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Navy Medical Center San Diego

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34800 Bob Wilson Drive
San Diego, CA 92134

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Naval Medical Center San Diego website

1-619-532-8225

Monday - Friday: 6:00 a.m. - 7:00 p.m.
Weekends: 8:00 a.m. - 4:30 p.m.

At Naval Medical Center San Diego, our number one priority is providing the safest, highest quality patient-centered medical care for our veterans, service members and their families.  We are committed to operational readiness, outstanding customer service, and always delivering world-class health care. 

  • You can see for yourself how well we are doing.
  • Click on one of the links to learn how we measure our performance.

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.
  • If you have questions, please contact the Patient Administration office at your military treatment facility or a beneficiary counseling and assistance coordinator

Download Spreadsheet of Metrics

  • 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 in the Military Health System

    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 to a patient and that require immediate reporting, response and investigation. More reported events don’t necessarily mean more events have occurred. It could mean that more providers have reported events. This measure is a system-wide one that gives you a snapshot of what kind of sentinel events the entire system reported in 2014 and 2015.

    Download the Report

    Sentinel Events by Military Hospital

    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 to a patient and that require immediate reporting, response and investigation. More reported events don’t necessarily mean more events have occurred.  It could mean that more providers have reported events. This measure is a facility-specific one that shows you what sentinel events occurred in individual hospitals or clinics. NOTE: Your military hospital or clinic may not be on this list. Some do not provide services that can result in a reportable event, while others may not have enough data to report in a way that protects patient privacy.

    Download the Report

    Patient Safety Event Reporting

    You expect us to keep you safe when you are in one of our hospitals or clinics. One way we do that is by reporting and reviewing Patient Safety Events so 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" events where a patient isn't harmed, but could have been. 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 because the MHS integrates dental into its medical system. 

    The table below shows patient safety reporting in FY 2014, as compared with FY 2013, stratified by harm classification.

    The table below shows patient safety reporting in FY 2014, as compared with FY 2013, stratified by harm classification.

    Catheter Associated Urinary Tract Infections (CAUTI)

    A catheter is a drainage tube that is inserted into a patient’s urinary bladder through the urethra and is left in place to collect urine while a patient is immobile or incontinent. Catheters can become an easy way for germs to enter the body and cause serious infections in the urinary tract. These infections are called catheter-associated urinary tract infections (CAUTIs), and they can cause additional illness or may be deadly.

    What we measure

    We track the number of infections developed by patients in the ICU 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 are 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.

    Table: Catheter Associated Urinary Tract Infections (CAUTI)

    Comparison to Benchmark
    CY2014 Q1-Q2 CY2014 Q3-Q4 CY2015 Q1-Q2 CY2015 Q3-Q4 CY2016 Q1-Q2 CY2016 Q3-Q4
    No Different Than The National Benchmark No Different Than The National Benchmark No Different Than The National Benchmark No Different Than The National Benchmark No Different Than The National Benchmark No Different Than The National Benchmark

    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 so the patient can receive fluids and medication. Central lines can become an easy way for germs to enter the body and cause serious infections in the blood. These infections are called central line-associated bloodstream infections (CLABSIs), and they can be deadly.

    What we measure

    We track the number of infections developed by patients in the ICU because of central-line devices. We study our infection rates by line days—the number of infections divided by the number of line days (number of patients in a day with at least one central line). The rate is the number of occurrences per 1,000 line days.

    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.

    Table: Central Line Associated Blood Stream Infections (CLABSI)

    Comparison to Benchmark
    CY2014 Q1-Q2 CY2014 Q3-Q4 CY2015 Q1-Q2 CY2015 Q3-Q4 CY2016 Q1-Q2 CY2016 Q3-Q4
    No Different Than The National Benchmark No Different Than The National Benchmark No Different Than The National Benchmark No Different Than The National Benchmark No Different Than The National Benchmark No Different Than The National Benchmark
  • 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
    2016-Apr 2016-May 2016-Jun 2016-Jul 2016-Aug 2016-Sep 2016-Oct 2016-Nov 2016-Dec 2017-Jan 2017-Feb 2017-Mar 2017-Apr 2017-May 2017-Jun Goal
    0.91 0.99 0.89 0.97 0.79 0.84 0.96 0.9 0.94 0.81 0.83 0.67 0.66 0.6 0.53 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 Routine Appointments

    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
    2016-Apr 2016-May 2016-Jun 2016-Jul 2016-Aug 2016-Sep 2016-Oct 2016-Nov 2016-Dec 2017-Jan 2017-Feb 2017-Mar 2017-Apr 2017-May 2017-Jun Goal
    3.69 3.96 5 4.82 5.01 5.51 5.87 6.45 5.09 4.6 5.18 4.13 4.13 3.9 4.45 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

    FY2016 Q3 FY2016 Q4 FY2017 Q1 Benchmark
    65% 64% 63% 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

