5	UC San Francisco Medical Center	DPH	Q-CAR2	Q-PCE	▶ Systemic Corticosteroid	Reported	0.5814	0	0.636	None	28	0	41	0	68.3%	0	1	0	YesS
PY5	UC San Francisco Medical Center	DPH	Q-CAR2	Q-PCE	▶ Bronchodilator	Reported	0.907	0	0.9057	None	39	0	41	0	95.1%	0	1	N/A	YesS
PY5	UC San Francisco Medical Center	DPH	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	N/A	Yes
PY5	UC San Francisco Medical Center	DPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Reported	1	0	0.78	None	714	0	729	0	97.9%	0	1	N/A	Yes
PY5	UC San Francisco Medical Center	DPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Reported	1.0055	0	0	None	29	0	36.8732	0	0.7865	0	1	N/A	Yes
PY5	UC San Francisco Medical Center	DPH	Q-EC1	Q-QPP47	Advance Care Plan	Reported	0.7868	0	0.8001	None	4522	0	12126	0	37.3%	0	0	0	Yes
PY5	UC San Francisco Medical Center	DPH	Q-IHE1	Q-IHE1	▶ Controlling High Blood Pressure (CBP) - -Black/African American	Reported	0.5481	0	0.5601	None	225	0	345	0	65.2%	0	1	0.5	YesS
PY5	UC San Francisco Medical Center	DPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	1	0.5	Yes
PY5	UC San Francisco Medical Center	DPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Reported	0.8069	0	0.8099	None	121	0	143	0	84.6%	0	1	1	Yes
PY5	UC San Francisco Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	Reported	N/A	3	N/A	3	23	0	None	4	None	4	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	Reported	N/A	3	N/A	3	32	0	43	0	74.4%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : White	Reported	N/A	3	N/A	3	23	0	None	4	None	4	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	37	0	42	0	88.1%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	Reported	N/A	3	N/A	3	121	0	143	0	84.6%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	26	0	None	4	None	4	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	92	0	112	0	82.1%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	121	0	143	0	84.6%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Reported	0.5586	0	0.7932	None	123	0	143	0	86.0%	0	1	1	Yes
PY5	UC San Francisco Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Asian	Reported	N/A	3	N/A	3	23	0	None	4	None	4	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Black or African American	Reported	N/A	3	N/A	3	37	0	43	0	86.1%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : White	Reported	N/A	3	N/A	3	25	0	None	4	None	4	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	31	0	42	0	73.8%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Total	Reported	N/A	3	N/A	3	123	0	143	0	86.0%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	23	0	None	4	None	4	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	97	0	112	0	86.6%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	123	0	143	0	86.0%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC San Francisco Medical Center	DPH	Q-OA1	Q-URI	Appropriate Treatment for Upper Respiratory Infection (URI)	Reported	0.981	0	0.9434	None	590	0	598	0	98.7%	0	1	N/A	Yes
PY5	UC San Francisco Medical Center	DPH	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	None
PY5	UC San Francisco Medical Center	DPH	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	None
PY5	UC San Francisco Medical Center	DPH	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Reported	0.8209	0	0.8216	None	385	0	451	0	85.4%	0	1	0.5	Yes
PY5	UC San Francisco Medical Center	DPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.5541	0	0.5625	None	900	0	1380	0	65.2%	0	1	0.5	Yes
PY5	UC San Francisco Medical Center	DPH	Q-PC10	Q-LSC	Lead Screening in Children	Reported	0.4574	0	0.6131	None	143	0	242	0	59.1%	0	0	0	Yes
PY5	UC San Francisco Medical Center	DPH	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	None
PY5	UC San Francisco Medical Center	DPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Reported	0.6382	0	0.6462	None	21876	0	34737	0	63.0%	0	0	0	Yes
PY5	UC San Francisco Medical Center	DPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.5722	0	0.6049	None	3938	0	6580	0	59.9%	0	0.75	0	Yes
PY5	UC San Francisco Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 2	Reported	0.4448	0	0.4923	None	899	0	2173	0	41.4%	0	0	0	YesS
PY5	UC San Francisco Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 3	Reported	0.9215	0	0.9246	None	24129	0	26872	0	89.8%	0	0	0	YesS
PY5	UC San Francisco Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 1 (informational only)	Reported	0.9758	0	0	None	25403	0	26872	0	94.5%	0	N/A	N/A	YesI
