Measurement Year Region Consultant Name Hospital Name Measure ID Measure Name Outcome Detail Aim Statement Point At Risk Point Earned Baseline Rate Final Target Rate Final Rate Target Achieved
2024 UTICA Denise Hull Adirondack Health 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 12/5/2023 Adirondack Health aims to improve the rate of severe sepsis 3-hour bundle compliance which can help with the overall mortality rate of sepsis patients Baseline Data DOS: 10/1/22 - 9/30/23 Baseline Numerator: 38 Baseline Denominator: 49 Baseline Rate: 77.55% FInal Target DOS: 1/1/2024 - 12/31/2024 Final Target Rate: 80.95% " 30 0 77.55 80.95 0 No
2024 UTICA 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 12/5/2023 Adirondack Health aims to maintain or improve the rate of readmissions. Reducing readmissions improves patient experience and decreases the total cost of care for the health care industry. Baseline Data DOS 11/1/22 - 10/31/23 Baseline Numerator 106 Baseline Denominator 1,680 Baseline Rate 6.3% Final Target Rate 6.3% Final Target DOS 1/1/24 - 12/31/24 " 15 0 6.31 14.6 0 No
2024 UTICA Denise Hull Adirondack Health 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 12/5/2023 Adirondack Health aims to improve the rate of severe sepsis 6-hour bundle compliance which can help with the overall mortality rate of sepsis patients Baseline Data DOS 10/1/22 - 9/30/23 Baseline Numerator 15 Baseline Denominator 26 Baseline Rate 57.69% Final Target Rate 69.28% Final Target DOS 1/1/24 - 12/31/24 30 0 57.69 69.28 0 No
2024 UTICA Denise Hull Adirondack Health 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 12/5/2023 Adirondack Health aims to improve the process and outcomes for ED patients with multiple chronic conditions receiving a follow up service with primary care. A follow up service will make sure any unmet needs are addressed and possibly prevent a return to the ED. Baseline Data DOS 1/1/23 - 9/30/23 Baseline Numerator 219 Baseline Denominator 829 Baseline Rate 26.4% Final Target Rate 33.0% Final Target DOS 1/1/24 - 12/31/24 15 0 26.42 33 0 No
2024 UTICA Denise Hull Adirondack Health H_QUIET_HSP_A_P Quietness - Star Rating Maintain or increase the patient satisfaction score for quietness in the hospital environment - Maintenance Measure 12/5/2023 Adirondack Health aims to maintain or improve the patient satisfaction score for ""Quietness of hospital environment"". Baseline Data DOS 11/1/22 - 10/31/23 Baseline Numerator 347 Baseline Denominator 557 Baseline Target: 62.3% Final Target 62.3% Final Target DOS 1/1/24 - 12/31/24 " 10 0 62.3 62 0 No
2024 UTICA Laurie Foster 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 12/13/2023 Maintain readmission rates below 14.6% throughout CY '24. This will be a maintenance measure, noting a baseline of 10.46% (61/583). Alice Hyde as recently transitioned to a Critical Access Hospital and has swing beds. Due to baseline having no swing beds, data will exclude swing readmissions as previously discussed. Readmissions will include the standard CMS readmission algorithm exclusions and will be for patients 18 years and older for all payers. Data source is Vizient. 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. 12/13/2023 The A.O. Fox Memorial Hospital all cause/all payer readmission rate is below the CMS benchmark goal of 14.6% (lower performance rate is better) for the final measurement period 1/1/2024 – 12/31/2024. A.O. Fox Memorial Hospital aims to continue the deployment of evidence-based practices for the purpose of reducing overall all cause readmissions and improving quality of life. For data collection purposes, the baseline data and measurement period denominator is defined as all inpatient admissions to A. O. Fox Memorial Hospital in an acute care bed, minus the following exclusion patient admission types per the index admission (CMS): 1. Admitted to a PPS-exempt cancer hospital. 2. Admitted for primary psychiatric diagnosis. 3. Admitted for rehabilitation. 4. Admitted for medical treatment of cancer. 5. Discharged against medical advice. 6. With a principal diagnosis code of COVID-19 (U07.1) or with a secondary diagnosis code of COVID-19 coded as present on admission on the index admission claim. The baseline and measurement period numerator is defined to include ALL patients readmitted to an acute care bed within the Bassett Healthcare Network within 30 days of discharge from an acute care bed at A.O. Fox Hospital – regardless of payer type but excluding the patient types as noted above with denominator definition. Baseline data DOS is fiscal year 07.01.22 – 06.30.23. The denominator is 1,464 (total number of all inpatient discharges regardless of payer) and the numerator is 168 (total number of all inpatients discharged and readmitted to inpatient status in any hospital within the Bassett Healthcare Network within 30 days. The baseline performance rate is 11.48% and the benchmark utilized is 14.6%. As this is a maintenance measure as defined by the health plan (baseline rate better than benchmark rate – lower is better in this project). Denominator and numerator definitions are the same for the baseline and measurement periods (as noted above), ensuring matching populations are captured in the same way. 50 0 11.48 14.6 0 No
2024 UTICA Shannon Campbell A.O. Fox Hospital 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. 12/13/2023 A.O. Fox Memorial Hospital aims to perform equal to or better (higher is better in this project) than the CMS benchmark of 84.67% for this project during the measurement period of 01.01.24 – 12.31.24; with the medication reconciliation being performed on the day of discharge or within 30 days for inpatients discharged to home or home with home health and who have primary care practitioners within the Bassett Healthcare network (excluding those patients with an inpatient admission for elective surgery procedures). For data collection purposes, denominator definition for baseline data and measurement period is as follows: All A.O. Fox Hospital inpatients, excluding those admitted post elective surgery, but including those who are discharged to home or home health AND have a primary care practitioner within the Bassett Healthcare Network during the performance period of 1/1/2024 – 12/31/2024. The numerator is defined as those eligible discharges that have complete documentation of an initial transition of care telephone call or attempt on or within 30 days following. The d/c summary should include an applicable medication reconciliation performed by at minimum scope of practice wise, a Registered Nurse at time of discharge. This action at discharge also meets the projects’ criteria and should be included in the data collection toward numerator inclusion -regardless of the TOC call attempt being made. Baseline data for this project is as follows: Baseline data collection period is FS 07.01.22 – 06.30.23. The denominator (defined above) is 454. The numerator (as defined above) is 454. The baseline performance rate is 100% and the benchmark is 84.67% per CMS. The final target rate is 84.67% as this project is considered as a MM by the health plan’s definitions (baseline performance rate better than benchmark – higher is better for this project). Denominator and numerator definitions are the same for the baseline and measurement periods (as noted above), ensuring matching populations are measured in the same way. 25 0 100 84.67 0 No
2024 UTICA Shannon Campbell A.O. Fox Hospital 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. 12/13/2023 A.O. Fox Memorial Hospital aims to maintain or perform better than the CMS benchmark in Transition of Care activities including a project objective of communication; with in-network primary care practitioners following an inpatient, non-elective surgical discharge to home or home with home health for the measurement period of 01.01.24 – 12.31.24. For data collection purposes – both baseline and active measurement periods are measuring all A.O. Fox Hospital inpatients, excluding those admitted post elective surgery but including those who are otherwise discharged to home or home health AND have a primary care practitioner within the Bassett Healthcare Network during the performance period of 01.01.24 – 12.31.24 – all eligible patients will be included in the denominator (definition). The numerator is defined as those eligible (denominator) patients where there is completed documentation of a transition of care telephone call or attempt on or within 2 calendar days following an eligible discharge (documentation of the TOC will trigger or create the ‘acknowledgement’ of the receipt of discharge information in the EMR for each eligible patient by the outpatient care team – which includes a PCP and care manager). It is standard practice for discharge summaries to include a completed med rec document- which can be transmitted to the PCP/Assigned care manager via electronically by the health system wide used EMR, EPIC. Baseline data for this project is as follows: Baseline data DOS is fiscal year 07.01.22 – 06.30.23. The denominator (as defined above) is 454 and the numerator (as defined above) is 358. The baseline performance rate is 78.85% and the benchmark utilized is 46.72%. The final target rate is 46.72% as this is a maintenance measure as defined by the health plan (baseline rate better than benchmark rate – higher is better in this project). Denominator and numerator definitions are the same for the baseline and measurement periods (as noted above), ensuring matching populations are captured in the same way. 25 0 78.85 46.72 0 No
2024 STIER Teresa Stokelin Arnot Ogden Medical Center SEV_SEP_3HR Severe Sepsis 3-Hour Bundle Increase baseline rate 12/13/2023 We will increase our Severe Sepsis 3 Hour bundle compliance rate from our baseline year rate of 81.40% Our target goal rate is 83.91% for the measurement year. In our baseline year: Date October 1, 2022- September 30, 2023 Numerator 267 Denominator 328 Baseline Rate 81.40% Numerator- number of patients received all of the 3-hour bundle measures Denominator- Patients aged 18 years and over who meet CMS Sep-1 criteria for severe sepsis 30 0 81.4 83.91 0 No
2024 STIER Teresa Stokelin Arnot Ogden Medical Center H_COMP_1_A_P Nurse communication - Star Rating Maintain or increase baseline rate 12/13/2023 Patients who reported that their nurses ""Always"" communicated well. Aim Statement: We will maintain or increase our rate of patients who response on the Press Ganey Survey that the nurses Always communicated well at or above 79%, In our baseline year: November 1,2022 through October 31, 2023, Number of surveys 725 Baseline Rate 79.32% 10 0 79.32 79 0 No
2024 STIER Teresa Stokelin Arnot Ogden Medical Center SEV_SEP_6HR Severe Sepsis 6-Hour Bundle Increase baseline rate 12/13/2023 We will increase our Severe Sepsis 3 Hour bundle compliance rate from our baseline year rate of 80.22% Our target goal rate is 85.38% for the measurement year In our baseline year: Date October 1, 2022- September 30,2023 Numerator 146 Denominator 182 Baseline Rate 80.22% Numerator- number of patients received all of the 6-hour bundle measures if indicated Denominator- Patients aged 18 years and over who meet CMS Sep-1 criteria for severe sepsis. 30 0 80.22 85.38 0 No
2024 STIER Teresa Stokelin Arnot Ogden Medical Center TOC_HEDIS3 Medication Reconciliation Conducted Medication Reconciliation. Maintain or increase baseline rate. 12/13/2023 Measures HEDIS Medication Reconciliation Medication Reconciliation on the date of discharge through 30 days after discharge (31 total days) for inpatients age 18 yrs or older Aim Statement We will maintain or increase our compliance rate of inpatient medication reconciliation at discharge for patients 18 yrs. of age or older who have been admitted as inpatient at 84.7% or above. In our baseline year: Date October 1, 2022- September 30,2023 Numerator 5728 Denominator 6386 Baseline Rate 59.0% 15 0 89.7 84.67 0 No
2024 STIER Teresa Stokelin Arnot Ogden Medical Center TOC_HEDIS2 Receipt of Discharge Information Receipt Discharge Information. Maintain or increase baseline rate. 12/13/2023 Hedis Transitions of Care 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 for inpatients age 18 yrs. or older Aim Statement We will maintain or increase our compliance rate of completed discharge information documentation for patient 18years of age and older who have been admitted as inpatients above the target goal rate of 46.72% In our baseline year: Date October 1, 2022- September 30, 2023 Numerator 5600 Denominator 9490 Baseline Rate 56% 15 0 59.01 46.72 0 No
2024 CNY Denise Hull Auburn Community Hospital PPC_POST Postnatal Care Increase the percentage of deliveries that had a postpartum visit on or between 7 and 84 days after delivery. 12/7/2023 To increase our to increase the percentage of postpartum visits on or between 7 and 84 days after delivery above 43.88% Our data is derived from Hospital (Paragon) and OBGYN Office system (MEDENT). Our internal IT department arw e in the process of creating reports to identify both the Numerator (Medent) and the Denominator ( Paragon) patients. Baseline Date DOS 10/1/22 to 9/30/23 Baseline Numerator 115 Baseline Denominator 328 Baseline Rate 35.06% Final Target Rate 43.83% Final Target DOS1/1/2024 - 12/31/2024 15 0 35.06 43.83 0 No
2024 CNY Denise Hull Auburn Community Hospital H_COMP_1_A_P Nurse communication - Star Rating Increase the HCAHPS score for Patients who reported that their nurses "Always" communicated well. 12/7/2023 To increase our Nurse Communication Star rating above 69.43% Our data is derived from Press Ganey Patient Satisfaction Surveys. A sample of inpatients are sent a patient satisfaction survey by Press Ganey. Press Ganey tabulates the responses and shares the outcome data with us monthly. Our baseline data is from October 1, 2022 to September 30, 2023. During that period of time, we had 333 inpatients rate Nurse Communication a Top Box score out of 503 Inpatient surveys returned for a baseline rate of 66.2 %. 30 0 66.2 69.43 0 No
2024 CNY Denise Hull Auburn Community Hospital 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. 12/7/2023 To increase our Discharge Information Star rating above 84.51% Our data is derived from Press Ganey Patient Satisfaction Surveys. A sample of inpatients are sent a patient satisfaction survey by Press Ganey. Press Ganey tabulates the responses and shares the outcome data with us monthly. Our baseline data is from October 1, 2022 to September 30, 2023. During that period of time, we had 396 inpatients rate Discharge Information a Top Box score out of 471 Inpatient surveys returned for a baseline rate of 84.08 %. 30 0 84.08 84.51 0 No
2024 CNY Denise Hull Auburn Community Hospital 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. 12/7/2023 To increase our Communication about medications Star rating above 48.45% Our data is derived from Press Ganey Patient Satisfaction Surveys. A sample of inpatients are sent a patient satisfaction survey by Press Ganey. Press Ganey tabulates the responses and shares the outcome data with us monthly. Our baseline data is from October 1, 2022 to September 30, 2023. During that period of time, we had 135 inpatients rate Nurse Communication a Top Box score out of 309 Inpatient surveys returned for a baseline rate of 43.69 %. 10 0 43.69 48.45 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 12/7/2023 To continue to maintain a 30 day ALL cause All Payor readmission rate below 14.6%. Baseline Date DOS 10/1/2022 - 9/30/2023 Baseline Numerator 446 Baseline Denominator 4161 Baseline Rate 10.72% Final Target Rate 14.6% Final Target DOS 1/1/2024 - 12/31/2024 15 0 10.72 14.6 0 No
2024 UTICA Shannon Campbell Bassett Medical Center 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%. 12/14/2023 In effort to decrease the overall sepsis mortality rate, Bassett Medical Center is committed to increasing the 3-hour severe sepsis bundle compliance rate to be greater than/equal to 83.99%. Quarterly performance will be tracked from 1/1/24 - 12/31/24 for this goal for patients => 18YO with a diagnosis of severe sepsis. Baseline data collected from 07.01.22 - 06.30.23 revealed a denominator (all patients diagnosed with severe sepis) 131, 107 patients were compliant with the 3 HR bundle (numerator). This is a baseline rate of 81.68%. The current benchmark is 91%. The final target rate for PY 01.01.24 - 12.31.24 is 83.99%. The PY denominator and numerator populations are the same as the baseline. PROJECT GOAL: TO INCREASE FROM BASELINE OF 81.68% IN THE 3HR SEVERE SEPSIS BUNDLE TO 83.99% OR HIGHER FROM 01.01.24 - 12.31.24. 30 0 81.68 83.99 0 No
