| 2024 |
UTICA |
developer, Denise Hull |
Adirondack Health |
| READM_ALL |
All Cause Rate of readmission after discharge from hospital (hospital-wide) |
Maintain or reduce the readmission rate for hospitalized patients, excluding inpatient psych - Maintenance Measure |
15 |
0 |
6.31 |
14.6 |
0 |
No |
| FMC_7 |
Follow-Up After Emergency Department Visit for People With Multiple High-Risk Chronic Conditions / 7 Day* |
Increase the percentage of follow up service for ED patients with multiple chronic conditions |
15 |
0 |
26.42 |
33 |
0 |
No |
| SEV_SEP_3HR |
Severe Sepsis 3-Hour Bundle |
Increase the rate of compliance with each of the measure elements of severe sepsis management, 3-hour bundle |
30 |
0 |
77.55 |
80.95 |
0 |
No |
| SEV_SEP_6HR |
Severe Sepsis 6-Hour Bundle |
Increase the rate of compliance with each of the measure elements of severe sepsis management, 6-hour bundle |
30 |
0 |
57.69 |
69.28 |
0 |
No |
| H_QUIET_HSP_A_P |
Quietness - Star Rating |
Maintain or increase the patient satisfaction score for quietness in the hospital environment - Maintenance Measure |
10 |
0 |
62.3 |
62 |
0 |
No |
| 2024 |
UTICA |
|
Alice Hyde Medical Center |
| READM_ALL |
All Cause Rate of readmission after discharge from hospital (hospital-wide) |
Maintenance Measure: To maintain or decrease the rate of all-cause readmissions |
100 |
0 |
10.46 |
14.6 |
0 |
No |
| 2024 |
UTICA |
Shannon Campbell |
A.O. Fox Hospital |
| READM_ALL |
All Cause Rate of readmission after discharge from hospital (hospital-wide) |
MAINTENANCE MEASURE: GOAL IS TO MAINTAIN OR FINISH LOWER THAN BENCHMARK OF 14.60% FROM 01.01.24 - 12.31.24 as lower performance rates are better. |
50 |
0 |
11.48 |
14.6 |
0 |
No |
| TOC_HEDIS2 |
Receipt of Discharge Information |
RECEIPT OF DISCHARGE: MAINTENANCE MEASURE: GOAL IS TO MAINTAIN OR FINISH HIGHER THAN BENCHMARK OF 46.72% FROM 01.01.24 - 12.31.24 as higher performance rates are better. |
25 |
0 |
78.85 |
46.72 |
0 |
No |
| TOC_HEDIS3 |
Medication Reconciliation Conducted |
MEDICATION RECONCILATION: MAINTENANCE MEASURE: GOAL IS TO MAINTAIN OR FINISH HIGHER THAN BENCHMARK OF 84.67% FROM 01.01.24 - 12.31.24 as higher performance rates are better. |
25 |
0 |
100 |
84.67 |
0 |
No |
| 2024 |
STIER |
Teresa Stokelin |
Arnot Ogden Medical Center |
| SEV_SEP_3HR |
Severe Sepsis 3-Hour Bundle |
Increase baseline rate |
30 |
0 |
81.4 |
83.91 |
0 |
No |
| SEV_SEP_6HR |
Severe Sepsis 6-Hour Bundle |
Increase baseline rate |
30 |
0 |
80.22 |
85.38 |
0 |
No |
| H_COMP_1_A_P |
Nurse communication - Star Rating |
Maintain or increase baseline rate |
10 |
0 |
79.32 |
79 |
0 |
No |
| TOC_HEDIS2 |
Receipt of Discharge Information |
Receipt Discharge Information. Maintain or increase baseline rate. |
15 |
0 |
59.01 |
46.72 |
0 |
No |
| TOC_HEDIS3 |
Medication Reconciliation Conducted |
Medication Reconciliation. Maintain or increase baseline rate. |
15 |
0 |
89.7 |
84.67 |
0 |
No |
| 2024 |
CNY |
Denise Hull |
Auburn Community Hospital |
| READM_ALL |
All Cause Rate of readmission after discharge from hospital (hospital-wide) |
Maintain or reduce readmissions for all-cause, all-payors - Maintenance Measure |
15 |
0 |
10.72 |
14.6 |
0 |
No |
| PPC_POST |
Postnatal Care |
Increase the percentage of deliveries that had a postpartum visit on or between 7 and 84 days after delivery. |
15 |
0 |
35.06 |
43.83 |
0 |
No |
| H_COMP_1_A_P |
Nurse communication - Star Rating |
Increase the HCAHPS score for Patients who reported that their nurses "Always" communicated well. |
30 |
0 |
66.2 |
69.43 |
0 |
No |
| H_COMP_5_A_P |
Communication about medicines - Star Rating |
increase HCAHPS score for Patients who reported that staff "Always" explained about medicines before giving it to them. |
10 |
0 |
43.69 |
48.45 |
0 |
No |
| H_COMP_6_Y_P |
Discharge information - Star Rating |
Increase the HCAHPS score for Patients who reported that YES, they were given information about what to do during their recovery at home. |
30 |
0 |
84.08 |
84.51 |
0 |
No |
| 2024 |
UTICA |
Shannon Campbell |
Bassett Medical Center |
| READM_ALL |
All Cause Rate of readmission after discharge from hospital (hospital-wide) |
Maintain an all cause/all payer readmissions at or below 14.60%
Maintenance Measure |
15 |
0 |
10.88 |
14.6 |
0 |
No |
| PPC_POST |
Postnatal Care |
Increase the number of postpartum care visits occurring between 7 and 84 days after delivery to be greater than/equal to 88.33% for patients who delivered at Bassett Medical Center and utilize an in-network provider for follow-up care. |
15 |
0 |
85.9 |
88.33 |
0 |
No |
| OP_35_ED |
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy
|
Maintain a BMC Emergency Departments visit rate of ≤5.40% from patients who received chemotherapy treatment from a Bassett cancer treatment clinic within 30 days
Maintenance Measure |
30 |
0 |
1.15 |
5.4 |
0 |
No |
| SEV_SEP_3HR |
Severe Sepsis 3-Hour Bundle |
Increase the 3-hour severe sepsis bundle compliance to a percentage greater than/equal to 83.99%. |
30 |
0 |
81.68 |
83.99 |
0 |
No |
| H_COMP_3_A_P |
Staff responsiveness - Star Rating |
