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 1252023 Adirondack Health aims to improve the rate of severe sepsis 3hour bundle compliance which can help with the overall mortality rate of sepsis patients Baseline Data DOS 10122 93023 Baseline Numerator 38 Baseline Denominator 49 Baseline Rate 7755 FInal Target DOS 112024 12312024 Final Target Rate 8095 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 1252023 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 11122 103123 Baseline Numerator 106 Baseline Denominator 1680 Baseline Rate 63 Final Target Rate 63 Final Target DOS 1124 123124 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 1252023 Adirondack Health aims to improve the rate of severe sepsis 6hour bundle compliance which can help with the overall mortality rate of sepsis patients Baseline Data DOS 10122 93023 Baseline Numerator 15 Baseline Denominator 26 Baseline Rate 5769 Final Target Rate 6928 Final Target DOS 1124 123124 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 1252023 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 1123 93023 Baseline Numerator 219 Baseline Denominator 829 Baseline Rate 264 Final Target Rate 330 Final Target DOS 1124 123124 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 1252023 Adirondack Health aims to maintain or improve the patient satisfaction score for Quietness of hospital environment Baseline Data DOS 11122 103123 Baseline Numerator 347 Baseline Denominator 557 Baseline Target 623 Final Target 623 Final Target DOS 1124 123124 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 12132023 Maintain readmission rates below 146 throughout CY 24 This will be a maintenance measure noting a baseline of 1046 61583 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. 12132023 The AO Fox Memorial Hospital all causeall payer readmission rate is below the CMS benchmark goal of 146 lower performance rate is better for the final measurement period 112024 12312024 AO Fox Memorial Hospital aims to continue the deployment of evidencebased 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 PPSexempt 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 COVID19 U071 or with a secondary diagnosis code of COVID19 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 AO Fox Hospital regardless of payer type but excluding the patient types as noted above with denominator definition Baseline data DOS is fiscal year 070122 063023 The denominator is 1464 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 1148 and the benchmark utilized is 146 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. 12132023 AO Fox Memorial Hospital aims to perform equal to or better higher is better in this project than the CMS benchmark of 8467 for this project during the measurement period of 010124 123124 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 AO 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 112024 12312024 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 dc 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 070122 063023 The denominator defined above is 454 The numerator as defined above is 454 The baseline performance rate is 100 and the benchmark is 8467 per CMS The final target rate is 8467 as this project is considered as a MM by the health plans 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. 12132023 AO 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 innetwork primary care practitioners following an inpatient nonelective surgical discharge to home or home with home health for the measurement period of 010124 123124 For data collection purposes both baseline and active measurement periods are measuring all AO 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 010124 123124 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 PCPAssigned 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 070122 063023 The denominator as defined above is 454 and the numerator as defined above is 358 The baseline performance rate is 7885 and the benchmark utilized is 4672 The final target rate is 4672 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 12132023 We will increase our Severe Sepsis 3 Hour bundle compliance rate from our baseline year rate of 8140 Our target goal rate is 8391 for the measurement year In our baseline year Date October 1 2022 September 30 2023 Numerator 267 Denominator 328 Baseline Rate 8140 Numerator number of patients received all of the 3hour bundle measures Denominator Patients aged 18 years and over who meet CMS Sep1 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 12132023 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 12022 through October 31 2023 Number of surveys 725 Baseline Rate 7932 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 12132023 We will increase our Severe Sepsis 3 Hour bundle compliance rate from our baseline year rate of 8022 Our target goal rate is 8538 for the measurement year In our baseline year Date October 1 2022 September 302023 Numerator 146 Denominator 182 Baseline Rate 8022 Numerator number of patients received all of the 6hour bundle measures if indicated Denominator Patients aged 18 years and over who meet CMS Sep1 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. 12132023 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 847 or above In our baseline year Date October 1 2022 September 302023 Numerator 5728 Denominator 6386 Baseline Rate 590 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. 12132023 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 4672 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. 1272023 To increase our to increase the percentage of postpartum visits on or between 7 and 84 days after delivery above 4388 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 10122 to 93023 Baseline Numerator 115 Baseline Denominator 328 Baseline Rate 3506 Final Target Rate 4383 Final Target DOS112024 12312024 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. 1272023 To increase our Nurse Communication Star rating above 6943 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 662 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. 1272023 To increase our Discharge Information Star rating above 8451 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 8408 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. 1272023 To increase our Communication about medications Star rating above 4845 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 4369 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 1272023 To continue to maintain a 30 day ALL cause All Payor readmission rate below 146 Baseline Date DOS 1012022 9302023 Baseline Numerator 446 Baseline Denominator 4161 Baseline Rate 1072 Final Target Rate 146 Final Target DOS 112024 12312024 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%. 12142023 In effort to decrease the overall sepsis mortality rate Bassett Medical Center is committed to increasing the 3hour severe sepsis bundle compliance rate to be greater thanequal to 8399 Quarterly performance will be tracked from 1124 123124 for this goal for patients 18YO with a diagnosis of severe sepsis Baseline data collected from 070122 063023 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 8168 The current benchmark is 91 The final target rate for PY 010124 123124 is 8399 The PY denominator and numerator populations are the same as the baseline PROJECT GOAL TO INCREASE FROM BASELINE OF 8168 IN THE 3HR SEVERE SEPSIS BUNDLE TO 8399 OR HIGHER FROM 010124 123124 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. 