Disclaimer:

• One measure is not an indication of a facility's quality. Sometimes a smaller population can make a measure move pretty drastically from quarter to quarter, so don't be alarmed if you see a dip or a spike.
• If there is no data included with the description of the measures below, it may be because your facility doesn't offer that particular service or treatment.
• Some data is reported every month or quarter and some is reported once a year. Occasionally, a measure is no longer used. But we continue to provide the data from past years as a reference.
• The dates we report data may vary by measure. Measuring quality, safety, access and patient experience requires time to ensure data is valid and accurate.
• We report the same Healthcare Effectiveness Data and Information Set ( Click to closeHEDISThe Healthcare Effectiveness Data and Information Set (HEDIS®) is a registered trademark of the National Committee for Quality Assurance (NCQA).HEDIS) used by many civilian health care practices to monitor quality of care provided in the MHS. Before posting HEDIS data, a National Committee for Quality Assurance (NCQA) certified auditor reviews and approves the measure process and data.
• We report some of the measures in Calendar Year (CY) and some measures in Fiscal Year (FY). Calendar years begin on January 1st. Fiscal years begin on October 1st.
• If you have questions, please contact the Patient Administration office at your military medical treatment facility or a beneficiary counseling and assistance coordinator

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Patient Safety

There are many factors the Military Health System tracks related to Patient Safety. Additional measures will be added here as they are made available.

• Joint Patient Safety Reporting

  You expect us to keep you safe when you’re in one of our hospitals or clinics. One way we do that is by reporting and reviewing Patient Safety Events. That way, we can identify and fix potentially unsafe conditions in our hospitals and clinics. Patient Safety Events are any avoidable event that could result in harm to a patient. This includes what we call "near miss" or “close call” events. These are events that never reaches the patient, but could have resulted in harm under different circumstances. All facilities in the MHS Click to closeDirect CareDirect care refers to military hospitals and clinics, also known as “military treatment facilities” and “MTFs.”Direct Care system voluntarily report their patient safety events to the MHS Patient Safety Program. Unlike most other health systems, we also report events in our dental program. This is because the MHS integrates dental into its medical system. More reporting doesn’t necessarily mean that a facility is less safe. It actually provides MHS with data to learn from and make improvements. Joint Patient Safety Reporting (JPSR) data are updated in April for the previous calendar year.

  Table: Joint Patient Safety Reporting

  Comparison to Benchmark

  2015	2016	2017	2018	2019	2020	2021	2022	2023	2024
  Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closeNDND = No data availableND	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closeNDND = No data availableND	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**

• Sentinel Events

  We encourage our medical staffs to report all types of patient safety events – injuries, illnesses, and especially deaths. Sentinel Events are those that result in harm or death to a patient. They require immediate reporting, response, and investigation. This measure is a facility specific one that shows you what sentinel events occurred in individual hospitals or clinics. Your military hospital or clinic may not be on this list. Some don’t provide services that can result in a Sentinel Event. Others may not have enough data to report in a way that protects patient privacy. Data are updated in April of each year and cover the previous calendar year.

  Table: Sentinel Events

  Comparison to Benchmark

  2014	2015	2016	2017	2018	2019	2020	2021	2022	2023	2024
  Click to closeNDND = No data availableND	Click to closeNDND = No data availableND	Click to closeNDND = No data availableND	Click to closeNDND = No data availableND	Click to closeNDND = No data availableND	Click to closeNDND = No data availableND	Click to closeNDND = No data availableND	Click to closeNDND = No data availableND	Click to closeNDND = No data availableND	Click to closeNDND = No data availableND	Click to closeNDND = No data availableND

Quality of Care

There are many factors the Military Health System tracks related to Quality of Care. For your convenience we have categorized these in the below sections:

• Treatment of Common Cold

  The common cold or upper respiratory infection (URI) is a common reason individuals visit their provider. Most of these infections are viral and an antibiotic won’t help. There’s a national effort to reduce overuse of antibiotics. Overuse is contributing to an increase in organisms that are resistant to popular antibiotics.

  What we measure

  We measure the number of visits of enrollees with an upper respiratory infection for 3 months of age and older who were diagnosed with upper URI who weren't given an antibiotic prescription. A higher number is better. Talk to your provider about when antibiotics are appropriate to help prevent a global threat from antibiotic resistant organisms.

  This is one of the measures from the Core Quality Measures Collaborative.  Additional information can be found at: https://p4qm.org/CQMC.

  Graph: No Data

  Table: Treatment of Common Cold

  Percentage of Beneficiaries Diagnosed with an Upper Respiratory Infection and Were Not Given a Prescription

  2022-Mar	2022-Apr	2022-May	2022-Jun	2022-Jul	2022-Aug	2022-Sep	2022-Oct	2022-Nov	2022-Dec	2023-Jan	2023-Feb	2023-Mar	2024-Feb	2024-Mar	2024-Apr	2024-May	2024-Jun	2024-Jul	2024-Aug	2024-Sep	2024-Oct	2024-Nov	2024-Dec	2025-Jan	Benchmark
  Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	Click to closePDPD = Proprietary dataPD