Increase the percentage of CMS HCAHPS "Staff responsiveness" (Patients who report “Always” receiving help as soon as they wanted) hospital score to ≥56.22%. |
10 |
0 |
53.21 |
56.22 |
0 |
No |
| 2024 |
UTICA |
Jennifer de Jong |
Canton-Potsdam Hospital |
| TOC_HEDIS1 |
Notification of Inpatient Admission |
MAINTENANCE MEASURE: To maintain the rate of inpatient admission notification to outpatient providers at or above the benchmark |
50 |
0 |
99.52 |
56.2 |
0 |
No |
| TOC_HEDIS2 |
Receipt of Discharge Information |
MAINTENANCE MEASURE: To maintain the rate of discharge information sent to outpatient providers at or above the benchmark |
50 |
0 |
95.51 |
46.72 |
0 |
No |
| 2024 |
UTICA |
|
Champlain Valley Physicians Hospital |
| READM_ALL |
All Cause Rate of readmission after discharge from hospital (hospital-wide) |
Maintenance Measure. To maintain or even decrease the rate of all-cause readmissions. |
20 |
0 |
10.54 |
14.6 |
0 |
No |
| PPC_POST |
Postnatal Care |
Increase the rate of postpartum visits completed 7-84 days after delivery |
10 |
0 |
54.41 |
65.54 |
0 |
No |
| SEP_SH_3HR |
Septic Shock 3-Hour Bundle |
Increase compliance with the 3 hour septic shock treatment bundle |
30 |
0 |
59.09 |
69.46 |
0 |
No |
| H_COMP_2_A_P |
Doctor communication - Star Rating |
Increase patient satisfaction with doctors' communications |
10 |
0 |
71.95 |
73.8 |
0 |
No |
| H_COMP_7_SA |
Care Transitions - Star Rating |
Increase patients' understanding of their care prior to discharge |
30 |
0 |
43.97 |
45.78 |
0 |
No |
| 2024 |
ROCH |
Jennifer de Jong |
Clifton Springs Hospital & Clinic |
| READM_30_HF |
Heart failure (HF) 30-day readmission rate |
Improvement - The Centers for Medicare & Medicaid Services (CMS) 30-day risk-standardized readmission measures assess a broad set of healthcare activities that affect patients’ well-being. Patients who receive high-quality care during their hospitalizations and their transition to the outpatient setting will likely have better outcomes, such as survival, functional ability, and quality of life. Assessing the readmission status of patients helps to identify opportunities related to hospital discharge processes, ambulatory availability and process, and transition of care processes. The goal is be at or below the national benchmark. |
10 |
0 |
21.82 |
21.37 |
0 |
No |
| H_COMP_2_A_P |
Doctor communication - Star Rating |
Maintain - The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a national, standardized publically reported survey on patient’s perspectives on their hospital care. The question related to doctor communication are used in a variety of CMS programs as well as other publically reported programs such as Leapfrog. Information from this question helps to identify clinical performance opportunities as it relates to patient’s perception of their care. The goal is be at or below the national benchmark.
Maintenance Measure |
30 |
0 |
82.91 |
79 |
0 |
No |
| TOC_HEDIS1 |
Notification of Inpatient Admission |
Notification of Inpatient Admission - Maintain - Documentation in the medical record of receipt of notification of inpatient admission on the day of admission or within the following 2 calendar days.
Maintenance Measure |
15 |
0 |
99.91 |
56.2 |
0 |
No |
| TOC_HEDIS2 |
Receipt of Discharge Information |
Receipt of Discharge Information - Maintain - Documentation in the medical record of receipt of discharge information on the day of discharge or within the following 2 calendar days.
Maintenance Measure |
15 |
0 |
95.45 |
46.72 |
0 |
No |
| PSI_12 |
Perioperative pulmonary embolism or deep vein thrombosis rate |
Improvement - Perioperative pulmonary embolism or deep vein thrombosis (secondary diagnosis) per 1,000 surgical discharges for patients ages 18 years and older. Excludes cases with principal diagnosis for pulmonary embolism or deep vein thrombosis; cases with secondary diagnosis for pulmonary embolism or deep vein thrombosis present on admission; cases in which interruption of vena cava occurs before or on the same day as the first operating room procedure; and obstetric discharges. |
30 |
0 |
6.25 |
4.88 |
0 |
No |
| 2024 |
UTICA |
Denise Hull |
Community Memorial Hospital |
| OP_22 |
ED Left Without Being Seen |
Decrease the number of patients leaving without being seen in the ED. |
30 |
0 |
1.42 |
1.07 |
0 |
No |
| H_HSP_RATING_9_10 |
Overall hospital rating - Star Rating |
Increase the Top Box Score for Star Rating of 9/10. |
30 |
0 |
68.96 |
69.31 |
0 |
No |
| TOC_HEDIS1 |
Notification of Inpatient Admission |
MAINTENANCE MEASURE: Continue to maintain and improve notification of Inpatient admissions |
20 |
0 |
79.69 |
56.2 |
0 |
No |
| TOC_HEDIS2 |
Receipt of Discharge Information |
MAINTENANCE MEASURE: Continue to maintain and improve receipt of discharge information |
20 |
0 |
85.88 |
46.72 |
0 |
No |
| 2024 |
CNY |
Shelly LoPresti |
Crouse Hospital |
| PSI_10 |
Postoperative acute kidney injury requiring dialysis rate |
Maintain or decrease percent hospital discharges with postoperative acute kidney failure (secondary diagnosis) requiring dialysis.