12142023 Bassett Medical Center will increase the number of postpartum care visits occurring between 7 and 84 days after delivery to be greater thanequal to 8833 for patients who delivered at Bassett Medical Center and utilize an innetwork provider for followup care For this goal deliveries at BMC occurring between 010124 093024 will be within the scope as we are targeting improvements in postdelivery care from 784 days Baseline data of the 936 deliveries for patients who utilize innetwork OBGYN providers occurring between 7122 and 63023 804 postpartum care visits occurred within 7 and 84 days 8590 The baseline and PY denominator populations are those patients who delivered at BMC with an innetwork 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 innetwork provider THE PROJECT GOAL Increase the number of postpartum care visits occurring between 7 and 84 days after delivery to be greater thanequal to 8833 from the benchmark of for patients who delivered at Bassett Medical Center with an innetwork provider and utilize an innetwork provider for the followup 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 12142023 Maintain the total number of Bassett Medical Center Emergency Department ED visits to less thanequal to 540 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 010124 through 123124 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 100122 through 093023 indicate there were 129 BMC emergency departments visits numerator out of the 11190 denominator cancer treatment patients Baseline of 115 is better than the CMS benchmark target of 540 risk adjusted calculated rate thus this goal will be a maintenance measure PROJECT GOAL TO FINISH 010124 123124 AT LESS THAN THE BENCHMARK OF 540 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 12142023 The Bassett Medical Center all causeall payer readmission rate has outperformed the national benchmark in 2023 therefore in 2024 benchmark 1460 it has been established as a maintenance measure BMC will sustain an all causeall payer readmissions rate below national benchmark 1460 for all patients admitted to acute care beds for the time period of 01012024 through 12312024 denominator Numerator will be patients readmitted within 30 days of eligible admission Baseline data indicates 970 patients out of the 8917 BMC admissions 1088 experienced a readmission with 30 days for the time period of 7122 through 63023 PROJECT GOAL Maintain an all causeall payer readmissions at or below 1460 Maintenance Measure Final target rate is to be at or below 1460 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%. 12142023 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 5622 Baseline data indicates 614 responses out of 1154 returned surveys 5321 for the time period 7122 63023 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 increaseimprovement 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 BMCs Star Rating score Leapfrog score etc Data will be collected for the time period of 1124 through 123124 THE PROJECT GOAL TO INCREASE THE HCAHPS QUESTION OF STAFF RESPONSIVENESS ANSWER INCREASE FOR ALWAYS RECEIVING HELP AS SOON AS THEY WANTED FROM 5321 TO 5622 OR HIGHER FROM 010124 123124 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 12132023 To maintain the rate of notifiying the appropriate outpatient providers of inpatient admissions at or above the benchmark rate of 562 For data collection all patients who were admitted to CantonPotsdam 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 3956Baseline Denominator 3975 9952 Final time period 112024 12312024 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 12132023 To maintain the rate of sending discharge summariesinformation to appropriate outpatient providers at or above the benchmark rate of 4672 For data collection all patients who were discharged from CantonPotsdam 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 9551 Final time period 112024 12312024 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 11292023 Improve Care Transition Top Box to 4578 or better over CY 24 Baseline 412233123 was 3327554397 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. 11292023 Maintain 30day readmission rate at 146 or below for CY 24 Baseline 412233123 was 56053151054 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 diseasealcholol 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 CMSVizient 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 11292023 Improve postnatal care followup appointments for CVPH patients with follow up care with HN employed physicians to 6554 Baseline 412233123 excudes April 1st data due to Epic go live is 3897155441 Data pulled from Epic SQL data base Note we will only be able to track patients within our Epic Data base however through improving CVPHbased 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 11292023 Increase Doc Communication domain Top Box to 7380 or higher during CY 24 Baseline 412233123 was 548761 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 11292023 Improve Septic Shock 3hour bundle compliance to 6946 over CY 24 Baseline 412233123 was 26445909 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. 1262023 The Centers for Medicare Medicaid Services CMS 30day riskstandardized readmission measures assess a broad set of healthcare activities that affect patients wellbeing Patients who receive highquality 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 32 per 1000 The CMS definitions are used for both the numerator and denominator Improvement Measure Heart failure HF 30day readmission rate 2022 Baseline Data Num12 Denom55 Rate2182 Vol Min190 Vol MetNo NB2020 Target2137 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 1262023 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 4672 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 nonacute 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 Num1572 Denom1647 Rate9545 NB4672 TargetMaintain 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 1262023 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 5620 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 nonacute 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 Num2134 Denom2136 Rate9991 Vol Min190 Vol MetYes NB5620 TargetMaintain 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 1262023 The Hospital Consumer Assessment of Healthcare Providers and Systems HCAHPS is a national standardized publically reported survey on patients 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 patients 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 Num1645 Denom1984 Rate8291 VolMinNone NB79 TargetMaintain 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. 1262023 Perioperative pulmonary embolism or deep vein thrombosis secondary diagnosis per 1000 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 1000 discharges The user must multiply the rate obtained from the software by 1000 to report events per 1000 hospital discharges HAC National Benchmark 363 Rate per 1000 Improvement Measure PSI12 PEDVT 2022 Baseline Data Num2 Denom320 Rate625 Vol Min190 Vol MetYes NB341 Target488 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 1282023 Continue to maintain and improve sending discharge information to providers for inpatient medicalsurgical admissions at or above the target rate of 4672 for 11202412312024 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. 