35th Medical Group - Misawa AFB Medical Facility

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	CY2021 Q1-Q2
  0	0	0	0	0	0	0	0	0	0	0

• 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	CY2021 Q1-Q2
  0	0	0	0	0	0	0	0	0	0	0

• 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	CY2021
  223	773	539	408	354	415	460	3020

• 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	CY2021
  PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	NDND = No data availableND	NDND = No data availableND	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	NDND = No data availableND	NDND = No data availableND	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	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:

• Access to Acute Care Appointments

  Seeing your provider in a timely manner is important to you—and to us. Our goal is for you get the right level of care, at the right time, by the right provider.

  What we measure

  We measure the average number of days it takes to be seen for an acute medical condition. If the military hospital or clinic can't get you an appointment with your primary care manager within the access standards (within 24 hours - 1 day), they will get you an appointment with another provider. We monitor this metric on a monthly basis and make more appointments available when the measure shows we need to.

  Graph: Access to Acute Care Appointments

  Average Days Until Third Next Available Appointment Within 24 Hours

  Table: Access to Acute Care Appointments

  Average Days Until Third Next Available Appointment Within 24 Hours

  2019-Dec	2019-Aug	2019-Sept	2019-Oct	2019-Nov	2020-Dec	2020-Jan	2020-Feb	2020-Mar	2020-Apr	2020-May	2020-Jun	2020-Jul	2020-Aug	2020-Sep	2020-Oct	2020-Nov	2021-Dec	2021-Jan	2021-Feb	2021-Mar	2021-Apr	2021-May	2021-Jun	2021-Jul	2021-Aug	2021-Sep	2021-Oct	2021-Nov	2022-Dec	2022-Jan	2022-Feb	Goal
  1.07	1.7	0.82	1	3.95	1.91	1.29	1.81	4.27	0.6	0.97	0.64	0.99	1.7	1.04	0.93	1.91	0.78	0.88	0.84	1.79	2.96	1.62	1.89	2.97	6.91	2.56	2.17	2.89	11.48	4.29	2.92	1

• Access to Routine Appointments

  Seeing your provider in a timely manner is important to you—and to us. Our goal is for you get the right level of care, at the right time, by the right provider.

  What we measure

  We measure the average number of days it takes to be seen for routine appointment. If the military hospital or clinic can't get you an appointment with your primary care manager within the access standards (within 7 days), they will get you an appointment with another provider. We monitor this metric on a monthly basis and make more appointments available when the measure shows we need to.

  Graph: Access to Care Routine

  Average Days Until Third Next Available Appointment For Routine or Follow-up Care

  Table: Access to Routine Appointments

  Average Days Until Third Next Available Appointment For Routine or Follow-up Care

  2019-Dec	2019-Aug	2019-Sept	2019-Oct	2019-Nov	2020-Dec	2020-Jan	2020-Feb	2020-Mar	2020-Apr	2020-May	2020-Jun	2020-Jul	2020-Aug	2020-Sep	2020-Oct	2020-Nov	2021-Dec	2021-Jan	2021-Feb	2021-Mar	2021-Apr	2021-May	2021-Jun	2021-Jul	2021-Aug	2021-Sep	2021-Oct	2021-Nov	2022-Dec	2022-Jan	2022-Feb	Goal
  8.98	6.63	4.68	6.87	11.51	9.86	7.68	6.89	7.76	1.36	1.33	2.19	5.79	8.16	4.86	2.68	9.86	4.5	3.9	4.52	9.84	11.27	7.48	9.76	12.74	8.92	11	8.8	8.34	8.99	10.43	11.37	7

• Care Transition

  "During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left."
  "When I left the hospital, I had a good understanding of the things I was responsible for in managing my health."
  "When I left the hospital, I clearly understood the purpose for taking each of my medications."

  (4-point scale: 1-Never, 2-Sometimes, 3-Usually, 4-Always. Percent satisfied is a cumulative 11 points or higher out of a total of 12 points.)

  Patients reported whether they and/or their caregivers understood the type of care the patient would need once the patient left the hospital. Patients reported whether:

  • Hospital staff considered their health care options and wishes when deciding what kind of care they would need after leaving the hospital;
  • They and/or their caregivers understood what they would have to do to take care of themselves after leaving the hospital; and
  • They knew what medications they would be taking and why they would be taking them after leaving the hospital.

  Table: Care Transition

  Percentage of Patients Who Reported They Understood The Care They Would Need When They Left The Hospital

  FY2016 Q3	FY2016 Q4	FY2017 Q1	FY2017 Q2	Benchmark
  PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	52%

• Cleanliness of Hospital Environment

  "During this hospital stay, how often were your room and bathroom kept clean?"

  (4-point scale: 1-Never, 2-Sometimes, 3-Usually, 4-Always. Percent satisfied is "Always".)

  Patients reported how often their hospital room and bathroom were kept clean.

  Table: Cleanliness of Hospital Environment

  Percentage of Patients Who Reported Their Hospital Room and Bathroom Was Always Clean

  FY2016 Q3	FY2016 Q4	FY2017 Q1	FY2017 Q2	Benchmark
  PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	74%

• Communication about Medicines

  "Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?
  "Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?"

  (4-point scale: 1-Never, 2-Sometimes, 3-Usually, 4-Always. Percent satisfied is a cumulative 7 points or higher out of a total of 8 points.)

  If patients were given medicine that they had not taken before, the survey asked how often staff explained about the medicine. “Explained” means that hospital staff told what the medicine was for and what side effects it might have before they gave it to the patient.