2024 UTICA Shannon Campbell Bassett Medical Center 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. 12/14/2023 Bassett Medical Center will 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. For this goal, deliveries at BMC occurring between 01.01.24 - 09.30.24 will be within the scope, as we are targeting improvements in post-delivery care from 7-84 days. Baseline data: of the 936 deliveries (for patients who utilize in-network OB/GYN providers), occurring between 7/1/22 and 6/30/23), 804 postpartum care visits occurred within 7 and 84 days (85.90%). The baseline and PY denominator populations are those patients who delivered at BMC (with an in-network provider). The numerator population for both baseline and PY will measure those patients in the denominator who complete a PostPartum visit 7 -84 days post delivery with an in-network provider. THE PROJECT GOAL: Increase the number of postpartum care visits occurring between 7 and 84 days after delivery to be greater than/equal to 88.33% (from the benchmark of for patients who delivered at Bassett Medical Center (with an in-network provider) and utilize an in-network provider for the follow-up care visit. 15 0 85.9 88.33 0 No
2024 UTICA Shannon Campbell Bassett Medical Center 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 12/14/2023 Maintain the total number of Bassett Medical Center Emergency Department (ED) visits to less than/equal to 5.40% (benchmark rate) for patients (=> 18YO) who have received chemotherapy treatment within 30 days from a Bassett cancer treatment clinic for the following diagnosis: anemia, dehydration, diarrhea, emesis, fever, nausea, neutropenia, pain, pneumonia or sepsis. PY time frame is 01/01/24 through 12/31/24. The baseline and PY denominator populations include BMC cancer treatment centers (receiving chemo treatment). The baseline and PY numerator includes those in the denominator who then experienced an ED visit at a BMC ED for the following diagnosis: anemia, dehydration, diarrhea, emesis, fever, nausea, neutropenia, pain, pneumonia or sepsis. Baseline data collected from 10/01/22 through 09/30/23, indicate there were 129 BMC emergency departments visits (numerator) out of the 11,190 (denominator) cancer treatment patients. Baseline of 1.15% is better than the CMS benchmark target of 5.40% (risk adjusted calculated rate), thus this goal will be a maintenance measure. PROJECT GOAL: TO FINISH 01.01.24 -12.31.24 AT LESS THAN THE BENCHMARK OF 5.40%. THIS IS A MAINTENANCE MEASURE. 30 0 1.15 5.4 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 12/14/2023 The Bassett Medical Center all cause/all payer readmission rate has outperformed the national benchmark in 2023, therefore in 2024 (benchmark 14.60%) it has been established as a maintenance measure. BMC will sustain an all cause/all payer readmissions rate below national benchmark (14.60%) for all patients admitted to acute care beds for the time period of 01/01/2024 through 12/31/2024 (denominator). Numerator will be patients readmitted within 30 days of eligible admission. Baseline data indicates 970 patients out of the 8917 BMC admissions (10.88%) experienced a readmission with 30 days for the time period of 7/1/22 through 6/30/23. PROJECT GOAL: Maintain an all cause/all payer readmissions at or below 14.60% (Maintenance Measure). Final target rate is to be at or below 14.60%. PY denominator and numerator definitions are the same as baseline populations. 15 0 10.88 14.6 0 No
2024 UTICA Shannon Campbell Bassett Medical Center 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%. " 12/14/2023 Bassett Medical Center will improve (increase) the CMS HCAHPs Staff responsiveness (Patients who report “Always” receiving help as soon as they wanted) hospital score to ≥56.22%. Baseline data indicates 614 responses out of 1154 returned surveys (53.21%), for the time period 7/1/22 - 6/30/23, who reported “Always”, thus highlighting opportunity for improvement. The baseline and PY denominator populations are defined as those patients who returned surverys. The numerator population for baseline and PY are those patients who are in the denominator and reported 'Always' receiving help as soon as they wanted. The increase/improvement will be accomplished by levering both technological advancements and initiatives designed to drive shifts in culture. A goal of Bassett Healthcare is to improve the patient experience. Working to improve our responsiveness rate will ultimately contribute toward improving our overall Willingness to Recommend performance. This will positively affect BMC’s Star Rating score, Leapfrog score, etc. Data will be collected for the time period of 1/1/24 through 12/31/24. THE PROJECT GOAL: TO INCREASE THE HCAHPS QUESTION OF STAFF RESPONSIVENESS - ANSWER INCREASE FOR ALWAYS RECEIVING HELP AS SOON AS THEY WANTED FROM 53.21% TO 56.22% OR HIGHER FROM 01.01.24 -12.31.24." 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 12/13/2023 To maintain the rate of notifiying the appropriate outpatient providers of inpatient admissions at or above the benchmark rate of 56.2%. For data collection, all patients who were admitted to Canton-Potsdam Hospital will be included, (regardless of payor type), in the following measure definition using HEDIS inclusion criteria:   Numerator = Completed Inpatient Admission Notifications to Patients’ PCPs Denominator = All Inpatient Admissions Baseline Numerator 3956/Baseline Denominator 3975 = 99.52%   Final time period – 1/1/2024 – 12/31/2024 50 0 99.52 56.2 0 No
2024 UTICA Jennifer de Jong Canton-Potsdam Hospital TOC_HEDIS2 Receipt of Discharge Information MAINTENANCE MEASURE: To maintain the rate of discharge information sent to outpatient providers at or above the benchmark 12/13/2023 To maintain the rate of sending discharge summaries/information to appropriate outpatient providers at or above the benchmark rate of 46.72%. For data collection, all patients who were discharged from Canton-Potsdam Hospital will be included, (regardless of payor type), in the following measure definition using HEDIS inclusion criteria:   Numerator = Number of Discharge Summaries Sent to Patients’ PCPs Denominator = All Inpatient Discharges   Baseline Numerator 3450 /Baseline Denominator 3612 = 95.51% Final time period – 1/1/2024 – 12/31/2024 50 0 95.51 46.72 0 No
2024 UTICA Laurie Foster Champlain Valley Physicians Hospital H_COMP_7_SA Care Transitions - Star Rating Increase patients' understanding of their care prior to discharge 11/29/2023 Improve Care Transition Top Box to 45.78% or better over CY '24. Baseline (4/1/22-3/31/23) was 332/755=43.97% using Press Ganey data base, Top Box Score by received date 30 0 43.97 45.78 0 No
2024 UTICA Laurie Foster 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. 11/29/2023 Maintain 30-day readmission rate at 14.6% or below for CY '24. Baseline (4/1/22-3/31/23) was 560/5315=10.54%. Data source was Vizient using 2023 Community Hospital Risk Model and AHRQ v2023. Standard restrictions utilized CMS algorithm for unplanned readmissions and all for readmission type. Readmission flags were standard which exclude rehab, dialysis, and mental disease/alcholol and drug use. Denominator cases excluded are death at 1st admit. Criteria was set for 18 years and older (vs. CMS 65+) and to include all payers. CMS standard restrictions used as otherwise defined in CMS/Vizient model. 20 0 10.54 14.6 0 No
2024 UTICA Laurie Foster Champlain Valley Physicians Hospital PPC_POST Postnatal Care Increase the rate of postpartum visits completed 7-84 days after delivery 11/29/2023 Improve postnatal care followup appointments for CVPH patients with follow up care with HN employed physicians to 65.54%. Baseline (4/1/22-3/31/23 excudes April 1st data due to Epic go live) is 389/715=54.41%. Data pulled from Epic SQL data base. Note: we will only be able to track patients within our Epic Data base; however, through improving CVPH-based follow up care, we will be able to drive the overall care for all patients who delivery at CVPH." 10 0 54.41 65.54 0 No
2024 UTICA Laurie Foster Champlain Valley Physicians Hospital H_COMP_2_A_P Doctor communication - Star Rating Increase patient satisfaction with doctors' communications 11/29/2023 Increase Doc Communication domain Top Box to 73.80% or higher during CY '24. Baseline (4/1/22-3/31/23) was 548/761 using Press Ganey data base by received date. 10 0 71.95 73.8 0 No
2024 UTICA Laurie Foster Champlain Valley Physicians Hospital SEP_SH_3HR Septic Shock 3-Hour Bundle Increase compliance with the 3 hour septic shock treatment bundle 11/29/2023 Improve Septic Shock 3-hour bundle compliance to 69.46% over CY '24. Baseline (4/1/22-3/31/23) was 26/44=59.09%. Goal for bundle compliance will be for all patients. It is noted that the baseline data was established by obtaining a sample of patient data and extrapolating to create 12 months' worth of data. " 30 0 59.09 69.46 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. 12/6/2023 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.   National Benchmark: Rate 3.2 per 1,000 The CMS definitions are used for both the numerator and denominator Improvement Measure: Heart failure (HF) 30-day readmission rate - 2022 Baseline Data - Num:12 Denom:55 Rate:21.82% Vol Min:190 Vol Met:No NB:20.20% Target:21.37% 10 0 21.82 21.37 0 No
2024 ROCH Jennifer de Jong Clifton Springs Hospital & Clinic 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 12/6/2023 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. National Benchmark: 46.72% Numerator: 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.   Denominator Definition: Acute or non-acute inpatient discharges for Medicare beneficiaries 18 years and older. The denominator is based on discharges, not members. Members may appear more than once. - For Administrative Specification, the denominator is the eligible population. - For Hybrid Specification, the denominator is a systematic sample drawn from the eligible population.   Baseline Period - Receipt of Discharge Information: October 2022 – September 2023 Maintenance Measure: Transitions of Care - Receipt of Discharge Information - October 2022 - September 2023 Baseline Data - Num:1572 Denom:1647 Rate:95.45% NB:46.72% Target:Maintain 15 0 95.45 46.72 0 No
2024 ROCH Jennifer de Jong Clifton Springs Hospital & Clinic 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 12/6/2023 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. National Benchmark: 56.20% Numerator: 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. Denominator Definition: Acute or non-acute inpatient discharges for Medicare beneficiaries 18 years and older. The denominator is based on discharges, not members. Members may appear more than once. - For Administrative Specification, the denominator is the eligible population. - For Hybrid Specification, the denominator is a systematic sample drawn from the eligible population. Baseline Period - Notification of Inpatient Admission: October 2022 – September 2023 Maintenance Measure: Transitions of Care - Notification of Inpatient Admission - October 2022 - September 2023 Baseline Data - Num:2134 Denom:2136 Rate:99.91% Vol Min:190 Vol Met:Yes NB:56.20% Target:Maintain 15 0 99.91 56.2 0 No
2024 ROCH Jennifer de Jong Clifton Springs Hospital & Clinic 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 12/6/2023 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. National Benchmark: 79% The CMS definitions are used for both the numerator and denominator.   Maintenance Measure: Feb 2022 - Jan 2023 Baseline - Doctor Communication Star Rating - Num:1645 Denom:1984 Rate:82.91% VolMin:None NB:79% Target:Maintain 30 0 82.91 79 0 No
2024 ROCH Jennifer de Jong Clifton Springs Hospital & Clinic 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. 12/6/2023 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. [NOTE: The software provides the rate per hospital discharge. However, common practice reports the measure as per 1,000 discharges. The user must multiply the rate obtained from the software by 1,000 to report events per 1,000 hospital discharges.] HAC.   National Benchmark: 3.63 Rate per 1,000 Improvement Measure: PSI-12 PE/DVT - 2022 Baseline Data - Num:2 Denom:320 Rate:6.25 Vol Min:190 Vol Met:Yes NB:3.41 Target:4.88 30 0 6.25 4.88 0 No
2024 UTICA Denise Hull Community Memorial Hospital TOC_HEDIS2 Receipt of Discharge Information MAINTENANCE MEASURE: Continue to maintain and improve receipt of discharge information 12/8/2023 Continue to maintain and improve sending discharge information to providers for inpatient medical/surgical admissions at or above the target rate of 46.72% for 1/1/2024-12/31/2024. 20 0 85.88 46.72 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. 12/8/2023 Reduce the number of patients leaving without being seen prior to seeing a provider in the Emergency Department from 1.42% to 1.07% or less. 30 0 1.42 1.07 0 No
2024 UTICA Denise Hull Community Memorial Hospital H_HSP_RATING_9_10 Overall hospital rating - Star Rating Increase the Top Box Score for Star Rating of 9/10. 12/8/2023 Increase the top box composite score for acute medical and surgical patients who give the hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest) from 68.96% to 69.31% or greater for the time period of 1/1/2024-12/31/2024. 30 0 68.96 69.31 0 No
2024 UTICA Denise Hull Community Memorial Hospital TOC_HEDIS1 Notification of Inpatient Admission MAINTENANCE MEASURE: Continue to maintain and improve notification of Inpatient admissions 12/8/2023 Continue to maintain and improve notification of inpatient medical/surgical admissions at or above the target rate of 56.2% for the time period of 1/1/2024-12/31/2024. 20 0 79.69 56.2 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 12/11/2023 Goal is to maintain or decrease percent hospital discharges with postoperative acute kidney failure (secondary diagnosis) requiring dialysis during the HPIP 2024 measurement period. The baseline is collected from 1/1/2022-12/31/2022 with the respective numerator of 1 and denominator of 1886 resulting in a rate of 0.53. The goal will be to maintain or decrease this rate of 0.53 for the final measurement period of 1/1/2024-12/31/2024. For data collection, all patients age equal to or greater than 18 years admitted to Crouse Hospital and undergoing a surgical procedure will be included based on the AHRQ definitions. Hospital discharges with postoperative acute kidney failure (secondary diagnosis) requiring dialysis per 1,000 elective surgical discharges for patients ages 18 years and older. Excludes discharges with principal diagnosis of acute kidney failure; with secondary diagnosis of acute kidney failure present on admission; with a dialysis procedure before or on the same day as the first operating room procedure; with a dialysis access procedure before or on the same day as the first operating room procedure; with cardiac arrest, severe cardiac dysrhythmia, shock, chronic kidney disease stage 5 or end stage renal disease; with a principal diagnosis of urinary tract obstruction; with partial nephrectomy procedure on a solitary kidney; and obstetric discharges. Numerator includes: Discharges, among cases meeting the inclusion and exclusion rules for the denominator, with any secondary ICD-10-CM diagnosis code for acute kidney failure and any listed ICD-10- PCS procedure code for dialysis. Denominator includes: Elective surgical discharges, for patient’s ages 18 years and older, with any listed ICD-10-PCS procedure code for an operating room procedure. Elective surgical discharges are defined by specific MS-DRG codes with admission type recorded as elective." 30 0 0.53 0.92 0 No