1282023 Reduce the number of patients leaving without being seen prior to seeing a provider in the Emergency Department from 142 to 107 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. 1282023 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 6896 to 6931 or greater for the time period of 11202412312024 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 1282023 Continue to maintain and improve notification of inpatient medicalsurgical admissions at or above the target rate of 562 for the time period of 11202412312024 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 12112023 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 11202212312022 with the respective numerator of 1 and denominator of 1886 resulting in a rate of 053 The goal will be to maintain or decrease this rate of 053 for the final measurement period of 11202412312024 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 1000 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 ICD10CM diagnosis code for acute kidney failure and any listed ICD10 PCS procedure code for dialysis Denominator includes Elective surgical discharges for patients ages 18 years and older with any listed ICD10PCS procedure code for an operating room procedure Elective surgical discharges are defined by specific MSDRG 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 1282023 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 1122123122 with the respective numerator of 112 and denominator of 151 which results in a baseline rate of 7417 The goal will be to increase the rate to 8085 compliance with the 6 hour bundle with severe sepsis or septic shock for the final measurement period of 1124123124 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 mLkg crystalloid fluids OR within three hours of septic shock Resuscitation with 30 mLkg 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 mmolL Repeat volume status and tissue perfusion assessment is performed Denominator Patients with an ICD10CM Principal or Other Diagnosis Code of U071 COVID19 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 1282023 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 11202212312022 with the respective numerator 1353 and denominator 2310 which results in a baseline rate of 5857 The goal will be to increase the rate to 6158 for the final measurement period of 11202412312024 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 1282023 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 11202212312022 with the respective numerator of 10992 and denominator of15557 which results in a baseline rate of 704 The goal will be to achieve the target of 7429 for the final measurement period of 112412312024 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 Denominatoracute and nonacute 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 1272023 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 11202212312022 with the respective numerator 15822 and denominator 21366 which results in a baseline rate of 740 The goal will be maintained at 7405 or increased for the final measurement period of 1124123124 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 nonacute 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 12132023 Our goal is to improve our score to 7251 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 apositive patient experience ensure patient safety and quality of care Executive Team leaders will conduct unit by unit listening sessions with the frontline 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 12132023 The goal is to maintain our calendar year 2022 performance of 12361302 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 12132023 The calendar year 2024 goal is to maintain our calendar year 2022 performance of 72412842 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. 12132023 Our goal is to reach 7244 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 25 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 7244 by the end of 2024 Please refer to the above interventions and implementations listed to reach our goal of 7251 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 12142023 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 12142023 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 12142023 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 andor caregivers not fully understanding discharge instructions new diagnosis medications and the true need for followup with their PCP andor 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 inptobs 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 12142023 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 12142023 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 andor caregivers not fully understanding discharge instructions new diagnosis medications and the true need for followup with their PCP andor 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 inptobs 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 12132023 To maintain the rate of notifiying the appropriate outpatient providers of inpatient admissions at or above the benchmark rate of 562 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 260Baseline Denominator 260 100 Final time period 112024 12312024 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 12132023 To maintain the rate of sending discharge summariesinformation to appropriate outpatient providers at or above the benchmark rate of 4672 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 7815 Final time period 112024 12312024 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 1272023 To maintain the rate of readmissions to the hospital from the 2023 FY baseline rate of 664 to a target of 146 calculated by of patients readmittedtotal eligible discharges by the end of December 2024 with a measurement period of 11202412312024 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 1272023 To increase the rate of 6hour severe sepsis bundle compliance from the 2023 FY baseline rate of 8583 to a target rate of 8958 calculated by of compliant cases of patients meeting severe sepsis criteria by the end of December 2024 with a measurement period of 11202412312024 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 1272023 To reduce the rate of inpatient hospital falls with hip fracture from the 2023 FY baseline rate of 052 to a target of 39 calculated by of fallsadmissions1000 By the end of December 2024 with a measurement period of 11202412312024 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. 1272023 To increase the rate of followup visits completed within 7days for emergency room patients with highrisk chronic conditions from the 2023 FY baseline rate of 220 to a target rate of 275 calculated by of followup visits completed of ED discharges by the end of December 2024 with a measurement period of 11202412312024 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 1262023 To reduce the rate of inpatient hospital falls with hip fracture from the 2023 FY baseline rate of 029 to a target of 22 calculated by of fallsadmissions1000 By the end of December 2024 with a measurement period of 11202412312024 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 1262023 To maintain the rate of readmissions to the hospital from the 2023 FY baseline rate of 108 to a target of 1460 calculated by of patients readmittedtotal eligible discharges by the end of December 2024 with a measurement period of 11202412312024 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 1262023 To increase the rate of postpartum followup visits completed between days 7 and 84 days postpartum from the 2023 FY baseline rate of 1312 to a target rate of 164 calculated by of postpartum followup visits completed of births by the end of September 2024 with a measurement period of 11202409302024 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 1262023 To increase the rate of 6hour severe sepsis bundle compliance from the 2023 FY baseline rate of 9213 to a target rate of 9426 calculated by of compliant cases of patients meeting severe sepsis criteria by the end of December 2024 with a measurement period of 11202412312024 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. 