PY5	UC San Francisco Medical Center	DPH	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	0	0	Yes
PY5	UC San Francisco Medical Center	DPH	Q-PC15	Q-WCC	▶ Counseling for Physical Activity	Reported	0.6062	0	0.6249	None	2441	0	3142	0	77.7%	0	1	0.5	YesS
PY5	UC San Francisco Medical Center	DPH	Q-PC15	Q-WCC	▶ Counseling for Nutrition	Reported	0.6205	0	0.6409	None	2447	0	3142	0	77.9%	0	1	0.5	YesS
PY5	UC San Francisco Medical Center	DPH	Q-PC15	Q-WCC	▶ BMI	Reported	0.906	0	0.8718	None	2856	0	3142	0	90.9%	0	1	N/A	YesS
PY5	UC San Francisco Medical Center	DPH	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	N/A	Yes
PY5	UC San Francisco Medical Center	DPH	Q-PC16	Q-W30	▶ First 15 Months	Reported	0.6381	0	0.6426	None	53	0	75	0	70.7%	0	1	1	YesS
PY5	UC San Francisco Medical Center	DPH	Q-PC16	Q-W30	▶ 15 Months-30 Months	Reported	0.691	0	0.7047	None	155	0	242	0	64.1%	0	0	0	YesS
PY5	UC San Francisco Medical Center	DPH	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	0.5	0	Yes
PY5	UC San Francisco Medical Center	DPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Reported	0.6453	0	0.6488	None	2690	0	4025	0	66.8%	0	1	0.5	Yes
PY5	UC San Francisco Medical Center	DPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.6323	0	0.6197	None	3178	0	5221	0	60.9%	0	0	0	Yes
PY5	UC San Francisco Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	12	0	None	4	None	4	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	631	0	915	0	69.0%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	624	0	1156	0	54.0%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	34	0	76	0	44.7%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	437	0	716	0	61.0%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	276	0	472	0	58.5%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	1164	0	1863	0	62.5%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	3178	0	5221	0	60.9%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	978	0	1535	0	63.7%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	2125	0	3508	0	60.6%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	75	0	178	0	42.1%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	3178	0	5221	0	60.9%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Reported	0.5078	0	0.5107	None	99	0	241	0	41.1%	0	0	0	Yes
PY5	UC San Francisco Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Asian	Reported	N/A	3	N/A	3	35	0	54	0	64.8%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Black or African American	Reported	N/A	3	N/A	3	11	0	51	0	21.6%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : White	Reported	N/A	3	N/A	3	None	1	30	0	None	1	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	35	0	81	0	43.2%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Total	Reported	N/A	3	N/A	3	99	0	241	0	41.1%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	30	0	67	0	44.8%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	64	0	165	0	38.8%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	99	0	241	0	41.1%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Reported	0.515	0	0.5297	None	229	0	401	0	57.1%	0	1	1	Yes
PY5	UC San Francisco Medical Center	DPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.6664	0	0.6046	None	2857	0	4322	0	66.1%	0	1	N/A	Yes
PY5	UC San Francisco Medical Center	DPH	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Reported	0.5502	0	0.3665	None	335	0	509	0	65.8%	0	1	1	Yes
PY5	UC San Francisco Medical Center	DPH	Q-PC8	Q-CMS349	HIV Screening Measure	Reported	0.7203	0	0.6263	None	4680	0	6402	0	73.1%	0	1	N/A	Yes
PY5	UC San Francisco Medical Center	DPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Reported	0.3534	0	0.3687	None	115	0	282	0	40.8%	0	1	1	Yes
PY5	UC San Francisco Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Asian	Reported	N/A	3	N/A	3	35	0	58	0	60.3%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Black or African American	Reported	N/A	3	N/A	3	17	0	75	0	22.7%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : White	Reported	N/A	3	N/A	3	13	0	32	0	40.6%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	41	0	98	0	41.8%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Total	Reported	N/A	3	N/A	3	115	0	282	0	40.8%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	31	0	64	0	48.4%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	84	0	204	0	41.2%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	0	0	None	4	None	4	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	115	0	282	0	40.8%	0	N/A	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Reported	1	0	1	None	103	0	103	0	100.0%	0	1	N/A	Yes