Maintenance Measure |
30 |
0 |
0.53 |
0.92 |
0 |
No |
| SEV_SEP_6HR |
Severe Sepsis 6-Hour Bundle |
Increase percent compliance with 6 hour bundle for adult patients diagnosed with severe sepsis or septic shock |
30 |
0 |
74.17 |
80.85 |
0 |
No |
| H_HSP_RATING_9_10 |
Overall hospital rating - Star Rating |
Increase percentage of patients who give Crouse Hospital a rating of 9 of 10 on a scale of 0-10 on HCAHPS survey |
10 |
0 |
58.57 |
61.58 |
0 |
No |
| TOC_HEDIS1 |
Notification of Inpatient Admission |
Maintain or increase percentage of notifiction of inpatient admission on the day of admission or within following 2 calendar days
Maintenance Measure |
15 |
0 |
74.05 |
56.2 |
0 |
No |
| TOC_HEDIS3 |
Medication Reconciliation Conducted |
Increase percentage medication reconciliation conducted by a prescribing practitioner, pharmacist or RN on the date of discharge through 30 days post discharge |
15 |
0 |
70.66 |
74.29 |
0 |
No |
| 2024 |
WNY |
Denise Hull |
Erie County Medical Center |
| FUI_7 |
Follow-Up After High-Intensity Care for Substance Use Disorder Total / 7 Day |
Maintain CY2022 baseline rate |
30 |
0 |
94.93 |
57.46 |
0 |
No |
| H_COMP_1_A_P |
Nurse communication - Star Rating |
Increase to meet final target rate |
10 |
0 |
70.34 |
72.51 |
0 |
No |
| H_COMP_2_A_P |
Doctor communication - Star Rating |
Increase to meet final target rate. |
30 |
0 |
70.27 |
72.44 |
0 |
No |
| H_COMP_6_Y_P |
Discharge information - Star Rating |
Maintain CY2022 baseline rate |
30 |
0 |
86 |
86 |
0 |
No |
| 2024 |
ROCH |
Teresa Stokelin |
F.F. Thompson Hospital |
| H_COMP_5_A_P |
Communication about medicines - Star Rating |
Increase number of patients answering always to staff explained about medicines before giving to them on Press Ganey Satisfaction Survey |
30 |
0 |
53 |
55.04 |
0 |
No |
| H_COMP_7_SA |
Care Transitions - Star Rating |
Increase number of patients answering always to they understood their care when they left the hospital on Press Ganey Satisfaction Survey |
10 |
0 |
44 |
45.81 |
0 |
No |
| H_RECMND_DY |
Recommend hospital - Star Rating |
Increase number of patients answering always to Recommend Hospital on Press Ganey Satisfaction Survey |
30 |
0 |
68 |
68.17 |
0 |
No |
| TOC_HEDIS1 |
Notification of Inpatient Admission |
Notification of Inpatient Admission - goal is to increase % of notification of inpt admission.
Maintenance measure |
15 |
0 |
84.35 |
56.2 |
0 |
No |
| TOC_HEDIS2 |
Receipt of Discharge Information |
Receipt of discharge information - goal is to increase % documentation of receipt of d/c information.
Maintenance measure |
15 |
0 |
98.22 |
46.72 |
0 |
No |
| 2024 |
UTICA |
Jennifer de Jong |
Gouverneur Hospital |
| TOC_HEDIS1 |
Notification of Inpatient Admission |
MAINTENANCE MEASURE: To maintain the rate of inpatient admission notification to outpatient providers at or above the benchmark rate |
50 |
0 |
100 |
56.2 |
0 |
No |
| TOC_HEDIS2 |
Receipt of Discharge Information |
MAINTENANCE MEASURE: To maintain the rate of discharge information sent to outpatient providers at or above the benchmark rate |
50 |
0 |
78.15 |
46.72 |
0 |
No |
| 2024 |
STIER |
Shannon Campbell, |
Guthrie Corning Hospital |
| READM_ALL |
All Cause Rate of readmission after discharge from hospital (hospital-wide) |
To maintain the rate of all-cause readmissions to the hospital at <14.60%
Maintenance Measure |
10 |
0 |
6.64 |
14.6 |
0 |
No |
| FMC_7 |
Follow-Up After Emergency Department Visit for People With Multiple High-Risk Chronic Conditions / 7 Day* |
To increase the rate of follow-up visits completed within 7-days for emergency room patients with high-risk chronic conditions. |
30 |
0 |
22 |
27.5 |
0 |
No |
| PSI_08 |
In-hospital fall with hip fracture rate |
To reduce the rate of inpatient hospital falls with hip fracture |
30 |
0 |
0.52 |
0.39 |
0 |
No |
| SEV_SEP_6HR |
Severe Sepsis 6-Hour Bundle |
To increase the rate of 6-hour severe sepsis bundle compliance for patients meeting severe sepsis criteria |
30 |
0 |
85.83 |
89.58 |
0 |
No |
| 2024 |
CNY |
Shannon Campbell, |
Guthrie Cortland Medical Center |
| READM_ALL |
All Cause Rate of readmission after discharge from hospital (hospital-wide) |
MAINTENANCE MEASURE: Maintain our rate of all cause rate readmissions after dischare from the hospital |
10 |
0 |
10.79 |
14.6 |
0 |
No |
| PPC_POST |
Postnatal Care |
Increase rate of deliveries that have a postpartum visit on or between 7 and 84 days after delivery |
30 |
0 |
13.12 |
16.4 |
0 |
No |
| PSI_08 |
In-hospital fall with hip fracture rate |
Decrease the rate of inpatient hospital falls that result in hip fractures |
30 |
0 |
0.29 |
0.22 |
0 |
No |
| SEV_SEP_6HR |
Severe Sepsis 6-Hour Bundle |
Increase severe sepsis 6-hour bundle compliance rates for patients who meet criteria for severe sepsis |
30 |
0 |
92.13 |
94.26 |
0 |
No |
| 2024 |
STIER |
Shannon Campbell, |
Guthrie Lourdes Hospital |
| READM_30_HF |
Heart failure (HF) 30-day readmission rate |
PROJECT GOAL: TO DECREASE HF READMISSION FROM 21.53% TO 21.14%: 01.01.24 -12.31.24, AS LOWER PERFORMANCE RATES ARE BETTER |
15 |
0 |
21.53 |
21.14 |
0 |
No |
| PPC_POST |
Postnatal Care |
PROJECT GOAL: TO INCREASE POSTPARTUM FOLLOW UP VISITS (7 -84 DAYS) FROM 36.09% TO 45.11%: 01.01.24 - 12.31.24, AS HIGHER PERFORMANCE RATES ARE BETTER. |
15 |
0 |
36.09 |
45.11 |
0 |
No |
| COMP_HIP_KNEE |
Hospital-Level Risk-Standardized Complication Rate Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) |
PROJECT GOAL: TO DECREASE # OF PATIENTS W/ELECTIVE PRIMARY THA/TKA ADMISSION 90 DAYS POST OP FROM 5.83 TO 4.56 01.01.24 - 12.31.24 AS LOWER PERFORMANCE RATES ARE BETTER |
30 |
0 |
5.83 |
4.56 |
0 |
No |
| OP_35_ADM |
Rate of inpatient admissions for patients receiving outpatient chemotherapy
|
PROJECT GOAL: TO DECREASE # OF PATIENTS =>18YO ADMITTED W/IN 30 DAYS OF OUTPATIENT CHEMOTHERAPY FROM 27.08% TO 20.31%: 01.01.24 - 12.31.24 AS LOWER PERFORMANCE RATES ARE BETTER |
30 |
0 |
27.08 |
20.31 |
0 |
No |
| H_COMP_7_SA |
Care Transitions - Star Rating |
PROJECT GOAL: TO INCREASE % OF PATIENTS WHO "STRONGLY AGREE" (ON SURVEY) THAT THEY UNDERSTOOD THEIR CARE WHILE HOSPITALIZED FROM 47.32% TO 48.29%: 01.01.24 - 12.31.24 AS HIGHER PERFORMANCE RATES ARE BETTER |
10 |
0 |
47.32 |
48.29 |
0 |
No |
| 2024 |
ROCH |
Teresa Stokelin |
Highland Hospital |
| OP_22 |
ED Left Without Being Seen |
Improve Percentage of patients who left the emergency department before being seen by a qualified medical personnel. Lower percentages are better. |
30 |
0 |
8.6 |
6.45 |
0 |
No |
| H_COMP_2_A_P |
Doctor communication - Star Rating |
Improvement Measure |
10 |
0 |
78.71 |
79 |
0 |
No |
| H_COMP_6_Y_P |
Discharge information - Star Rating |
Maintain Patients who reported that YES, they were given information about what to do during their recovery at home.
