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Regional President:

2025 HPIP/SHIP Measures At-Risk
Hospital Name Consultant Name Measure Points At Risk Baseline Rate Target Rate Q1 Actual Rate Q2 Actual Rate Q3 Actual Rate Q4 Actual Rate Final Actual Rate
Auburn Community Hospital Denise Hull
All Cause Rate of readmission after discharge from hospital (hospital-wide) 15% 11.38 14.6 12.76 11.47 0 0 0
Postnatal Care 15% 70.23 77.6 0 0.00 0 0 0
Perioperative pulmonary embolism or deep vein thrombosis rate 20.00 3.76 3.72 46.19 43.51 0 0 0
Nurse communication - Star Rating 20% 75.15 76.2 50.00 94.00 0 0 0
Communication about medicines - Star Rating 20% 53.06 55.34 83.63 90.55 0 0 0
Discharge information - Star Rating 10% 81.56 82.7 66.96 68.31 0 0 0
Crouse Hospital Shelly LoPresti
Notification of Inpatient Admission 15% 98.93 56.2 71.28 70.05 0 0 0
Medication Reconciliation Conducted 15% 76.42 78.64 99.56 99.45 0 0 0
Postoperative acute kidney injury requiring dialysis rate 30.00 0 1.57 93.45 92.97 0 0 0
ED Left Without Being Seen 30% 0.8 0.56 0.08 0.10 0 0 0
Recommend hospital - Star Rating 10% 68.19 68.39 0 0.00 0 0 0
Guthrie Cortland Medical Center Laurie Foster
All Cause Rate of readmission after discharge from hospital (hospital-wide) 30% 12.39 14.6 13.10 13.88 0 0 0
Discharge information - Star Rating 30% 82.77 83.68 81.62 86.10 0 0 0
ED Left Without Being Seen 30% 2 1.4 1.44 1.37 0 0 0
Communication about medicines - Star Rating 10% 51.29 54.06 54.59 59.78 0 0 0
Oswego Hospital Denise Hull
All Cause Rate of readmission after discharge from hospital (hospital-wide) 15% 10.03 14.6 11.63 11.73 8.82 0 0
Follow-Up After Hospitalization for Mental Illness Total / 7 Day* 15% 88.35 61.43 95.82 96.80 0 0 0
Communication about medicines - Star Rating 30% 52.34 54.9 7.44 6.40 4.42 0 0
ED Left Without Being Seen 30% 7.25 5.07 63.69 56.92 60.00 0 0
Doctor communication - Star Rating 10% 80.17 79 83.35 82.61 81.82 0 0
Upstate University Hospital Denise Hull
All Cause Rate of readmission after discharge from hospital (hospital-wide) 30% 12.04 14.6 12.19 8.88 0 0 0
Iatrogenic pneumothorax rate 30.00 0.14 0.25 79.02 78.58 0 0 0
Rate of Referral time 30% 37.68 49.4 0.35 0.17 0 0 0
Doctor communication - Star Rating 10% 76.5 77.15 32.00 44.00 0 0 0
St. Joseph's Health Hospital Shelly LoPresti
Highland Hospital
Notification of Inpatient Admission 15% 96.53 56.2 96.02 96.14 0 0 0
Receipt of Discharge Information 15% 96.19 46.72 94.58 94.62 0 0 0
Doctor communication - Star Rating 30% 87.51 79 80.49 91.66 0 0 0
Discharge information - Star Rating 30% 90.43 86 87.00 89.26 0 0 0
Pressure Ulcer Rate 10.00 1.59 0.65 0 0.00 0 0 0
Jones Memorial Hospital
Notification of Inpatient Admission 50% 90.75 56.2 92.05 92.23 0 0 0
Receipt of Discharge Information 50% 95.04 46.72 92.05 94.05 0 0 0
Noyes Memorial Hospital
Notification of Inpatient Admission 15% 95.8 56.2 94.92 94.92 0 0 0
Receipt of Discharge Information 15% 96.78 46.72 95.44 94.51 0 0 0
Severe Sepsis 3-Hour Bundle 30% 83.61 85.78 64.29 82.50 0 0 0
Nurse communication - Star Rating 15% 76.07 76.91 61.70 61.00 0 0 0
Communication about medicines - Star Rating 15% 56.4 57.7 76.78 77.00 0 0 0
Doctor communication - Star Rating 10% 70.58 72.98 68.53 79.00 0 0 0
Rochester General Hospital Jennifer de Jong
Receipt of Discharge Information 15% 97.75 46.72 99.95 99.93 0 0 0