PY5	UC San Francisco Medical Center	DPH	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Reported	0.9878	0	0.92	None	4448	0	4554	0	97.7%	0	1	N/A	Yes
PY5	UC San Francisco Medical Center	DPH	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Reported	0.9143	0	0.9149	None	2544	0	2747	0	92.6%	0	1	0.5	Yes
PY5	UC San Francisco Medical Center	DPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	UC San Francisco Medical Center	DPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Reported	0.6504	0	0	None	35	0	54.504	0	0.6422	0	1	N/A	Yes
PY5	Ventura County Medical Center	DPH	Q-BH1	Q-COB	Concurrent Use of Opioids and Benzodiazepines (COB-AD)	Reported	0.1225	0	0.1187	None	109	0	1033	0	10.6%	0	1	0.5	Yes
PY5	Ventura County Medical Center	DPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Ventura County Medical Center	DPH	Q-BH3	Q-FUA	▶ 7 Days	Reported	0.1047	0	0.1172	None	42	0	254	0	16.5%	0	1	0.5	YesS
PY5	Ventura County Medical Center	DPH	Q-BH3	Q-FUA	▶ 30 Days	Reported	0.2016	0	0.214	None	78	0	254	0	30.7%	0	1	0.5	YesS
PY5	Ventura County Medical Center	DPH	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	0.5	Yes
PY5	Ventura County Medical Center	DPH	Q-BH4	Q-OHD	Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)	Reported	0.0345	0	0.0337	None	20	0	845	0	2.4%	0	1	0.5	Yes
PY5	Ventura County Medical Center	DPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Ventura County Medical Center	DPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Ventura County Medical Center	DPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.5447	0	0.557	None	2414	0	4083	0	59.1%	0	1	0.5	Yes
PY5	Ventura County Medical Center	DPH	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	0.8259	0	0.8353	None	381	0	437	0	87.2%	0	1	0.5	Yes
PY5	Ventura County Medical Center	DPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.9272	0	0.9199	None	824	0	887	0	92.9%	0	1	N/A	Yes
PY5	Ventura County Medical Center	DPH	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	0.8365	0	0.8406	None	232	0	267	0	86.9%	0	1	0.5	Yes
PY5	Ventura County Medical Center	DPH	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	None
PY5	Ventura County Medical Center	DPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	0.381	0	0.377	None	27	0	70	0	38.6%	0	0	0	YesS
PY5	Ventura County Medical Center	DPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	0.3669	0	0.3643	None	709	0	2041	0	34.7%	0	1	0.5	YesS
PY5	Ventura County Medical Center	DPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.3568	0	0.3552	None	1102	0	3195	0	34.5%	0	1	0.5	YesS
PY5	Ventura County Medical Center	DPH	Q-CAD1	Q-HBD	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	0.6667	0	Yes
PY5	Ventura County Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	17	0	58	0	29.3%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	50	0	218	0	22.9%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	26	0	65	0	40.0%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	970	0	2748	0	35.3%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	34	0	None	1	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	30	0	64	0	46.9%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	1102	0	3195	0	34.5%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	709	0	2041	0	34.7%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	356	0	1084	0	32.8%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	37	0	70	0	52.9%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	1102	0	3195	0	34.5%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.4872	0	0.5015	None	1949	0	3195	0	61.0%	0	1	0.5	Yes
PY5	Ventura County Medical Center	DPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Reported	0.5248	0	0.4676	None	1824	0	3270	0	55.8%	0	1	N/A	Yes
PY5	Ventura County Medical Center	DPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Reported	0.5778	0	0.773	None	199	0	252	0	79.0%	0	1	0	Yes
PY5	Ventura County Medical Center	DPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Ventura County Medical Center	DPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Ventura County Medical Center	DPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Reported	0.9503	0	0.78	None	1616	0	1705	0	94.8%	0	1	N/A	Yes