2024 CNY Shelly LoPresti Crouse Hospital 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 12/8/2023 Goal is to increase percent compliance with 6 hour bundle for adult patients diagnosed with severe sepsis or septic shock durng the HPIP 2024 measurement period. The baseline data is collected from 1/1/22-12/31/22 with the respective numerator of 112 and denominator of 151 which results in a baseline rate of 74.17%. The goal will be to increase the rate to 80.85% compliance with the 6 hour bundle with severe sepsis or septic shock for the final measurement period of 1/1/24-12/31/24. For data collection, all patients age greater than or equal to 18 years admited to Crouse Hospital will be included (regardless of payor type), in following measure definition using the CMS Measure Inventory Too for lSevere Sepsis and Septic Shock. Numerator Adult Patients who received ALL of the following: Within three hours of presentation of severe sepsis: * Initial lactate level measurement * Broad spectrum or other antibiotics administered * Blood cultures drawn prior to antibiotics AND received within six hours of presentation of severe sepsis. ONLY if the initial lactate is elevated: * Repeat lactate level measurement AND within three hours of initial hypotension: * Resuscitation with 30 mL/kg crystalloid fluids OR within three hours of septic shock: * Resuscitation with 30 mL/kg crystalloid fluids AND within six hours of septic shock presentation, ONLY if hypotension persists after fluid administration: * Vasopressors are administered AND within six hours of septic shock presentation, if hypotension persists after fluid administration or initial lactate >= 4 mmol/L: * Repeat volume status and tissue perfusion assessment is performed. Denominator: Patients with an ICD-10-CM Principal or Other Diagnosis Code of U07.1 (COVID-19) * Directive for Comfort Care or Palliative Care within six hours of presentation of severe sepsis * Directive for Comfort Care or Palliative Care within six hours of presentation of septic shock * Administrative contraindication to care within six hours of presentation of severe sepsis * Administrative contraindication to care within six hours of presentation of septic shock * Length of Stay >120 days * Transfer in from another acute care facility * Patients enrolled in a clinical trial for sepsis, severe sepsis or septic shock treatment or intervention * Patients with severe sepsis who are discharged within six hours of presentation * Patients with septic shock who are discharged within six hours of presentation * Patients receiving IV antibiotics for more than 24 hours prior to presentation of severe sepsis. 30 0 74.17 80.85 0 No
2024 CNY Shelly LoPresti Crouse Hospital 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 12/8/2023 Goal is to increase percent of patients who gave Crouse Hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest) through the HCAHPS survey. The survey is sent out through vendor Press Ganey to a random sample of discharged patients (alive) age greater than or equal to 18 years. The baseline data is collected from 1/1/2022-12/31/2022 with the respective numerator 1353 and denominator 2310 which results in a baseline rate of 58.57%. The goal will be to increase the rate to 61.58% for the final measurement period of 1/1/2024-12/31/2024. For data collection the hospital uses Press Ganey as a CMS approved vendor to sample inpatients age 18 and older discharged alive from Crouse Hospital. The numerator will include all patients responding to the survey that rated their experience at Crouse Hosptial a rating of 9 or 10 with the denominator being total N of all inpatients surveyed providing response. 10 0 58.57 61.58 0 No
2024 CNY Shelly LoPresti Crouse Hospital 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 12/8/2023 Goals is to increase percentage medication reconciliation conducted by a prescribing practitioner, pharmacist or RN on the date of discharge through 30 days post discharge during the HPIP 2024 measurement period. The baseline data is collected from 1/1/2022-12/31/2022 with the respective numerator of 10992 and denominator of15557 which results in a baseline rate of 70.4. The goal will be to achieve the target of 74.29% for the final measurement period of 1/1/24-12/31/2024. For data collection, all patients age greater than or equal to 18 years admitted to Crouse Hospital will be included (regardless of payor type) in the following measure definition using Transitions of Care HEDIS criteria: Completion of medication reconciliation on the date of discharge through 30 days post discharge. Denominator-acute and non-acute inpatient discharges for all payor beneficiaries 18 years or older. The denominator is based on discharges, not members. Members may appear more than once. 15 0 70.66 74.29 0 No
2024 CNY Shelly LoPresti Crouse Hospital 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 12/7/2023 Goal is to maintain or increase percentage of notification of inpatient admission on the day of admission or within following 2 calendar days during the HPIP 2024 measurement period. The baseline data is collected from 1/1/2022-12/31/2022 with the respective numerator 15822 and denominator 21366 which results in a baseline rate of 74.0. The goal will be maintained at 74.05% or increased for the final measurement period of 1/1/24-12/31/24. For data collection, all patients age greater than or equal to 18 years admitted to Crouse Hospital will be included, (regardless of payor type), in the following measure definition using Transition of Care HEDIS criteria Numerator:  Notification of inpatient admission: Documentation of receipt of notification of inpatient admission on the day of admission or the following day Denominator: Acute or non-acute inpatient discharges for all payor beneficiaries 18 years and older. The denominator is based on discharges, not members. Members may appear more than once. 15 0 74.05 56.2 0 No
2024 WNY Denise Hull Erie County Medical Center H_COMP_1_A_P Nurse communication - Star Rating Increase to meet final target rate 12/13/2023 Our goal is to improve our score to 72.51% by the end of 2024. Nurses must create meaningful and purposeful engagements with patients in order to educate them about their health, their treatment, and ensure that they follow their treatment plan when they are discharged. Not only will this increase the opportunities for better outcomes for patients, it will also create trust, a positive patient experience, ensure patient safety and quality of care. Executive Team leaders will conduct unit by unit listening sessions with the front-line nursing staff in order to gain feedback and perspective of current needs and opportunity from their perspective. Front staff meetings will continue to be conducted, and a summary will be provided to each Unit Manager. Managers will be required to identify improvement plans by a date to be determined by the Sr. VP of Nursing. Additionally, Patient Experience Leaders will continue monthly Human Experience training as an organization and by units. Unit Managers monthly meetings will continue to conduct monthly. The ongoing training program that will be used is The Beryl Institute, PX 101 a seven module educational sessions. We will resume our Press Ganey monthly meetings with the unit managers to provide consistent clarity of the improvement process for their units. 10 0 70.34 72.51 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 12/13/2023 The goal is to maintain our calendar year 2022 performance of (1236/1302) 95% 30 0 94.93 57.46 0 No
2024 WNY Denise Hull Erie County Medical Center H_COMP_6_Y_P Discharge information - Star Rating Maintain CY2022 baseline rate 12/13/2023 The calendar year 2024 goal is to maintain our calendar year 2022 performance of (724.12/842) 86%. 30 0 86 86 0 No
2024 WNY Denise Hull Erie County Medical Center H_COMP_2_A_P Doctor communication - Star Rating Increase to meet final target rate. 12/13/2023 Our goal is to reach 72.44% by the end of 2024. With improved Physician Communication there is a greater opportunity to build a relationship with the patient and increase adherence to treatment and better outcomes for patients. The Serious Illness training program will be facilitated by palliative care leaders. The program was developed through collaboration with Harvard Medical School and Ariadne Labs. The 2.5 hour training will continue to be offered on a quarterly basis, in which there will be groups of 10 and the teams will be multidisciplinary. This training requires interactive role play of the participants to ensure understanding and successful outcomes. We will continue to use our Press Ganey Scores for our gap analysis. Our goal is to improve our score to 72.44% by the end of 2024. Please refer to the above interventions, and implementations listed to reach our goal of 72.51%. We are looking forward to increasing our communication scores which will positively impact our patient outcomes including with aiding the elimination of our patient disparities. 30 0 70.27 72.44 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 12/14/2023 Thompson Health wants patients and their caregivers to fully understand what medications they are receiving and what the potential side effects are. In addition, we want patients to fully understand new medications and their medication regime when they are discharged. Good communication and instructions for medications are key to good patient care, patient satisfaction and aids in keeping patients from returning to the hospital. Thompson wants all patients and their caregivers to understand the medication plan both while in the hospital and after they leave and wants to encourage them to ask any questions they may have. With this measure we will use the Press Ganey HCAPHS % score which indicates the % of inpatients who completed a Press Ganey survey and reported that staff ALWAYS explained medicines before giving it to them. 30 0 53 55.04 0 No
2024 ROCH Teresa Stokelin F.F. Thompson Hospital H_RECMND_DY Recommend hospital - Star Rating Increase number of patients answering always to Recommend Hospital on Press Ganey Satisfaction Survey 12/14/2023 Thompson Health wants patients to recommend our services without hesitation because that means they believe we deliver exceptional care and service. This supports our mission, vision and values. Our vision is to become the leading community healthcare system in Western New York. Our values – CARES – Commitment, Action, Respect, Excellence and Service along with our drive to be a High Reliability Organization demonstrates our commitment to deliver safe, quality care all while making patients feel at ease and at home. Press Ganey manages our patient satisfaction surveys. The HCAHPS survey is sent to a random sampling of our adult patients after their discharge from our hospital allowing them the opportunity rate their experience with us. This feedback helps us understand patient perceptions and improve our delivery of care and service. The percentage reported for this measure is the percent of adult inpatient discharges who completed the survey and answered yes they would definitely recommend the hospital. 30 0 68 68.17 0 No
2024 ROCH Teresa Stokelin F.F. Thompson Hospital TOC_HEDIS1 Notification of Inpatient Admission Notification of Inpatient Admission - goal is to increase % of notification of inpt admission. Maintenance measure 12/14/2023 Transitions from the inpatient (hospital) to home often result in care coordination issues. These challenges include but are not limited to communication breakdowns between the hospital and the outpatient providers (PCPs), issues with medication changes/ omissions, pending diagnostic testing and patients and/or caregivers not fully understanding discharge instructions, new diagnosis, medications and the true need for follow-up with their PCP and/or specialist. Alerting the PCP that their patient has been admitted allows for better care coordination both while the patient is in the hospital and after they are discharged. We aim to ensure the transmission of admission information to the PCP unless the patient refuses for inpatient and observation level patients at Thompson Health. Denominator = # patients (inpt/obs) discharged from the hospital and the numerator = # patients with admission information confirmed sent to their provider. 15 0 84.35 56.2 0 No
2024 ROCH Teresa Stokelin F.F. Thompson Hospital 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 12/14/2023 Thompson Health wants patients and their caregivers to fully understand their care when leaving the hospital. Good communication and instructions for medications, wound care, diet etc are key to good patient care, patient satisfaction and helps us keep patients from returning to the hospital. We want patients and their caregivers to actively participate in this planning so that we can help build a plan they like but also keep them well and safe. Thompson wants all patients and their caregivers to understand the post discharge plan of care, their responsibilities to manage their health, the medication plan and to ask any questions they have. With this measure we will use the Press Ganey HCAPHS % score which indicates the % of inpatients who completed a Press Ganey survey and reported that they strongly agree they understood their care when they left the hospital. 10 0 44 45.81 0 No
2024 ROCH Teresa Stokelin F.F. Thompson Hospital TOC_HEDIS2 Receipt of Discharge Information Receipt of discharge information - goal is to increase % documentation of receipt of d/c information. Maintenance measure 12/14/2023 Transitions from the inpatient (hospital) to home often result in care coordination issues. These challenges include but are not limited to communication breakdowns between the hospital and the outpatient providers (PCPs), issues with medication changes/ omissions, pending diagnostic testing and patients and/or caregivers not fully understanding discharge instructions, new diagnosis, medications and the true need for follow-up with their PCP and/or specialist. We aim to ensure the transmission of discharge information to the PCP unless the patient refuses for inpatient and observation level patients at Thompson Health. Denominator = # patients (inpt/obs) discharged from the hospital and the numerator = # patients with discharge information confirmed sent to their provider. 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 12/13/2023 To maintain the rate of notifiying the appropriate outpatient providers of inpatient admissions at or above the benchmark rate of 56.2%. For data collection, all patients who were admitted to Gouverneur Hospital will be included, (regardless of payor type), in the following measure definition using HEDIS inclusion criteria:   Numerator = Completed Inpatient Admission Notifications to Patients’ PCPs Denominator = All Inpatient Admissions Baseline Numerator 260/Baseline Denominator 260 = 100%   Final time period – 1/1/2024 – 12/31/2024 50 0 100 56.2 0 No
2024 UTICA Jennifer de Jong Gouverneur Hospital 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 12/13/2023 To maintain the rate of sending discharge summaries/information to appropriate outpatient providers at or above the benchmark rate of 46.72%. For data collection, all patients who were discharged from Gouverneur Hospital will be included, (regardless of payor type), in the following measure definition using HEDIS inclusion criteria:   Numerator = Number of Discharge Summaries Sent to Patients’ PCPs Denominator = All Inpatient Discharges   Baseline Numerator 186 /Baseline Denominator 238 = 78.15% Final time period – 1/1/2024 – 12/31/2024 50 0 78.15 46.72 0 No
2024 STIER Shannon Campbell, Laurie Foster 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 12/7/2023 To maintain the rate of readmissions to the hospital from the 2023 FY baseline rate of 6.64% to a target of <14.6% (calculated by # of patients readmitted/total eligible discharges), by the end of December 2024, with a measurement period of 1/1/2024-12/31/2024. 10 0 6.64 14.6 0 No
2024 STIER Shannon Campbell, Laurie Foster Guthrie Corning Hospital 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 12/7/2023 To increase the rate of 6-hour severe sepsis bundle compliance from the 2023 FY baseline rate of 85.83% to a target rate of 89.58% (calculated by # of compliant cases/# of patients meeting severe sepsis criteria), by the end of December 2024, with a measurement period of 1/1/2024-12/31/2024 30 0 85.83 89.58 0 No