Maintenance Measure |
30 |
0 |
86.28 |
86 |
0 |
No |
| TOC_HEDIS1 |
Notification of Inpatient Admission |
1. Notification of Inpatient Admission. Documentation in the medical record of receipt of notification of inpatient admission on the day of admission or within the following 2 calendar days
Maintenance Measure |
15 |
0 |
95.28 |
56.2 |
0 |
No |
| TOC_HEDIS2 |
Receipt of Discharge Information |
2. Receipt of Discharge Information. Documentation in the medical record of receipt of discharge information on the day of discharge or within the following 2 calendar days.
Maintenance Measure |
15 |
0 |
98.62 |
46.72 |
0 |
No |
| 2024 |
ROCH |
Teresa Stokelin |
Jones Memorial Hospital |
| PPC_POST |
Postnatal Care |
To increase the number of delivered patients who follow up within 7-84 days for postpartum care after delivery |
100 |
0 |
76.72 |
81.45 |
0 |
No |
| 2024 |
WNY |
Denise Hull |
Kaleida Health |
| FMC_7 |
Follow-Up After Emergency Department Visit for People With Multiple High-Risk Chronic Conditions / 7 Day* |
Increase Follow-Up After Emergency Department Visit for People With Multiple High-Risk Chronic Conditions / 7 Day |
30 |
0 |
38.63 |
46.39 |
0 |
No |
| SEP_SH_6HR |
Septic Shock 6-Hour Bundle |
Increase Septic Shock 6-Hour bundle |
30 |
0 |
90.57 |
92.9 |
0 |
No |
| SEV_SEP_6HR |
Severe Sepsis 6-Hour Bundle |
Increase Severe Sepsis 6-Hour bundle |
30 |
0 |
86.71 |
90.05 |
0 |
No |
| H_COMP_3_A_P |
Staff responsiveness - Star Rating |
Increase top box score for HCAHPS Responsiveness of Staff |
10 |
0 |
54.1 |
56.88 |
0 |
No |
| 2024 |
UTICA |
Denise Hull |
Lewis County General Hospital |
| READM_ALL |
All Cause Rate of readmission after discharge from hospital (hospital-wide) |
MAINTENANCE MEASURE: Maintain or even decrease the rate of readmissions below the current level |
100 |
0 |
9.66 |
14.6 |
0 |
No |
| 2024 |
UTICA |
Jennifer de Jong |
Massena Hospital |
| TOC_HEDIS1 |
Notification of Inpatient Admission |
MAINTENANCE MEASURE: To maintain the rate of inpatient admission notification to outpatient providers at or above the benchmark |
50 |
0 |
100 |
56.2 |
0 |
No |
| TOC_HEDIS2 |
Receipt of Discharge Information |
MAINTENANCE MEASURE: To maintain the rate of discharge information sent to outpatient providers at or above the benchmark |
50 |
0 |
72.7 |
46.72 |
0 |
No |
| 2024 |
UTICA |
|
MVHS, Inc. (Wynn Hospital) |
| OP_22 |
ED Left Without Being Seen |
To decrease the rate of patients who leave the ED without being seen |
30 |
0 |
4.49 |
3.37 |
0 |
No |
| PSI_08 |
In-hospital fall with hip fracture rate |
To decrease the rate of hip fractures associated with in-hospital falls |
30 |
0 |
0.18 |
0.14 |
0 |
No |
| H_COMP_1_A_P |
Nurse communication - Star Rating |
To increase the number of patients who rate their nurses' as "always communicating well" |
10 |
0 |
72.34 |
74.01 |
0 |
No |
| TOC_HEDIS2 |
Receipt of Discharge Information |
MAINTENANCE MEASURE: To maintain or increase the rate of inpatient care summaries sent to patients' outpatient providers after hospital discharge. |
15 |
0 |
51.87 |
46.72 |
0 |
No |
| TOC_HEDIS3 |
Medication Reconciliation Conducted |
MAINTENANCE MEASURE: To maintain or increase the rate of medication reconciliation that occurs on date of discharge-30 days after discharge |
15 |
0 |
96.18 |
84.67 |
0 |
No |
| 2024 |
ROCH |
Jennifer de Jong |
Newark-Wayne Community Hospital |
| H_COMP_1_A_P |
Nurse communication - Star Rating |
|
30 |
0 |
72.37 |
74.04 |
0 |
No |
| H_COMP_2_A_P |
Doctor communication - Star Rating |
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a national, standardized publically reported survey on patient’s perspectives on their hospital care. The questions related to doctor communication are used in a variety of CMS programs as well as other publically reported programs such as Leapfrog. Information from this question helps to identify clinical performance opportunities as it relates to patient’s perception of their care. The goal is be at or below the national benchmark. |
30 |
0 |
75.09 |
76.06 |
0 |
No |
| H_COMP_6_Y_P |
Discharge information - Star Rating |
|
10 |
0 |
83.15 |
83.79 |
0 |
No |
| TOC_HEDIS1 |
Notification of Inpatient Admission |
Notification of Inpatient Admission - Documentation in the medical record of receipt of notification of inpatient admission on the day of admission or within the following 2 calendar days.