PY5	Ventura County Medical Center	DPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Ventura County Medical Center	DPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Ventura County Medical Center	DPH	Q-IHE1	Q-IHE1	▶ Chlamydia Screening in Women (CHL) - -American Indian/Alaskan Native	Reported	0.43	0	0.4829	None	63	0	125	0	50.4%	0	1	0	YesS
PY5	Ventura County Medical Center	DPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	1	0	Yes
PY5	Ventura County Medical Center	DPH	Q-IHE2	Q-IHE2	▶ Preventive Care and Screening: Influenza Immunization - -Black/African American	Reported	0.4513	0	0.478	None	252	0	426	0	59.2%	0	1	0.5	YesS
PY5	Ventura County Medical Center	DPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Reported	N/A	3	N/A	3	N/A	3	N/A	3	N/A	3	1	0.5	Yes
PY5	Ventura County Medical Center	DPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Reported	0.1859	0	0.22	None	58	0	345	0	16.8%	0	1	N/A	Yes
PY5	Ventura County Medical Center	DPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Reported	0.6747	0	0.6834	None	918	0	1095	0	83.8%	0	1	0.5	Yes
PY5	Ventura County Medical Center	DPH	Q-MPH4	Q-PPC-PST	Prenatal and Postpartum Care: Postpartum Care (PPC-PST)	Reported	0.7882	0	0.7931	None	662	0	804	0	82.3%	0	1	1	Yes
PY5	Ventura County Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	18	0	None	4	None	4	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Asian	Reported	N/A	3	N/A	3	12	0	None	4	None	4	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : White	Reported	N/A	3	N/A	3	589	0	712	0	82.7%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	26	0	31	0	83.9%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	11	0	None	4	None	4	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Race : Total	Reported	N/A	3	N/A	3	662	0	804	0	82.3%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	524	0	620	0	84.5%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	126	0	166	0	75.9%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	12	0	None	4	None	4	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-MPH4	Q-PPC-PST	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	662	0	804	0	82.3%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-MPH5	Q-PPC-PRE	Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-PRE)	Reported	0.8472	0	0.8547	None	711	0	804	0	88.4%	0	1	1	Yes
PY5	Ventura County Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	17	0	None	4	None	4	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Asian	Reported	N/A	3	N/A	3	15	0	None	4	None	4	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : White	Reported	N/A	3	N/A	3	633	0	712	0	88.9%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	25	0	31	0	80.7%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	12	0	None	4	None	4	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Race : Total	Reported	N/A	3	N/A	3	711	0	804	0	88.4%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	553	0	620	0	89.2%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	144	0	166	0	86.8%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	14	0	None	4	None	4	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-MPH5	Q-PPC-PRE	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	711	0	804	0	88.4%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Ventura County Medical Center	DPH	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	None
PY5	Ventura County Medical Center	DPH	Q-OA2	Q-AAB	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)	Reported	0.9506	0	0.7039	None	175	0	205	0	85.4%	0	1	N/A	Yes
PY5	Ventura County Medical Center	DPH	Q-OA3	Q-QPP415	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older	Reported	0.6813	0	0.7983	None	148	0	173	0	85.6%	0	1	0	Yes
PY5	Ventura County Medical Center	DPH	Q-OA4	Q-LBP	Use of Imaging Studies for Low Back Pain (LBP)	Reported	0.8856	0	0.8282	None	522	0	582	0	89.7%	0	1	N/A	Yes
PY5	Ventura County Medical Center	DPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.5338	0	0.5442	None	2269	0	3925	0	57.8%	0	1	0.5	Yes
PY5	Ventura County Medical Center	DPH	Q-PC10	Q-LSC	Lead Screening in Children	Reported	0.4855	0	0.6131	None	899	0	1560	0	57.6%	0	0	0	Yes
PY5	Ventura County Medical Center	DPH	Q-PC11	Q-CMS69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Reported	0.6369	0	0.6661	None	21594	0	29627	0	72.9%	0	1	0.5	Yes
PY5	Ventura County Medical Center	DPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Reported	0.5935	0	0.606	None	18379	0	25969	0	70.8%	0	1	0.5	Yes
