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MISSION Act Quality Measure Community Comparison for Central Alabama 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 69.50 % 57.20 % (2) BETTER
Comprehensive Diabetes Care - Blood Pressure Control Higher is better 72.00 % 54.40 % (2) BETTER
Death rate for Congestive Heart Failure Lower is better 9.30 11.30 (1) N/A
Death rate for COPD Lower is better 7.30 8.40 (1) N/A
Death rate for Heart Attack Lower is better N/A (13) 12.40 (10) N/A
Death rate for Pneumonia Lower is better 14.60 16.60 (1) N/A
Flu Shots for Adults Ages 19-65 Higher is better * 53.40 % (2) N/A
Follow-Up After Hospitalization For Mental Illness 30 days (Total) Higher is better 94.00 % 66.70 % (2) BETTER
Follow-Up After Hospitalization For Mental Illness 7 days (Total) Higher is better 70.70 % 42.80 % (2) BETTER
Poor Blood Glucose Control Among Diabetics Lower is better 22.40 % 37.10 % (2) BETTER
Screening for Breast Cancer Higher is better 88.80 % 69.00 % (2) BETTER
Screening for Cervical Cancer Higher is better 78.90 % 73.10 % (2) BETTER
Smoking and Tobacco Cessation - Advise Smokers to Quit Higher is better 100.00 % 79.80 % (2) BETTER
Safe Care
Catheter-associated urinary tract infection Lower is better 2.110 2.016 (1,6) SAME
Central line-associated bloodstream infection Lower is better 0.000 2.175 (1,6) BETTER
Veteran-Centered Care
Care Coordination Higher is better 54.00 % 60.00 % (12) WORSE
Care Transition Higher is better 54.00 % 52.00 % (1) SAME
Overall Rating of Hospital Higher is better 67.00 % 71.00 % (1) SAME
Overall Rating of Provider Higher is better 69.00 % 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