Boston - FY2014Q3 Measure Measure Unit Preferred Direction Facility Benchmark 10th-50th-90th ptile 1. Acute care Standardized Mortality Ratio (SMR) O/E љ 0.860 0.528 0.528 - 0.847 - 1.163 2. Acute care 30-day Standardized Mortality Ratio (SMR30) O/E љ 0.788 0.740 0.740 - 0.937 - 1.154 O/E љ 0.916 0.616 0.616 - 0.977 - 1.385 a. Catheter associated urinary tract infection inf/1k device days љ 2.334 0.000 0.000 - 1.056 - 2.883 b. Central line associated bloodstream infection inf/1k device days љ 0.478 0.000 0.000 - 0.509 - 1.990 c. Ventilator associated Pneumonia inf/1k device days љ 1.609 0.000 0.000 - 0.000 - 3.536 inf/1k bed days љ 0.137 0.000 0.000 - 0.103 - 0.352 O/E љ 1.006 0.000 0.000 - 0.786 - 1.292 1. AMI RSMR % љ 2. CHF RSMR % љ 4.755 6.469 6.469 - 7.521 - 9.129 3. Pneumonia RSMR % љ 8.443 8.025 8.025 - 9.687 - 11.708 1. AMI RSRR % љ 12.699 12.913 12.913 - 13.347 - 13.835 2. CHF RSRR % љ 19.680 18.792 18.792 - 20.003 - 21.820 3. Pneumonia RSRR % љ 15.442 13.834 13.834 - 15.161 - 16.549 Adjusted length of stay days љ 4.662 3.842 3.842 - 4.665 - 5.639 % ј 98.347 99.130 95.991 - 97.804 - 99.130 wct % ј 89.025 92.688 87.432 - 90.035 - 92.688 1. Patient satisfaction score (0-300) ј 259.377 2. Best places to work score (1-100) ј 68.030 68.078 56.979 - 63.445 - 68.078 a. Overall job satisfaction score (1-5) ј 3.825 3.794 3.544 - 3.692 - 3.794 b. Satisfaction with organization score (1-5) ј 3.675 3.655 3.271 - 3.491 - 3.655 c. Recommend my organization as a good place to work score (1-5) ј 3.956 3.926 3.481 - 3.735 - 3.926 % љ 2.159 2.900 2.900 - 6.041 - 10.275 hosp/1000 pts љ 31.909 23.316 23.316 - 29.492 - 36.950 a. Primary care new patient wait time <=30 days from create date % ј 70.754 92.160 45.111 - 73.849 - 92.160 b. Primary care established patient prospective wait time <=30 days % ј 99.133 99.493 92.385 - 97.903 - 99.493 a. Specialty care new patient wait time <=30 days from create date % ј 82.806 83.493 54.778 - 69.449 - 83.493 b. Specialty care established patient prospective wait time <=30 days % ј 98.300 98.812 93.349 - 96.970 - 98.812 a. Mental health new patient wait time <=14 days from create date % ј 83.589 82.952 55.766 - 70.615 - 82.952 b. Mental health established patient prospective wait time <=14 days % ј 93.476 98.858 90.208 - 96.563 - 98.858 seconds љ 30.116 21.436 21.436 - 60.811 - 176.152 % љ 7.095 4.389 4.389 - 8.847 - 21.675 casemix adjusted % ј 55.678 54.526 38.411 - 46.780 - 54.526 Acute care mortality Avoidable adverse events 1. In-hospital complications 2. Health care associated infections (HAI) d. Methicillin-resistant Staphylococcus aureus (MRSA) infection 3. Patient safety indicator (PSI) CMS 30-day Risk Standardized Mortality Rate (RSMR) CMS 30-day Risk Standardized Readmission Rate (RSRR) Performance measures 1. Inpatient performance measures (ORYX) 2. Outpatient performance measures (HEDIS) Customer satisfaction 3. Registered nurse turnover rate Ambulatory Care Sensitive Condition hospitalizations 270.109 242.174 - 258.058 - 270.109 Access 1. Primary care wait time 2. Specialty care wait time 3. Mental health wait time 4. Call responsiveness a. Call center speed in responding to calls in seconds b. Call center abandonment rate 5. PCMH survey Access composite and selected questions a. Access composite b. Get an urget care appointment as soon as needed casemix adjusted % ј 56.663 59.228 40.552 - 51.420 - 59.228 c. Get a routine care appointment as soon as needed casemix adjusted % ј 64.377 64.780 48.061 - 57.127 - 64.780 score (0-100) ј 95.403 96.093 91.008 - 94.386 - 96.093 Efficiency (1/SFA) Providence - FY2014Q3 Measure Measure Unit Preferred Direction Facility Benchmark 10th-50th-90th ptile 1. Acute care Standardized Mortality Ratio (SMR) O/E љ 0.838 0.528 0.528 - 0.847 - 1.163 2. Acute care 30-day Standardized Mortality Ratio (SMR30) O/E љ 1.247 0.740 0.740 - 0.937 - 1.154 O/E љ 1.216 0.616 0.616 - 0.977 - 1.385 a. Catheter associated urinary tract infection inf/1k device days љ 0.000 0.000 0.000 - 1.056 - 2.883 b. Central line associated bloodstream infection inf/1k device days љ 0.000 0.000 0.000 - 0.509 - 1.990 c. Ventilator associated Pneumonia inf/1k device days љ 5.634 0.000 0.000 - 0.000 - 3.536 inf/1k bed days љ 0.211 0.000 0.000 - 0.103 - 0.352 O/E љ 1.316 0.000 0.000 - 0.786 - 1.292 1. AMI RSMR % љ 2. CHF RSMR % љ 9.792 6.469 6.469 - 7.521 - 9.129 3. Pneumonia RSMR % љ 9.881 8.025 8.025 - 9.687 - 11.708 1. AMI RSRR % љ 13.648 12.913 12.913 - 13.347 - 13.835 2. CHF RSRR % љ 20.710 18.792 18.792 - 20.003 - 21.820 3. Pneumonia RSRR % љ 15.411 13.834 13.834 - 15.161 - 16.549 Adjusted length of stay days љ 4.408 3.842 3.842 - 4.665 - 5.639 % ј 97.966 99.130 95.991 - 97.804 - 99.130 wct % ј 86.692 92.688 87.432 - 90.035 - 92.688 1. Patient satisfaction score (0-300) ј 263.169 2. Best places to work score (1-100) ј 63.827 68.078 56.979 - 63.445 - 68.078 a. Overall job satisfaction score (1-5) ј 3.692 3.794 3.544 - 3.692 - 3.794 b. Satisfaction with organization score (1-5) ј 3.466 3.655 3.271 - 3.491 - 3.655 c. Recommend my organization as a good place to work score (1-5) ј 3.738 3.926 3.481 - 3.735 - 3.926 % љ 6.579 2.900 2.900 - 6.041 - 10.275 hosp/1000 pts љ 46.726 23.316 23.316 - 29.492 - 36.950 a. Primary care new patient wait time <=30 days from create date % ј 58.440 92.160 45.111 - 73.849 - 92.160 b. Primary care established patient prospective wait time <=30 days % ј 97.567 99.493 92.385 - 97.903 - 99.493 a. Specialty care new patient wait time <=30 days from create date % ј 87.708 83.493 54.778 - 69.449 - 83.493 b. Specialty care established patient prospective wait time <=30 days % ј 97.168 98.812 93.349 - 96.970 - 98.812 a. Mental health new patient wait time <=14 days from create date % ј 84.451 82.952 55.766 - 70.615 - 82.952 b. Mental health established patient prospective wait time <=14 days % ј 92.908 98.858 90.208 - 96.563 - 98.858 seconds љ 70.004 21.436 21.436 - 60.811 - 176.152 % љ 8.160 4.389 4.389 - 8.847 - 21.675 casemix adjusted % ј 51.872 54.526 38.411 - 46.780 - 54.526 Acute care mortality Avoidable adverse events 1. In-hospital complications 2. Health care associated infections (HAI) d. Methicillin-resistant Staphylococcus aureus (MRSA) infection 3. Patient safety indicator (PSI) CMS 30-day Risk Standardized Mortality Rate (RSMR) CMS 30-day Risk Standardized Readmission Rate (RSRR) Performance measures 1. Inpatient performance measures (ORYX) 2. Outpatient performance measures (HEDIS) Customer satisfaction 3. Registered nurse turnover rate Ambulatory Care Sensitive Condition hospitalizations 270.109 242.174 - 258.058 - 270.109 Access 1. Primary care wait time 2. Specialty care wait time 3. Mental health wait time 4. Call responsiveness a. Call center speed in responding to calls in seconds b. Call center abandonment rate 5. PCMH survey Access composite and selected questions a. Access composite b. Get an urget care appointment as soon as needed casemix adjusted % ј 55.040 59.228 40.552 - 51.420 - 59.228 c. Get a routine care appointment as soon as needed casemix adjusted % ј 61.357 64.780 48.061 - 57.127 - 64.780 score (0-100) ј 94.541 96.093 91.008 - 94.386 - 96.093 Efficiency (1/SFA)