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 (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 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
  29	20	23	26	42	18	10	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
  Click to closeNDND = No data availableND	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 closeNDND = No data availableND	Click to closeNDND = No data availableND	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 closeNDND = No data availableND	Click to closeNDND = No data availableND

Patient Satisfaction / Access

There are many factors the Military Health System tracks related to Patient Satisfaction and Access. For your convenience we have categorized these in the below sections:

• Provider Communication

  It is important that providers communicate clearly and effectively with patients, their families, and caregivers. We want to ensure everyone understands and can use the information we provide to make healthy choices and good decisions about their healthcare. When provider-patient communication is effective, adherence to treatment recommendations increases, better health outcomes are achieved, and the patients and their families’ satisfaction with health care improves.

  What we measure

  Patients reported how well their provider explained things clearly, listened, showed respect, and whether they spent enough time with them. Please complete and return any surveys you receive to us. We want to know what you think and to learn what we are doing well and how we can improve.

  This measure is reported quarterly. If the data appears to be a little delayed, please remember, it takes time to make sure the information is statistically valid in order to make improvements in our system that will benefit our patients.

  Graph: Provider Communication

  Percentage of TROSS and JOES survey respondents selecting the top rating on select questions related to quality of care

  Table: Provider Communication

  Percentage of TROSS and JOES survey respondents selecting the top rating on select questions related to quality of care

  2014-Q2	2014-Q3	2014-Q4	2015-Q1	2015-Q2	2015-Q3	2016-Q4	Benchmark
  71%	100%	95%	100%	69%	67%	0%	86%

• Satisfaction With Getting Needed Care

  Seeing your provider when you need to is important to you – and to us. We want to ensure that you get the care you need when you need it. This measure lets us know if you think we responded appropriately to your appointment request.

  What we measure

  We send out surveys to a sample of our patients after their health care appointments. We measure your satisfaction and study trends by each hospital or clinic, by markets, by regions, by Service, and for the entire system. This helps us see where and how we can do better. Please complete and return any surveys you receive to us. We want to know what you think and how we can improve. Take advantage of all of the opportunities to get care you need: the 24/7 Nurse Advice Line, secure email with your provider, or same-day appointments. We aim to ensure you get the care you need when you need it.

  Graph: Satisfaction With Getting Needed Care

  Percentage of Beneficiaries' Rating "Able to See Provider When Needed (Agree/Strongly Agree)"

  Table: Satisfaction With Getting Needed Care

  Percentage of Beneficiaries' Rating "Able to See Provider When Needed (Agree/Strongly Agree)"

  2016-Nov
  100%

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:

• Low Back Pain Imaging

  Evidence shows that many patients diagnosed with low back pain receive excessive medical tests that can lead to unnecessary worry and unneeded surgery. For the majority of individuals who experience severe low back pain, pain improves after two weeks. Avoiding imaging tests like x-ray, MRI, and CT scans can prevent harm to patients and reduce health care costs. Data shown for this HEDIS measure is the most recently approved by NCQA.

  What we measure

  We measure the percentage of adults age 18 to 50 years with a primary diagnosis of low back pain who didn’t have an imaging test (e.g., plain X-ray, MRI or CT scan) within 28 days of the diagnosis. A higher score means a better performance. Talk with your provider about alternatives to unnecessary medical tests for low back pain, and discuss alternatives to surgery for addressing your pain.

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

  Graph: No Data

  Table: Low Back Pain Imaging

  Percentage of Patients 18 - 50 Years Old Who Did Not Have an Imaging Test Within 28 Days of a Primary Diagnosis of Low Back Pain

  2021-Apr	2021-May	2021-Jun	2021-Jul	2021-Aug	2021-Sep	2021-Oct	2021-Nov	Average for health plans nationwide (HEDIS 50th Percentile)
  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