Maintenance Measure |
15 |
0 |
84.04 |
56.2 |
0 |
No |
| TOC_HEDIS2 |
Receipt of Discharge Information |
Receipt of Discharge Information. Receipt of Discharge Information - Documentation in the medical record of receipt of discharge information on the day of discharge or within the following 2 calendar days.
Maintenance Measure |
15 |
0 |
95.46 |
46.72 |
0 |
No |
| 2024 |
WNY |
Denise Hull |
Niagara Falls Memorial Medical Center |
| READM_ALL |
All Cause Rate of readmission after discharge from hospital (hospital-wide) |
MAINTENANCE MEASURE: To maintain and possibly reduce the overall readmission rate for acute patients discharged. |
100 |
0 |
8.87 |
14.6 |
0 |
No |
| 2024 |
ROCH |
Teresa Stokelin |
Noyes Memorial Hospital |
| SEV_SEP_3HR |
Severe Sepsis 3-Hour Bundle |
Increase Complaince with Severe Sepsis 3 hour Bundle |
10 |
0 |
78.2 |
81.42 |
0 |
No |
| H_COMP_1_A_P |
Nurse communication - Star Rating |
Increase nurse communication rating |
10 |
0 |
72.85 |
74.35 |
0 |
No |
| H_COMP_5_A_P |
Communication about medicines - Star Rating |
Maintain Communications about medications
MAINTENTANCE MEASURE |
50 |
0 |
68.87 |
61 |
0 |
No |
| TOC_HEDIS1 |
Notification of Inpatient Admission |
1. Notification of Inpatient Admission. Documentation in the medical record of receipt of notification of inpatient admission on the day of admission or within the following 2 calendar days.
MAINTENTANCE MEASURE |
15 |
0 |
95.69 |
56.2 |
0 |
No |
| TOC_HEDIS2 |
Receipt of Discharge Information |
2. Receipt of Discharge Information. Documentation in the medical record of receipt of discharge information on the day of discharge or within the following 2 calendar days
MAINTENANCE MEASURE |
15 |
0 |
97.34 |
46.72 |
0 |
No |
| 2024 |
UTICA |
|
Oneida Health |
| PPC_POST |
Postnatal Care |
MAINTENANCE MEASURE. The goal of this project is to maintain or increase this measure in order to ensure that all patients receive follow up care after delivery. |
30 |
0 |
96.77 |
95.38 |
0 |
No |
| OP_22 |
ED Left Without Being Seen |
The project goal is to decrease this measure from 2.27% to 1.70% or lower in order to demonstrate an improvement with treating all patients that come through the ED. |
30 |
0 |
2.27 |
1.7 |
0 |
No |
| SEP_SH_3HR |
Septic Shock 3-Hour Bundle |
The project goal is to increase this measure from 79.2% to 83.09% or higher in order to demonstrate appropriate and standardized care for patients with sepsis. |
30 |
0 |
79.22 |
83.09 |
0 |
No |
| H_COMP_7_SA |
Care Transitions - Star Rating |
MAINTENANCE MEASURE. The project goal is to maintain or increase this measure in order to make sure patients understand their care. |
10 |
0 |
54.08 |
51 |
0 |
No |
| 2024 |
WNY |
Denise Hull |
Orleans Community Health – Medina Memorial Hospital |
| READM_ALL |
All Cause Rate of readmission after discharge from hospital (hospital-wide) |
To decrease readmission rates after discharge from Medina Hopsital.
(Maintenance Measure) |
100 |
0 |
9.06 |
14.6 |
0 |
No |
| 2024 |
CNY |
Denise Hull |
Oswego Hospital |
| READM_ALL |
All Cause Rate of readmission after discharge from hospital (hospital-wide) |
Decrease the number of All hospital readmission - Maintenance Measure |
15 |
0 |
10.87 |
14.6 |
0 |
No |
| FUH_7_TOTAL |
Follow-Up After Hospitalization for Mental Illness Total / 7 Day* |
Increase the number of patients with a followup visit within 7 days after an inpatient Hospitalization |
15 |
0 |
37.01 |
43.97 |
0 |
No |
| OP_22 |
ED Left Without Being Seen |
Decrease Number of ED patients who Left Without Being seen |
30 |
0 |
8.23 |
6.17 |
0 |
No |
| H_COMP_2_A_P |
Doctor communication - Star Rating |
To improve Communication with providers - Maintenance Measure |
10 |
0 |
81 |
79 |
0 |
No |
| H_QUIET_HSP_A_P |
Quietness - Star Rating |
Increase patient satisfaction with Hospital environment as it relates to Quitness at night. |
30 |
0 |
61.5 |
61.66 |
0 |
No |
| 2024 |
ROCH |
Jennifer de Jong |
Rochester General Hospital |
| COMP_HIP_KNEE |
Hospital-Level Risk-Standardized Complication Rate Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) |
The Centers for Medicare & Medicaid Services’ (CMS’s) publicly reported risk-standardized complication measure for elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) assesses a broad set of healthcare activities that affect patients' well-being. The outcome for this measure captures eight different complications, each within a specific and clinically meaningful time period, during which the outcome can be attributed to the hospital that performed the procedure. Measuring and reporting risk-standardized complication rates helps to inform our providers of opportunities to improve and strengthen the care that we deliver. Decease |
20 |
0 |
3.58 |
3.47 |
0 |
No |
| PSI_08 |
In-hospital fall with hip fracture rate |
In hospital fall with hip fracture (secondary diagnosis) per 1,000 discharges for patients ages 18 years and older. Excludes cases that were admitted because of conditions that make them susceptible to falling (seizure disorder, syncope, stroke, occlusion of arteries, coma, cardiac arrest, poisoning, trauma, delirium or other psychoses, anoxic brain injury), have conditions associated with fragile bone (metastatic cancer, lymphoid malignancy, bone malignancy, cases with a principal diagnosis of hip fracture, cases with a secondary diagnosis of hip fracture present on admission, and obstetric cases. Decrease |
20 |
0 |
0.19 |
0.14 |
0 |
No |
| H_RECMND_DY |
Recommend hospital - Star Rating |
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a national, standardized publically reported survey on patient’s perspectives on their hospital care. The question related to willingness to recommend is used in a variety of CMS programs as well as other publically reported programs such as Leapfrog. Information from this question helps to identify clinical performance opportunities as it relates to patient’s perception of their care. The goal is be at or below the national benchmark. Increase |
10 |
0 |
57.91 |
60.74 |
0 |
No |
| TOC_HEDIS1 |
Notification of Inpatient Admission |
Notifiation of Inpatient Admissions: Documentation in the medical record of receipt of notification of inpatient admission on the day of admission or within the following 2 calendar days.
