Disclaimer:

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

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Patient Safety

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

• 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

  2021	2022	2023	2024
  Click to closeNDND = No data availableND	Click to closeNDND = No data availableND	Click to closeNDND = No data availableND	Click to closeNDND = No data availableND

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:

• 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 networks, 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)"

  2022-Jan	2022-Aug
  67%	87%

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: 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

  2021-Jun	2021-Jul	2021-Aug	2021-Sep	2021-Oct	2021-Nov	2021-Dec	2022-Jan	2022-Feb	2022-Mar	2022-Apr	2022-May	2022-Jun	2022-Jul	2022-Aug	2022-Sep	2022-Oct	2022-Nov	2022-Dec	2023-Jan	2023-Feb	2023-Mar	2023-Apr	2023-May	2023-Jun	2023-Jul	2023-Aug	2023-Sep	Average for health plans nationwide (HEDIS 50th Percentile)
  95%	97%	97%	97%	95%	95%	93%	95%	94%	94%	94%	95%	96%	94%	93%	91%	92%	92%	92%	92%	90%	85%	85%	85%	83%	83%	75%	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

• 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 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 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: https://p4qm.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

  2021-Jun	2021-Jul	2021-Aug	2021-Sep	2021-Oct	2021-Nov	2021-Dec	2022-Jan	2022-Feb	2022-Mar	2022-Apr	2022-May	2022-Jun	2022-Jul	2022-Aug	2022-Sep	2022-Oct	2022-Nov	2022-Dec	2023-Jan	2023-Feb	2023-Mar	2023-Apr	2023-May	2023-Jun	2023-Jul	2023-Aug	2023-Sep	2023-Oct	2023-Nov	2023-Dec	2024-Jan	2024-Feb	2024-Mar	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	2025-Nov	2025-Dec	2026-Jan	2026-Feb	Benchmark
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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