PY5	Ventura County Medical Center	DPH	Q-PC13	Q-CMS2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Reported	0.6236	0	0.6511	None	19736	0	31612	0	62.4%	0	0	0	Yes
PY5	Ventura County Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 2	Reported	0.5168	0	0.5571	None	1373	0	2432	0	56.5%	0	1	0	YesS
PY5	Ventura County Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 3	Reported	0.9476	0	0.9481	None	32631	0	33948	0	96.1%	0	1	0.5	YesS
PY5	Ventura County Medical Center	DPH	Q-PC14	Q-CMS138	▶ Rate 1 (informational only)	Reported	0.9933	0	0	None	33692	0	33950	0	99.2%	0	N/A	N/A	YesI
PY5	Ventura County Medical Center	DPH	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	0	Yes
PY5	Ventura County Medical Center	DPH	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	None
PY5	Ventura County Medical Center	DPH	Q-PC16	Q-W30	▶ 15 Months-30 Months	Reported	0.6655	0	0.6818	None	1126	0	1631	0	69.0%	0	1	0	YesS
PY5	Ventura County Medical Center	DPH	Q-PC16	Q-W30	▶ First 15 Months	Reported	0.7246	0	0.6833	None	300	0	378	0	79.4%	0	1	1	YesS
PY5	Ventura County Medical Center	DPH	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	0	Yes
PY5	Ventura County Medical Center	DPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Reported	0.529	0	0.5441	None	9233	0	16607	0	55.6%	0	1	0	Yes
PY5	Ventura County Medical Center	DPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.3918	0	0.4146	None	15168	0	36006	0	42.1%	0	1	0	Yes
PY5	Ventura County Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	511	0	1138	0	44.9%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	294	0	767	0	38.3%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	183	0	517	0	35.4%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	14	0	46	0	30.4%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	13454	0	30608	0	44.0%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	494	0	795	0	62.1%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	218	0	2135	0	10.2%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	15168	0	36006	0	42.1%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	12147	0	26293	0	46.2%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	2512	0	6576	0	38.2%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	509	0	3137	0	16.2%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	15168	0	36006	0	42.1%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Reported	0.3776	0	0.3935	None	590	0	1468	0	40.2%	0	1	0.5	Yes
PY5	Ventura County Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	53	0	77	0	68.8%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Asian	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : White	Reported	N/A	3	N/A	3	457	0	1185	0	38.6%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	62	0	106	0	58.5%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	66	0	None	1	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC4	Q-CIS	▶ Race : Total	Reported	N/A	3	N/A	3	590	0	1468	0	40.2%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	510	0	1149	0	44.4%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	74	0	262	0	28.2%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	57	0	None	1	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC4	Q-CIS	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	590	0	1468	0	40.2%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Reported	0.5127	0	0.5276	None	1603	0	2846	0	56.3%	0	1	1	Yes
PY5	Ventura County Medical Center	DPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Reported	0.4625	0	0.4767	None	6798	0	13716	0	49.6%	0	1	0.5	Yes
PY5	Ventura County Medical Center	DPH	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Reported	0.4148	0	0.3665	None	1584	0	3275	0	48.4%	0	1	1	Yes
PY5	Ventura County Medical Center	DPH	Q-PC8	Q-CMS349	HIV Screening Measure	Reported	0.5132	0	0.5245	None	14822	0	27571	0	53.8%	0	1	0.5	Yes
PY5	Ventura County Medical Center	DPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Reported	0.3263	0	0.3443	None	681	0	2016	0	33.8%	0	0.5	0	Yes