Maintenance Measure |
15 |
0 |
99.9 |
56.2 |
0 |
No |
| TOC_HEDIS2 |
Receipt of Discharge Information |
Receipt of Discharge Information: Documentation in the medical record of receipt of discharge information on the day of discharge or within the following 2 calendar days.
Maintenance Measure |
15 |
0 |
99.05 |
46.72 |
0 |
No |
| PSI_12 |
Perioperative pulmonary embolism or deep vein thrombosis rate |
Perioperative pulmonary embolism or deep vein thrombosis (secondary diagnosis) per 1,000 surgical discharges for patients ages 18 years and older. Excludes cases with principal diagnosis for pulmonary embolism or deep vein thrombosis; cases with secondary diagnosis for pulmonary embolism or deep vein thrombosis present on admission; cases in which interruption of vena cava occurs before or on the same day as the first operating room procedure; and obstetric discharges. Decease |
20 |
0 |
4.08 |
3.87 |
0 |
No |
| 2024 |
UTICA |
Shannon Campbell |
Rome Health |
| READM_ALL |
All Cause Rate of readmission after discharge from hospital (hospital-wide) |
Maintenance measure: Complete calendar year 2024 at or below the benchmark of 14.60% as lower performance rates are better |
30 |
0 |
5.59 |
14.6 |
0 |
No |
| SEV_SEP_3HR |
Severe Sepsis 3-Hour Bundle |
Increase measure outcome: Complete calendar year 2024 at or above target of 79.79% as higher performance rates are better |
30 |
0 |
75.89 |
79.79 |
0 |
No |
| H_COMP_1_A_P |
Nurse communication - Star Rating |
Increase measure outcome: Complete calendar year 2024 at or above target of 77.10% as higher performance rates are better |
10 |
0 |
76.51 |
77.1 |
0 |
No |
| H_QUIET_HSP_A_P |
Quietness - Star Rating |
Increase measure outcome: Complete calendar year 2024 at or above target of 54.80% as higher performance rates are better |
30 |
0 |
52.38 |
54.8 |
0 |
No |
| 2024 |
WNY |
|
Roswell |
| 2024 |
UTICA |
|
Samaritan Hospital |
| READM_ALL |
All Cause Rate of readmission after discharge from hospital (hospital-wide) |
MAINTENANCE MEASURE: To maintain or even decrease the rate of all-cause readmission |
15 |
0 |
9.6 |
14.6 |
0 |
No |
| READM_30_COPD |
Obstructive Pulmonary Disease (COPD) Hospitalization 30-day readmission rate |
MAINTENANCE MEASURE: To maintain or even decrease the rate of COPD readmissions |
10 |
0 |
11.96 |
19.3 |
0 |
No |
| PPC_POST |
Postnatal Care |
To increase the rate of delivered patients who follow up 7-84 days after delivery |
15 |
0 |
81.93 |
85.3 |
0 |
No |
| SEV_SEP_3HR |
Severe Sepsis 3-Hour Bundle |
To increase the rate of compliance with the 3 hour severe sepsis treatment bundle |
30 |
0 |
76.06 |
79.97 |
0 |
No |
| H_HSP_RATING_9_10 |
Overall hospital rating - Star Rating |
To increase the number of patients who rate the hospital 9 or 10 out of 10 |
30 |
0 |
60.31 |
62.79 |
0 |
No |
| 2024 |
STIER |
Teresa Stokelin |
Schuyler Hospital |
| OP_22 |
ED Left Without Being Seen |
The goal of this project is to decrease the amount of patients who leave the ED without being seen |
30 |
0 |
0.74 |
0.56 |
0 |
No |
| TOC_HEDIS1 |
Notification of Inpatient Admission |
The goal of increasing the rate of in-patient admission notification to each patient’s primary care provider is to ensure continuity of care, therefore increasing quality of care. |
35 |
0 |
46.36 |
48.86 |
0 |
No |
| TOC_HEDIS2 |
Receipt of Discharge Information |
MAINTENANCE MEASURE. The goal of increasing the rate of discharge information sent to each patient’s primary care provider is to ensure transition of care, medication reconciliation with in-patient stay, and to best manage care. |
35 |
0 |
53.86 |
46.72 |
0 |
No |
| 2024 |
STIER |
Teresa Stokelin |
St. James Hospital |
| TOC_HEDIS1 |
Notification of Inpatient Admission |
MAINTENTANCE MEASURE 1. Notification of Inpatient Admission. Documentation in the medical record of receipt of notification of inpatient admission on the day of admission or within the following 2 calendar days. |
50 |
0 |
92.16 |
56.2 |
0 |
No |
| TOC_HEDIS2 |
Receipt of Discharge Information |
MAINTENANCE MEASURE 2. Receipt of Discharge Information. Documentation in the medical record of receipt of discharge information on the day of discharge or within the following 2 calendar days |
50 |
0 |
95.25 |
46.72 |
0 |
No |
| 2024 |
CNY |
Shelly LoPresti |
St. Joseph's Health Hospital |
| READM_30_AMI |
Acute myocardial infarction (AMI) 30-day readmission rate |
In collaboration with Transitional Care Management, Maintain the AMI readmission rates below benchmark.