2024 STIER Shannon Campbell, Laurie Foster Guthrie Corning Hospital PSI_08 In-hospital fall with hip fracture rate To reduce the rate of inpatient hospital falls with hip fracture 12/7/2023 To reduce the rate of inpatient hospital falls with hip fracture from the 2023 FY baseline rate of 0.52 to a target of <.39, (calculated by #of falls/#admissions*1000). By the end of December 2024, with a measurement period of 1/1/2024-12/31/2024. 30 0 0.52 0.39 0 No
2024 STIER Shannon Campbell, Laurie Foster Guthrie Corning Hospital 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. 12/7/2023 To increase the rate of follow-up visits completed within 7-days for emergency room patients with high-risk chronic conditions from the 2023 FY baseline rate of 22.0% to a target rate of 27.5% (calculated by # of follow-up visits completed/# of ED discharges), by the end of December 2024, with a measurement period of 1/1/2024-12/31/2024. 30 0 22 27.5 0 No
2024 CNY Shannon Campbell, Laurie Foster Guthrie Cortland Medical Center PSI_08 In-hospital fall with hip fracture rate Decrease the rate of inpatient hospital falls that result in hip fractures 12/6/2023 To reduce the rate of inpatient hospital falls with hip fracture from the 2023 FY baseline rate of 0.29 to a target of <.22, (calculated by #of falls/#admissions*1000), By the end of December 2024, with a measurement period of 1/1/2024-12/31/2024. 30 0 0.29 0.22 0 No
2024 CNY Shannon Campbell, Laurie Foster 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 12/6/2023 To maintain the rate of readmissions to the hospital from the 2023 FY baseline rate of 10.8% to a target of <14.60% (calculated by # of patients readmitted/total eligible discharges), by the end of December 2024, with a measurement period of 1/1/2024-12/31/2024. 10 0 10.79 14.6 0 No
2024 CNY Shannon Campbell, Laurie Foster Guthrie Cortland Medical Center PPC_POST Postnatal Care Increase rate of deliveries that have a postpartum visit on or between 7 and 84 days after delivery 12/6/2023 To increase the rate of postpartum follow-up visits completed between days 7 and 84 days postpartum from the 2023 FY baseline rate of 13.12% to a target rate of 16.4% (calculated by # of postpartum follow-up visits completed/# of births), by the end of September 2024, with a measurement period of 1/1/2024-09/30/2024. 30 0 13.12 16.4 0 No
2024 CNY Shannon Campbell, Laurie Foster Guthrie Cortland Medical Center SEV_SEP_6HR Severe Sepsis 6-Hour Bundle Increase severe sepsis 6-hour bundle compliance rates for patients who meet criteria for severe sepsis 12/6/2023 To increase the rate of 6-hour severe sepsis bundle compliance from the 2023 FY baseline rate of 92.13% to a target rate of 94.26% (calculated by # of compliant cases/# of patients meeting severe sepsis criteria), by the end of December 2024, with a measurement period of 1/1/2024-12/31/2024. 30 0 92.13 94.26 0 No
2024 STIER Shannon Campbell, Laurie Foster Guthrie Lourdes Hospital 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. 12/12/2023 Prenatal and Postpartum Care PPC - This measure is part of the HEDIS timeliness of care Prenatal Care program, It evaluates hospitals percentages of deliveries in which women had a postpartum visit on or between 7 and 84 days after delivery. Postpartum care PPC Measure - Lourdes will track postpartum visits that occur on day 7 through day 84 after delivery of Lourdes postnatal population. The denominator will be the total number of births by Lourdes providers. The numerator will be those cases that had a postpartum visit on day 7through day 84. 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. Lourdes baseline data used is calendar year 2022. The baseline numerator for this time period is 266, the baseline denominator is 737. The baseline rate is 36.09%. The final target achievement for 12/31/2024 is 45.11%. Final num/den for 2024 = 332.46/737 final rate > = 45.11% (at or higher than the final target) 15 0 36.09 45.11 0 No
2024 STIER Shannon Campbell, Laurie Foster Guthrie Lourdes Hospital 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 12/12/2023 OP-35 Admission - A CMS measure that rates inpatient admissions for patients receiving outpatient chemotherapy. This measure evaluates patients >= 18years of age who were admitted 30 days after receiving outpatient chemotherapy. The denominator includes Medicare FFS patients, it excludes leukemia patients. The numerator includes Inpatients whose diagnosis is one or more inpatient admissions for anemia, dehydration, diarrhea, emesis, fever, nausea, neutropenia, pain, pneumonia, or sepsis within 30 days of chemotherapy treatment. 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. Lourdes baseline data used is Fiscal year 2023. The baseline numerator for this time period is 325. The baseline denominator for this time period is 1,200. The baseline rate = 27.08%. The final Target rate = 20.31%. Final 2024 num/den = 243.72/1200 = 20.31%. 30 0 27.08 20.31 0 No
2024 STIER Shannon Campbell, Laurie Foster 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 12/12/2023 Heart failure (HF) 30-day readmission measure is part of the CMS Hospital Readmission Reduction program that encourages hospitals to evaluate their spectrum of care for patients and help transition patients to outpatient or other post-discharge care thus reducing readmission. HF-30-day readmission - The outcome evaluated is unplanned HF 30-day risk-standardized readmission rate (RSRR), as measured from the date of discharge of the index HF admission. The inclusions are as follows: a principal discharge diagnosis of HF, patient aged 65+, enrolled in Medicare FFS Part A and Part B for 12months, VA beneficiaries, and not transferred to another acute care facility. PROJECT GOAL: TO DECREASE HF READMISSION FROM 21.53% TO 21.14%: 01.01.24 -12.31.24, AS LOWER PERFORMANCE RATES ARE BETTER. Lourdes baseline data used is calendar year 2022. The baseline numerator for this time period is 93 (readmitted HF patients), the baseline denominator is 432 (HF admissions that meet criteria). The baseline rate is 21.53%. The final target achievement for 12/31/2024 is 21.14%. Final num/den = 91.32/432 final rate < = 21.14% (at or lower than the final target) 15 0 21.53 21.14 0 No
2024 STIER Shannon Campbell, Laurie Foster Guthrie Lourdes Hospital 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 12/12/2023 Comp HIP/Knee - comp H/K - This is a CMS complication outcome measure that evaluates specified complications that occur in THA/TKA patients from the date of index admission to 90-day post op. The Measure - The denominator: Includes all Medicare FFS beneficiaries aged 65+ who are hospitalized for elective primary THA and/or TKA procedures, must have 12 months of continuous Medicare Part A and B enrollment prior to the procedure. The Numerator: Patients who experience complication with an elective primary THA and/or TKA procedures. Coded as not present on arrival and have an index admission up to 90 days post-date. 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 Lourdes baseline data used is calendar year 2022. The baseline numerator for this time period is 13, the baseline denominator is 223. The baseline rate is 5.83. The final target achievement for 12/31/2024 is 4.56. Final num/den for 2024 = 10.16/223 final rate > = 4.56 (at or lower than the final target) 30 0 5.83 4.56 0 No
2024 STIER Shannon Campbell, Laurie Foster Guthrie Lourdes Hospital 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 12/12/2023 H-Comp-7-SA, Care transitions - star ratings. evaluates patients' comprehension of their care upon leaving the hospital. It relies on the HCAHPS survey to gauge patients' opinions and perceptions of their hospital experience. Specifically, it targets patients who "Strongly Agree" that they understood their care transition post-hospitalization. Numerator - Identify the number of patients who select "Strongly Agree" regarding their comprehension of care transitions upon discharge. Denominator - Determine the total number of completed surveys received. Compute the percentage of patients who "Strongly Agree" out of the total completed surveys to derive the measure score. Lourdes baseline time period is calendar year 2022. Numerator/Denominator for 2022 = 793/1676 = 47.32%. 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 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 12/11/2023 Transition of care is an essential metric to ensure continuity of care and safety. The metric is assed by 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. Our aim is to maintain our communication with the ambulatory primary care practices when patients 18 years old are admitted to Highland Hospital as evidenced by documentation of transitions of care. The numerator includes:  Receipt of discharge information: Documentation of receipt of discharge information on the day of discharge or the following day The Denominator includes: Acute or non-acute inpatient discharges for Medicare beneficiaries 18 years and older. Baseline Data: Our baseline data from the calendar year 2022 (1/1/22 to 12/31/22) included 16616/16842 (receipt of discharge information) for an overall compliance of 98.62%. Our final target must be maintained at over 46.72%. 15 0 98.62 46.72 0 No
2024 ROCH Teresa Stokelin Highland Hospital H_COMP_2_A_P Doctor communication - Star Rating Improvement Measure 12/15/2023 Communication with doctor is essential to the quality of the care provided and to improve the health literacy of the patient. Our aim is to improve our communication with doctors domain be above or at benchmark with a final target of 79%. Our baseline time period is data ( 78.71%) from calendar year 2022 (1/1/22 to 12/31/22) had a dominator includes all surveys returned with a baseline N of 2008 surveys. 10 0 78.71 79 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. 12/12/2023 The measure OP-22 is an important ED metric that not only improves patient experience but also ensures quality of care for our community. Our aim is to decrease the percentage of patients leaving without being seen by 2/1/2025 a qualified medical personnel by 25%. The Numerator includes: The total number of patients who left without being seen (LWBS) by a physician/APN/PA. The Denominator includes: The total number of patients who presented to the emergency department (ED) Baseline Data: Our baseline data from the calendar year 2022 (1/1/22 to 12/31/22) included 3,637 L'WBS/42,280 Total Visits = 8.6%. In order to reduce our metrics by 25% we will need to improve our rate to 6.45%. However, the benchmark is .0001%. 30 0 8.6 6.45 0 No
2024 ROCH Teresa Stokelin Highland Hospital 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 12/15/2023 Patient-centered care is a critical facet of healthcare quality. Our aim is to maintain discharge information from 1/1/2024 to 12/31/2024 above the benchmark of 86 % via the patient satisfaction scores. The baseline demonitor includes all returned survey which is 1856. 30 0 86.28 86 0 No
2024 ROCH Teresa Stokelin Highland Hospital 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 12/11/2023 Transition of care is an essential metric to ensure continuity of care and safety. The metrics is assessed by notification of Inpatient Admission. Our aim to maintain our communication with the ambulatory primary care practices when patient 18 years of are admitted to Highland hospital as evidence by documentation in the medical record on the day or within 2 days of admissions. The numerator includes Notification of inpatient admission: Documentation of receipt of notification of inpatient admission on the day of admission or the following day and 2. Receipt of discharge information:  The Denominator includes: Acute or non-acute inpatient discharges for Medicare beneficiaries 18 years and older Baseline Data: Our baseline data from calendar year 2022 (1/1/22 to 12/31/22) included 16052/16842 (admission notifications) for an overall compliance of 95.27% . Our final target must be maintained over 56.20%. 15 0 95.28 56.2 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 12/15/2023 To increase the number of post-partum patients that receive follow up care 7 to 84 days after delivery. The denominator will be the total number of women that deliver at UR Jones, and the numerator will be the number of women that receive follow up care within 7 to 84 days of 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 12/7/2023 Increase follow up after BGMC emergency department visit for people with multiple high risk chronic conditions within 7 days, from 38.6% (baseline) to 46.4% to be measured Jan-Dec 2024. 68% of patients who are admitted to BGMC are categorized at high risk for readmission with the CERNER readmission risk score month over month in the 2023 period. Through utilization of the Care Navigation program, we aim to support rapid follow up with patients referred to our Universal Care Navigation Program. 30 0 38.63 46.39 0 No
2024 WNY Denise Hull Kaleida Health SEV_SEP_6HR Severe Sepsis 6-Hour Bundle Increase Severe Sepsis 6-Hour bundle 12/5/2023 Improve Kaleida Health’s Severe Sepsis 6 Hour bundle compliance from a baseline of 86.71% to a goal of 90.05% in performance year 2024, Jan-Nov (December data will not be available in time to close out this measure). Baseline Numerator 359 Baseline Denominator 414 Baseline Rate 86.71% Final Target Rate 90.05% Final Target DOS Jan 1, 2024 -Nov 30, 2025 12/7/2023 Improve Kaleida Health’s Severe Sepsis 6 Hour bundle compliance from a baseline of 86.71% to a goal of 90.05% in performance year 2024, Jan-Nov (December data will not be available in time to close out this measure). 30 0 86.71 90.05 0 No
2024 WNY Denise Hull Kaleida Health SEP_SH_6HR Septic Shock 6-Hour Bundle Increase Septic Shock 6-Hour bundle 12/1/2023 Improve Kaleida Health’s Septic Shock 6 Hour bundle compliance from a baseline of 90.57% to a goal of 92.9% in performance year 2024, Jan – Nov (December data will not be available in time to close out this measure). Baseline Date DOS 3Q22-2Q23 Baseline Numerator 144 Baseline Denominator 159 Baseline Rate 90.57 12/7/2023 Improve Kaleida Health’s Septic Shock 6 Hour bundle compliance from a baseline of 90.57% to a goal of 92.9% in performance year 2024, Jan – Nov (December data will not be available in time to close out this measure). 30 0 90.57 92.9 0 No
2024 WNY Denise Hull Kaleida Health H_COMP_3_A_P Staff responsiveness - Star Rating Increase top box score for HCAHPS Responsiveness of Staff 12/1/2023 Improve Kaleida Health patient experience HCAHPS Responsiveness of Staff to a top box score of 56.88 during for discharged patients during the performance period of Jan – Dec 2024. Baseline Data DOS 4Q22-3Q23 Baseline Rate 54.10% 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 12/8/2023 All cause readmission rates will be maintained or decrease below the target baseline of 14.6%. Numerator = All cause readmissions with a baseline of 80 patients Denominator = All inpatient acute care discharges (excluding observation and swing bed patients) with a baseline of 828 patients 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 12/13/2023 To maintain the rate of notifiying the appropriate outpatient providers of inpatient admissions at or above the benchmark rate of 56.2%. For data collection, all patients who were admitted to Massena Hospital will be included, (regardless of payor type), in the following measure definition using HEDIS inclusion criteria:   Numerator = Completed Inpatient Admission Notifications to Patients’ PCPs Denominator = All Inpatient Admissions Baseline Numerator 911/Baseline Denominator 911 = 100%   Final time period – 1/1/2024 – 12/31/2024 50 0 100 56.2 0 No