  Table: Communication about Medicines

  Percentage of Patients Who Reported that Hospital Staff Explained The Purpose and Side Effects of Medicine Before They Received It

  FY2016 Q3	FY2016 Q4	FY2017 Q1	FY2017 Q2	Benchmark
  PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	64%

• Communication with Doctors

  "During this hospital stay, how often did doctors treat you with courtesy and respect?"
  "During this hospital stay, how often did doctors listen carefully to you?"
  "During this hospital stay, how often did doctors explain things in a way you could understand?"

  (4-point scale: 1-Never, 2-Sometimes, 3-Usually, 4-Always. Percent satisfied is a cumulative 11 points or higher out of a total of 12 points.)

  Patients reported how often their doctors communicated well with them during their hospital stay. “Communicated well” means doctors explained things clearly, listened carefully to the patient, and treated the patient with courtesy and respect.

  Table: Communication with Doctors

  Percentage of Patients who Were Satisfied with their Communication with Doctors

  FY2016 Q3	FY2016 Q4	FY2017 Q1	FY2017 Q2	Benchmark
  PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	81%

• Communication with Nurses

  "During this hospital stay, how often did nurses treat you with courtesy and respect?"
  "During this hospital stay, how often did nurses listen carefully to you?"
  "During this hospital stay, how often did nurses explain things in a way that you could understand?"

  (4-point scale: 1-Never, 2-Sometimes, 3-Usually, 4-Always. Percent satisfied is a cumulative 11 or higher out of a total of 12 points.)

  Patients reported how often their nurses communicated well with them during their hospital stay. “Communicated well” means nurses explained things clearly, listened carefully to the patient, and treated the patient with courtesy and respect.

  Table: Communication with Nurses

  Percentage of Patients Who Were Satisfied With Their Communication with Nurses

  FY2016 Q3	FY2016 Q4	FY2017 Q1	FY2017 Q2	Benchmark
  PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	80%

• Discharge Information

  "During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?"
  "During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?"

  (2-point scale: 1-No, 2-Yes. Percent Satisfied is a cumulative score of 4 out of a total of 4 points.)

  The survey asked patients about information they were given when they were ready to leave the hospital. Patients reported whether hospital staff had discussed the help they would need at home. Patients also reported whether they were given written information about symptoms or health problems to watch for during their recovery.

  Table: Discharge Information

  Percentage of Patients Who Were Provided With Discharge Information

  FY2016 Q3	FY2016 Q4	FY2017 Q1	FY2017 Q2	Benchmark
  PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	87%

• Health Care Survey of DoD Beneficiaries

  The Health Care Survey of DoD Beneficiaries (HCSDB) surveys about 250,000 TRICARE beneficiaries annually and provides a comprehensive look at their opinions about a wide range of health care issues such as access to care, preventive services and their satisfaction with their doctors, health plan, coverage and the health care staff's communication and customer service efforts.

  View Survey Results Download Survey Reports

• Overall Hospital Rating

  "Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?"

  (11-point scale: 0-Worst Hospital Possible to 10-Best Hospital Possible. Percent satisfied is 9 or 10.)

  The overall rating summarizes up to 57 quality measures reflecting common conditions that hospitals treat, such as heart attacks or pneumonia. Hospitals may perform more complex services or procedures not reflected in the measures on Hospital Compare. The overall rating shows how well each hospital performed, on average, compared to other hospitals in the U.S.

  • The overall rating ranges from one to five stars. 
  • The more stars, the better a hospital performed on the available quality measures. 
  • The most common overall rating is 3 stars.

  Table: Overall Hospital Rating

  Percentage of Patients Who Rated the Hospital with a 9 or 10 out of 10

  FY2016 Q3	FY2016 Q4	FY2017 Q1	FY2017 Q2	Benchmark
  PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	72%

• 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

  2019-Apr	2019-May	2019-Jun	2019-Jul	2019-Aug	2019-Sept	2019-Oct	2019-Nov	2019-Dec	2020-Jan	2020-Feb	2020-Mar	2020-Apr	2020-May	2020-Jun	2020-Jul	2020-Aug	2020-Sep	2020-Oct	2020-Nov	2020-Dec	2021-Jan	2021-Feb	2021-Mar	2021-Apr	2021-May	2021-Jun	2021-Jul	2021-Oct	2021-Dec	2022-Feb	2022-Mar	Goal
  58.8%	60.2%	43.2%	38.5%	39.7%	38.94%	34.79%	30.95%	40.38%	55.06%	62.21%	66.28%	42.69%	36.62%	55%	51.5%	53.6%	51.5%	61.7%	65.1%	66%	73%	69.4%	60%	40.63%	32.17%	63.25%	63.13%	42.25%	43.53%	43.7%	57.09%	65%

• 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

  FY2019 Q1	FY2019 Q2	FY2019 Q3	FY2019 Q4	FY2020 Q1	FY2020 Q2	FY2020 Q3	FY2020 Q4	FY2021 Q1	FY2021 Q2
  88%	77%	90%	77%	89%	77%	66%	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**

• Quietness of Hospital Environment

  "During this hospital stay, how often was the area around your room quiet at night?"

  (4-point scale: 1-Never, 2-Sometimes, 3-Usually, 4-Always. Percent satisfied is "Always".)

  Patients reported how often their hospital room and bathroom were kept clean.

  Table: Quietness of Hospital Environment

  Percentage of Patients Who Reported Their Hospital Room Was Always Quiet

  FY2016 Q3	FY2016 Q4	FY2017 Q1	FY2017 Q2	Benchmark
  PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	62%

• Recommend Hospital

  We value your opinion on your hospital stay. We want to see how we’re doing over time, and how we compare to civilian hospitals.

