559th Medical Group at Joint Base San Antonio-Lackland, Texas

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

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.

• Catheter Associated Urinary Tract Infections (CAUTI)

  A catheter is a drainage tube that is inserted into a patient’s urinary bladder through the urethra. It is left in place to collect urine while a patient is immobile or incontinent. Catheters can become a way for germs to enter the body and cause infections in the urinary tract. These infections are called catheter-associated urinary tract infections (CAUTIs). They can cause additional illness. Catheters are used when medically necessary as determined by your provider. They are removed as soon as they are no longer needed.

  What we measure

  We track the number of infections developed by patients in the hospital due to CAUTIs. We look at the number of infections compared to the number of expected infections based on the number of patients who had catheters during the time frame being measured.

  You and your family should ask about our processes for preventing infections. You’re encouraged to be proactive with your care team and ask for catheters to be removed at the earliest possible time that it can be safely removed. For more information please visit the Center for Disease Control website at https://www.cdc.gov/hai/ca_uti/cauti_faqs.html.

  CAUTI data is updated twice a year in April and October.

  Table: Catheter Associated Urinary Tract Infections (CAUTI)

  Comparison to Benchmark

  CY2016 Q1-Q2	CY2016 Q3-Q4	CY2017 Q1-Q2	CY2017 Q3-Q4	CY2018 Q1-Q2	CY2018 Q3-Q4	CY2019 Q1-Q2	CY2019 Q3-Q4	CY2020 Q1-Q2	CY2020 Q3-Q4
  NDND = No data availableND	NDND = No data availableND	NDND = No data availableND	NDND = No data availableND	NDND = No data availableND	NDND = No data availableND	NDND = No data availableND	NDND = No data availableND	NDND = No data availableND	NDND = No data availableND

• Central Line Associated Blood Stream Infections (CLABSI)

  A central line is a narrow tube inserted by a doctor into a large vein of a patient’s neck or chest. This is so the patient can receive fluids or medication, or so that blood can be collected for medical tests. Central lines can become a way for germs to enter the body and cause infections in the blood. These infections are called central line-associated bloodstream infections (CLABSIs). Central lines are used when medically necessary as determined by your provider. They are removed as soon as they are no longer needed.

  What we measure

  We track the number of infections developed by patients in the hospital because of central-line devices. We look at the number of infections compared to the number of expected infections based on the number of patients who had central lines during the time frame being measured. For more information please visit the Center for Disease Control website at https://www.cdc.gov/hai/bsi/clabsi-resources.html.

  You and your family should ask about our processes for preventing infections. You are encouraged to be proactive with your care team and ask for the central lines to be removed at the earliest possible time that it can be safely removed.

  CLABSI data is updated twice a year in April and October.

  Table: Central Line Associated Blood Stream Infections (CLABSI)

  Comparison to Benchmark

  CY2016 Q1-Q2	CY2016 Q3-Q4	CY2017 Q1-Q2	CY2017 Q3-Q4	CY2018 Q1-Q2	CY2018 Q3-Q4	CY2019 Q1-Q2	CY2019 Q3-Q4	CY2020 Q1-Q2	CY2020 Q3-Q4
  NDND = No data availableND	NDND = No data availableND	NDND = No data availableND	NDND = No data availableND	NDND = No data availableND	NDND = No data availableND	NDND = No data availableND	NDND = No data availableND	NDND = No data availableND	NDND = No data availableND

• 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.

  Download JPSR Report Data

  Table: Joint Patient Safety Reporting

  Comparison to Benchmark

  CY2014	CY2015	CY2016	CY2017	CY2018	CY2019	CY2020
  13	27	78	56	91	69	76

• 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

  CY2014	CY2015	CY2016	CY2017	CY2018	CY2019	CY2020
  NDND = No data availableND	NDND = No data availableND	NDND = No data availableND	NDND = No data availableND	NDND = No data availableND	NDND = No data availableND	NDND = 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

  2021-Dec	Goal
  0%**** = Low number of cases, percentages may vary greatly0%**	65%

• 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)"

  FY2018 Q1	FY2018 Q2	FY2018 Q3	FY2018 Q4	FY2019 Q3	FY2019 Q4	FY2020 Q1	FY2020 Q2	FY2020 Q3	FY2020 Q4	FY2021 Q1	FY2021 Q2	FY2021 Q3	FY2021 Q4
  88.33%	83.33%	75.97%	74.22%	76.26%	57.95%	56.09%	66.09%	72.8%	88%	63.76%	70.16%	68.57%	59.85%

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:

• Accreditation Status
  • We require our clinics and hospitals to undergo on-site surveys by nationally-recognized accreditation organizations every three years. 
  • We track accreditation status for all of our hospitals and clinics, along with when their last survey was completed.

  Table: Accreditation Status

  Accredidation Status

  Accredited
  2017-Jul