2024 UTICA Jennifer de Jong Massena Hospital TOC_HEDIS2 Receipt of Discharge Information MAINTENANCE MEASURE: To maintain the rate of discharge information sent to outpatient providers at or above the benchmark 12/13/2023 To maintain the rate of sending discharge summaries/information to appropriate outpatient providers at or above the benchmark rate of 46.72%. For data collection, all patients who were discharged from Massena Hospital will be included, (regardless of payor type), in the following measure definition using HEDIS inclusion criteria:   Numerator = Number of Discharge Summaries Sent to Patients’ PCPs Denominator = All Inpatient Discharges   Baseline Numerator 615 /Baseline Denominator 846 = 72.7% Final time period – 1/1/2024 – 12/31/2024 50 0 72.7 46.72 0 No
2024 UTICA Laurie Foster MVHS, Inc. (Wynn Hospital) 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 12/14/2023 In an effort to improve the transition of care, reduce hospital readmissions, and improve patient satisfaction with the Discharge Process, MVHS has contracted with Tribe Health to assist with the Care Transition process. One of the transitions of care process with include post discharge calls with the patients/caregiver to ensure good understanding of the medication regime at discharge. 15 0 96.18 84.67 0 No
2024 UTICA Laurie Foster MVHS, Inc. (Wynn Hospital) PSI_08 In-hospital fall with hip fracture rate To decrease the rate of hip fractures associated with in-hospital falls 12/14/2023 According to the AHRQ - Each year, somewhere between 700,000 and 1,000,000 people in the United States fall in the hospital. A fall may result in fractures, lacerations, or internal bleeding, leading to increased health care utilization. Research shows that close to one-third of falls can be prevented. Fall prevention involves managing a patient's underlying fall risk factors and optimizing the hospital's physical design and environment. MVHS is looking to prevent falls and falls with injury, by sanctioning a nursing lead fall prevention performance Improvement team. The team is responsible for reviewing and making recommendations to the MVHS Fall Policy, as well as analyzing fall data for patterns and trends and recommended process improvements targeted at preventing falls. 30 0 0.18 0.14 0 No
2024 UTICA Laurie Foster MVHS, Inc. (Wynn Hospital) H_COMP_1_A_P Nurse communication - Star Rating To increase the number of patients who rate their nurses' as "always communicating well" 12/14/2023 Sustained improvement in HCAPHS, requires organization level commitment to the patient experience, as well as implementation of specific proven strategies to effect improvements. 10 0 72.34 74.01 0 No
2024 UTICA Laurie Foster MVHS, Inc. (Wynn Hospital) OP_22 ED Left Without Being Seen To decrease the rate of patients who leave the ED without being seen 12/14/2023 Since volume in the ED picked up after Covid we have experienced a steady increase in out LWOB seen rate with a 2022 peak of 4.49 percent. OP-22 is considered by CMS to be a reflection of ED throughput, but it also represents a risk to patients that leave before receiving necessary emergency care, as well as being a reflection of lost revenue and patient dissatisfaction. 30 0 4.49 3.37 0 No
2024 UTICA Laurie Foster MVHS, Inc. (Wynn Hospital) 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. 12/14/2023 In an effort to improve transitions of care, reduce hospital readmissions and improve patient satisfaction with the discharge process, MVHS has contracted with Tribe Health to assist with the Care Transition process. A smooth and seamless handoff communication between the inpatient care team and the outpatient care team is crucial to the care transition process. With our EMR, Epic, electronic transmission of the visit summary can help facilitate this communication. 15 0 51.87 46.72 0 No
2024 ROCH Jennifer de Jong Newark-Wayne Community Hospital H_COMP_6_Y_P Discharge information - Star Rating 12/6/2023 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 discharge information 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. National Benchmark: 86% Question wording supplied by CMS   Improvement Measure: Discharge information - Star Rating - 2022 Baseline Data - Num:1327 Denom:1596 Rate:83.15% Vol Min:461 NB:86% Target:83.79% 10 0 83.15 83.79 0 No
2024 ROCH Jennifer de Jong Newark-Wayne Community Hospital 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 12/6/2023 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. National Benchmark: 56.20% Numerator: 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.    Denominator Definition: Acute or non-acute inpatient discharges for Medicare beneficiaries 18 years and older. The denominator is based on discharges, not members. Members may appear more than once. - For Administrative Specification, the denominator is the eligible population. - For Hybrid Specification, the denominator is a systematic sample drawn from the eligible population.   Baseline Period - Notification of Inpatient Admission: October 2022 – September 2023 Maintenance Measure: Transitions of Care - Notification of Inpatient Admission - October 2022 - September 2023 Baseline Data - Num:4819 Denom:5734 Rate:84.04% Vol Min:461 Vol Met:Yes NB:56.20% Target:Maintain 15 0 84.04 56.2 0 No
2024 ROCH Jennifer de Jong Newark-Wayne Community Hospital 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. 12/6/2023 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.   National Benchmark: 79%   Question wording supplied by CMS   Improvement Measure: Jul 2022 - Jun 2023 Baseline - Doctor Communication Star Rating - Num:1981 Denom:2638 Rate:75.09% VolMin:None NB:79% Target:76.06% 30 0 75.09 76.06 0 No
2024 ROCH Jennifer de Jong Newark-Wayne Community Hospital H_COMP_1_A_P Nurse communication - Star Rating 12/6/2023 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 nurse 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.   National Benchmark: 79%   Question wording supplied by CMS   Improvement Measure: Jul 2022 - Jun 2023 Baseline - Nurse Communication Star Rating - Num:1923 Denom:2657 Rate:72.37% VolMin:None NB:79% Target:74.04% 30 0 72.37 74.04 0 No
2024 ROCH Jennifer de Jong Newark-Wayne Community Hospital 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 12/6/2023 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. National Benchmark: 46.72%   Numerator: 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.   Denominator Definition: Acute or non-acute inpatient discharges for Medicare beneficiaries 18 years and older. The denominator is based on discharges, not members. Members may appear more than once. - For Administrative Specification, the denominator is the eligible population. - For Hybrid Specification, the denominator is a systematic sample drawn from the eligible population.   Baseline Period - Receipt of Discharge Information: October 2022 – September 2023 Maintenance Measure: Transitions of Care - Receipt of Discharge Information - October 2022 - September 2023 Baseline Data - Num:4250 Denom:4452 Rate:95.46% NB:46.72% Target:Maintain 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. 12/7/2023 The aim of the project is to maintain and even reduce the overall acute readmission rate for acute patients discharged from Niagara Falls Memorial Medical Center to at or below the benchmark goal of 14.6%. Thirty-day acute readmission data for the period July 1, 2022 through June 30, 2023 serve as the baseline for the project. For the aforesaid period, there were 2,773 acute discharges from Niagara Falls Memorial. Of these total discharges, a total of 246 thirty-day readmissions were recorded. To calculate the thirty-day readmission rate, the number of 30-day readmissions (246) serves as the numerator and the total number of acute discharges (2,773) serve as the denominator. When the number of 30-day readmissions is divided by the number of discharges, a 30-day readmission rate of 8.87% results. This project will measure and report quarterly on the cumulative acute readmission rates which are recorded at the end of each of the four quarters of the period January 1, 2024 through December 31, 2024. At the end of the fourth quarter, the goal is to achieve a 30-day acute readmission rate to at or below the benchmark goal of 14.6%. The targeted 2024 year-end readmission rate and rates for the first, second and third quarters, will be reported on in percentage terms. 100 0 8.87 14.6 0 No
2024 ROCH Teresa Stokelin Noyes Memorial Hospital 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 " Transition from the inpatient (hospital) setting back to home often results in poor care coordination, including communication lapses between inpatient and outpatient (a setting other than a hospital) providers; intentional and unintentional medication changes; incomplete diagnostic work-ups; and inadequate patient, caregiver and provider understanding of diagnoses, medication and follow-up needs. Ensure the transmittal of discharge information to the PCP, when PCP present and not explicitly refused by the patient, for all hospital discharges from a visit as an inpatient or observation patient at Noyes Hospital.Baseline data collected from CY 2022 resulted in a rate of 97.34%. The goal will be to maintain above 46.72% for CY 2024. 15 0 97.34 46.72 0 No
2024 ROCH Teresa Stokelin Noyes Memorial Hospital H_COMP_5_A_P Communication about medicines - Star Rating Maintain Communications about medications MAINTENTANCE MEASURE Maintain communications about medications with patients for Press Ganey scores. Baseline data collected from 1/1/23-12/17/23 resulted in a rate of 68.87%. The goal will be to maintain at or above 61.00% for CY 2024." 50 0 68.87 61 0 No
2024 ROCH Teresa Stokelin Noyes Memorial Hospital H_COMP_1_A_P Nurse communication - Star Rating Increase nurse communication rating Increase nursing communication for Press Ganey scores. Baseline data collected from 12/1/22-11/30/23 resulted in a rate of 72.85%. The goal will be to increase nursing communication for Press Ganey scores to or above 74.35% for CY 2024. 10 0 72.85 74.35 0 No
2024 ROCH Teresa Stokelin Noyes Memorial Hospital 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 " Transition from the inpatient (hospital) setting back to home often results in poor care coordination, including communication lapses between inpatient and outpatient (a setting other than a hospital) providers; intentional and unintentional medication changes; incomplete diagnostic work-ups; and inadequate patient, caregiver and provider understanding of diagnoses, medication and follow-up needs. 12/19/23 Goal is to maintain or increase percentage of notificationn of inpatient admissions and documentation in the medical record of receipt of notification of inpatient admission on the day of admission or within the following 2 calendar days. Baseline data collected from CY 2022 resulted in a rate of 95.69%. The goal will be maintained above 56.20% for CY 2024." 15 0 95.69 56.2 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 Increase compliance with severe sepsis 3 hour bundle in CY 2024. Baseline data collected from 10/1/22-9/30/23 resulted in a rate of 78.20%. The goal will be to increase compliance to 81.42% or above for CY 2024." 10 0 78.2 81.42 0 No
2024 UTICA Laurie Foster 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. 12/6/2023 The project is to track the percentage of all deliveries completed at Oneida regardless of payor type that had a postpartum visit on or between 7 and 84 days after delivery. The goal is to maintain this measure at or above 95.38% throughout the 2024 calendar year. Currently, Oneida Health is tracking this measure at 96.7%. The baseline denominator is 496 and the baseliine numerator is 480. 5/31/24: Measure definition addendum to reflect negotiated contract discussion: For delivered patients who no-show, if documentation is submitted in the ""Results"" section of the PDSA that indicates the number of no-shows, as well as the specific steps by Oneida's team to re-engage the patient for postpartum follow-up, then these patients can be removed from the numerator and denominator for the measurement period. " 30 0 96.77 95.38 0 No
2024 UTICA Laurie Foster Oneida Health 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. 12/1/2023 The project goal for the OP_22 measure, or left the ED without being seen, is to decrease our percentage from 2.27% to 1.7%, with a long-term goal to reach the benchmark of .0001%. The baseline numerator is 540 and baseline denominator is 23,737, leading to the baseline rate of 2.27%. The patient population will be all patient who report to the ED regardless of payor type, but leave without being seen. Monitoring will be conducted throughout the calendar year of 2024 and the data will be gathered by the Emergency Department nurse manager. " 30 0 2.27 1.7 0 No
2024 UTICA Laurie Foster Oneida Health 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. 12/1/2023 The project goal for the septic shock 3 hour bundle is to increase our percentage to 83.09% or higher, with a long term goal being to return to 100%. For data collection, all patients admitted to Oneida Hospital will be included, (regardless of payor type), in the following measure definition using CMS exclusion criteria: Patients who receive all elements of the 3-hour sepsis treatment bundle All inpatients age 18+ with the diagnosis of severe sepsis/septic shock The baseline numerator is 61 and the baseline denominator is 77, with the baseline rate being 79.2 percent for the time period of 7/1/22 to 6/30/23. The area of focus includes the use of resuscitation with crystalloid fluids not being done in 3 hours. The patient population that will be included are the patients that are identified as being at risk for septic shock in the emergency department as well as all inpatient units. Monitoring will be conducted throughout the calendar year of 2024. This data will be gathered by our infection prevention team." 30 0 79.22 83.09 0 No
2024 UTICA Laurie Foster Oneida Health 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. 12/1/2023 The project goal is to maintain a compliance rate of 51.00% or better for the HCAHPS domain for care transitions in order to make sure patients understand their care and needs at discharge. Monitoring will be conducted, at minimum, on a quarterly basis and as needed for the calendar year of 2024. The units involved will be med/surg, OB/GYN, and ICU. " 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) 11/24/2023 Project to reduce annual readmit rate to ensure we do not have unnecessary surge of inpatients. With the closure of Lockport Hospital, census continues to grow creates staffing and resource challenges, as well as placement issues. Goal is to maintain the readmission rate below the benchmark goal of 14.6% for the final measurement period 1/1/24-12/31/24. For data collection, all patients admitted/readmitted to Medina Hospital will be included, (regardless of payor type), in the following measure definition using CMS exclusion criteria: Patients Readmitted to an Acute Care Bed _______w/in 30 Days of Discharge from an Acute Care Bed_______ All Acute Care Inpatient Admissions During Measurement Period 100 0 9.06 14.6 0 No
2024 CNY Denise Hull Oswego Hospital H_COMP_2_A_P Doctor communication - Star Rating To improve Communication with providers - Maintenance Measure 12/12/2023 The objective is to improve rate of patients who report the Doctors "Always" communicated well, focusing on our inpatient population and the hospitalist program. This objective is important for a multitude of reasons, including: Readmission avoidance, Length of stay initiatives, Overall star rating for the Hospital, Discharge planning, and the patient’s understanding of their own disease process. Baseline Data DOS 10/1/2022 - 9/30/2023 Baseline Numerator Baseline Denominator Baseline Rate: 81% Final Target Rate 79% (maintenance measure) Final Target DOS 1/1/2024 - 12/31/2024 10 0 81 79 0 No
2024 CNY Denise Hull Oswego Hospital H_QUIET_HSP_A_P Quietness - Star Rating Increase patient satisfaction with Hospital environment as it relates to Quitness at night. 12/12/2023 The goal of this project is to improve the patient comfort, Rest, and satisfaction while hospitalized. We have recognized there is room for improvement. Baseline Data DOS: 10/1/2022 - 9/30/2023 Baseline Numerator: Baseline Denominator Baseline Rate 61.5% Final Target Rate 61.66% Final Target DOS 1/1/2024 - 12/31/2024 30 0 61.5 61.66 0 No
