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1 Percentage Summary Report Page 1 of 5 Data As Of: 07/27/2016 Total Performance Facility State National Unweighted Domain Weighting Weighted Domain Clinical Care Process Subdomain % Clinical Care Outcomes Subdomain % Patient and Caregiver Centered Experience of Care/Care Coordination Domain % Safety Domain % Efficiency and Cost Reduction Domain % Value-Based Percentage Payment Summary - Fiscal Year 2017 Base Operating DRG Payment Reduction Value-Based Incentive Payment Percentages Net change in Base Operating DRG Payment Value-Based Incentive Payment Adjustment Factor Exchange Function Slope % % % Reference the Hospital Value-Based Purchasing page on QualityNet for report information, calculations, and Hospital VBP resources.
2 Clinical Care Detail Report Page 2 of 5 Process s Numerator Denominator Acute Myocardial Infarction AMI-7a Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival Perinatal Care PC-01 Elective Delivery Prior to 39 Completed Weeks HBVP Metrics Baseline Numerator Denominator Performance s points 0 cases 0 cases - 0 cases 0 cases Gestation Preventative IMM-2 Influenza Immunization Baseline Period: 10/01/ /30/2012 Performance Period: 10/01/ /30/2015 Condition/ Procedure Outcomes s Eligible Discharges Baseline Period Rate Eligible Discharges Performance 30-Day Risk-Standardized Mortality s Acute Myocardial Infarction (AMI) 30-Day Mortality Rate Heart Failure (HF) 30-Day Mortality Rate Pneumonia (PN) 30-Day Mortality Rate Eligible Clinical Care Process s: 2 out of 3 Unweighted Clinical Care Process s Subdomain : Weighted Clinical Care Process s Subdomain : Eligible Clinical Care Outcomes s: 2 out of 3 Unweighted Clinical Care Outcomes s Subdomain : Weighted Clinical Care Outcomes s Subdomain : * A dash (-) indicates that the minimum requirements were not met for calculation. * "0 cases" indicates that no cases met the criteria for inclusion in the measure calculation.
3 Patient and Caregiver Centered Experience of Care/Care Coordination Detail Report Page 3 of 5 HCAHPS Dimensions Baseline Performance Period Rate Floor Dimension Communication with Nurses 85.56% 83.68% 58.14% 78.19% 86.61% Communication with Doctors 82.41% 92.29% 63.58% 80.51% 88.80% Responsiveness of Hospital Staff 75.46% 76.91% 37.29% 65.05% 80.01% Pain Management 77.92% 79.62% 49.53% 70.28% 78.33% Communication about Medicines 66.63% 71.27% 41.42% 62.88% 73.36% Cleanliness and Quietness of Hospital Environment 79.66% 81.40% 44.32% 65.30% 79.39% Discharge Information % 85.80% 64.09% 85.91% 91.23% Overall Rating of Hospital 68.96% 75.59% 35.99% 70.02% 84.60% HCAHPS Base : 59 HCAHPS Consistency : 19 Unweighted Patient and Caregiver Centered Experience of Care/Care Coordination Domain : Weighted Patient and Caregiver Centered Experience of Care/Care Coordination Domain : HCAHPS Surveys Completed during the Performance period: The Discharge Information HCAHPS Dimension in bold italic font was used to calculate the HCAHPS Consistency.
4 Safety s Detail Report Page 4 of 5 Baseline Period: 10/01/ /30/2012 Performance Period: 10/01/ /30/2015 AHRQ Composite s Index Value Index Value Complication/patient safety for selected indicators (composite) Healthcare Associated Observed Predicted Standardized Ratio (SIR) Observed Predicted Standardized Ratio (SIR) Catheter-Associated Urinary Tract Infection Central Line-Associated Blood Stream Infection Clostridium difficile Infection Methicillin-Resistant Staphylococcus aureus Bacteremia Surgical Site Infection (SSI) N/A N/A - N/A N/A - N/A N/A N/A N/A - SSI-Abdominal Hysterectomy SSI-Colon Surgery Eligible Safety s: 3 out of 6 Unweighted Safety Domain : Weighted Safety Domain : * "N/A" indicates no data were available or submitted for this measure. * A dash (-) indicates that the minimum requirements were not met for calculation.
5 Efficiency and Cost Reduction Detail Report Page 5 of 5 Efficiency s Median Median Medicare Spending per Beneficiary () $19, $19, $22, $20, Eligible Efficiency and Cost Reduction : 1 out of 1 Unweighted Efficiency and Cost Reduction Domain : Weighted Efficiency and Cost Reduction Domain : # of Episodes: 351
Value-based incentive payment percentage 3
Report Run Date: 07/12/2013 Hospital Value-Based Purchasing Value-Based Percentage Payment Summary Report Page 1 of 5 Percentage Summary Report Data as of 1 : 07/08/2013 Total Score Facility State National
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