PY5	Ventura County Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	20	0	56	0	35.7%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Asian	Reported	N/A	3	N/A	3	13	0	46	0	28.3%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : White	Reported	N/A	3	N/A	3	617	0	1761	0	35.0%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	16	0	41	0	39.0%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	89	0	None	1	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC9	Q-IMA	▶ Race : Total	Reported	N/A	3	N/A	3	681	0	2016	0	33.8%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	588	0	1551	0	37.9%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	72	0	327	0	22.0%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	21	0	138	0	15.2%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PC9	Q-IMA	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	681	0	2016	0	33.8%	0	N/A	None	None
PY5	Ventura County Medical Center	DPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Ventura County Medical Center	DPH	Q-PS2	Q-QPP23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Reported	0.9853	0	0.92	None	1330	0	1350	0	98.5%	0	1	N/A	Yes
PY5	Ventura County Medical Center	DPH	Q-PS3	Q-QPP76	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections	Reported	0.5	0	0.542	None	175	0	260	0	67.3%	0	1	0	Yes
PY5	Ventura County Medical Center	DPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Reported	1.0334	0	0	None	14	0	15.113	0	0.9264	0	0	N/A	Yes
PY5	Ventura County Medical Center	DPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Reported	0.7593	0	0.795	None	4	0	7.012	0	0.5705	0	1	N/A	Yes
PY5	Washington Hospital Healthcare District	DMPH	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	None
PY5	Washington Hospital Healthcare District	DMPH	Q-BH2	Q-DRR-E	Depression Remission or Response for Adolescents and Adults (DRR-E)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Washington Hospital Healthcare District	DMPH	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	None
PY5	Washington Hospital Healthcare District	DMPH	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	None
PY5	Washington Hospital Healthcare District	DMPH	Q-BH5	Q-FUI	Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-BH6	Q-POD	Pharmacotherapy for Opioid Use Disorder*	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-CAC1	Q-CBP	Controlling High Blood Pressure (CBP)	Reported	0.7157	0	0.6679	None	247	0	360	0	68.6%	0	1	N/A	Yes
PY5	Washington Hospital Healthcare District	DMPH	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	None
PY5	Washington Hospital Healthcare District	DMPH	Q-CAC3	Q-QPP6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Reported	0.9462	0	0.9199	None	157	0	176	0	89.2%	0	N/A	N/A	No
PY5	Washington Hospital Healthcare District	DMPH	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	None
PY5	Washington Hospital Healthcare District	DMPH	Q-CAC5	Q-CMS347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Reported	0.6726	0	0.6892	None	228	0	320	0	71.3%	0	1	0	Yes
PY5	Washington Hospital Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Black/African-American	Reported	None	2	N/A	None	None	1	None	4	None	1	N/A	N/A	NoS
PY5	Washington Hospital Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Hispanic/Latino	Reported	None	2	0.3406	None	None	1	37	0	None	1	1	N/A	YesS
PY5	Washington Hospital Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Total Population	Reported	0.2121	0	0.3406	None	44	0	199	0	22.1%	0	1	N/A	YesS
PY5	Washington Hospital Healthcare District	DMPH	Q-CAD1	Q-HBD	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	N/A	Yes
PY5	Washington Hospital Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Race : Asian	Reported	N/A	3	N/A	3	16	0	86	0	18.6%	0	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Race : White	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	13	0	60	0	21.7%	0	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Race : Total	Reported	N/A	3	N/A	3	44	0	199	0	22.1%	0	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	37	0	None	1	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	35	0	160	0	21.9%	0	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-CAD1	Q-HBD	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	44	0	199	0	22.1%	0	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-CAD2	Q-EED	Comprehensive Diabetes Care: Eye Exam (CDC-E)	Reported	0.5515	0	0.5594	None	95	0	199	0	47.7%	0	N/A	N/A	No
PY5	Washington Hospital Healthcare District	DMPH	Q-CAD3	Q-KED	Kidney Health Evaluation for Patients with Diabetes	Reported	0.5604	0	0.4676	None	147	0	217	0	67.7%	0	1	N/A	Yes