  What we measure

  We send out the same survey to all of our patients, whether you receive care from a military provider or a civilian provider in the network. This measure shows the results to the question: Would you recommend this hospital to others? Please complete and return any surveys you receive to us. We want to know what you think and how we can improve.

  Graph: Recommend Hospital

  Percentage of Patients Who Would Recommend this MTF to Others

  Table: Recommend Hospital

  Percentage of Patients Who Would Recommend this MTF to Others

  FY2016 Q3	FY2016 Q4	FY2017 Q1	FY2017 Q2	National Civilian Benchmark Average
  48%**** = Low number of cases, percentages may vary greatly48%**	40%**** = Low number of cases, percentages may vary greatly40%**	87.97%	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	71%

• Responsiveness of Hospital Staff

  "During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?"
  "How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?"

  (4-point scale: 1-Never, 2-Sometimes, 3-Usually, 4-Always. Percent satisfied is a cumulative 7 points or higher out of a total of 8 points.)

  Patients reported how often they were helped quickly when they used the call button or needed help in getting to the bathroom or using a bedpan.

  Table: Responsiveness of Hospital Staff

  Percentage of Patients Who Reported They Were Helped Quickly When They Used The Call Button

  FY2016 Q3	FY2016 Q4	FY2017 Q1	FY2017 Q2	Benchmark
  PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	68%

• 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)"

  FY2017 Q1	FY2017 Q2	FY2017 Q3	FY2017 Q4	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	FY2022 Q1
  89.32%	84%	86%	74.93%	93.72%	82.35%	86.09%	84%	87.62%	78.71%	86.24%	87.27%	77.5%	83%	93.71%	85.87%	93.86%	67.44%	79.91%

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
  2018-May

• Alcohol & Other Drug Use Treatment Provided or Offered at Discharge

  We measure the percentage of adult patients (with an alcohol or drug misuse disorder) who were offered a prescription or a referral for addiction treatment. 

  Table: Alcohol & Other Drug Use Treatment Provided or Offered at Discharge

  Percentage of Hospitalized Inpatients

  CY2016 Q1	CY2016 Q2	CY2016 Q3	CY2016 Q4	CY2017 Q1	CY2017 Q2	CY2017 Q3	CY2017 Q4	CY2018 Q1	CY2018 Q2	CY2018 Q3	CY2018 Q4	CY2019 Q1	CY2019 Q2
  PHIPHI = Too few patients to display due to risk of PHI releasePHI	NDND = No data availableND	NDND = No data availableND	PHIPHI = Too few patients to display due to risk of PHI releasePHI	PHIPHI = Too few patients to display due to risk of PHI releasePHI	NDND = No data availableND	PHIPHI = Too few patients to display due to risk of PHI releasePHI	PHIPHI = Too few patients to display due to risk of PHI releasePHI	PHIPHI = Too few patients to display due to risk of PHI releasePHI	PHIPHI = Too few patients to display due to risk of PHI releasePHI	NDND = No data availableND	NDND = No data availableND	NDND = No data availableND	NDND = No data availableND

• Antidepressant Medication Management (Acute)

  The percentage of patients 18 years of age and older who were diagnosed with a new episode of major depression, treated with antidepressant medication, and who remained on an antidepressant medication for at least 84 days (12 weeks).

  Graph: Antidepressant Medication Management Acute

  Percentage of Patients Who Remained on an Antidepressant Medication For At Least 84 days

  Table: Antidepressant Medication Management (Acute)

  Percentage of Patients Who Remained on an Antidepressant Medication For At Least 84 days

  CY2016 Q2	CY2016 Q3	CY2016 Q4	CY2017 Q1	CY2017 Q2	CY2017 Q3	CY2017 Q4	CY2018 Q1	CY2018 Q2	CY2018 Q3	CY2018 Q4	CY2019 Q1	CY2019 Q2	CY2019 Q3	CY2019 Q4	CY2020 Q1	CY2020 Q2	CY2020 Q3	Benchmark
  71.67%	71.7%	71.15%	72.13%	72.92%	71.7%	69.39%	59.26%	65%	66.67%	71.11%	71.7%	78.57%	75.44%	74.19%	66%	66%	66.2%	PDPD = Proprietary dataPD

• Antidepressant Medication Management (Continuation)

  The percentage of members 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression and who remained on an antidepressant medication for at least 180 days (6 months).

  Graph: Antidepressant Medication Management Continuation

  Percentage of Patients Who Remained on an Antidepressant Medication For At Least 180 days

  Table: Antidepressant Medication Management (Continuation)

  Percentage of Patients Who Remained on an Antidepressant Medication For At Least 180 days

  CY2016 Q2	CY2016 Q3	CY2016 Q4	CY2017 Q1	CY2017 Q2	CY2017 Q3	CY2017 Q4	CY2018 Q1	CY2018 Q2	CY2018 Q3	CY2018 Q4	CY2019 Q1	CY2019 Q2	CY2019 Q3	CY2019 Q4	CY2020 Q1	CY2020 Q2	CY2020 Q3	Benchmark
  46.67%	52.83%	59.62%	55.74%	52.08%	49.06%	44.9%	44.44%	49%	50%	42.22%	45.28%	44.64%	36.84%	41.94%	39%	39%	39.44%	PDPD = Proprietary dataPD

• Babies Delivered Electively

  A normal pregnancy is 40 weeks. Research has shown that babies who are 'full term' (39-41 weeks of pregnancy) are less likely to have complications and require Neonatal Intensive Care support.

