Hospital Value-Based Purchasing
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Value-Based Percentage Payment Summary Report
Percentage Summary Report
Provider: 190034
Reporting Period: Fiscal Year 2021
Data As Of: 07/28/2020
Total Performance Score Facility State National
31.333333333333 32.509343434343 33.908563949140
Unweighted Domain Score Weighting Weighted Domain Score
Clinical Outcomes Domain 25.000000000000 33.3% 8.333333333333
Person and Community Engagement Domain
69.000000000000 33.3% 23.000000000000
Safety Domain - -
-Efficiency and Cost Reduction Domain 0.000000000000 33.3% 0.000000000000
Base Operating DRG Payment Amount Reduction
Value-Based Incentive Payment Percentages
Net change in Base Operating DRG Payment Amount
Value-Based Incentive
Payment Adjustment Factor Exchange Function Slope
Value-Based Percentage Payment
Summary - Fiscal Year 2021 2.0000000000% 2.0101536514% +0.0101536514% 1.0001015365 3.2076919972
Calculated values were subject to rounding.
Reference the Hospital Value-Based Purchasing page on QualityNet for report information, calculations, and Hospital VBP resources. * A dash (-) indicates that the minimum requirements were not met for calculation.
Hospital Value-Based Purchasing
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Value-Based Percentage Payment Summary Report
Clinical Outcomes Detail Report
Provider: 190034
Reporting Period: Fiscal Year 2021
Mortality Baseline Period(AMI,HF,COPD): 07/01/2011 - 06/30/2014 Mortality Performance Period(AMI,HF,COPD): 07/01/2016 - 06/30/2019 Mortality Baseline Period (PN): 07/01/2012 - 06/30/2015
Mortality Performance Period (PN): 09/01/2017 - 06/30/2019
FY 2021 Baseline Period Totals FY 2021 Performance Period Totals HVBP Metrics
Mortality Measures
Number of Eligible Discharges
Baseline Period Rate
Number of Eligible Discharges
Performance Period Rate Achievement
Threshold Benchmark Improvement Points Achievement Points Measure Score 30-Day Risk-Standardized Mortality Measures
Acute Myocardial Infarction (AMI) 30-Day Mortality Rate 9 0.855388 3 0.873909 0.860355 0.879714 - -
-Chronic Obstructive Pulmonary Disease (COPD) 30-Day Mortality Rate 37 0.925920 53 0.908722 0.923253 0.938664 0 0 0
Heart Failure (HF) 30-Day Mortality Rate 118 0.867844 132 0.868396 0.883803 0.906144 0 0 0
Pneumonia (PN) 30-Day Mortality Rate 147 0.842652 61 0.841472 0.836122 0.870506 0 2 2
Baseline Period: 04/01/2011 - 03/31/2014
Performance Period: 04/01/2016 - 03/31/2019 FY 2021 Baseline Period Totals FY 2021 Performance Period Totals HVBP Metrics
Complication Measure Number of Eligible Discharges Baseline Period Rate Number of Eligible Discharges Performance Period Rate Achievement Threshold Benchmark Improvement Points Achievement Points Measure Score Elective Primary Total Hip Arthroplasty/Total Knee
Arthroplasty Complication Rate 42 0.030854 39 0.024263 0.031157 0.022418 7 8 8
Clinical Outcomes Measures: 4 out of 5
Unweighted Clinical Outcomes Measures Domain Score: 25.000000000000 Weighted Clinical Outcomes Measures Domain Score: 8.333333333333
Calculated values were subject to rounding.
