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

Download Spreadsheet of Metrics  Download Archived Measure Metrics  New MTF Search

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 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 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

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:

• Primary Care Manager Continuity

  When your provider team is familiar with your medical history, it's good for you, especially if you have more complex medical issues. Our Patient Centered Medical Homes (PCMHs) help you see the same provider team. Your PCMH team aims to keep you healthy by suggesting preventive services that may prevent more complex problems later. We track this measure to find out how often you are seen by your assigned primary care manager (PCM).

  What we measure

  We measure the percent of appointments where the patient saw their own provider. We use our electronic health record to monitor which provider you see. We understand that there may be times when you want to be seen quickly – and don’t need to see your PCM, but we want to make sure you're seen by your primary medical team when you want. Ask for your provider by name. If we can’t get you an appointment with your provider, we'll try to get you seen by a provider on the same team. They know your medical needs and history. And, if you aren’t concerned about continuity of provider in some circumstances, let us know that, too.

  Graph: Primary Care Manager Continuity

  Percentage of Time a Provider Treats His/Her Assigned Patients

  Table: Primary Care Manager Continuity

  Percentage of Time a Provider Treats His/Her Assigned Patients

  2024-Jun	2024-Jul	2024-Aug	2024-Sep	2024-Oct	2024-Nov	2024-Dec	2025-Jan	2025-Feb	2025-Mar	2025-Apr	2025-May	2025-Jun	2025-Jul	2025-Aug	2025-Sep	Goal
  0%	0%	0%	0%	0%	0%	0%	0%	0%	0%	0%	0%	0%	0%	0%	0%	65%

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 Click to closeHEDISThe Healthcare Effectiveness Data and Information Set (HEDIS®) is a registered trademark of the National Committee for Quality Assurance (NCQA).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: https://p4qm.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

  2024-May	2024-Jun	2024-Jul	2024-Aug	2024-Sep	2024-Oct	2024-Nov	2024-Dec	2025-Jan	2025-Feb	2025-Mar	2025-May	2025-Jun	2025-Jul	2025-Aug	2025-Sep	2025-Oct	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 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

• 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

  2024-Apr	2024-May	2024-Jun	2024-Jul	2024-Aug	2024-Sep	2024-Oct	2024-Nov	2024-Dec	2025-Jan	2025-Feb	2025-Mar	2025-Apr	2025-May	2025-Jun	2025-Jul	2025-Aug	2025-Sep	2025-Oct	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 closePDPD = Proprietary dataPD