  What we measure

  This is a measure that is tracked for the Military Health System and across the nation. We count the number of babies delivered by 'choice' (elective), who are younger (less) than 39 weeks, whose mother is not in labor and has no medical complications. Talk to your doctor about the best time to deliver your baby.

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

  Graph: Elective Delivery

  Percentage of Elective Deliveries Before 39 Weeks

  Table: Babies Delivered Electively

  Percentage of Elective Deliveries Before 39 Weeks

  CY2016 Q1	CY2016 Q2	CY2016 Q3	CY2016 Q4	CY2017 Q1	CY2017 Q2	CY2017 Q3	CY2017 Q4	CY2018 Q1	CY2018 Q2	CY2018 Q3	CY2018 Q4	CY2019 Q1	CY2019 Q2	CY2019 Q3	CY2019 Q4	CY2020 Q1	CY2020 Q2	CY2020 Q3	CY2020 Q4	The National Rate
  PHIPHI = Too few patients to display due to risk of PHI releasePHI	NDND = No data availableND	NDND = No data availableND	0%	PHIPHI = Too few patients to display due to risk of PHI releasePHI	PHIPHI = Too few patients to display due to risk of PHI releasePHI	PHIPHI = Too few patients to display due to risk of PHI releasePHI	PHIPHI = Too few patients to display due to risk of PHI releasePHI	PHIPHI = Too few patients to display due to risk of PHI releasePHI	PHIPHI = Too few patients to display due to risk of PHI releasePHI	PHIPHI = Too few patients to display due to risk of PHI releasePHI	PHIPHI = Too few patients to display due to risk of PHI releasePHI	NDND = No data availableND	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	0%	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	2.35%

• Breast Cancer Screen

  This measure tracks the percentage of women 50–74 years of age who had at least one mammogram to screen for breast cancer in the past two years. Data shown for this HEDIS measure is the most recently approved by NCQA. 

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

  Graph: Breast Cancer Screen

  Percentage of Women 50 - 74 Years Old Who Had At Least One Mammogram to Screen For Breast Cancer in the Past Two Years

  Table: Breast Cancer Screen

  Percentage of Women 50 - 74 Years Old Who Had At Least One Mammogram to Screen For Breast Cancer in the Past Two Years

  CY2013 Q1	CY2013 Q2	CY2013 Q3	CY2013 Q4	CY2014 Q1	CY2014 Q2	CY2014 Q3	CY2014 Q4	CY2015 Q1	CY2015 Q2	CY2015 Q3	CY2015 Q4	CY2016 Q1	CY2016 Q2	CY2016 Q3	CY2016 Q4	CY2017 Q1	CY2017 Q2	CY2017 Q3	CY2017 Q4	CY2018 Q1	CY2018 Q2	CY2018 Q3	CY2018 Q4	CY2019 Q1	CY2019 Q2	CY2019 Q3	CY2019 Q4	CY2020 Q1	CY2020 Q2	CY2020 Q3	CY2020 Q4	CY2021 Q1	CY2021 Q2	CY2021 Q3	CY2021 Q4	Average for health plans nationwide (HEDIS 50th Percentile)
  67.18%	73.1%	72.93%	73.08%	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	1%	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHIPHI = Too few patients to display due to risk of PHI releasePHI	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	51.61%	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PDPD = Proprietary dataPD

• Cervical Cancer Screen

  This measure shows the percentage of women age 21–64 years who had one or more Pap tests to screen for cervical cancer in the past 3 years. Data shown for this HEDIS measure is the most recently approved by NCQA. 

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

  Graph: Cervical Cancer Screen

  Percentage of Women 21 - 64 Years Old Who Had One or More Pap Tests to Screen For Cervical Cancer in the Past Three Years

  Table: Cervical Cancer Screen

  Percentage of Women 21 - 64 Years Old Who Had One or More Pap Tests to Screen For Cervical Cancer in the Past Three Years

  CY2013 Q1	CY2013 Q2	CY2013 Q3	CY2013 Q4	CY2014 Q1	CY2014 Q2	CY2014 Q3	CY2014 Q4	CY2015 Q1	CY2015 Q2	CY2015 Q3	CY2015 Q4	CY2016 Q1	CY2016 Q2	CY2016 Q3	CY2016 Q4	CY2017 Q1	CY2017 Q2	CY2017 Q3	CY2018 Q1	CY2018 Q2	CY2018 Q3	CY2018 Q4	CY2019 Q1	CY2019 Q2	CY2019 Q3	CY2019 Q4	CY2020 Q1	CY2020 Q2	CY2020 Q3	CY2021 Q1	CY2021 Q2	CY2021 Q3	CY2021 Q4	Average for health plans nationwide (HEDIS 50th Percentile)
  80.3%	79.47%	80.77%	81.06%	81.98%	79.98%	81.49%	79.49%	77.56%	79.35%	79.26%	79.22%	79.14%	80.04%	78.12%	79.22%	81.54%	82.17%	81.38%	81.39%	81.71%	81.77%	82%	80.9%	78.59%	78.47%	79.66%	80.48%	78.95%	86.77%	86.06%	85.53%	87.6%	88.59%	PDPD = Proprietary dataPD

• Cesarean Section

  There is no ideal target for this measure. The data is collected so that facilities can identify whether their rates of cesarean birth vary from rates at other facilities. With this information, hospitals can explore differences in their medical management of women in labor.

  What we measure

  We measure the percentage of cesarean section deliveries among mothers having their first baby.