2024 CNY Denise Hull Oswego Hospital OP_22 ED Left Without Being Seen Decrease Number of ED patients who Left Without Being seen 12/12/2023 Our goal is to reduce the number of ED patient leaving before being seen / treated. The percentage of patients leaving has increased since COVID and we would like to return to / improve upon pre-pandemic percentages. Baseline Data DOS: Jul 1, 2022 - June 30, 2023 Baseline Numerator: 2252 Baseline Denominator 27362 Baseline Rate 8.23% Final Target Rate 6.17% Final Target DOS 1/1/2024 - 12/31/2024 30 0 8.23 6.17 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 12/12/2023 Our readmission rate for the inpatient population (both Medical and Behavioral Services) has been increase for the last couple a years. Our goal is to continue to/ improve upon the rates of readmissions and continue the work we have started this year through this project.. We will be working with the Medical/Surgical units, ICU, and Behavioral Health locations. Baseline Data DOS 7/1/2022 - 6/30/23 Baseline Numerator 413 Baseline Denominator 3800 Baseline Rate 10.87% Final Target Rate 14.6% (maintenance measure) Final Target DOS 1/1/2024 - 12/31/2024 15 0 10.87 14.6 0 No
2024 CNY Denise Hull Oswego Hospital 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 12/12/2023 The goal of this project is to improve the Care of our Patients who have had inpatient Stays. Please note: Our Inpatient Behavioral Health Unit serves only those >18 years of age. Baseline Data DOS 7/1/2022 - 6/30/23 Baseline Numerator 436 Baseline Denominator 1178 Baseline Rate 37.01% Final Target Rate 43.97% Final Target DOS 12/31/2024 15 0 37.01 43.97 0 No
2024 ROCH Jennifer de Jong Rochester General Hospital 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 12/6/2023 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. National Benchmark: 56.20%   Numerator: 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.   Denominator Definition: Acute or non-acute inpatient discharges for Medicare beneficiaries 18 years and older. The denominator is based on discharges, not members. Members may appear more than once. - For Administrative Specification, the denominator is the eligible population. - For Hybrid Specification, the denominator is a systematic sample drawn from the eligible population.   Baseline Period - Notification of Inpatient Admission: October 2022 – September 2023   Maintenance Measure: Transitions of Care - Notification of Inpatient Admission - October 2022 - September 2023 Baseline Data - Num:26192 Denom:26217 Rate:99.90% Vol Min:2667 Vol Met:Yes NB:56.20% Target:Maintain 15 0 99.9 56.2 0 No
2024 ROCH Jennifer de Jong Rochester General Hospital 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 12/6/2023 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. [NOTE: The software provides the rate per hospital discharge. However, common practice reports the measure as per 1,000 discharges. The user must multiply the rate obtained from the software by 1,000 to report events per 1,000 hospital discharges.] The goal is to be at or better than national benchmark.   National Benchmark: 0.07 Rate per 1,000   The AHRQ 2022 definitions are used for both the numerator and denominator   Improvement Measure: PSI-08 In-hospital fall with hip fracture rate - 2022 Baseline Data - Num:4 Denom:20785 Rate:0.19 Vol Min:None Vol Met:Yes NB:0.07 Target:0.14 20 0 0.19 0.14 0 No
2024 ROCH Jennifer de Jong Rochester General Hospital 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 12/6/2023 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. [NOTE: The software provides the rate per hospital discharge. However, common practice reports the measure as per 1,000 discharges. The user must multiply the rate obtained from the software by 1,000 to report events per 1,000 hospital discharges.] HAC   National Benchmark: 3.63 Rate per 1,000    Improvement Measure: PSI-12 PE/DVT - October 2022 - September 2023 Baseline Data - Num:29 Denom:7104 Rate:4.08 Vol Min:2667 Vol Met:Yes NB:3.41 Target:3.87 20 0 4.08 3.87 0 No
2024 ROCH Jennifer de Jong Rochester General Hospital 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 12/6/2023 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.    National Benchmark: 69% The CMS definitions are used for both the numerator and denominator   Improvement Measure: Recommend hospital - Star Rating - 2022 Baseline Data - Num:2523 Denom:4357 Rate:57.91% Vol Min:None NB:69% Target:60.74% 10 0 57.91 60.74 0 No
2024 ROCH Jennifer de Jong Rochester General Hospital 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 12/6/2023 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. National Benchmark: 46.72%   Numerator: 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.   Denominator Definition: Acute or non-acute inpatient discharges for Medicare beneficiaries 18 years and older. The denominator is based on discharges, not members. Members may appear more than once. - For Administrative Specification, the denominator is the eligible population. - For Hybrid Specification, the denominator is a systematic sample drawn from the eligible population.  Baseline Period - Receipt of Discharge Information: October 2022 – September 2023   Maintenance Measure: Transitions of Care - Receipt of Discharge Information - October 2022 - September 2023 Baseline Data - Num:22306 Denom:22520 Rate:99.05% NB:46.72% Target:Maintain 15 0 99.05 46.72 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 12/6/2023 THA/THK Complications 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 to be at or better than national benchmark.   National Benchmark: Rate 3.20   The CMS definitions are used for both the numerator and denominator   Improvement Measure: THA/THK Complication Rate: Apr 2022 - Mar 2023 Baseline Data - Num:10 Denom:279 Rate:3.58 VolMin:None NB:3.20 Target:3.47 20 0 3.58 3.47 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 12/18/2023 Baseline data: DOS 10.1.2022 - 9.30.2023, denominator 3005 and numerator 168. Baseline rate 5.59%. Target is to maintain the all cause readmission rate at or below the benchmark goal of 14.6% for the final measurement period 1/1/2024-12/31/2024. The denominator for baseline data and PY data will include all patients admitted to Rome Health/ and numerator will include all eligible admissions that are readmitted to Rome Health (regardless of payor type), in the following measure definition using CMS exclusion criteria: Patients readmitted to an acute care bed to Rome Health w/in 30 days of discharge from an acute care bed from Rome Health for all acute care inpatient admissions during measurement period (numerator). Inclusion/Exclusion Criteria: This measure estimates a hospital-level, 30-day readmission rate for patients discharged from the hospital after an admission for any eligible condition except for certain planned readmissions. Readmission is defined as unplanned readmission for any cause within 30 days of the discharge date for the index admission. Measure excludes index admissions for patients that meet any of the following exclusion criteria: 1. Admitted to a PPS-exempt cancer hospital; 2. Admitted for primary psychiatric diagnosis; 3. Admitted for rehabilitation; 4. Admitted for medical treatment of cancer; 5. Discharged against medical advice; 6. With a principal diagnosis code of COVID-19 (U07.1) or with a secondary diagnosis code of COVID-19 coded as present on admission on the index admission claim. 30 0 5.59 14.6 0 No
2024 UTICA Shannon Campbell Rome Health 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 12/18/2023 Rome Health is committed to improve the patients experience rating with a focus on the patients perception for whether their room was ""Always"" quiet at night. Baseline data: DOS 10.1.2022 - 9.30.2023, denominator 441 and numerator 231. Baseline rate is 52.38%. Target is to improve the Press Ganey response for patients who reported that the area around their room was ""Always"" quiet at night to 54.70% for calendar year 2024 (1.1.2024 - 12.31.2024). The denominator for baseline data and calendar year data will include all Rome Health discharged patients completing the Press Ganey HCHAPS survey and responding to the question about the quietness of their room and numerator will include all patients who have responded that their room was ""Always"" quiet at night. 30 0 52.38 54.8 0 No
2024 UTICA Shannon Campbell Rome Health 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 12/18/2023 Sepsis is a complex medical emergency requiring prompt recognition and evidence based intervention to decrease morbidity and mortality for those experiencing this condition. Rome Health is committed to improve their compliance to the 3-hour severe sepsis bundle. Baseline data: DOS 10.1.2022-9.30.2023, denominator 141 and numerator 107. Baseline rate is 75.89%. Target is to achieve 79.80% or greater 3-hoursevere sepsis bundle compliance for calendar year 1.1.2024 - 12.31.2024. The denominator for baseline data and CY data will include all patients 18 years and older admitted to Rome Health with a diagnosis of severe sepsis and numerator includes all patients who receive all of the 3-hour sepsis bundle elements (initial lactate, blood cultures prior to antibiotics, broad spectrum or other antibiotics administered, and fluid resuscitation (crystalloids) within 3 hours or the identification of sepsis. CMS Definition: This measure focuses on adults 18 years and older with a diagnosis of septic shock. Consistent with Surviving Sepsis Campaign guidelines, the measure contains several elements, including measurement of lactate, obtaining blood cultures, administering broad spectrum antibiotics, fluid resuscitation, vasopressor administration, reassessment of volume status and tissue perfusion, and repeat lactate measurement. As reflected in the data elements and their definitions, these elements should be performed in the early management of severe sepsis and septic shock. Rome Health Definition: Severe Sepsis - Sepsis associated with new organ dysfunction in any organ system. Signs of organ dysfunction can include, but are not limited to: Creatinine >2.0mg/dl or UOP <0.5ml/kg/hr for 2 hours, Increase O2 need to maintain SPO2 >90, Acute respiratory failure, BiPap or CPAP, Platelets < 100,000ul, MAP <65 or SBP< 90 or 40 mmHg lower than last known normal, Total Bilirubin >2mg/dl, jaundice, or new petechiae, INR >1.5 or a PPT > 60 secs off therapy, Glasgow Coma Scale < 15 ,Lactate > 2.0 mmol/L 30 0 75.89 79.79 0 No
2024 UTICA Shannon Campbell Rome Health 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 12/18/2023 Rome Health is committed to improve the patients experience rating with a focus on the patients perception of nurse communication. Baseline data: DOS 10.1.2022 - 9.30.2023, denominator 447 and numerator 342. Baseline rate is 52.38%. Target is to improve the Press Ganey response for patients who reported that the nurse communication score is rated as ""Always"" for calendar year 2024 (1.1.2024 - 12.31.2024). The denominator for baseline data and calendar year data will include all Rome Health discharged patients completing the Press Ganey HCHAPS survey and responding to the question about the nurse communication and numerator will include all patients who have responded that their room was ""Always"" for nurse communication. The HCAHPS survey is a measure of patient experience in the hospital. The HCAHPS star ratings combine the results of multiple questions from the HCAHPS Survey. The Communication with Nurses star rating summarizes how well patients feel that their nurses explained things clearly, listened carefully to the patient, and treated the patient with courtesy and respect. Effective communication between nurses and patients can prevent errors like medication mix-ups or misdiagnoses. 10 0 76.51 77.1 0 No
2024 UTICA Laurie Foster Samaritan Hospital SEV_SEP_3HR Severe Sepsis 3-Hour Bundle To increase the rate of compliance with the 3 hour severe sepsis treatment bundle 12/14/2023 SMC will increase our compliance with the severe sepsis 3-hr bundle to 79.97% (based on target calculator) from 76.06% for the measurement period of 1.1.24-12.31.24. 30 0 76.06 79.97 0 No
2024 UTICA Laurie Foster 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 12/14/2023 SMC will maintain our percentage of all-cause readmissions between 9.6%-14.6% for the measurement period of 1.1.24-12.31.24. 15 0 9.6 14.6 0 No
2024 UTICA Laurie Foster Samaritan Hospital READM_30_COPD Obstructive Pulmonary Disease (COPD) Hospitalization 30-day readmission rate MAINTENANCE MEASURE: To maintain or even decrease the rate of COPD readmissions 12/14/2023 SMC will maintain our COPD readmission percent between 11.96% -19.30% for the measurement period of 1.1.24-12.31.24. 10 0 11.96 19.3 0 No
2024 UTICA Laurie Foster Samaritan Hospital PPC_POST Postnatal Care To increase the rate of delivered patients who follow up 7-84 days after delivery 12/14/2023 12.14.23 SMC will increase the percentage of our Women's Wellness post-partum patients that have a post-partum visit on or between 7-84 days from 81.93% to 85.3% for the measurement period of January 1, 2024-September 30, 2024. 15 0 81.93 85.3 0 No
2024 UTICA Laurie Foster Samaritan Hospital 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 12/14/2023 SMC will increase our HCAHPS overall Top Box hospital rating from our baseline of 60.31% to 62.79% based on the target calculator. Numerator is not required with this measure. 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 12/11/2023 The goal of this project is to reduce patients left without being seen in the Schuyler Emergency Department. Left Without Being Seen patients are those who have only been triaged and are in the waiting room when they leave. Patients who leave without being seen are at higher risk for a safety event without adequate care, as they have not received a Medical Screening Exam. Numerator = patients who leave without being assessed by a qualified medical professional. Denominator = total ED visits. For our baseline, we are examining October 2022 through September of 2023. For this baseline, the numerator = 60. Denominator = 8115 total visits. This gives a baseline Left Without Being Seen rate of 0.74%. Our goal is to decrease this to a Left Without Being Seen rate of 0.56%. 30 0 0.74 0.56 0 No
2024 STIER Teresa Stokelin Schuyler Hospital 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. 12/11/2023 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. The denominator for this care transitions metrics is in-patient discharges from October 2022 through September 2023, totaling 453. The numerator is the number of PCPs notified of in-patient admission, for the same time period, totaling 210. This produces a baseline rate of 46.36%, and our goal is to increase this rate to 48.86%. This ensures the transition of care to and from in-patient providers and each patient’s primary care provider, which relates in better health outcomes. 35 0 46.36 48.86 0 No
2024 STIER Teresa Stokelin Schuyler Hospital 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. 12/11/2023 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. The numerator is the extrapolated results of July to September 2023 Rochester RHIO data of discharge information transmitted and received, which was 61 (when multiplied by four to have a year’s worth of data, this was 244). The denominator for this care transitions metrics is in-patient discharges from October 2022 through September 2023, totaling 453. This results in a baseline rate of 53.86%, and the goal is to maintain this rate, although striving for higher continuity of care is always the goal. 35 0 53.86 46.72 0 No