Notification of Inpatient Admission 15% 99.93 56.2 96.63 96.89 0 0 0
Hospital Fall with Fracture 30.00 0.36 0.33 86.60 86.61 0 0 0
Latrogenic Pneumothorax Rate 30.00 0.14 0.19 0.55 0.70 0 0 0
Severe Sepsis 3-Hour Bundle 0% 75.78 80.11 0 0.00 0 0 0
Doctor Communication - Star Rating 0% 75.19 76.26 86.67 43.33 0 0 0
Discharge information - Star Rating 10% 86.67 86 77.80 77.55 0 0 0
F.F. Thompson Hospital
Notification of Inpatient Admission 15% 87.13 56.2 94.30 95.89 0 0 0
Receipt of Discharge Information 15% 97.66 46.72 97.68 97.41 0 0 0
Recommend hospital - Star Rating 30% 73.5 69 73.96 74.60 0 0 0
Doctor communication - Star Rating 30% 80.59 79 81.08 86.09 0 0 0
Communication about medicines - Star Rating 10% 60.25 60.43 64.38 59.05 0 0 0
United Memorial Medical Center Jennifer de Jong
Notification of Inpatient Admission 15% 99.83 56.2 99.58 98.41 0 0 0
Receipt of Discharge Information 15% 92.41 46.72 90.80 91.18 0 0 0
Discharge information - Star Rating 30% 87.67 86 86.40 86.33 0 0 0
ED Left Without Being Seen 30% 3.28 2.3 1.40 1.67 0 0 0
Doctor communication - Star Rating 10% 77.19 77.65 75.76 74.50 0 0 0
Unity Hospital Jennifer de Jong
Notification of Inpatient Admission 15% 99.81 56.2 99.80 99.67 0 0 0
Receipt of Discharge Information 15% 99.36 46.72 99.06 99.48 0 0 0
Postoperative hemorrhage or hematoma rate 20.00 1.63 2.26 87.30 85.54 0 0 0
Perioperative pulmonary embolism or deep vein thrombosis rate 20.00 1.92 3.47 1.59 3.48 0 0 0
Abdominopelvic accidental puncture or laceration rate 20.00 1.64 1.15 0 0.00 0 0 0
Discharge information - Star Rating 10% 84.24 84.75 0 1.88 0 0 0
Strong Memorial Hospital
Notification of Inpatient Admission 15% 92.83 56.2 5.61 6.27 0 0 0
Receipt of Discharge Information 15% 92.59 46.72 93.64 93.81 0 0 0
Recommend hospital - Star Rating 30% 87.16 69 91.02 91.49 0 0 0
Communication about medicines - Star Rating 30% 77.06 61 86.01 85.64 0 0 0
Time to Initiation of Postoperative Radiation Therapy (PORT) for Patients with Head and Neck Cancer 10.00 9.02 7.47 77.33 76.17 0 0 0
Clifton Springs Hospital & Clinic Jennifer de Jong
Notification of Inpatient Admission 15% 100 56.2 100.00 100.00 0 0 0
Receipt of Discharge Information 15% 94.06 46.72 97.04 92.31 0 0 0
Doctor communication - Star Rating 30% 84.07 79 83.10 86.10 0 0 0
Severe Sepsis 3-Hour Bundle 30% 86.49 87.7 100.00 60.00 0 0 0
Nurse communication - Star Rating 10% 83.35 79 81.70 81.00 0 0 0
Newark-Wayne Community Hospital Jennifer de Jong
Notification of Inpatient Admission 15% 84.63 56.2 83.84 83.91 0 0 0
Receipt of Discharge Information 15% 95.47 46.72 95.62 95.23 0 0 0
Nurse communication - Star Rating 30% 76.24 77.08 75.90 82.60 0 0 0
Doctor communication - Star Rating 30% 77.97 78.2 76.80 83.66 0 0 0
Discharge information - Star Rating 10% 82.36 83.27 86.42 84.40 0 0 0
Canton-Potsdam Hospital Jennifer de Jong
Receipt of Discharge Information 35% 95.38 46.72 99.61 99.03 0 0 0
Notification of Inpatient Admission 35% 99.57 56.2 94.81 96.57 0 0 0
Staff responsiveness - Star Rating 15% 63.53 63.91 9.62 0.00 0 0 0
Perioperative pulmonary embolism or deep vein thrombosis rate 15.00 13.3 9.31 65.22 64.91 0 0 0
Champlain Valley Physicians Hospital Laurie Foster
All Cause Rate of readmission after discharge from hospital (hospital-wide) 30% 12.08 14.6 11.73 14.42 0 0 0
Discharge information - Star Rating 30% 83.21 83.92 75.86 61.22 0 0 0
Severe Sepsis 3-Hour Bundle 30% 74.36 79.04 89.03 85.49 0 0 0