  Table: Cesarean Section

  Percentage of First Time Mothers

  CY2016 Q1	CY2016 Q2	CY2016 Q3	CY2016 Q4	CY2017 Q1	CY2017 Q2	CY2017 Q3	CY2017 Q4	CY2018 Q1	CY2018 Q2	CY2018 Q3	CY2018 Q4	CY2019 Q1	CY2019 Q2	CY2019 Q3	CY2019 Q4	CY2020 Q1	CY2020 Q2	CY2020 Q3	CY2020 Q4	CY2021 Q1	CY2021 Q2	CY2021 Q3	CY2021 Q4
  PHIPHI = Too few patients to display due to risk of PHI releasePHI	PHIPHI = Too few patients to display due to risk of PHI releasePHI	12.5%	27.78%	27.78%	7.69%	28.57%	30.77%	27.27%	26.67%	16.67%	0%	15.38%	43.48%	0%	40%	20%	27.78%	26.32%	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	33.33%	25%	30.77%	23.81%

• Chlamydia Screening

  The percentage of women 16 to 24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year. Data shown for this HEDIS measure is the most recently approved by NCQA.

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

  Graph: Chlamydia Screening

  Percentage of Woman Who Had At Least One Test For Chlamydia

  Table: Chlamydia Screening

  Percentage of Woman Who Had At Least One Test For Chlamydia

  CY2013 Q1	CY2013 Q2	CY2013 Q3	CY2013 Q4	CY2014 Q1	CY2014 Q2	CY2014 Q3	CY2014 Q4	CY2015 Q1	CY2015 Q2	CY2015 Q3	CY2015 Q4	CY2016 Q1	CY2016 Q2	CY2016 Q3	CY2016 Q4	CY2017 Q1	CY2017 Q2	CY2017 Q3	CY2017 Q4	CY2018 Q1	CY2018 Q2	CY2018 Q3	CY2018 Q4	CY2019 Q1	CY2019 Q2	CY2019 Q3	CY2019 Q4	CY2020 Q1	CY2020 Q2	CY2020 Q3	Benchmark
  52.35%	54.57%	54.84%	55.81%	55.2%	55.11%	52.7%	55.63%	52.68%	55.75%	57.04%	55.13%	58.75%	55.81%	59.2%	55.43%	52.08%	51.72%	58.24%	58.42%	63.16%	63.9%	55.97%	57.49%	60.87%	54.93%	62.23%	61.89%	64.5%	69.42%	70.61%	PDPD = Proprietary dataPD

• Colorectal Cancer Screening

  This measure shows the number of our patients age 51 to 75 years who had a screening test for colorectal cancer. Data shown for this HEDIS measure is the most recently approved by NCQA.

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

  Graph: Colorectal Cancer Screening

  Percentage of Patients 51 - 75 Years Old Who Had a Screening Test for Colorectal Cancer

  Table: Colorectal Cancer Screening

  Percentage of Patients 51 - 75 Years Old Who Had a Screening Test for Colorectal Cancer

  CY2013 Q1	CY2013 Q2	CY2013 Q3	CY2013 Q4	CY2014 Q1	CY2014 Q2	CY2014 Q3	CY2014 Q4	CY2015 Q1	CY2015 Q2	CY2015 Q3	CY2015 Q4	CY2016 Q1	CY2016 Q2	CY2016 Q3	CY2016 Q4	CY2017 Q1	CY2017 Q2	CY2017 Q3	CY2017 Q4	CY2018 Q1	CY2018 Q2	CY2018 Q3	CY2018 Q4	CY2019 Q1	CY2019 Q2	CY2019 Q3	CY2019 Q4	CY2020 Q1	CY2020 Q2	CY2020 Q3	CY2020 Q4	CY2021 Q1	CY2021 Q2	CY2021 Q3	CY2021 Q4	Average for health plans nationwide (HEDIS 50th Percentile)
  65.22%	66.67%	57.14%	41.18%	52.63%	57.69%	59.09%	65.52%	70.97%	69.23%	64%	66.67%	68.18%	68%	72%	76.19%	76.19%	72%	72.22%	65%	70%	80.95%	84.21%	87.5%	73.68%	80.95%	85.71%	86.96%	86.96%	86.36%	91.3%	91%	86.96%	87.5%	67.42%	85%	PDPD = Proprietary dataPD

• Diabetes A1c Test

  This measure shows the percentage of adults with diabetes who had an A1c blood sugar test. Data shown for this HEDIS measure is the most recently approved by NCQA.

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

  Graph: Diabetes A1c Test

  Percentage of Patients Who Had an A1c Blood Sugar Test

  Table: Diabetes A1c Test

  Percentage of Patients Who Had an A1c Blood Sugar Test

  CY2013 Q1	CY2013 Q2	CY2013 Q3	CY2013 Q4	CY2014 Q1	CY2014 Q2	CY2014 Q3	CY2014 Q4	CY2015 Q1	CY2015 Q2	CY2015 Q3	CY2015 Q4	CY2016 Q1	CY2016 Q2	CY2016 Q3	CY2016 Q4	CY2017 Q1	CY2017 Q2	CY2017 Q3	CY2017 Q4	CY2018 Q1	CY2018 Q2	CY2018 Q3	CY2018 Q4	CY2019 Q1	CY2019 Q2	CY2019 Q3	CY2019 Q4	CY2020 Q1	CY2020 Q2	CY2020 Q3	CY2020 Q4	CY2021 Q1	CY2021 Q2	CY2021 Q3	CY2021 Q4	Average for health plans nationwide (HEDIS 50th Percentile)
  82.61%	90.91%	95%	1%	1%	1%	1%	93.75%	82.35%	94.74%	78.95%	89.47%	89.47%	88.24%	91.67%	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	91.67%	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	1%	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	90.91%	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	72.73%	1%	90.91%	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	90.91%	92.86%	85.71%	79%	85.71%	1%	92%	1%	PDPD = Proprietary dataPD

• Exclusive Breast Milk Feeding

  U.S. medical leaders recommend that infants are fed only breast milk for six months after they are born. One measure of success is an increase in the rate of infants being fed only breast milk for the duration of their hospital stay after birth.