12122023 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 3609 TO 4511 010124 123124 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 3609 The final target achievement for 12312024 is 4511 Final numden for 2024 33246737 final rate 4511 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 12122023 OP35 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 WIN 30 DAYS OF OUTPATIENT CHEMOTHERAPY FROM 2708 TO 2031 010124 123124 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 1200 The baseline rate 2708 The final Target rate 2031 Final 2024 numden 243721200 2031 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 12122023 Heart failure HF 30day 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 postdischarge care thus reducing readmission HF30day readmission The outcome evaluated is unplanned HF 30day riskstandardized 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 2153 TO 2114 010124 123124 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 2153 The final target achievement for 12312024 is 2114 Final numden 9132432 final rate 2114 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 12122023 Comp HIPKnee comp HK This is a CMS complication outcome measure that evaluates specified complications that occur in THATKA patients from the date of index admission to 90day post op The Measure The denominator Includes all Medicare FFS beneficiaries aged 65 who are hospitalized for elective primary THA andor 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 andor TKA procedures Coded as not present on arrival and have an index admission up to 90 days postdate PROJECT GOAL TO DECREASE OF PATIENTS WELECTIVE PRIMARY THATKA ADMISSION 90 DAYS POST OP FROM 583 TO 456 010124 123124 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 583 The final target achievement for 12312024 is 456 Final numden for 2024 1016223 final rate 456 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 12122023 HComp7SA 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 posthospitalization 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 NumeratorDenominator for 2022 7931676 4732 PROJECT GOAL TO INCREASE OF PATIENTS WHO STRONGLY AGREE ON SURVEY THAT THEY UNDERSTOOD THEIR CARE WHILE HOSPITALIZED FROM 4732 TO 4829 010124 123124 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 12112023 Transition of care is an essential metric to ensure continuity of care and safety The metric is assed by Receipt of Discharge InformationDocumentation 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 nonacute inpatient discharges for Medicare beneficiaries 18 years and older Baseline Data Our baseline data from the calendar year 2022 1122 to 123122 included 1661616842 receipt of discharge information for an overall compliance of 9862 Our final target must be maintained at over 4672 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 12152023 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 7871 from calendar year 2022 1122 to 123122 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. 12122023 The measure OP22 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 212025 a qualified medical personnel by 25 The Numerator includes The total number of patients who left without being seen LWBS by a physicianAPNPA 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 1122 to 123122 included 3637 LWBS42280 Total Visits 86 In order to reduce our metrics by 25 we will need to improve our rate to 645 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 12152023 Patientcentered care is a critical facet of healthcare quality Our aim is to maintain discharge information from 112024 to 12312024 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 12112023 Transition of care is an essential metric to ensure continuity of care and safety The metrics is assessed by notification of Inpatient AdmissionOur 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 nonacute inpatient discharges for Medicare beneficiaries 18 years and older Baseline Data Our baseline data from calendar year 2022 1122 to 123122 included 1605216842 admission notifications for an overall compliance of 9527 Our final target must be maintained over 5620 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 12152023 To increase the number of postpartum 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 1272023 Increase follow up after BGMC emergency department visit for people with multiple high risk chronic conditions within 7 days from 386 baseline to 464 to be measured JanDec 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 1252023 Improve Kaleida Healths Severe Sepsis 6 Hour bundle compliance from a baseline of 8671 to a goal of 9005 in performance year 2024 JanNov December data will not be available in time to close out this measure Baseline Numerator 359 Baseline Denominator 414 Baseline Rate 8671 Final Target Rate 9005 Final Target DOS Jan 1 2024 Nov 30 2025 1272023 Improve Kaleida Healths Severe Sepsis 6 Hour bundle compliance from a baseline of 8671 to a goal of 9005 in performance year 2024 JanNov 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 1212023 Improve Kaleida Healths Septic Shock 6 Hour bundle compliance from a baseline of 9057 to a goal of 929 in performance year 2024 Jan Nov December data will not be available in time to close out this measure Baseline Date DOS 3Q222Q23 Baseline Numerator 144 Baseline Denominator 159 Baseline Rate 9057 1272023 Improve Kaleida Healths Septic Shock 6 Hour bundle compliance from a baseline of 9057 to a goal of 929 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 1212023 Improve Kaleida Health patient experience HCAHPS Responsiveness of Staff to a top box score of 5688 during for discharged patients during the performance period of Jan Dec 2024 Baseline Data DOS 4Q223Q23 Baseline Rate 5410 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 1282023 All cause readmission rates will be maintained or decrease below the target baseline of 146 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 12132023 To maintain the rate of notifiying the appropriate outpatient providers of inpatient admissions at or above the benchmark rate of 562 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 911Baseline Denominator 911 100 Final time period 112024 12312024 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 12132023 To maintain the rate of sending discharge summariesinformation to appropriate outpatient providers at or above the benchmark rate of 4672 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 846 727 Final time period 112024 12312024 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 12142023 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 patientscaregiver 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 12142023 According to the AHRQ Each year somewhere between 700000 and 1000000 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 onethird of falls can be prevented Fall prevention involves managing a patients underlying fall risk factors and optimizing the hospitals 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" 12142023 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 12142023 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 449 percent OP22 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. 