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MISSION Act Quality Measure Community Comparison for Puget Sound, WA Health Care System

Last Updated: 02/14/2024
Next Update: 05/14/2024
Data is updated Quarterly
Measure Measure Direction VA Hospital Results Community Benchmark VA vs. Community
Effective Care
Adequate Control of High Blood Pressure Higher is better 68.80 % (2) 57.90 % (2) BETTER
Cardiovascular Disease Patients Receiving Statin Therapy Higher is better 88.40 % (2) 83.20 % (2) BETTER
Colorectal Cancer Screening Higher is better 75.20 % (2) 64.10 % (2) BETTER
Comprehensive Diabetes Care - Blood Pressure Control Higher is better 68.50 % (2) 60.90 % (2) BETTER
Death rate for Congestive Heart Failure Lower is better 6.10 (1) 11.80 (1) BETTER
Death rate for COPD Lower is better 9.30 (1) 9.20 (1) SAME
Death rate for Heart Attack Lower is better 12.00 (1) 12.60 (1) SAME
Death rate for Pneumonia Lower is better 13.90 (1) 18.20 (1) SAME
Diabetes Patients Receiving Statin Therapy Higher is better 76.50 % (2) 64.20 % (2) BETTER
Flu Shots for Adults Ages 19-65 Higher is better 20.80 % (2) 56.30 % (2) WORSE
Follow-Up After Hospitalization For Mental Illness 30 days (Total) Higher is better 95.30 % (2) 70.20 % (2) BETTER
Follow-Up After Hospitalization For Mental Illness 7 days (Total) Higher is better 80.30 % (2) 47.80 % (2) BETTER
Non-recommended PSA-based Screening in Older Men (Prostate Screening) Lower is better 12.80 % (2) 27.60 % (2) BETTER
Poor Blood Glucose Control Among Diabetics Lower is better 19.20 % (2) 35.70 % (2) BETTER
Screening for Breast Cancer Higher is better 78.50 % (2) 68.80 % (2) BETTER
Screening for Cervical Cancer Higher is better 80.10 % (2) 72.30 % (2) BETTER
Smoking and Tobacco Cessation - Advise Smokers to Quit Higher is better 98.90 % (2) 79.80 % (2) BETTER
Safe Care
Catheter-associated urinary tract infection Lower is better 0.330 2.016 BETTER
Central line-associated bloodstream infection Lower is better 0.750 2.175 BETTER
Death among surgical inpatients Lower is better 136.31 (10) 143.04 (10) TOO FEW CASES
Veteran-Centered Care
Care Coordination Higher is better 61.00 % (12) 60.00 % (12) SAME
Care Transition Higher is better 62.00 % (1) 50.00 % (1) BETTER
Overall Rating of Hospital Higher is better 69.00 % (1) 69.00 % (1) SAME
Overall Rating of Provider Higher is better 74.00 % (12) 73.00 % (12) SAME
* 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