Hospital Value-Based Purchasing
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Value-Based Percentage Payment Summary Report
Person and Community Engagement Detail Report
Provider: 190034
Reporting Period: Fiscal Year 2021
Baseline Period: 01/01/2017 - 12/31/2017
Performance Period: 01/01/2019 - 12/31/2019
HCAHPS Dimensions Baseline Period Rate
Performance Period
Rate Floor
Achievement
Threshold Benchmark Improvement Points Achievement Points Dimension Score
Communication with Nurses 81.47% 87.3248% 42.06% 79.06% 87.36% 9 9 9
Communication with Doctors 87.05% 90.2765% 41.99% 79.91% 88.10% 9 10 10
Responsiveness of Hospital Staff 66.77% 78.0413% 33.89% 65.77% 81.00% 7 8 8
Communication about Medicines 62.18% 69.0704% 33.19% 63.83% 74.75% 5 5 5
Cleanliness and Quietness of Hospital
Environment 73.36% 81.2909% 30.60% 65.61% 79.58% 9 10 10
Discharge Information1 87.38% 84.5324% 66.94% 87.38% 92.17% 0 0 0
Care Transition 50.01% 60.1449% 6.53% 51.87% 63.32% 7 7 7
Overall Rating of Hospital 67.48% 74.2829% 34.70% 71.80% 85.67% 3 2 3
HCAHPS Base Score: 52 HCAHPS Consistency Score: 17
Unweighted Person and Community Engagement Domain Score: 69.000000000000 Weighted Person and Community Engagement Domain Score: 23.000000000000 HCAHPS Surveys Completed during the Performance period: 135
Calculated values were subject to rounding.
Hospital Value-Based Purchasing
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Value-Based Percentage Payment Summary Report
Safety Measures Detail Report
Provider: 190034
Reporting Period: Fiscal Year 2021
Baseline Period: 01/01/2017 - 12/31/2017
Performance Period: 01/01/2019 - 12/31/2019
FY 2021
Baseline Period Totals
FY 2021
Performance Period Totals HVBP Metrics
Healthcare Associated Infections
Number of Observed Infections (Numerator) Number of Predicted Infections (Denominator) Standardized Infections Ratio (SIR) Number of Observed Infections (Numerator) Number of Predicted Infections (Denominator) Standardized Infections Ratio (SIR) Achievement Threshold Benchmark Improvement Points Achievement
Points Measure Score
Catheter-Associated Urinary Tract Infection 1 0.902 - 2 0.671 - 0.774 0.000 - -
-Central Line-Associated Blood Stream Infection 1 0.517 - 0 0.482 - 0.687 0.000 - -
-Clostridium difficile Infection 2 2.400 0.833 2 2.615 0.765 0.748 0.067 0 0 0
Methicillin-Resistant Staphylococcus aureus
Bacteremia 0 0.154 - 1 0.100 - 0.763 0.000 - -
-Surgical Site Infection (SSI) N/A N/A - N/A N/A - N/A N/A N/A N/A
-SSI-Abdominal Hysterectomy 0 0.052 - 0 0.040 - 0.726 0.000 - -
-SSI-Colon Surgery 1 0.514 - 0 0.413 - 0.754 0.000 - -
-Eligible Safety Measures: 1 out of 5 Unweighted Safety Domain Score:
Weighted Safety Domain Score:
-Calculated values were subject to rounding.
* "N/A" indicates no data were available or submitted for this measure.
Hospital Value-Based Purchasing
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Value-Based Percentage Payment Summary Report
Efficiency and Cost Reduction Detail Report
Provider: 190034
Reporting Period: Fiscal Year 2021
Baseline Period: 01/01/2017 - 12/31/2017
Performance Period: 01/01/2019 - 12/31/2019
FY 2021
Baseline Period Totals
FY 2021
Performance Period Totals HVBP Metrics
Efficiency Measures MSPB Amount (Numerator) Median MSPB Amount (Denominator) MSPB Measure MSPB Amount (Numerator) Median MSPB Amount (Denominator) MSPB Measure Achievement Threshold Benchmark Improvement Points Achievement Points Measure Score Medicare Spending per Beneficiary (MSPB) $22,247.68 $21,127.95 1.052997 $25,066.40 $22,212.62 1.128476 0.987266 0.852083 0 0 0 Eligible Efficiency and Cost Reduction Measure: 1 out of 1
Unweighted Efficiency and Cost Reduction Domain Score: 0.000000000000 Weighted Efficiency and Cost Reduction Domain Score: 0.000000000000 # of Episodes: 318