2024 STIER Teresa Stokelin St. James Hospital 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 12/15/2023 https://www.ncqa.org/hedis/measures/transitions-of-care/ - accessed 12/13/2023 Transition from the inpatient (hospital) setting back to home often results in poor care coordination, including communication lapses between inpatient and outpatient (a setting other than a hospital) providers; intentional and unintentional medication changes; incomplete diagnostic work-ups; and inadequate patient, caregiver and provider understanding of diagnoses, medication and follow-up needs. Ensure the transmittal of discharge information to the PCP, when PCP present and not explicitly refused by the patient, for all hospital discharges from a visit as an inpatient or observation patient at St James Hospital. 50 0 95.25 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. 12/15/2023 https://www.ncqa.org/hedis/measures/transitions-of-care/ - accessed 12/13/2023 Transition from the inpatient (hospital) setting back to home often results in poor care coordination, including communication lapses between inpatient and outpatient (a setting other than a hospital) providers; intentional and unintentional medication changes; incomplete diagnostic work-ups; and inadequate patient, caregiver and provider understanding of diagnoses, medication and follow-up needs. 50 0 92.16 56.2 0 No
2024 CNY Shelly LoPresti St. Joseph's Health Hospital FUM_7 Follow-Up After Emergency Department Visit for Mental Illness / 7 Day* Increase the Mental Health 7 day follow-up rate 1/2/2024 SJH has been working on this goal for 4 years and intends to continue to support these initiatives through increase ing operational supports and quality initiatives. This goal is to Increase the ED 7 day follow up for Mental Health from 31.25% to 39.06% for the final measurement period of 01/01/2024 - 12/31/2024. For the data collection, all data will be provided by Excellus to align with the ACQA so it’s for Excellus attributed patients ONLY." 7.5 0 31.25 39.06 0 No
2024 CNY Shelly LoPresti St. Joseph's Health Hospital OP_22 ED Left Without Being Seen Reduce the ED left without being seen percent. 1/2/2024 SJH aims to provide top quality care to all in need. St. Joseph's Emergency Services Leadership is committed to decreasing the ""Left without being seen"" incidences from 3% to 2.25% in the calendar year 2024. Goal is to improve the ED left without being seen percentage to 2.25% from 3.00% for the final measurement period 01/01/2024 - 12/31/2024. For the data collection, all applicable Emergency Department patients will be included (regardless of payor) , in the following definition: Percentage of patients who left the emergency department before being seen by a qualified medical personnel. 30 0 3 2.25 0 No
2024 CNY Shelly LoPresti St. Joseph's Health Hospital READM_30_HF Heart failure (HF) 30-day readmission rate In collaboration with Transitional Care Management, reduce the HF readmission rates. 1/2/2024 In the 2024 calendar year, SJH will reduce the HF Readmission rates from 23.38% to 22.42% for the measure period of 01/01/2024-12/13/2024. For data collection, all patient admitted/readmitted to SJH will be included, regardless of payer in the following measure definition. This measure estimates a hospital-level, 30-day risk-standardized readmission rate (RSRR) for patients discharged from the hospital with a principal discharge diagnosis of heart failure (HF). " 7.5 0 23.38 22.42 0 No
2024 CNY Shelly LoPresti St. Joseph's Health Hospital H_COMP_1_A_P Nurse communication - Star Rating Increase the Nurse Communication Star Rating 1/3/2024 In the 2024 calendar year, SJH will increase the Nurse Communication Star Rating from 77.33% to 77.73% for the measure period of 01/01/2024-12/31/2024. For data collection, all patient admitted/readmitted to SJH will be included, regardless of payer in the following measure definition. This measure is defined as Patients who reported that their nurses ""Always"" communicated well. 30 0 77.33 77.73 0 No
2024 CNY Shelly LoPresti St. Joseph's Health Hospital 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 1/2/2024 SJH has been working on this goal for 4 years and intends to continue to support these initiatives through increase ing operational supports and quality initiatives. This goal is to ensure the ED 7 day follow up for Substance abuses at or below 18.26% for the final measurement period of 01/01/2024 - 12/31/2024. For the data collection, all data will be provided by Excellus to align with the ACQA so it’s for Excellus attributed patients ONLY. 10 0 29.41 18.26 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 1/2/2024 In the 2024 calendar year, SJH will maintain the AMI Readmission rates below the benchmark of 14% for the measure period of 01/01/2024-12/13/2024. For data collection, all patient admitted/readmitted to SJH will be included, regardless of payer in the following measure definition. This measure estimates a hospital-level, 30-day risk-standardized readmission rate (RSRR) for patients discharged from the hospital with a principal discharge diagnosis of acute myocardial infarction (AMI). " 15 0 8.6 14 0 No
2024 ROCH Teresa Stokelin Strong Memorial Hospital 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. 12/15/2023 https://www.ncqa.org/hedis/measures/transitions-of-care/ - accessed 12/13/2023 Transition from the inpatient (hospital) setting back to home often results in poor care coordination, including communication lapses between inpatient and outpatient (a setting other than a hospital) providers; intentional and unintentional medication changes; incomplete diagnostic work-ups; and inadequate patient, caregiver and provider understanding of diagnoses, medication and follow-up needs. 15 0 92.63 56.2 0 No
2024 ROCH Teresa Stokelin Strong Memorial Hospital 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. 12/15/2023 https://www.ncqa.org/hedis/measures/transitions-of-care/ - accessed 12/13/2023 Transition from the inpatient (hospital) setting back to home often results in poor care coordination, including communication lapses between inpatient and outpatient (a setting other than a hospital) providers; intentional and unintentional medication changes; incomplete diagnostic work-ups; and inadequate patient, caregiver and provider understanding of diagnoses, medication and follow-up needs. Ensure the transmittal of discharge information to the PCP, when PCP present and not explicitly refused by the patient, for all hospital discharges from a visit as an inpatient or observation patient at Strong Memorial Hospital. 15 0 98.24 46.72 0 No
2024 ROCH Teresa Stokelin Strong Memorial Hospital BDC Blues Distinction Measures Reduction in opioid prescriptions for discharges from the Surgical Oncology unit (WCC5) 12/15/2023 Health care is stuck in the middle of the opioid overdose epidemic. Clinicians want to provide compassionate, patient-focused care, yet few alternatives match the potency of opioids to effectively manage pain. There is no perfectly safe dose of opioids; the risk of developing opioid use disorder (OUD) exists for anyone using chronic opioids. However, there are also risks to untreated chronic pain and rapid opioid tapering can potentially trigger mental health crises. Additionally, we face public pressure to fix the problem of OUD with limited resources and a fractured system that often separates substance-use treatment from other health care services. 10 0 21 15.75 0 No
2024 ROCH Teresa Stokelin Strong Memorial Hospital H_RECMND_DY Recommend hospital - Star Rating MAINTENANCE Linear Mean of Returned Surveys 12/15/2023 Overall willingness of patients and families to recommend the hospital demonstrates an overall satisfaction and sense of safety with the care being provided during the hospitalization. The HCAHPS survey is sent to a random sample of adult patients after hospital discharge eliciting their feedback on the hospital experience. Results from this survey help to inform overall patient perceptions of care provided. 50 0 87.09 69 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 12/15/2023 PSls provide information on potentially avoidable safety events that represent opportunities for improvement in the delivery of care. • Hospital-level indicators detect potential safety problems that occur during a patient's hospital stay • They include area-level indicators for potentially preventable adverse events during a hospital stay to help assess total incidence within a region Population as defined by AHRQ PSI Measure Specification 10 0 3.05 2.29 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 12/15/2023 Maintain 30 day all cause unplanned readmission rates for patients admitted to UHSH with a primary diagnosis of COPD at or below the benchmark 19.3% for the measurement period of 1/1/2024-12/31/2024. Target population: Age 65+ patients, all insurance, admitted inpatient to UHSH (Wilson Medical Center and Binghamton General Hospital) with a primary diagnosis of COPD or primary diagnosis of acute respiratory failure with a secondary diagnosis of COPD exacerbation utilizing CMS definitions of a qualifying admission (denominator population for baseline and PY) and eligible readmission numerator population for baseline and PY). BASELINE DATA: DOS 10.01.22 – 09.30.23. Denominator is 146. Numerator is 19. Baseline rate is 19/146= 13.01%. PROJECT GOAL: Maintain 30 day all cause unplanned readmission rates for patients admitted to UHSH with a primary diagnosis of COPD at or below the benchmark 19.3% for the measurement period." 7.5 0 13.01 19.3 0 No
2024 STIER Shannon Campbell United Health Services Hospitals 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. 12/15/2023 Who: Patients established with a UHSH PCP discharged to their community setting from the Acute Inpatient setting at UHS Hospitals (denominator population for baseline and PY). What: Increase the rate of Discharge encounters where the Patients PCP received and acknowledged a notification of their patients Discharge to the Inpatient setting day of event up to the next 2 calendar days (Numerator population for baseline and PY). Where: BGH and WMH When: 1/1/2024 – 12/31/2024 BASELINE DATA: DOS 10.01.22 – 9.30.23. Denominator is 7930. The numerator is 2612. Baseline rate is 2612/7930= 32.94%. 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 up to the next 2 calendar days. PROJECT GOAL: Our Discharge Notification acknowledgement percentage rate should increase from our baseline rate of 32.94% to finish the PY equal to or higher than the target rate of 36.78% (based on the CMS benchmark of 46.72%)." 7.5 0 32.94 36.78 0 No
2024 STIER Shannon Campbell United Health Services Hospitals 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. 12/15/2023 Who: UHSH inpatients who are discharged with a stage 3,4, or unstageable wound that was not present on admission to the hospital (denominator population for baseline and PY). What: UHSH will reduce 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 (numerator population for baseline and PY). Where: UHS Wilson Medical Center and UHS Binghamton General Hospital. When: 1/1/2024 – 12/31/2024 BASELINE DATA: DOS 10.01.22- 09.30.23. Denominator is 8311. Numerator is 26. Baseline rate is 26/8311*1000 Decrease the number of UHSH Patients 18+ Surgical or Medical Inpatients discharged with a stage 3,4, or unstageable wound that was not present on admission to the hospital to 2.35/1000 discharges for the measurement period 1/1/2024 – 12/31/2024. This is a reduction of 25% from the 10/1/2022 – 9/30/2023 baseline of 3.13/1000 discharges. 20 0 3.13 2.35 0 No
2024 STIER Shannon Campbell United Health Services Hospitals 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. 12/15/2023 Who: Any Patient that used UHSH for their Delivery and Prenatal care at UHSH (denominator population for baseline and PY). What: UHSH will increase the percentage of Post-partum appointments for Patients that had their delivery and Prenatal care at UHSH to 74.57% on day 7 – 84 post-delivery event (numerator population for baseline and PY). Where: UHS Hospitals (WMH and BGH) When: 1/1/2024 – 12/31/2024 BASELINE DATA: DOS 11.01.22 – 10.31.23. Denominator is 888. Numerator is 591. Baseline rate is 591/888= 66.55%. PROJECT GOAL: 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. The Post-partum visit is important to address any physical or mental problems post-delivery, 50% of pregnancy related deaths happen after birth, roughly 70% if women describe at least one physical problem during the first 12 months in the post-partum period, 25% of these women are diagnosed with a problem of moderate severity and 20% have severe problems. Failure to attend a post-partum visit can lead to Post partum depression, bleeding, compromised breast health, poor weight control, lower back pain, dyspareunia, and blood pressure concerns. Our data shows that on average 30% 35% of patients do not attend a post-partum visit." 20 0 66.55 74.57 0 No
2024 STIER Shannon Campbell United Health Services Hospitals 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 12/15/2023 Who: Patients established with a UHSH PCP discharged to their community setting from the Acute Inpatient setting at UHS Hospitals (denominator population for baseline and PY). What: Increase the rate of Inpatient Admission encounters where the Patient’s PCP received and acknowledged an EMR notification of their patients Admission to the Inpatient setting within 72 hours. Day of event plus the following 2 calendar days (Numerator population for baseline and PY). Where: BGH and WMH When: 1/1/2024 – 12/31/2024 (PY) Baseline Data: DOS 10.01.22 – 09.30.23. Denominator is 7930 and numerator is 4545. Baseline percentage rate is 4545/7930=57.31%. PROJECT GOAL: Maintain or finish the PY higher than benchmark of 56.20% for 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 the 2 following calendar days of event. 7.5 0 57.31 56.2 0 No
2024 STIER Shannon Campbell United Health Services Hospitals 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. 12/15/2023 WHO: UHSH Inpatients who receive Press Ganey surveys (denominator population for baseline and PY). WHAT: UHSH will improve the composite score regarding Communication about Medicines to 54.05% (numerator population – answered specific question in survey – for baseline and PY). WHERE: UHS Wilson Medical Center and UHS Binghamton General Hospital WHEN: 1/1/2024 – 12/31/2024 BASELINE DATA: DOS 9.01.22 - 8.31.23. Denominator is 4348. Numerator is 2246. Baseline percentage rate is 2246/4348 = 51.66%. PROJECT GOAL: 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
2024 STIER Shannon Campbell United Health Services Hospitals 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. 12/15/2023 WHO: UHSH Inpatients who receive Press Ganey surveys (Denominator population for baseline and PY). WHAT: UHSH will improve RN communication score to 75.88%, by 12/31/2024 (Numerator population returned surveys with specific question(s) answered – for baseline and PY). WHERE: UHS Wilson Medical BASELINE DATA: DOS 10.01.22 – 09.30.23. Denominator is 4844. Numerator is 3620. Baseline percentage rate of performance is 3620/4844=74.73%. PROJECT GOAL: 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
2024 STIER Shannon Campbell United Health Services Hospitals 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 12/15/2023 Who: Inpatients age 65+, all insurances, with a primary diagnosis of pneumonia (denominator population baseline and PY). What: 30 day all cause unplanned readmission as defined by CMS (numerator population for baseline and PY). Where: Wilson Medical Center and Binghamton General Hospital When: 1/1/2024 – 12/31/2024 BASELINE DATA: DOS 10.01.22 – 09.30.23. Denominator is 580. Numerator is 76. Baseline percentage rate is 76/580= 13.10%. PROJECT GOAL: Maintain 30 day all cause unplanned readmission rates for patients admitted to UHSH with a primary diagnosis of pneumonia at or below the benchmark 16.9% for the measurement period. Maintain 30 day all cause unplanned readmission rates for patients admitted to UHSH with a primary diagnosis of pneumonia at or below the benchmark 16.9% for the measurement period of 1/1/2024-12/31/2024. Target population: Age 65+ patients, all insurance, admitted inpatient to UHSH (Wilson Medical Center and Binghamton General Hospital) with a primary diagnosis of pneumonia or primary diagnosis of sepsis with a secondary diagnosis of pneumonia. (At this time our EPIC build does not support the exclusion of severe sepsis patients outlined in the CMS definition of the pneumonia cohort and will be included in the target population) utilizing the CMS definitions of a qualifying admission and readmission. 7.5 0 13.1 16.9 0 No