Maintenance Measure |
15 |
0 |
8.6 |
14 |
0 |
No |
| READM_30_HF |
Heart failure (HF) 30-day readmission rate |
In collaboration with Transitional Care Management, reduce the HF readmission rates. |
7.5 |
0 |
23.38 |
22.42 |
0 |
No |
| FUA_7 |
Follow-Up After Emergency Department Visit for Alcohol and Other Drug Dependence/ 7 Day* |
Maintain the 7 day follow-up rate below benchmark
Maintenance Measure |
10 |
0 |
29.41 |
18.26 |
0 |
No |
| FUM_7 |
Follow-Up After Emergency Department Visit for Mental Illness / 7 Day* |
Increase the Mental Health 7 day follow-up rate |
7.5 |
0 |
31.25 |
39.06 |
0 |
No |
| OP_22 |
ED Left Without Being Seen |
Reduce the ED left without being seen percent. |
30 |
0 |
3 |
2.25 |
0 |
No |
| H_COMP_1_A_P |
Nurse communication - Star Rating |
Increase the Nurse Communication Star Rating |
30 |
0 |
77.33 |
77.73 |
0 |
No |
| 2024 |
ROCH |
Teresa Stokelin |
Strong Memorial Hospital |
| PSI_10 |
Postoperative acute kidney injury requiring dialysis rate |
Reduce rate per 1,000 elective surgical admissions |
10 |
0 |
3.05 |
2.29 |
0 |
No |
| BDC |
Blues Distinction Measures |
Reduction in opioid prescriptions for discharges from the Surgical Oncology unit (WCC5) |
10 |
0 |
21 |
15.75 |
0 |
No |
| H_RECMND_DY |
Recommend hospital - Star Rating |
MAINTENANCE
Linear Mean of Returned Surveys |
50 |
0 |
87.09 |
69 |
0 |
No |
| TOC_HEDIS1 |
Notification of Inpatient Admission |
MAINTENANCE
Notification of Inpatient Admission. Documentation in the medical record of receipt of notification of inpatient admission on the day of admission or within the following 2 calendar days. |
15 |
0 |
92.63 |
56.2 |
0 |
No |
| TOC_HEDIS2 |
Receipt of Discharge Information |
MAINTENANCE
Receipt of Discharge Information. Documentation in the medical record of receipt of discharge information on the day of discharge or within the following 2 calendar days. |
15 |
0 |
98.24 |
46.72 |
0 |
No |
| 2024 |
STIER |
Shannon Campbell |
United Health Services Hospitals |
| READM_30_COPD |
Obstructive Pulmonary Disease (COPD) Hospitalization 30-day readmission rate |
Maintain 30 day all cause unplanned readmission rates for patients admitted to UHSH with a primary diagnosis of COPD at or below the benchmark 19.30% for the measurement period.
Maintenance Measure |
7.5 |
0 |
13.01 |
19.3 |
0 |
No |
| READM_30_PN |
Hospital 30-Day, All-Cause, Risk-Standardization Readmission Rate (RSRR) Following Pneumonia Hospitalization |
Maintain 30 day all cause unplanned readmission rates for patients admitted to UHSH with a primary diagnosis of pneumonia at or below the benchmark 16.90% for the measurement period.
Maintenance Measure |
7.5 |
0 |
13.1 |
16.9 |
0 |
No |
| H_COMP_1_A_P |
Nurse communication - Star Rating |
Increase our RN Communication Patient Experience score from baseline percentage of 74.73% equal to or higher than 75.88% during the measurement period as higher performance rates are better. |
20 |
0 |
74.73 |
75.88 |
0 |
No |
| H_COMP_5_A_P |
Communication about medicines - Star Rating |
Increase our Medications Communication Patient Experience score from baseline rate of 51.66% equal to or higher than 54.05% during the measurement period as higher performance rates are better. |
10 |
0 |
51.66 |
54.05 |
0 |
No |
| TOC_HEDIS1 |
Notification of Inpatient Admission |
Maintain or increase the rate of Inpatient Admission where the Patient' s UHSH PCP - received and acknowledged an EMR notification of their patient's Admission from the Inpatient setting day of event plus 2 calendar days after event - as higher performance rates are better - during the measurement period. Baseline percentage is higher than benchmark.
Maintenance Measure |
7.5 |
0 |
57.31 |
56.2 |
0 |
No |
| TOC_HEDIS2 |
Receipt of Discharge Information |
Increase the rate of Discharge encounters where the Patient's UHSH PCP - received and acknowledged an EMR notification of their patient's Discharge from the Inpatient setting day of event plus 2 calendar days after event - from baseline percentage of 32.94% equal or higher than 36.78% as higher performance rates are better. |
7.5 |
0 |
32.94 |
36.78 |
0 |
No |
| PPC_POST |
Postnatal Care |
Increase the percentage of Patients that attend their Post Partum visit (day 7 -84 post live delivery) that saw a UHSH Provider for their Prenatal Care - from baseline percentage of 66.55% to equal or higher than 74.57% during the measurement period as higher performance rates are better. |
20 |
0 |
66.55 |
74.57 |
0 |
No |
| PSI_03 |
Pressure ulcer rate |
UHSH will decrease the number of adult (18 years and older) patients with hospital acquired stage 3,4, or unstageable pressure injuries with a length of stay of 3 days or more during the measurement period - from baseline of 3.13 rate and finish equal to or lower than target rate 2.35 as lower performance rates are better. |
20 |
0 |
3.13 |
2.35 |
0 |
No |
| 2024 |
ROCH |
Jennifer de Jong |
United Memorial Medical Center |
| READM_30_HF |
Heart failure (HF) 30-day readmission rate |
The Centers for Medicare & Medicaid Services (CMS) 30-day risk-standardized readmission measures assess a broad set of healthcare activities that affect patients’ well-being. Patients who receive high-quality care during their hospitalizations and their transition to the outpatient setting will likely have better outcomes, such as survival, functional ability, and quality of life. Assessing the readmission status of patients helps to identify opportunities related to hospital discharge processes, ambulatory availability and process, and transition of care processes. The goal is be at or below the national benchmark. Decrease |
10 |
0 |
25.57 |
23.79 |
0 |
No |
| H_COMP_1_A_P |
Nurse communication - Star Rating |
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a national, standardized publicly reported survey on patient’s perspectives on their hospital care. The questions related to nurse communication are used in a variety of CMS programs as well as other publicly reported programs such as Leapfrog. Information from this question helps to identify clinical performance opportunities as it relates to patient’s perception of their care. The goal is be at or below the national benchmark. Increase |
30 |
0 |
75.71 |
76.49 |
0 |
No |
| H_RECMND_DY |
Recommend hospital - Star Rating |
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a national, standardized publicly reported survey on patient’s perspectives on their hospital care. The question related to willingness to recommend is used in a variety of CMS programs as well as other publicly reported programs such as Leapfrog. Information from this question helps to identify clinical performance opportunities as it relates to patient’s perception of their care. The goal is be at or below the national benchmark. Increase |
30 |
0 |
55.69 |
59.13 |
0 |
No |
| TOC_HEDIS1 |
Notification of Inpatient Admission |
Notification of Inpatient Admissions - Documentation in the medical record of receipt of notification of inpatient admission on the day of admission or within the following 2 calendar days.