  What we measure

  We measure the percentage of newborns exclusively fed breast milk during the newborn’s entire hospitalization.

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

  Table: Exclusive Breast Milk Feeding

  Percentage of Newborns

  CY2016 Q1	CY2016 Q2	CY2016 Q3	CY2016 Q4	CY2017 Q1	CY2017 Q2	CY2017 Q3	CY2017 Q4	CY2018 Q1	CY2018 Q2	CY2018 Q3	CY2018 Q4	CY2019 Q1	CY2019 Q2
  65.52%	77.78%	81.82%	78.95%	69.23%	70.37%	80.77%	73.91%	62.86%	73.33%	71.05%	58.33%	48.48%	65.63%

• Influenza Immunization

  We measure the number patients (age 6 months and older who are hospitalized during flu season) who are screened for previous flu vaccine and, if needed, given the flu vaccine, before being discharged from the hospital. 

  Table: Influenza Immunization

  Percentage of Acute Care Inpatients

  CY2016 Q1	CY2016 Q2	CY2016 Q3	CY2016 Q4	CY2017 Q1	CY2017 Q2	CY2017 Q3	CY2017 Q4	CY2018 Q1	CY2018 Q2	CY2018 Q3	CY2018 Q4	CY2019 Q1	CY2019 Q2	CY2019 Q3	CY2019 Q4	CY2020 Q1	CY2020 Q2	CY2020 Q3	CY2020 Q4
  75%	NDND = No data availableND	NDND = No data availableND	40.85%	86.05%	NDND = No data availableND	NDND = No data availableND	59.18%	83.33%	NDND = No data availableND	NDND = No data availableND	69.23%	71.43%	NDND = No data availableND	0%	65.15%	76.79%	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	84.85%

• 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: 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

  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

  CY2016 Q1	CY2016 Q2	CY2016 Q3	CY2016 Q4	CY2017 Q1	CY2017 Q2	CY2017 Q3	CY2017 Q4	CY2018 Q1	CY2018 Q2	CY2018 Q3	CY2018 Q4	CY2019 Q1	CY2019 Q2	CY2019 Q3	CY2019 Q4	CY2020 Q1	CY2020 Q2	CY2020 Q3	CY2020 Q4	CY2021 Q1	CY2021 Q2	CY2021 Q3	CY2021 Q4	Average for health plans nationwide (HEDIS 50th Percentile)
  83.76%	85.92%	84.02%	84.74%	83.88%	84.38%	84.07%	83%	81.76%	81.52%	80.62%	80.98%	80.33%	83.64%	82.24%	83.5%	86.18%	84.52%	84.73%	85%	85.62%	85.06%	86.56%	83.1%	PDPD = Proprietary dataPD

• Median Time from Emergency Department (ED) Arrival to ED Departure for Admitted ED Patients

  Median time (in minutes) from Emergency Department arrival to the time of Emergency Department departure for patients admitted to the facility from the Emergency Department

  Graph: Median Time from Emergency Department (ED) Arrival to ED Departure for Admitted ED Patients

  Median Time in Minutes

  Table: Median Time from Emergency Department (ED) Arrival to ED Departure for Admitted ED Patients

  Median Time in Minutes

  CY2016 Q1	CY2016 Q2	CY2016 Q3	CY2016 Q4	CY2017 Q1	CY2017 Q2	CY2017 Q3	CY2017 Q4	CY2018 Q1	CY2018 Q2	CY2018 Q3	CY2018 Q4	CY2019 Q1	CY2019 Q2	CY2019 Q3	CY2019 Q4	CY2020 Q1	CY2020 Q2	CY2020 Q3	CY2020 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	NDND = No data availableND	NDND = No data availableND	NDND = No data availableND	NDND = No data availableND	0	0	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**

• Mental Health Follow Up 30 Days

  Patients hospitalized to treat mental illness need follow up care. This follow up care helps make sure the progress made during the patient’s hospital stay transitions to the home or work environment. It also helps your health care team catch problems that might arise after leaving the hospital. Data shown for this HEDIS measure is the most recently approved by NCQA.

  What we measure

  We measure the percentage of discharges of individuals age 6 years and older who had a follow-up outpatient visit within 7 days and 30 days of discharge after being hospitalized for treatment of certain mental illnesses. If you have recently been discharged from a hospital for mental health care, please keep any scheduled appointments. If you aren’t sure if you have an appointment, call your mental health provider and schedule one.