12142023 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 1262023 The Hospital Consumer Assessment of Healthcare Providers and Systems HCAHPS is a national standardized publically reported survey on patients 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 patients 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 Num1327 Denom1596 Rate8315 Vol Min461 NB86 Target8379 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 1262023 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 5620 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 nonacute 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 Num4819 Denom5734 Rate8404 Vol Min461 Vol MetYes NB5620 TargetMaintain 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. 1262023 The Hospital Consumer Assessment of Healthcare Providers and Systems HCAHPS is a national standardized publically reported survey on patients 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 patients 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 Num1981 Denom2638 Rate7509 VolMinNone NB79 Target7606 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 1262023 The Hospital Consumer Assessment of Healthcare Providers and Systems HCAHPS is a national standardized publically reported survey on patients 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 patients 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 Num1923 Denom2657 Rate7237 VolMinNone NB79 Target7404 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 1262023 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 4672 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 nonacute 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 Num4250 Denom4452 Rate9546 NB4672 TargetMaintain 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. 1272023 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 146 Thirtyday 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 2773 acute discharges from Niagara Falls Memorial Of these total discharges a total of 246 thirtyday readmissions were recorded To calculate the thirtyday readmission rate the number of 30day readmissions 246 serves as the numerator and the total number of acute discharges 2773 serve as the denominator When the number of 30day readmissions is divided by the number of discharges a 30day readmission rate of 887 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 30day acute readmission rate to at or below the benchmark goal of 146 The targeted 2024 yearend 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 workups and inadequate patient caregiver and provider understanding of diagnoses medication and followup 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 HospitalBaseline data collected from CY 2022 resulted in a rate of 9734 The goal will be to maintain above 4672 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 1123121723 resulted in a rate of 6887 The goal will be to maintain at or above 6100 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 12122113023 resulted in a rate of 7285 The goal will be to increase nursing communication for Press Ganey scores to or above 7435 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 workups and inadequate patient caregiver and provider understanding of diagnoses medication and followup needs 121923 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 9569 The goal will be maintained above 5620 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 1012293023 resulted in a rate of 7820 The goal will be to increase compliance to 8142 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. 1262023 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 9538 throughout the 2024 calendar year Currently Oneida Health is tracking this measure at 967 The baseline denominator is 496 and the baseliine numerator is 480 53124 Measure definition addendum to reflect negotiated contract discussion For delivered patients who noshow if documentation is submitted in the Results section of the PDSA that indicates the number of noshows as well as the specific steps by Oneidas team to reengage the patient for postpartum followup 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. 1212023 The project goal for the OP22 measure or left the ED without being seen is to decrease our percentage from 227 to 17 with a longterm goal to reach the benchmark of 0001 The baseline numerator is 540 and baseline denominator is 23737 leading to the baseline rate of 227 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. 1212023 The project goal for the septic shock 3 hour bundle is to increase our percentage to 8309 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 3hour sepsis treatment bundle All inpatients age 18 with the diagnosis of severe sepsisseptic shock The baseline numerator is 61 and the baseline denominator is 77 with the baseline rate being 792 percent for the time period of 7122 to 63023 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. 1212023 The project goal is to maintain a compliance rate of 5100 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 medsurg OBGYN 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) 11242023 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 146 for the final measurement period 1124123124 For data collection all patients admittedreadmitted 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 win 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 12122023 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 patients understanding of their own disease process Baseline Data DOS 1012022 9302023 Baseline Numerator Baseline Denominator Baseline Rate 81 Final Target Rate 79 maintenance measure Final Target DOS 112024 12312024 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. 12122023 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 1012022 9302023 Baseline Numerator Baseline Denominator Baseline Rate 615 Final Target Rate 6166 Final Target DOS 112024 12312024 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 12122023 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 prepandemic percentages Baseline Data DOS Jul 1 2022 June 30 2023 Baseline Numerator 2252 Baseline Denominator 27362 Baseline Rate 823 Final Target Rate 617 Final Target DOS 112024 12312024 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 12122023 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 MedicalSurgical units ICU and Behavioral Health locations Baseline Data DOS 712022 63023 Baseline Numerator 413 Baseline Denominator 3800 Baseline Rate 1087 Final Target Rate 146 maintenance measure Final Target DOS 112024 12312024 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 12122023 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 712022 63023 Baseline Numerator 436 Baseline Denominator 1178 Baseline Rate 3701 Final Target Rate 4397 Final Target DOS 12312024 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 1262023 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 5620 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 nonacute 