Percentage Summary Report Page 1 of 5 Data As Of: 07/27/2016 Total Performance Facility State National 35.250000000000 37.325750561167 35.561361414483 Unweighted Domain Weighting Weighted Domain Clinical Care Process Subdomain 5.000000000000 5% 0.250000000000 Clinical Care Outcomes Subdomain 30.000000000000 25% 7.500000000000 Patient and Caregiver Centered Experience of Care/Care Coordination Domain 78.000000000000 25% 19.500000000000 Safety Domain 40.000000000000 20% 8.000000000000 Efficiency and Cost Reduction Domain 0.000000000000 25% 0.000000000000 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 2.0000000000% 2.1654019881% +0.1654019881% 1.0016540199 3.0714921816 Reference the Hospital Value-Based Purchasing page on QualityNet for report information, calculations, and Hospital VBP resources.
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 - 0.954545 1.000000 - - - - 0 20 0.000000 1 32 0.031250 0.031250 0.000000 0 1 1 1 Gestation Preventative IMM-2 Influenza Immunization 222 248 0.895161 212 242 0.876033 0.951607 0.997739 0 0 0 0 Baseline Period: 10/01/2010-06/30/2012 Performance Period: 10/01/2013-06/30/2015 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 10 0.843309 3 0.860799 0.851458 0.871669 - - - Heart Failure (HF) 30-Day Mortality Rate 112 0.849916 73 0.866524 0.881794 0.903985 3 0 3 Pneumonia (PN) 30-Day Mortality Rate 102 0.872141 53 0.883094 0.882986 0.908124 3 1 3 Eligible Clinical Care Process s: 2 out of 3 Unweighted Clinical Care Process s Subdomain : 5.000000000000 Weighted Clinical Care Process s Subdomain : 0.250000000000 Eligible Clinical Care Outcomes s: 2 out of 3 Unweighted Clinical Care Outcomes s Subdomain : 30.000000000000 Weighted Clinical Care Outcomes s Subdomain : 7.500000000000 * 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.
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% 0 6 6 Communication with Doctors 82.41% 92.29% 63.58% 80.51% 88.80% 9 10 10 Responsiveness of Hospital Staff 75.46% 76.91% 37.29% 65.05% 80.01% 3 8 8 Pain Management 77.92% 79.62% 49.53% 70.28% 78.33% 9 10 10 Communication about Medicines 66.63% 71.27% 41.42% 62.88% 73.36% 6 8 8 Cleanliness and Quietness of Hospital Environment 79.66% 81.40% 44.32% 65.30% 79.39% 9 10 10 Discharge Information 1 82.62% 85.80% 64.09% 85.91% 91.23% 3 0 3 Overall Rating of Hospital 68.96% 75.59% 35.99% 70.02% 84.60% 4 4 4 HCAHPS Base : 59 HCAHPS Consistency : 19 Unweighted Patient and Caregiver Centered Experience of Care/Care Coordination Domain : 78.000000000000 Weighted Patient and Caregiver Centered Experience of Care/Care Coordination Domain : 19.500000000000 HCAHPS Surveys Completed during the Performance period: 129 1 The Discharge Information HCAHPS Dimension in bold italic font was used to calculate the HCAHPS Consistency.
Safety s Detail Report Page 4 of 5 Baseline Period: 10/01/2010-06/30/2012 Performance Period: 10/01/2013-06/30/2015 AHRQ Composite s Index Value Index Value Complication/patient safety for selected indicators (composite) Healthcare Associated Observed 0.615685 0.614686 0.777936 0.547889 0 7 7 Predicted Standardized Ratio (SIR) Observed Predicted Standardized Ratio (SIR) Catheter-Associated Urinary Tract Infection 2 1.226 1.631 1 1.506 0.664 0.845 0.000 5 2 5 Central Line-Associated Blood Stream Infection 0 0.506-1 0.909-0.457 0.000 - - - Clostridium difficile Infection 2 4.390 0.456 2 2.247 0.890 0.750 0.000 0 0 0 Methicillin-Resistant Staphylococcus aureus Bacteremia 0 0.685-0 0.271-0.799 0.000 - - - Surgical Site Infection (SSI) N/A N/A - N/A N/A - N/A N/A N/A N/A - SSI-Abdominal Hysterectomy 0 0.199-0 0.096-0.698 0.000 - - - SSI-Colon Surgery 0 0.384-0 0.202-0.751 0.000 - - - Eligible Safety s: 3 out of 6 Unweighted Safety Domain : 40.000000000000 Weighted Safety Domain : 8.000000000000 * "N/A" indicates no data were available or submitted for this measure. * A dash (-) indicates that the minimum requirements were not met for calculation.
Efficiency and Cost Reduction Detail Report Page 5 of 5 Efficiency s Median Median Medicare Spending per Beneficiary () $19,739.77 $19,473.51 1.013673 $22,431.83 $20,473.32 1.095661 0.987666 0.829199 0 0 0 Eligible Efficiency and Cost Reduction : 1 out of 1 Unweighted Efficiency and Cost Reduction Domain : 0.000000000000 Weighted Efficiency and Cost Reduction Domain : 0.000000000000 # of Episodes: 351