Overall hospital rating - Star Rating 10% 57.61 61.24 64.80 65.14 0 0 0
Community Memorial Hospital Denise Hull
Gouverneur Hospital Jennifer de Jong
Notification of Inpatient Admission 35% 100 56.2 98.04 97.78 0 0 0
Receipt of Discharge Information 35% 79.45 46.72 90.24 85.71 0 0 0
Doctor communication - Star Rating 30% 71.01 73.28 69.23 75.60 0 0 0
Lewis County General Hospital Denise Hull
Bassett Medical Center
All Cause Rate of readmission after discharge from hospital (hospital-wide) 30% 12.51 14.6 11.29 12.31 0 0 0
Rate of inpatient admissions for patients receiving outpatient chemotherapy 30% 14.86 12.6 1.54 2.03 0 0 0
In-hospital fall with hip fracture rate 30.00 0.1 0.1 0 0.00 0 0 0
Nurse communication - Star Rating 10% 75.03 76.08 76.22 76.22 0 0 0
MVHS, Inc. (Wynn Hospital) Laurie Foster
All Cause Rate of readmission after discharge from hospital (hospital-wide) 30% 13.82 14.6 14.01 17.17 0 0 0
ED Left Without Being Seen 30% 3 2.1 2.85 2.50 2.08 0 0
Hospital Fall w/ Fracture 30.00 0.55 0.39 72.53 68.58 0 0 0
Nurse communication - Star Rating 10% 75.04 76.09 0.26 0.00 0.26 0 0
Massena Hospital Jennifer de Jong
Receipt of Discharge Information 35% 73.19 46.72 98.50 100.00 0 0 0
Notification of Inpatient Admission 35% 100 56.2 77.65 76.76 0 0 0
Perioperative pulmonary embolism or deep vein thrombosis rate 15.00 90.91 63.64 0 0.00 0 0 0
Staff responsiveness - Star Rating 15% 50 54.3 57.14 55.00 0 0 0
Adirondack Medical Center Denise Hull
All Cause Rate of readmission after discharge from hospital (hospital-wide) 30% 5.84 14.6 5.91 5.56 0 0 0
Severe Sepsis 3-Hour Bundle 30% 78.89 82.28 93.02 90.91 0 0 0
Overall hospital rating - Star Rating 30% 80.19 70 81.89 90.08 0 0 0
Recommend hospital - Star Rating 10% 85.44 69 84.13 85.00 0 0 0
Alice Hyde Medical Center Laurie Foster
A.O. Fox Hospital
Receipt of Discharge Information 25% 76.47 46.72 9.63 14.29 0 0 0
All Cause Rate of readmission after discharge from hospital (hospital-wide) 50% 12.81 14.6 75.97 77.91 0 0 0
Medication Reconciliation Conducted 25% 100 84.67 100.00 100.00 0 0 0
Oneida Health Hospital Laurie Foster
Postnatal Care 30% 99.36 95.38 98.78 0 0 0 0
Septic Shock 3-Hour Bundle 30% 71.91 78.31 80.95 0 0 0 0
ED Left Without Being Seen 30% 2.32 1.62 1.36 0 0 0 0
Discharge information - Star Rating 10% 91 86 91.51 0 0 0 0
Rome Health
All Cause Rate of readmission after discharge from hospital (hospital-wide) 30% 5.82 14.6 8.21 5.68 0 0 0
Postoperative respiratory failure rate 30.00 0 8.86 4.65 4.55 0 0 0
Discharge information - Star Rating 30% 85.06 85.32 84.89 87.30 0 0 0
Communication about medicines - Star Rating 10% 58.31 59.13 70.21 72.84 0 0 0
Samaritan Medical Center Laurie Foster
All Cause Rate of readmission after discharge from hospital (hospital-wide) 30% 10.61 14.6 12.47 10.47 0 0 0
Septic Shock 3-Hour Bundle 30% 88.14 89.9 95.45 85.29 0 0 0
Severe Sepsis 3-Hour Bundle 30% 85.62 87.08 93.33 100.00 0 0 0
Postnatal Care 10% 83.41 86.75 88.14 87.81 0 0 0
Erie County Medical Center Denise Hull
Follow-Up After High-Intensity Care for Substance Use Disorder Total / 7 Day 30% 92.78 57.46 96.07 94.61 0 0 0
Severe Sepsis 3-Hour Bundle 30% 90.2 90.47 4.80 3.90 0 0 0
ED Left Without Being Seen 30% 7.9 5.53 87.10 80.00 0 0 0
Discharge information - Star Rating 10% 89.03 86 86.04 88.61 0 0 0
Kaleida Health Denise Hull
