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MISSION Act Quality Measure Community Comparison for Bronx, NY Health Care System

Measure Measure Direction VA Hospital Results Community Benchmark VA vs. Community
Effective Care
Adequate Control of High Blood Pressure Higher is better 67.70 % 59.40 % (2) BETTER
Comprehensive Diabetes Care - Blood Pressure Control Higher is better 70.80 % 60.20 % (2) BETTER
Death rate for Congestive Heart Failure Lower is better 8.10 11.30 (1) N/A
Death rate for COPD Lower is better 7.80 8.40 (1) N/A
Death rate for Heart Attack Lower is better 12.50 12.40 (1) N/A
Death rate for Pneumonia Lower is better 17.80 16.60 (1) N/A
Flu Shots for Adults Ages 19-65 Higher is better * 54.20 % (2) N/A
Follow-Up After Hospitalization For Mental Illness 30 days (Total) Higher is better 96.20 % 74.60 % (2) BETTER
Follow-Up After Hospitalization For Mental Illness 7 days (Total) Higher is better 79.10 % 57.60 % (2) BETTER
Poor Blood Glucose Control Among Diabetics Lower is better 18.50 % 32.10 % (2) BETTER
Screening for Breast Cancer Higher is better 78.00 % 69.60 % (2) BETTER
Screening for Cervical Cancer Higher is better 94.20 % 75.60 % (2) BETTER
Smoking and Tobacco Cessation - Advise Smokers to Quit Higher is better 95.80 % 79.80 % (2) BETTER
Safe Care
Catheter-associated urinary tract infection Lower is better 2.470 2.016 (1,6) WORSE
Central line-associated bloodstream infection Lower is better 4.020 2.175 (1,6) WORSE
Death among surgical inpatients Lower is better 149.52 143.04 (10) N/A
Veteran-Centered Care
Care Coordination Higher is better 61.00 % 60.00 % (12) SAME
Care Transition Higher is better 52.00 % 46.00 % (1) SAME
Overall Rating of Hospital Higher is better 69.00 % 63.00 % (1) SAME
Overall Rating of Provider Higher is better 74.00 % 73.00 % (12) SAME

Last Updated: 05/2023

* Incomplete score; influenza season is ongoing.
1 -CMS Care Compare benchmark
2 -NCQA HEDIS benchmark.
3 -AHRQ CAHPS Database benchmark
4 -Benchmark Calculated from CMS data
5 -CMS Nursing Home Compare benchmark
6 -VA Only Data. For FY21, benchmark data is pre-COVID-19; VA data is inclusive of the pandemic timeframe
9 -Greater than 1000 lines days are needed to report the HAI measure
10 -The number of cases is too few to report
11 -Due to first year reporting with CMS, prior year facility rate is not available
12 -VA National Score
13 -No data for this reporting period