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

  Graph: Mental Health Follow Up 30 Days

  Percentage of Discharges of Individuals Ages 6 Years and Older who had a Follow-up Outpatient Visit Within 30 Days of Discharge After Being Hospitaliz

  Table: Mental Health Follow Up 30 Days

  Percentage of Discharges of Individuals Ages 6 Years and Older who had a Follow-up Outpatient Visit Within 30 Days of Discharge After Being Hospitaliz

  CY2013 Q1	CY2013 Q2	CY2013 Q3	CY2013 Q4	CY2014 Q1	CY2014 Q2	CY2014 Q3	CY2014 Q4	CY2015 Q1	CY2015 Q2	CY2015 Q3	CY2015 Q4	CY2016 Q1	CY2016 Q2	CY2016 Q3	CY2016 Q4	CY2017 Q1	CY2017 Q2	CY2017 Q3	CY2017 Q4	CY2018 Q1	CY2018 Q2	CY2018 Q3	CY2018 Q4	CY2019 Q4	CY2020 Q1	CY2020 Q2	Average for health plans nationwide (HEDIS 50th Percentile)
  1%	1%	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	1%	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	1%	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	1%	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PDPD = Proprietary dataPD

• Mental Health Follow Up 7 Days

  Patients hospitalized to treat mental illness need follow up care. This follow up care helps make sure the progress made during the patient’s hospital stay transitions to the home or work environment. It also helps your health care team catch problems that might arise after leaving the hospital. Data shown for this HEDIS measure is the most recently approved by NCQA.

  What we measure

  We measure the percentage of discharges of individuals age 6 years and older who had a follow-up outpatient visit within 7 days and 30 days of discharge after being hospitalized for treatment of certain mental illnesses. If you have recently been discharged from a hospital for mental health care, please keep any scheduled appointments. If you aren’t sure if you have an appointment, call your mental health provider and schedule one.

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

  Graph: Mental Health Follow Up 7 Days

  Percentage of Discharges of Individuals Ages 6 Years and Older who had a Follow-up Outpatient Visit Within 7 Days of Discharge After Being Hospitalize

  Table: Mental Health Follow Up 7 Days

  Percentage of Discharges of Individuals Ages 6 Years and Older who had a Follow-up Outpatient Visit Within 7 Days of Discharge After Being Hospitalize

  CY2013 Q1	CY2013 Q2	CY2013 Q3	CY2013 Q4	CY2014 Q1	CY2014 Q2	CY2014 Q3	CY2014 Q4	CY2015 Q1	CY2015 Q2	CY2015 Q3	CY2015 Q4	CY2016 Q1	CY2016 Q2	CY2016 Q3	CY2016 Q4	CY2017 Q1	CY2017 Q2	CY2017 Q3	CY2017 Q4	CY2018 Q1	CY2018 Q2	CY2018 Q3	CY2018 Q4	CY2019 Q4	CY2020 Q1	CY2020 Q2	CY2020 Q3	CY2021 Q1	CY2021 Q2	CY2021 Q3	CY2021 Q4	Average for health plans nationwide (HEDIS 50th Percentile)
  78.57%	72.73%	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	81.82%	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	81.82%	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	1%	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	81.82%	90.91%	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	1%	1%	PDPD = Proprietary dataPD

• National Surgical Quality Improvement Program (NSQIP) All Cases Mortality (deaths related to surgery)

  NSQIP All Cases Mortality is the rate of unexpected deaths after surgery. It is the rate of deaths that happen within 30 days after a surgery. These deaths sometimes happen because of problems related to the operation. They can also happen for unrelated reasons. Some deaths happen because patients are very sick.

  What We Measure

  The MHS measures the rate of death in the first 30 days after a surgery. Then we compare these rates to those at hundreds of hospitals around the country. The rates are reported as one of three categories. The first, “exemplary,” means the facility had fewer deaths than would be expected in similar patients going through a similar surgery. The second, “as expected,” means that the site had about the same number of deaths as expected. The third, “needs improvement,” means the facility had more deaths than would be expected.

  These measures are a reliable look at surgical quality. They are National Surgical Quality Improvement Program, or NSQIP, measures. These are made by the American College of Surgeons. They are based on the best available data. It includes data about how patients are doing 30 days after surgery.

  Talk to your medical team about the steps the MHS is taking to prevent unexpected deaths after surgery. If you see something that doesn't seem right, ask about it.
  
  

  Graph: No Data

  Table: National Surgical Quality Improvement Program (NSQIP) All Cases Mortality (deaths related to surgery)

  Comparison to Benchmark

  07/01/2016 - 06/30/2017	01/01/2017 - 12/31/2017	07/01/2017 - 06/30/2018	01/01/2018 - 12/31/2018	07/01/2018 - 06/30/2019	1/1/2019-12/31/2019	07/01/2019 - 06/30/2020	01/01/2020 - 12/31/2020
  As Expected	As Expected	As Expected	As Expected	As Expected	As Expected	As Expected	As Expected

• National Surgical Quality Improvement Program All Case Morbidity (complications related to surgery)

  Surgical illness or injury measures look at a number of different complications that can result from surgery, like infections, operations on the wrong area, or a return to the operating room to correct a complication.

  What we measure

  We measure these complications to get an all case morbidity rate. This rate shows the likelihood a surgery will have some sort of complication. Talk to your medical team about the steps we’re taking to prevent complications after your surgery. If you see something that doesn’t seem right, ask about it.

  Table: National Surgical Quality Improvement Program All Case Morbidity (complications related to surgery)

  Comparison to Benchmark

  07/01/2016 - 06/30/2017	01/01/2017 - 12/31/2017	7/1/2017-6/30/2018	1/1/2018-12/31/2018	7/1/2018-6/30/2019	1/1/2019-12/31/2019	7/1/2019-6/30/2020	1/1/2020-12/31/2020
  As Expected	As Expected	As Expected	As Expected	As Expected	As Expected	As Expected	As Expected

• Number of Deliveries

  When you're having a baby, it's important that you have confidence in the hospital you are considering for delivery. Hospitals that have fewer deliveries may not have as many resources such as Neonatal ICU or Maternal-Fetal Medicine specialists. Hospitals that deliver more babies may have additional specialties and experience for complicated pregnancies.