    FY2016 Q3 FY2016 Q4 FY2017 Q1 Benchmark
    78% 73% 75% 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

    FY2016 Q3 FY2016 Q4 FY2017 Q1 Benchmark
    76% 75% 78% 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

    FY2016 Q3 FY2016 Q4 FY2017 Q1 Benchmark
    85% 83% 85% 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

    FY2016 Q3 FY2016 Q4 FY2017 Q1 Benchmark
    85% 82% 83% 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

    FY2016 Q3 FY2016 Q4 FY2017 Q1 Benchmark
    91% 87% 91% 87%

    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

    FY2016 Q3 FY2016 Q4 FY2017 Q1 Benchmark
    69% 66% 64% 72%

    Pain Management

    "During this hospital stay, did you need medicine for pain?" (2-point scale: 1-No, 2-Yes)
    "During this hospital stay, how often was your pain well controlled?"

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

    (Percent satisfied is "Yes" and "Always".)

    If patients needed medicine for pain during their hospital stay, the survey asked how often their pain was well controlled. “Well controlled” means their pain was well controlled and that the hospital staff did everything they could to help patients with their pain

    Table: Pain Management

    FY2016 Q3 FY2016 Q4 FY2017 Q1 Benchmark
    72% 73% 71% 71%

    Primary Care Manager Continuity

    When your provider team is familiar with your medical history, it is 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 will work 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 the same medical team.

    What we measure

    We measure the percent of 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 primary care manager. But we want to ensure you are 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 will 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
    2016-Apr 2016-May 2016-Jun 2016-Jul 2016-Aug 2016-Sep 2016-Oct 2016-Nov 2016-Dec 2017-Jan 2017-Feb 2017-Mar 2017-Apr 2017-May 2017-Jun Goal
    59.5% 59.8% 57.6% 56.6% 57.4% 56.5% 57.8% 59.4% 58.2% 59.9% 58.6% 60.8% 56.8% 59.4% 57.7% 65%

    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

    FY2016 Q3 FY2016 Q4 FY2017 Q1 Benchmark
    62% 57% 63% 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 National Civilian Benchmark Average
    74% 74% 72% 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

    FY2016 Q3 FY2016 Q4 FY2017 Q1 Benchmark
    76% 73% 76% 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)"
    FY2016 Q4 FY2017 Q1 FY2017 Q2
    86% 85% 83%
  • 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

    Because you expect your hospital or clinic to provide quality care, 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
    Fully Accredited
    2016-Sep

    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: Complications Related to Surgery

    Comparison to Benchmark
    CY2015
    As Expected

    Elective Delivery

    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.

    Graph: Elective Delivery

    Percentage of Elective Deliveries Before 39 Weeks

    Table: Elective Delivery

    Percentage of Elective Deliveries Before 39 Weeks
    CY2013 CY2014 CY2015 The National Rate
    1% 3% 0% 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. 

    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
    CY2016 Q1 CY2016 Q2 CY2016 Q3 CY2016 Q4 Average for health plans nationwide (HEDIS 50th Percentile)
    83% 81% 81% 81% 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. 

    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
    CY2016 Q1 CY2016 Q2 CY2016 Q3 CY2016 Q4 Average for health plans nationwide (HEDIS 50th Percentile)
    80% 80% 80% 80% PDPD = Proprietary dataPD

    Child Common Cold

    The common cold or upper respiratory infection (URI) is a common reason children 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 children with an upper respiratory infection between the ages of 3 months to 18 years 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.

    Graph: Child Common Cold

    Percentage of Children 3 Months - 18 Years Diagnosed with an Upper Respiratory Infection and Were Not Given a Prescription

    Table: Child Common Cold

    Percentage of Children 3 Months - 18 Years Diagnosed with an Upper Respiratory Infection and Were Not Given a Prescription
    CY2016 Q1 CY2016 Q2 CY2016 Q3 CY2016 Q4 Average for health plans nationwide (HEDIS 50th Percentile)
    97% 98% 98% 98% PDPD = Proprietary dataPD

    Child 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 only children diagnosed with group A streptococcus (strep) pharyngitis be treated with antibiotics. A strep test is the definitive test of group A strep pharyngitis.

    What we measure

    We measure the percentage of children, ages 3 to 18, who were diagnosed with pharyngitis, received a strep test and were given an antibiotic. If you think your child 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.

    Graph: Child Strep Test

    Percentage of Children 3 Months - 18 Year Diagnosed with Pharyngitis Through a Strep Test and Received Antibiotics

    Table: Child Strep Test

    Percentage of Children 3 Months - 18 Year Diagnosed with Pharyngitis Through a Strep Test and Received Antibiotics
    CY2016 Q1 CY2016 Q2 CY2016 Q3 CY2016 Q4 Average for health plans nationwide (HEDIS 50th Percentile)
    87% 88% 88% 87% PDPD = Proprietary dataPD

    Children's Asthma Care

    The MHS measures metrics associated with Childhood Asthma Care. This section displays metrics about the application of that care.