Maintenance Measure |
15 |
0 |
99.91 |
56.2 |
0 |
No |
| TOC_HEDIS2 |
Receipt of Discharge Information |
Receipt of Discharge Information - Documentation in the medical record of receipt of discharge information on the day of discharge or within the following 2 calendar days.
Maintenance Measure |
15 |
0 |
92.14 |
46.72 |
0 |
No |
| 2024 |
ROCH |
Jennifer de Jong |
Unity Hospital |
| COMP_HIP_KNEE |
Hospital-Level Risk-Standardized Complication Rate Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) |
The Centers for Medicare & Medicaid Services’ (CMS’s) publicly reported risk-standardized complication measure for elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) assesses a broad set of healthcare activities that affect patients' well-being. The outcome for this measure captures eight different complications, each within a specific and clinically meaningful time period, during which the outcome can be attributed to the hospital that performed the procedure. Measuring and reporting risk-standardized complication rates helps to inform our providers of opportunities to improve and strengthen the care that we deliver. The goal is be at or below the national benchmark. Decrease |
20 |
0 |
3.69 |
3.55 |
0 |
No |
| PSI_08 |
In-hospital fall with hip fracture rate |
In hospital fall with hip fracture (secondary diagnosis) per 1,000 discharges for patients ages 18 years and older. Excludes cases that were admitted because of conditions that make them susceptible to falling (seizure disorder, syncope, stroke, occlusion of arteries, coma, cardiac arrest, poisoning, trauma, delirium or other psychoses, anoxic brain injury), have conditions associated with fragile bone (metastatic cancer, lymphoid malignancy, bone malignancy, cases with a principal diagnosis of hip fracture, cases with a secondary diagnosis of hip fracture present on admission, and obstetric cases. Decrease |
20 |
0 |
0.49 |
0.37 |
0 |
No |
| H_RECMND_DY |
Recommend hospital - Star Rating |
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a national, standardized publically reported survey on patient’s perspectives on their hospital care. The question related to willingness to recommend is used in a variety of CMS programs as well as other publically reported programs such as Leapfrog. Information from this question helps to identify clinical performance opportunities as it relates to patient’s perception of their care. The goal is be at or below the national benchmark. Increase |
10 |
0 |
59.49 |
61.94 |
0 |
No |
| TOC_HEDIS1 |
Notification of Inpatient Admission |
Notification of Inpatient Admission - Documentation in the medical record of receipt of notification of inpatient admission on the day of admission or within the following 2 calendar days.
Maintenance Measure |
15 |
0 |
99.81 |
56.2 |
0 |
No |
| TOC_HEDIS2 |
Receipt of Discharge Information |
Receipt of Discharge Information - Documentation in the medical record of receipt of discharge information on the day of discharge or within the following 2 calendar days.
Maintenance Measure |
15 |
0 |
99.35 |
46.72 |
0 |
No |
| PSI_12 |
Perioperative pulmonary embolism or deep vein thrombosis rate |
Perioperative pulmonary embolism or deep vein thrombosis (secondary diagnosis) per 1,000 surgical discharges for patients ages 18 years and older. Excludes cases with principal diagnosis for pulmonary embolism or deep vein thrombosis; cases with secondary diagnosis for pulmonary embolism or deep vein thrombosis present on admission; cases in which interruption of vena cava occurs before or on the same day as the first operating room procedure; and obstetric discharges. Decrease |
20 |
0 |
4.11 |
3.89 |
0 |
No |
| 2024 |
WNY |
Denise Hull |
UPMC Chautauqua |
| READM_30_HF |
Heart failure (HF) 30-day readmission rate |
Decrease HF readmissions (Maintenance Measure) |
15 |
0 |
15.65 |
20.2 |
0 |
No |
| PPC_POST |
Postnatal Care |
Increase postpartum follow up |
15 |
0 |
66.17 |
74.39 |
0 |
No |
| OP_22 |
ED Left Without Being Seen |
Decrease the amount of patients who left without being seen |
30 |
0 |
2.77 |
2.08 |
0 |
No |
| H_COMP_1_A_P |
Nurse communication - Star Rating |
Increase nursing communication to patients |
10 |
0 |
77 |
77.59 |
0 |
No |
| H_COMP_6_Y_P |
Discharge information - Star Rating |
Increase discharge instruction information education (Maintenance Measure) |
30 |
0 |
89.99 |
86 |
0 |
No |
| 2024 |
CNY |
Denise Hull |
Upstate University Hospital |
| READM_ALL |
All Cause Rate of readmission after discharge from hospital (hospital-wide) |
Decrease "All Cause" readmission rate after discharge from hospital
Maintenance Measure |
30 |
0 |
11.37 |
14.6 |
0 |
No |
| COMP_HIP_KNEE |
Hospital-Level Risk-Standardized Complication Rate Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) |
Maintain or decrease complication rate following elective THA and/or TKA surgery
Maintenance Measure |
30 |
0 |
1.03 |
3.2 |
0 |
No |
| OP_35_ED |
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy
|
Maintain or decrease visits to the ED from patients receiving outpatient chemotherapy
Maintenance Measure |
30 |
0 |
3.72 |
5.4 |
0 |
No |
| H_COMP_5_A_P |
Communication about medicines - Star Rating |
Improve communication about medicines |
10 |
0 |
60.18 |
60.33 |
0 |
No |