  What we measure

  We count and report the number of babies delivered in our military hospitals both by cesarean or normal delivery.

  Graph: Number of Deliveries

  Number of Babies Delivered

  Table: Number of Deliveries

  Number of Babies Delivered

  CY2013	CY2014	CY2015	CY2016	CY2017	CY2018	CY2019
  200	163	151	147	140	149	156

• Strep Test

  Pharyngitis, or inflammation of the throat, is the only condition among upper respiratory infections where your provider may determine that antibiotic use is appropriate. U.S. medical leaders recommend that individuals diagnosed with group A streptococcus (strep) pharyngitis be treated with antibiotics. A strep test is the definitive test of group A strep pharyngitis. Data shown for this HEDIS measure is the most recently approved by NCQA.

  What we measure

  We measure the percentage of enrollees ages 3 months of age and older, who were diagnosed with pharyngitis, received a strep test and were given an antibiotic. If you think you may have strep, ask for the test. If the test comes back positive and your child has strep, they should get an antibiotic. But, if the test is negative, an antibiotic isn’t needed.

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

  Graph: Strep Test

  Percentage of Beneficiaries Diagnosed with Pharyngitis Through a Strep Test and Received Antibiotics

  Table: Strep Test

  Percentage of Beneficiaries Diagnosed with Pharyngitis Through a Strep Test and Received Antibiotics

  CY2020 Q2	CY2020 Q3	CY2021 Q1	CY2021 Q2	CY2021 Q3	CY2021 Q4	Benchmark
  84.62%	84.38%	84.62%	87.1%	83.87%	80%	PDPD = Proprietary dataPD

• Tobacco Use Treatment

  We measure the percentage of hospitalized inpatients 18 years of age and older identified as current tobacco users who received practical counseling to quit and FDA-approved cessation medications.

  Table: Tobacco Use Treatment

  Percentage of Hospitalized Inpatients

  CY2016 Q1	CY2016 Q2	CY2016 Q3	CY2016 Q4	CY2017 Q1	CY2017 Q2	CY2017 Q3	CY2017 Q4	CY2018 Q1	CY2018 Q2	CY2018 Q3	CY2018 Q4	CY2019 Q1	CY2019 Q2	CY2019 Q3	CY2019 Q4
  PHIPHI = Too few patients to display due to risk of PHI releasePHI	NDND = No data availableND	PHIPHI = Too few patients to display due to risk of PHI releasePHI	0%	0%	0%	0%	PHIPHI = Too few patients to display due to risk of PHI releasePHI	PHIPHI = Too few patients to display due to risk of PHI releasePHI	PHIPHI = Too few patients to display due to risk of PHI releasePHI	PHIPHI = Too few patients to display due to risk of PHI releasePHI	0%	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**	0%	PHI**PHI = Too few patients to display due to risk of PHI release ** = Low number of cases, percentages may vary greatlyPHI**

• 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. Data shown for this HEDIS measure is the most recently approved by NCQA.

  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: http://www.qualityforum.org/CQMC/

  Graph: Treatment of Common Cold

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

  Table: Treatment of Common Cold

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

  CY2020 Q3	CY2021 Q3	CY2021 Q3	CY2021 Q3	CY2021 Q4	CY2021 Q4	CY2021 Q4	CY2022 Q1	CY2022 Q1	CY2022 Q1	Benchmark
  97.75%	96.86%	96.97%	96.32%	96.44%	96.19%	96.04%	96.4%	95.92%	95.65%	PDPD = Proprietary dataPD

• Well-Child Visits in the first 15 Months of Life

  In the first 15 months of a child’s life, there are a number of preventive and monitoring services. These early services may lead to lifelong health and wellness. Data shown for this HEDIS measure is the most recently approved by NCQA.

  What we measure

  We measure the number of well-child visits in the first 15 months of life, for both military and civilian appointments. Our goal is a child will have 6 well-child visits during these 15 months.

  This measure sees if military children have timely, easy access to health care services. If you recently moved or changed providers, talk with your new doctor about what appointments your child has already had.

  Graph: Well Child Visits

  Percentage of Babies who Have Six Well-Child Visits in Their First 15 Months of Life

  Table: Well-Child Visits in the first 15 Months of Life

  Percentage of Babies who Have Six Well-Child Visits in Their First 15 Months of Life

  CY2013 Q1	CY2013 Q2	CY2013 Q3	CY2013 Q4	CY2014 Q1	CY2014 Q2	CY2014 Q3	CY2014 Q4	CY2015 Q1	CY2015 Q2	CY2015 Q3	CY2015 Q4	CY2016 Q1	CY2016 Q2	CY2016 Q3	CY2016 Q4	CY2017 Q1	CY2017 Q2	CY2017 Q3	CY2017 Q4	CY2018 Q1	CY2018 Q2	CY2018 Q3	CY2018 Q4	CY2019 Q1	CY2019 Q2	CY2019 Q3	CY2019 Q4	CY2020 Q1	CY2020 Q2	CY2020 Q3	CY2020 Q4	CY2021 Q1	CY2021 Q2	CY2021 Q3	CY2021 Q4	Average for health plans nationwide (HEDIS 50th Percentile)
  76.77%	79.21%	81.19%	83.76%	86.18%	85.27%	83.06%	83.78%	83.33%	84.16%	83.81%	82.35%	80.85%	84.27%	88.61%	91.67%	97.01%	93.44%	93.1%	84.38%	85.71%	88.75%	88.61%	91.78%	89.09%	92.86%	94.59%	94.44%	90%	84.31%	85%	84%	82.57%	83.33%	79%	78.65%	PDPD = Proprietary dataPD