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 Num26192 Denom26217 Rate9990 Vol Min2667 Vol MetYes NB5620 TargetMaintain 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 1262023 In hospital fall with hip fracture secondary diagnosis per 1000 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 1000 discharges The user must multiply the rate obtained from the software by 1000 to report events per 1000 hospital discharges The goal is to be at or better than national benchmark National Benchmark 007 Rate per 1000 The AHRQ 2022 definitions are used for both the numerator and denominator Improvement Measure PSI08 Inhospital fall with hip fracture rate 2022 Baseline Data Num4 Denom20785 Rate019 Vol MinNone Vol MetYes NB007 Target014 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 1262023 Perioperative pulmonary embolism or deep vein thrombosis secondary diagnosis per 1000 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 1000 discharges The user must multiply the rate obtained from the software by 1000 to report events per 1000 hospital discharges HAC National Benchmark 363 Rate per 1000 Improvement Measure PSI12 PEDVT October 2022 September 2023 Baseline Data Num29 Denom7104 Rate408 Vol Min2667 Vol MetYes NB341 Target387 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 1262023 The Hospital Consumer Assessment of Healthcare Providers and Systems HCAHPS is a national standardized publically reported survey on patients 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 patients 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 Num2523 Denom4357 Rate5791 Vol MinNone NB69 Target6074 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 1262023 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 4672 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 nonacute 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 Num22306 Denom22520 Rate9905 NB4672 TargetMaintain 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 1262023 THATHK Complications The Centers for Medicare Medicaid Services CMSs publicly reported riskstandardized complication measure for elective primary total hip arthroplasty THA andor total knee arthroplasty TKA assesses a broad set of healthcare activities that affect patients wellbeing 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 riskstandardized 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 320 The CMS definitions are used for both the numerator and denominator Improvement Measure THATHK Complication Rate Apr 2022 Mar 2023 Baseline Data Num10 Denom279 Rate358 VolMinNone NB320 Target347 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 12182023 Baseline data DOS 1012022 9302023 denominator 3005 and numerator 168 Baseline rate 559 Target is to maintain the all cause readmission rate at or below the benchmark goal of 146 for the final measurement period 11202412312024 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 win 30 days of discharge from an acute care bed from Rome Health for all acute care inpatient admissions during measurement period numerator InclusionExclusion Criteria This measure estimates a hospitallevel 30day 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 PPSexempt 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 COVID19 U071 or with a secondary diagnosis code of COVID19 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 12182023 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 1012022 9302023 denominator 441 and numerator 231 Baseline rate is 5238 Target is to improve the Press Ganey response for patients who reported that the area around their room was Always quiet at night to 5470 for calendar year 2024 112024 12312024 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 12182023 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 3hour severe sepsis bundle Baseline data DOS 10120229302023 denominator 141 and numerator 107 Baseline rate is 7589 Target is to achieve 7980 or greater 3hoursevere sepsis bundle compliance for calendar year 112024 12312024 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 3hour 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 20mgdl or UOP 05mlkghr for 2 hours Increase O2 need to maintain SPO2 90 Acute respiratory failure BiPap or CPAP Platelets 100000ul MAP 65 or SBP 90 or 40 mmHg lower than last known normal Total Bilirubin 2mgdl jaundice or new petechiae INR 15 or a PPT 60 secs off therapy Glasgow Coma Scale 15 Lactate 20 mmolL 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 12182023 Rome Health is committed to improve the patients experience rating with a focus on the patients perception of nurse communication Baseline data DOS 1012022 9302023 denominator 447 and numerator 342 Baseline rate is 5238 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 112024 12312024 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 mixups 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 12142023 SMC will increase our compliance with the severe sepsis 3hr bundle to 7997 based on target calculator from 7606 for the measurement period of 1124123124 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 12142023 SMC will maintain our percentage of allcause readmissions between 96146 for the measurement period of 1124123124 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 12142023 SMC will maintain our COPD readmission percent between 1196 1930 for the measurement period of 1124123124 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 12142023 121423 SMC will increase the percentage of our Womens Wellness postpartum patients that have a postpartum visit on or between 784 days from 8193 to 853 for the measurement period of January 1 2024September 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 12142023 SMC will increase our HCAHPS overall Top Box hospital rating from our baseline of 6031 to 6279 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 12112023 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 074 Our goal is to decrease this to a Left Without Being Seen rate of 056 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. 12112023 The goal of increasing the rate of inpatient admission notification to each patients primary care provider is to ensure continuity of care therefore increasing quality of care The denominator for this care transitions metrics is inpatient discharges from October 2022 through September 2023 totaling 453 The numerator is the number of PCPs notified of inpatient admission for the same time period totaling 210 This produces a baseline rate of 4636 and our goal is to increase this rate to 4886 This ensures the transition of care to and from inpatient providers and each patients 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. 12112023 The goal of increasing the rate of discharge information sent to each patients primary care provider is to ensure transition of care medication reconciliation with inpatient stay and to best manage careThe 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 years worth of data this was 244 The denominator for this care transitions metrics is inpatient discharges from October 2022 through September 2023 totaling 453 This results in a baseline rate of 5386 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 12152023 httpswwwncqaorghedismeasurestransitionsofcare accessed 12132023 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 workups and inadequate patient caregiver and provider understanding of diagnoses medication and followup 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. 