    Graph: Children's Asthma Care

    Table: Children's Asthma Care

    CY2015 Q3 CY2015 Q4 CY2016 Q1
    100% 87% NDND = No data availableND

    Colorectal Cancer Screening

    This measure shows the number of our patients age 51 to 75 years who had a screening test for colorectal cancer. 

    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
    CY2016 Q1 CY2016 Q2 CY2016 Q3 CY2016 Q4 CY2017 Q1 Average for health plans nationwide (HEDIS 50th Percentile)
    74% 74% 74% 73% 73% PDPD = Proprietary dataPD

    Diabetes A1c Control <8

    This measure shows the percentage of adults tested whose results show their diabetes is under control.

    Graph: Diabetes A1c Control <8

    Percentage of Patients Who Had an A1c Blood Sugar Test Whose Results Show Their Diabetes is Under Control

    Table: Diabetes A1c Control <8

    Percentage of Patients Who Had an A1c Blood Sugar Test Whose Results Show Their Diabetes is Under Control
    CY2016 Q1 CY2016 Q2 CY2016 Q3 CY2016 Q4 Average for health plans nationwide (HEDIS 50th Percentile)
    71% 70% 70% 70% PDPD = Proprietary dataPD

    Diabetes A1c Test

    This measure shows the percentage of adults with diabetes who had an A1c blood sugar test.

    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
    CY2016 Q1 CY2016 Q2 CY2016 Q3 CY2016 Q4 Average for health plans nationwide (HEDIS 50th Percentile)
    93% 92% 92% 92% PDPD = Proprietary dataPD

    Immunization

    Getting your immunizations are important to overall health.  These measures are effective for discharges on and after January 1, 2012.  We measure the following: 

    • Overall rate for pneumococcal immunization
    • Rate for patients aged 65 and older for pneumococcal immunization
    • Rate for high risk patients aged 6-64 pneumococcal immunization
    • Rate for influenza immunization

    Graph: Immunization

    Table: Immunization

    CY2015 Q3 CY2015 Q4 CY2016 Q1
    NDND = No data availableND 65% 79%

    Inpatient Psychiatric Services

    The MHS measures metrics associated with Inpatient Psychiatric Services. This section displays metrics about the application of that care.

    Graph: Inpatient Psychiatric Services

    Table: Inpatient Psychiatric Services

    CY2015 Q3 CY2015 Q4 CY2016 Q1
    95% 99% 100%

    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.

    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.

    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 Average for health plans nationwide (HEDIS 50th Percentile)
    81% 81% 82% 83% PDPD = Proprietary dataPD

    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.

    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.

    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 Hospitalized for Treatment of Certain Mental Illnesses

    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 Hospitalized for Treatment of Certain Mental Illnesses
    CY2016 Q1 CY2016 Q2 CY2016 Q3 CY2016 Q4 CY2017 Q1 Average for health plans nationwide (HEDIS 50th Percentile)
    93% 90% 90% NDND = No data availableND 86% 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.

    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.

    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 Hospitalized for Treatment of Certain Mental Illnesses

    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 Hospitalized for Treatment of Certain Mental Illnesses
    CY2016 Q1 CY2016 Q2 CY2016 Q3 CY2016 Q4 Average for health plans nationwide (HEDIS 50th Percentile)
    87% 82% 81% NDND = No data availableND PDPD = Proprietary dataPD

    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
    3148 3094 2866

    Perinatal Care

    Perinatal care is care you get during your pregnancy. All perinatal care certified programs require the following measurements. This is mandatory regardless of the annual number of births at the facility. These include:

    • Elective delivery
    • Cesarean section
    • Antenatal steroids
    • Newborns with health care–associated bloodstream infections
    • Exclusive breast milk feeding

    Graph: Perinatal Care

    Table: Perinatal Care

    CY2015 Q3 CY2015 Q4 CY2016 Q1
    67% 100% 100%

    Venous Thromboembolism

    The venous thromboembolism (VTE) measures include:

    • VTE-1    Venous Thromboembolism Prophylaxis
    • VTE-2    Intensive Care Unit Venous Thromboembolism Prophylaxis
    • VTE-6    Hospital Acquired Potentially-Preventable Venous Thromboembolism

    Graph: Venous Thromboembolism

    Table: Venous Thromboembolism

    CY2015 Q3 CY2015 Q4 CY2016 Q1
    90% 95% 0%

    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.

    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 in the first 15 Months of Life

    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
    CY2016 Q1 CY2016 Q2 CY2016 Q3 CY2016 Q4 Average for health plans nationwide (HEDIS 50th Percentile)
    87% 85% 84% 84% PDPD = Proprietary dataPD

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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