Follow-Up After Emergency Department Visit for People With Multiple High-Risk Chronic Conditions / 7 Day* 30% 57.54 60.19 95.52 96.96 0 0 0
Nurse communication - Star Rating 20% 73.55 75.02 62.79 70.05 0 0 NaN
Severe Sepsis 3-Hour Bundle 20% 69.35 75.52 75.32 75.95 0 0 0
Doctor communication - Star Rating 20% 74.16 75.64 77.93 77.64 0 0 0
Overall hospital rating - Star Rating 10% 62.91 64.92 63.51 66.75 0 0 0
Niagara Falls Memorial Medical Center Denise Hull
UPMC Chautauqua Denise Hull
All Cause Rate of readmission after discharge from hospital (hospital-wide) 30% 9.08 14.6 10.83 11.58 0 0 0
Staff responsiveness - Star Rating 30% 92.9 65 71.23 71.70 0 0 0
ED Left Without Being Seen 30% 1.46 1.02 59.64 53.09 0 0 0
Doctor communication - Star Rating 10% 71.73 73.81 1.68 0.88 0 0 0
Catholic Health Denise Hull
All Cause Rate of readmission after discharge from hospital (hospital-wide) 15% 10.08 14.6 10.58 9.97 0 0 0
Notification of Inpatient Admission 7.5% 74.86 56.2 3.72 2.95 0 0 0
Receipt of Discharge Information 7.5% 55.77 46.72 79.00 79.46 0 0 0
Perioperative pulmonary embolism or deep vein thrombosis rate 30.00 3.96 3.86 79.47 79.96 0 0 0
Doctor communication - Star Rating 30% 75.08 76.13 65.31 0 0 0 0
Nurse communication - Star Rating 10% 77.08 77.54 88.64 0 0 0 0
Orleans Community Health - Medina Memorial Hospital Denise Hull
Roswell Park Comprehensive Cancer Center
Arnot Ogden Medical Center
All Cause Rate of readmission after discharge from hospital (hospital-wide) 30% 11.29 14.6 8.26 0 0 0 0
Severe Sepsis 3-Hour Bundle 30% 79.42 82.84 73.56 78.36 0 0 0
Severe Sepsis 6-Hour Bundle 30% 77.6 84.04 82.93 86.57 0 0 0
Medication Reconciliation Conducted 5% 97.24 84.67 96.77 98.58 0 0 0
Receipt of Discharge Information 5% 98.47 46.72 98.50 98.58 0 0 0
Guthrie Corning Hospital Laurie Foster
All Cause Rate of readmission after discharge from hospital (hospital-wide) 30% 10.74 14.6 12.72 11.52 0 0 0
Discharge information - Star Rating 30% 86.94 86 2.02 1.58 0 0 0
ED Left Without Being Seen 30% 3.3 2.31 85.64 88.73 0 0 0
Communication about medicines - Star Rating 10% 53.86 55.85 61.39 52.58 0 0 0
Schuyler Hospital
Notification of Inpatient Admission 25% 63.06 56.2 51.46 62.29 0 0 0
Receipt of Discharge Information 25% 69.32 46.72 63.39 64.02 0 0 0
Quietness - Star Rating 20% 45.16 50.13 0.26 0.20 0 0 0
ED Left Without Being Seen 30% 0.39 0.27 56.52 30.43 0 0 0
St. James Hospital
Notification of Inpatient Admission 50% 96.13 56.2 93.60 95.48 0 0 0
Receipt of Discharge Information 50% 95.64 46.72 98.93 97.61 0 0 0
Guthrie Lourdes Hospital Laurie Foster
All Cause Rate of readmission after discharge from hospital (hospital-wide) 30% 14.32 14.6 11.96 11.62 0 0 0
ED Left Without Being Seen 30% 2.5 1.75 82.46 82.89 0 0 0
Discharge information - Star Rating 30% 85.54 85.8 2.90 0.63 0 0 0
Communication about medicines - Star Rating 10% 55.26 56.86 50.88 53.64 0 0 0
United Health Services Hospitals
Receipt of Discharge Information 7.5% 43.03 44.02 2.02 0 0 0 0
Notification of Inpatient Admission 7.5% 64.17 56.2 77.88 79.54 0 0 0
All Cause Rate of readmission after discharge from hospital (hospital-wide) 15% 13.39 14.6 14.85 14.45 0 0 0
Pressure Ulcer Rate 0.00 2.48 1.73 64.78 63.29 0 0 0
Nurse communication - Star Rating 30% 75.14 76.19 48.30 50.84 0 0 0
Postnatal Care 30% 83.05 86.61 69.65 72.21 0 0 0
Recommend hospital - Star Rating 10% 58.34 61.32 89.65 81.62 0 0 0