12152023 httpswwwncqaorghedismeasurestransitionsofcare accessed 12132023 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 workups and inadequate patient caregiver and provider understanding of diagnoses medication and followup 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 122024 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 3125 to 3906 for the final measurement period of 01012024 12312024 For the data collection all data will be provided by Excellus to align with the ACQA so its 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. 122024 SJH aims to provide top quality care to all in need St Josephs Emergency Services Leadership is committed to decreasing the Left without being seen incidences from 3 to 225 in the calendar year 2024 Goal is to improve the ED left without being seen percentage to 225 from 300 for the final measurement period 01012024 12312024 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. 122024 In the 2024 calendar year SJH will reduce the HF Readmission rates from 2338 to 2242 for the measure period of 0101202412132024 For data collection all patient admittedreadmitted to SJH will be included regardless of payer in the following measure definition This measure estimates a hospitallevel 30day riskstandardized 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 132024 In the 2024 calendar year SJH will increase the Nurse Communication Star Rating from 7733 to 7773 for the measure period of 0101202412312024 For data collection all patient admittedreadmitted 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 122024 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 1826 for the final measurement period of 01012024 12312024 For the data collection all data will be provided by Excellus to align with the ACQA so its 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 122024 In the 2024 calendar year SJH will maintain the AMI Readmission rates below the benchmark of 14 for the measure period of 0101202412132024 For data collection all patient admittedreadmitted to SJH will be included regardless of payer in the following measure definition This measure estimates a hospitallevel 30day riskstandardized 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. 12152023 httpswwwncqaorghedismeasurestransitionsofcare accessed 12132023 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 workups and inadequate patient caregiver and provider understanding of diagnoses medication and followup 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. 12152023 httpswwwncqaorghedismeasurestransitionsofcare accessed 12132023 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 workups and inadequate patient caregiver and provider understanding of diagnoses medication and followup 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) 12152023 Health care is stuck in the middle of the opioid overdose epidemic Clinicians want to provide compassionate patientfocused 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 substanceuse 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 12152023 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 12152023 PSls provide information on potentially avoidable safety events that represent opportunities for improvement in the delivery of care Hospitallevel indicators detect potential safety problems that occur during a patients hospital stay They include arealevel 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 12152023 Maintain 30 day all cause unplanned readmission rates for patients admitted to UHSH with a primary diagnosis of COPD at or below the benchmark 193 for the measurement period of 11202412312024 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 100122 093023 Denominator is 146 Numerator is 19 Baseline rate is 19146 1301 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 193 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. 12152023 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 112024 12312024 BASELINE DATA DOS 100122 93023 Denominator is 7930 The numerator is 2612 Baseline rate is 26127930 3294 Increase the rate of Discharge encounters where the Patients UHSH PCP received and acknowledged an EMR notification of their patients 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 3294 to finish the PY equal to or higher than the target rate of 3678 based on the CMS benchmark of 4672 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. 12152023 Who UHSH inpatients who are discharged with a stage 34 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 34 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 112024 12312024 BASELINE DATA DOS 100122 093023 Denominator is 8311 Numerator is 26 Baseline rate is 2683111000 Decrease the number of UHSH Patients 18 Surgical or Medical Inpatients discharged with a stage 34 or unstageable wound that was not present on admission to the hospital to 2351000 discharges for the measurement period 112024 12312024 This is a reduction of 25 from the 1012022 9302023 baseline of 3131000 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. 12152023 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 Postpartum appointments for Patients that had their delivery and Prenatal care at UHSH to 7457 on day 7 84 postdelivery event numerator population for baseline and PY Where UHS Hospitals WMH and BGH When 112024 12312024 BASELINE DATA DOS 110122 103123 Denominator is 888 Numerator is 591 Baseline rate is 591888 6655 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 6655 to equal or higher than 7457 during the measurement period as higher performance rates are better The Postpartum visit is important to address any physical or mental problems postdelivery 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 postpartum period 25 of these women are diagnosed with a problem of moderate severity and 20 have severe problems Failure to attend a postpartum 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 postpartum 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 12152023 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 Patients 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 112024 12312024 PY Baseline Data DOS 100122 093023 Denominator is 7930 and numerator is 4545 Baseline percentage rate is 454579305731 PROJECT GOAL Maintain or finish the PY higher than benchmark of 5620 for Inpatient Admission where the Patients UHSH PCP received and acknowledged an EMR notification of their patients 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. 12152023 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 5405 numerator population answered specific question in survey for baseline and PY WHERE UHS Wilson Medical Center and UHS Binghamton General Hospital WHEN 112024 12312024 BASELINE DATA DOS 90122 83123 Denominator is 4348 Numerator is 2246 Baseline percentage rate is 22464348 5166 PROJECT GOAL Increase our Medications Communication Patient Experience score from baseline rate of 5166 equal to or higher than 5405 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. 