2024 ROCH Jennifer de Jong United Memorial Medical Center 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 12/7/2023 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 nurse 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. National Benchmark: 79%   Question wording supplied by CMS   Improvement Measure: Nurse Communication - January 2022 - December 2022 Baseline Data - Num:2048 Denom:2705 Rate:75.71% Vol Min:413 NB:79% Target Rate:76.49% 30 0 75.71 76.49 0 No
2024 ROCH Jennifer de Jong United Memorial Medical Center 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 12/7/2023 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. National Benchmark: 69% The CMS definitions are used for both the numerator and denominator Improvement Measure: Recommend hospital - Star Rating - 2022 Baseline Data - Num:494 Denom:887 Rate:55.69% Vol Min:1650 NB:69 Target:59.13% 30 0 55.69 59.13 0 No
2024 ROCH Jennifer de Jong United Memorial Medical Center 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 12/7/2023 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. National Benchmark: 46.72% Numerator: 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.   Denominator Definition: Acute or non-acute inpatient discharges for Medicare beneficiaries 18 years and older. The denominator is based on discharges, not members. Members may appear more than once. - For Administrative Specification, the denominator is the eligible population. - For Hybrid Specification, the denominator is a systematic sample drawn from the eligible population.   Baseline Period - Receipt of Discharge Information: October 2022 – September 2023 Maintenance Measure: Transitions of Care - Receipt of Discharge Information - October 2022 - September 2023 Baseline Data - Num:3563 Denom:3867 Rate:92.14% NB:46.72% Target:Maintain   " 15 0 92.14 46.72 0 No
2024 ROCH Jennifer de Jong United Memorial Medical Center 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 12/7/2023 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. National Benchmark: 56.20% Numerator: 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. Denominator Definition: Acute or non-acute inpatient discharges for Medicare beneficiaries 18 years and older. The denominator is based on discharges, not members. Members may appear more than once. - For Administrative Specification, the denominator is the eligible population. - For Hybrid Specification, the denominator is a systematic sample drawn from the eligible population. Baseline Period - Notification of Inpatient Admission: October 2022 – September 2023 Maintenance Measure: Transitions of Care - Notification of Inpatient Admission - October 2022 - September 2023 Baseline Data - Num:17170 Denom:17202 Rate:99.91% Vol Min:1650 Vol Met:Yes NB:56.20% Target:Maintain " 15 0 99.91 56.2 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 12/7/2023 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.   National Benchmark: Rate 20.20%   The CMS definitions are used for both the numerator and denominator   Improvement Measure: Heart failure (HF) 30-day readmission rate - 2022 Baseline Data - Num:45 Denom:176 Rate:25.57% Vol Min:1650 NB:20.20% Target:23.79% 10 0 25.57 23.79 0 No
2024 ROCH Jennifer de Jong Unity Hospital 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 12/7/2023 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.    National Benchmark: 69% The CMS definitions are used for both the numerator and denominator.   Improvement Measure: Recommend hospital - Star Rating - 2022 Baseline Data - Num:1642 Denom:2760 Rate:59.49% Vol Min:None NB:69% Target:61.94% 10 0 59.49 61.94 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 12/7/2023 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.    National Benchmark: Rate 3.20   The CMS definitions are used for both the numerator and denominator   Improvement Measure: THA/THK Complication Rate: 2022 Baseline Data - Num: 15 Denom: 407 Rate: 3.69 VolMin: None NB: 3.20 Target: 3.55 20 0 3.69 3.55 0 No
2024 ROCH Jennifer de Jong Unity Hospital 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 12/7/2023 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. [NOTE: The software provides the rate per hospital discharge. However, common practice reports the measure as per 1,000 discharges. The user must multiply the rate obtained from the software by 1,000 to report events per 1,000 hospital discharges.] The goal is to be at or better than national benchmark.   National Benchmark: 0.07 Rate per 1,000 The AHRQ 2022 definitions are used for both the numerator and denominator. Improvement Measure: PSI-08 In-hospital fall with hip fracture rate - 2022 Baseline Data -  Num:6 Denom:12137 Rate:0.49 Vol Min:None Vol Met:Yes NB:0.07 Target:0.37 20 0 0.49 0.37 0 No
2024 ROCH Jennifer de Jong Unity Hospital 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 12/7/2023 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. National Benchmark: 46.72%    Numerator: 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.   Denominator Definition: Acute or non-acute inpatient discharges for Medicare beneficiaries 18 years and older. The denominator is based on discharges, not members. Members may appear more than once. - For Administrative Specification, the denominator is the eligible population. - For Hybrid Specification, the denominator is a systematic sample drawn from the eligible population.   Baseline Period - Receipt of Discharge Information: October 2022 – September 2023    Maintenance Measure: Transitions of Care - Receipt of Discharge Information - October 2022 - September 2023 Baseline Data - Num:14888 Denom:14985 Rate:99.35% NB:46.72% Target:Maintain 15 0 99.35 46.72 0 No
2024 ROCH Jennifer de Jong Unity Hospital 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 12/7/2023 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. National Benchmark: 56.20%   Numerator: 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.   Denominator Definition: Acute or non-acute inpatient discharges for Medicare beneficiaries 18 years and older. The denominator is based on discharges, not members. Members may appear more than once. - For Administrative Specification, the denominator is the eligible population. - For Hybrid Specification, the denominator is a systematic sample drawn from the eligible population.   Baseline Period - Notification of Inpatient Admission: October 2022 – September 2023   Maintenance Measure: Transitions of Care - Notification of Inpatient Admission - October 2022 - September 2023 Baseline Data - Num:17170 Denom:17202 Rate:99.81% Vol Min:1650 Vol Met:Yes NB:56.20% Target:Maintain 15 0 99.81 56.2 0 No
2024 ROCH Jennifer de Jong Unity Hospital 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 12/7/2023 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. [NOTE: The software provides the rate per hospital discharge. However, common practice reports the measure as per 1,000 discharges. The user must multiply the rate obtained from the software by 1,000 to report events per 1,000 hospital discharges.] HAC   National Benchmark: 3.63 Rate per 1,000   Improvement Measure: PSI-12 PE/DVT - April 2022 - March 2023 Baseline Data - Num:12 Denom:2920 Rate:4.11 Vol Min:1650 Vol Met:Yes NB:3.41 Target:3.89 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) 11/30/2023 Heart failure is a leading cause of hospitalizations and readmissions. Baseline time period for the year of 2022. Preventing readmissions is a priority and the goal of this project. The baseline numerator will be readmissions with the diagnosis of CHF. The baseline numerator is 36. The denominator will be all admissions with the diagnosis of CHF. The baseline denomintor is 230. We will monitor this over the course of the year 2024. " 15 0 15.65 20.2 0 No
2024 WNY Denise Hull UPMC Chautauqua PPC_POST Postnatal Care Increase postpartum follow up 12/4/2023 Timely and adequate prenatal and postpartum care can set the stage for long-term health and well being of new mothers and their infants. Making sure our patients have adequate follow up care is a priority and goal of this project. The baseline numerator is 442, all patients who had a postpartum follow up appointment. The baseline denominator is 668, all deliveries at UPMC Chautauqua. We will monitor this over the course of 2024. 15 0 66.17 74.39 0 No
2024 WNY Denise Hull UPMC Chautauqua H_COMP_1_A_P Nurse communication - Star Rating Increase nursing communication to patients 12/4/2023 With a goal at continuing to improve communication from nursing staff to patients to ensure patients concerns, experiences, and needs are met this project is aimed at increasing the patient population who report that their nurses “Always” communicate well. This increase will be seen during the year of 2024. Currently the baseline numerator from 2022 is 569 and these are the patients who reported ""Always."" The baseline denominator is 739 and these are the completed HCAHPS surveys for 2022. We will utilize our HCAHPS surveys to report the numerator and denominators for 2024. Our final target goal is to be at 80% or higher by the end of 2024. This project is implemented on all inpatient units. " 10 0 77 77.59 0 No
2024 WNY Denise Hull UPMC Chautauqua OP_22 ED Left Without Being Seen Decrease the amount of patients who left without being seen 12/4/2023 Patients leave the emergency department before being seen when waiting rooms are crowded and wait times are long. This is a quality and safety concern for our patient population. The goal of this project is to decrease the number of patients who leave the emergency department without being seen by a qualified medical personnel. The baseline numerator is 987, the number of patients who left without being seen by qualified medical personnel. The baseline denominator is 35,672, the number of patients seen in the emergency department. The goal of this project is to decrease the number of patients who have left the emergency department without being seen over the course of the year 2024. " 30 0 2.77 2.08 0 No
2024 WNY Denise Hull UPMC Chautauqua H_COMP_6_Y_P Discharge information - Star Rating Increase discharge instruction information education (Maintenance Measure) 12/4/2023 In order to prevent complications, infections, falls, and adverse drug events at home we will continue to increase the effectiveness of discharge education at our hospital. The goal is to increase patient understanding to ensure they and their caregivers know what to do and what to expect upon discharge from this facility to their home. The baseline numerator is 665, the number of patients who respond ""Always"" on their HCAHPS surveys. The baseline denominator is 739, the number of patients who completed an HCAHPS survey. This project will be worked on for the entire year of 2024 with a goal of increasing our effectiveness to over 90%. 30 0 89.99 86 0 No
2024 CNY Denise Hull Upstate University Hospital H_COMP_5_A_P Communication about medicines - Star Rating Improve communication about medicines 11/28/2023 The purpose of this measure is to increase the patients understanding regarding their medications. It is important for patients to understand their medications (the reasons why they take them, how to take them, and potential side effects) in order to improve their health and potentially even decrease re admissions. Upstate's baseline rate between July 1, 2022 through June 30, 2023 is 60.18%. The goal is to have a higher number and based on that the target for Upstate is 60.33%. 10 0 60.18 60.33 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 11/27/2023 Upstate University Hospital is an active member of Vizient, a consortium of academic medical centers across the United States and as an addition to our membership we have recently begun an engagement regarding quality transformation. This nearly $2 million dollar engagement is to help us focus and improve our quality metrics. Involved in this metric improvement was selecting our key performance metrics and develop strategies and working groups to improve our metrics. We have selected 29 top metrics of which 7 focus on readmission, 8 focus on patient experience, 7 focus on patient safety, 5 focus on mortality, and 2 focus on timely and effective care. A major focus will be “grouping the components” in order to address like concerns. In order to continue to improve by decreasing readmissions and ensuring that all transitions of care are meeting the level of quality our patients deserve we are making this program a major focus. Overall hospital readmissions within 30 days indicate inadequate and ineffective initial treatment, determination of social needs, and transition of care, leading to poor patient quality outcomes and increased mortality risks. The quality engagement with Vizient has helped Upstate look at the transitions of care and determine what impact this has for our organization. To help us improve we are forming a “Transitions of Care committee” that will focus on system and process improvement to enhance inpatient care, transition of care, and post-acute care to reduce readmission rates, decreased financial burden, and improve key performance indicators such as: readmissions, safety, mortality, and timely and effective care. For 9/2022- 8/2023 baseline numerator is 2407 readmissions with a denominator of 21,165, which calculates to a rate of 11.37%. 30 0 11.37 14.6 0 No
2024 CNY Denise Hull Upstate University Hospital 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 11/28/2023 This initiative will focus on decreasing the number of patients that encounter complications as defined by CMS after receiving a total knee or total hip replacement. These diagnosis are defined as: (a)acute myocardial infarction (AMI) during the index admission or a subsequent inpatient admission that occurs within seven days from the start of the index admission; (b) pneumonia or other acute respiratory complication during the index admission or a subsequent inpatient admission that occurs within seven days from the start of the index admission; (c) sepsis/septicemia/shock during the index admission or a subsequent inpatient admission that occurs within seven days from the start of the index admission; (d) surgical site bleeding or other surgical site complication during the index admission or a subsequent inpatient admission within 30 days from the start of the index admission; (e)pulmonary embolism during the index admission or a subsequent inpatient admission within 30 days from the start of the index admission; (f)death during the index admission or within 30 days from the start of the index admission; (g)mechanical complication during the index admission or a subsequent inpatient admission that occurs within 90 days from the start of the index admission; or (h)periprosthetic joint infection/wound infection or other wound complication during the index admission or a subsequent inpatient admission that occurs within 90 days from the start of the index admission. The baseline for data abstraction is September 1, 2022 through August 31, 2023. During this time frame a total of 8 patients out of 776 total patients (or 1.03 rate) experienced complications. Therefore, the anticipated target for the calendar year of 2024 will be a rate of 3.20 or lower making this a maintenance msr. 12/ 19/2023 - 3rd MM msr approved per Laurie Foster due to msr list typo stating multiple rate by 1000 instead of 100. 30 0 1.03 3.2 0 No
2024 CNY Denise Hull Upstate University Hospital 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 11/28/2023 This initiative will focus on maintaining or decreasing the number of patients who receive chemotherapy and within 30 days of treatment are seen in the Emergency Department for the key list of symptoms/diagnosis. These specific symptoms/diseases are: anemia, dehydration, diarrhea, emesis, fever, nausea, neutropenia, pain, pneumonia or sepsis. The baseline data is for the time frame of January 1, 2022 through December 31, 2022 is a total of 645 patients received chemotherapy and 24 had Emergency Department visits within 30 days. This calculates to a rate of 3.72%. The target for this measure is 5.4% or less. 30 0 3.72 5.4 0 No