PY5	Washington Hospital Healthcare District	DMPH	Q-CAH1	Q-HVL	HIV Viral Suppression (HVL-AD)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-CAR1	Q-AMR	Asthma Medication Ratio (AMR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-CAR2	Q-PCE	Pharmacotherapy Management of COPD Exacerbation (PCE)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-CC1	Q-TRC	Transitions of Care (TRC)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-CC2	Q-PCR	Plan All-Cause Readmissions (PCR)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-EC1	Q-QPP47	Advance Care Plan	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-IHE1	Q-IHE1	Improving Health Equity 1	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-IHE2	Q-IHE2	Improving Health Equity 2	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-MPH1	Q-PC02	Cesarean Birth (PC02-CH)	Reported	None	2	0.22	None	None	1	43	0	None	1	1	N/A	Yes
PY5	Washington Hospital Healthcare District	DMPH	Q-MPH3	Q-PC05	Exclusive Breast Milk Feeding (PC-05)	Reported	0.6636	0	0.6734	None	82	0	117	0	70.1%	0	1	0.5	Yes
PY5	Washington Hospital Healthcare District	DMPH	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	None
PY5	Washington Hospital Healthcare District	DMPH	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	None
PY5	Washington Hospital Healthcare District	DMPH	Q-MPH6	Q-PRS-E	Prenatal Immunization Status	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Washington Hospital Healthcare District	DMPH	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	None
PY5	Washington Hospital Healthcare District	DMPH	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	None
PY5	Washington Hospital Healthcare District	DMPH	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	None
PY5	Washington Hospital Healthcare District	DMPH	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	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC1	Q-BCS	Breast Cancer Screening (BCS)	Reported	0.6471	0	0.6377	None	144	0	207	0	69.6%	0	1	N/A	Yes
PY5	Washington Hospital Healthcare District	DMPH	Q-PC10	Q-LSC	Lead Screening in Children	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Washington Hospital Healthcare District	DMPH	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	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC12	Q-CMS147	Preventive Care and Screening: Influenza Immunization	Reported	0.4491	0	0.476	None	1719	0	3688	0	46.6%	0	N/A	N/A	No
PY5	Washington Hospital Healthcare District	DMPH	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	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC14	Q-CMS138	▶ Rate 2	Reported	0.2177	0	0.2879	None	49	0	277	0	17.7%	0	N/A	N/A	NoS
PY5	Washington Hospital Healthcare District	DMPH	Q-PC14	Q-CMS138	▶ Rate 3	Reported	0.9158	0	0.9195	None	3464	0	3782	0	91.6%	0	N/A	N/A	NoS
PY5	Washington Hospital Healthcare District	DMPH	Q-PC14	Q-CMS138	▶ Rate 1 (informational only)	Reported	0.9756	0	0	None	3692	0	3782	0	97.6%	0	N/A	N/A	NoI
PY5	Washington Hospital Healthcare District	DMPH	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	N/A	None	No
PY5	Washington Hospital Healthcare District	DMPH	Q-PC15	Q-WCC	▶ Counseling for Physical Activity	Reported	0.8055	0	0.7932	None	417	0	562	0	74.2%	0	N/A	N/A	NoS
PY5	Washington Hospital Healthcare District	DMPH	Q-PC15	Q-WCC	▶ Counseling for Nutrition	Reported	0.8123	0	0.8136	None	416	0	562	0	74.0%	0	N/A	N/A	NoS
PY5	Washington Hospital Healthcare District	DMPH	Q-PC15	Q-WCC	▶ BMI	Reported	0.8925	0	0.8718	None	475	0	562	0	84.5%	0	N/A	N/A	NoS
PY5	Washington Hospital Healthcare District	DMPH	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	N/A	None	No
PY5	Washington Hospital Healthcare District	DMPH	Q-PC16	Q-W30	▶ 15 Months-30 Months	Reported	0.6774	0	0.6925	None	38	0	58	0	65.5%	0	N/A	N/A	NoS
PY5	Washington Hospital Healthcare District	DMPH	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	N/A	None	No
PY5	Washington Hospital Healthcare District	DMPH	Q-PC16	Q-W30	▶ First 15 Months	Reported	None	2	N/A	None	None	1	None	1	None	1	N/A	N/A	NoS
PY5	Washington Hospital Healthcare District	DMPH	Q-PC2	Q-CCS	Cervical Cancer Screening (CCS)	Reported	0.6673	0	0.6686	None	410	0	586	0	70.0%	0	1	0.5	Yes
PY5	Washington Hospital Healthcare District	DMPH	Q-PC3	Q-WCV	Child and Adolescent Well Care Visits	Reported	0.5532	0	0.5599	None	461	0	1069	0	43.1%	0	N/A	N/A	No