12152023 WHO UHSH Inpatients who receive Press Ganey surveys Denominator population for baseline and PY WHAT UHSH will improve RN communication score to 7588 by 12312024 Numerator population returned surveys with specific questions answered for baseline and PY WHERE UHS Wilson Medical BASELINE DATA DOS 100122 093023 Denominator is 4844 Numerator is 3620 Baseline percentage rate of performance is 362048447473 PROJECT GOAL Increase our RN Communication Patient Experience score from baseline percentage of 7473 equal to or higher than 7588 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 12152023 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 112024 12312024 BASELINE DATA DOS 100122 093023 Denominator is 580 Numerator is 76 Baseline percentage rate is 76580 1310 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 169 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 169 for the measurement period of 11202412312024 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 1272023 The Hospital Consumer Assessment of Healthcare Providers and Systems HCAHPS is a national standardized publically reported survey on patients 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 patients 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 Num2048 Denom2705 Rate7571 Vol Min413 NB79 Target Rate7649 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 1272023 The Hospital Consumer Assessment of Healthcare Providers and Systems HCAHPS is a national standardized publically reported survey on patients 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 patients 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 Num494 Denom887 Rate5569 Vol Min1650 NB69 Target5913 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 1272023 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 4672 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 nonacute 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 Num3563 Denom3867 Rate9214 NB4672 TargetMaintain 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 1272023 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 5620 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 nonacute 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 Num17170 Denom17202 Rate9991 Vol Min1650 Vol MetYes NB5620 TargetMaintain 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 1272023 The Centers for Medicare Medicaid Services CMS 30day riskstandardized readmission measures assess a broad set of healthcare activities that affect patients wellbeing Patients who receive highquality 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 2020 The CMS definitions are used for both the numerator and denominator Improvement Measure Heart failure HF 30day readmission rate 2022 Baseline Data Num45 Denom176 Rate2557 Vol Min1650 NB2020 Target2379 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 1272023 The Hospital Consumer Assessment of Healthcare Providers and Systems HCAHPS is a national standardized publically reported survey on patients 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 patients 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 Num1642 Denom2760 Rate5949 Vol MinNone NB69 Target6194 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 1272023 The Centers for Medicare Medicaid Services CMSs publicly reported riskstandardized complication measure for elective primary total hip arthroplasty THA andor total knee arthroplasty TKA assesses a broad set of healthcare activities that affect patients wellbeing 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 riskstandardized 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 320 The CMS definitions are used for both the numerator and denominator Improvement Measure THATHK Complication Rate 2022 Baseline Data Num 15 Denom 407 Rate 369 VolMin None NB 320 Target 355 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 1272023 In hospital fall with hip fracture secondary diagnosis per 1000 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 1000 discharges The user must multiply the rate obtained from the software by 1000 to report events per 1000 hospital discharges The goal is to be at or better than national benchmark National Benchmark 007 Rate per 1000 The AHRQ 2022 definitions are used for both the numerator and denominator Improvement Measure PSI08 Inhospital fall with hip fracture rate 2022 Baseline Data Num6 Denom12137 Rate049 Vol MinNone Vol MetYes NB007 Target037 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 1272023 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 4672 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 nonacute 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 Num14888 Denom14985 Rate9935 NB4672 TargetMaintain 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 1272023 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 5620 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 nonacute 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 Num17170 Denom17202 Rate9981 Vol Min1650 Vol MetYes NB5620 TargetMaintain 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 1272023 Perioperative pulmonary embolism or deep vein thrombosis secondary diagnosis per 1000 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 1000 discharges The user must multiply the rate obtained from the software by 1000 to report events per 1000 hospital discharges HAC National Benchmark 363 Rate per 1000 Improvement Measure PSI12 PEDVT April 2022 March 2023 Baseline Data Num12 Denom2920 Rate411 Vol Min1650 Vol MetYes NB341 Target389 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) 11302023 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 1242023 Timely and adequate prenatal and postpartum care can set the stage for longterm 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 1242023 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 1242023 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 35672 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) 1242023 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 11282023 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 Upstates baseline rate between July 1 2022 through June 30 2023 is 6018 The goal is to have a higher number and based on that the target for Upstate is 6033 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 11272023 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 postacute care to reduce readmission rates decreased financial burden and improve key performance indicators such as readmissions safety mortality and timely and effective care For 92022 82023 baseline numerator is 2407 readmissions with a denominator of 21165 which calculates to a rate of 1137 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 11282023 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 aacute 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 sepsissepticemiashock 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 epulmonary embolism during the index admission or a subsequent inpatient admission within 30 days from the start of the index admission fdeath during the index admission or within 30 days from the start of the index admission gmechanical complication during the index admission or a subsequent inpatient admission that occurs within 90 days from the start of the index admission or hperiprosthetic joint infectionwound 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 103 rate experienced complications Therefore the anticipated target for the calendar year of 2024 will be a rate of 320 or lower making this a maintenance msr 12 192023 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 11282023 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 symptomsdiagnosis These specific symptomsdiseases 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 372 The target for this measure is 54 or less 30 0 3.72 5.4 0 No