PY5	Washington Hospital Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Race : Asian	Reported	N/A	3	N/A	3	154	0	347	0	44.4%	0	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Race : Black or African American	Reported	N/A	3	N/A	3	37	0	77	0	48.1%	0	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Race : White	Reported	N/A	3	N/A	3	63	0	161	0	39.1%	0	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	20	0	47	0	42.6%	0	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	178	0	414	0	43.0%	0	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Race : Total	Reported	N/A	3	N/A	3	461	0	1069	0	43.1%	0	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	129	0	289	0	44.6%	0	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	323	0	629	0	51.4%	0	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	151	0	None	1	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC3	Q-WCV	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	461	0	1069	0	43.1%	0	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC4	Q-CIS	Childhood Immunization Status (CIS 10)	Reported	0.3	0	0.3237	None	19	0	53	0	35.9%	0	1	0	Yes
PY5	Washington Hospital Healthcare District	DMPH	Q-PC4	Q-CIS	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC4	Q-CIS	▶ Race : Asian	Reported	N/A	3	N/A	3	12	0	None	4	None	4	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC4	Q-CIS	▶ Race : Black or African American	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC4	Q-CIS	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC4	Q-CIS	▶ Race : White	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC4	Q-CIS	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC4	Q-CIS	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC4	Q-CIS	▶ Race : Total	Reported	N/A	3	N/A	3	19	0	53	0	35.9%	0	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	18	0	34	0	52.9%	0	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC4	Q-CIS	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	19	0	53	0	35.9%	0	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC5	Q-CHL	Chlamydia Screening in Women (CHL)	Reported	0.6515	0	0.6525	None	44	0	64	0	68.8%	0	1	1	Yes
PY5	Washington Hospital Healthcare District	DMPH	Q-PC6	Q-CMS130	Colorectal Cancer Screening	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC7	Q-DEV	Developmental Screening in the First Three Years of Life	Reported	0.2727	0	0.2821	None	31	0	95	0	32.6%	0	1	1	Yes
PY5	Washington Hospital Healthcare District	DMPH	Q-PC8	Q-CMS349	HIV Screening Measure	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC9	Q-IMA	Immunizations for Adolescents	Reported	0.2708	0	0.309	None	26	0	61	0	42.6%	0	1	1	Yes
PY5	Washington Hospital Healthcare District	DMPH	Q-PC9	Q-IMA	▶ Race : American Indian or Alaska Native	Reported	N/A	3	N/A	3	0	0	0	0	0.0%	0	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC9	Q-IMA	▶ Race : Asian	Reported	N/A	3	N/A	3	12	0	None	4	None	4	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC9	Q-IMA	▶ Race : Black or African American	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC9	Q-IMA	▶ Race : Native Hawaiian or Other Pacific Islander	Reported	N/A	3	N/A	3	0	0	None	1	None	1	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC9	Q-IMA	▶ Race : White	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC9	Q-IMA	▶ Race : Two or More Races	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC9	Q-IMA	▶ Race : Other/Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	4	None	1	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC9	Q-IMA	▶ Race : Total	Reported	N/A	3	N/A	3	26	0	61	0	42.6%	0	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Hispanic or Latino	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Not Hispanic or Latino	Reported	N/A	3	N/A	3	23	0	41	0	56.1%	0	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Declined/Unknown	Reported	N/A	3	N/A	3	None	1	None	1	None	1	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PC9	Q-IMA	▶ Ethnicity : Total	Reported	N/A	3	N/A	3	26	0	61	0	42.6%	0	N/A	None	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PS1	Q-STK-2	Discharged on Antithrombotic Therapy	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None
PY5	Washington Hospital Healthcare District	DMPH	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	None
PY5	Washington Hospital Healthcare District	DMPH	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	None
PY5	Washington Hospital Healthcare District	DMPH	Q-PS4	Q-CDI	Reduction in Hospital Acquired Clostridium Difficile Infections	Reported	0.1572	0	0.58	None	7	0	38.282	0	0.1829	0	1	N/A	Yes
PY5	Washington Hospital Healthcare District	DMPH	Q-PS5	Q-SSI	Surgical Site Infection (SSI)	Not Reported	None	None	None	None	None	None	None	None	None	None	None	None	None