Benchmark (%) 86.61

Achieve Pts Improve Pts

Patient Experience Consistency Points (max 20)

Understanding My Value-Based Purchasing Report This report displays data from the Fiscal Year 2017 Value-Based Purchasing (VBP) Program, which affects payments from

Patient Experience Domain Score (earned pts + consistency pts)/100

Improve Pts

Safety Score (points earned/potential points)**

Benchmark Achieve Pts Improve Pts

Efficiency Score (points earned/potential points)

Baseline: 01/01/2013–12/31/2013 Performance: 01/01/2015–12/31/2015

0.954545 1.000000 Benchmark

Baseline: 10/01/2010–06/30/2012 Performance: 10/01/2013–06/30/2015 Improve Pts

Clinical Care Domain Score (earned pts/potential pts)***

Measure Baseline Performance Floor (%) Threshold (%) Score* Communication w ith nurses 58.14 78.19 Communication w ith doctors 63.58 80.51 88.80 Responsiveness of hospital staff 37.29 65.05 80.01 Pain management 49.53 70.28 78.33 Communication about medications 41.42 62.88 73.36 Cleanliness and quietness 44.32 65.30 79.39 Discharge information 64.09 85.91 91.23 Overall rating of hospital 35.99 70.02 84.60

Measure Baseline Performance Threshold Benchmark Achieve Pts Score* 1AHRQ PSI-90 Composite 0.777936 0.547889 2CLABSI Central line associated BSI 0.457 0.000 2CAUTI Catheter associated UTI 0.845 0.000 2SSI Colon 0.751 0.000 2SSI Abdominal hysterectomy 0.698 0.000 2Composite SSI 2Clostridium difficile 0.750 0.000 2Methicillin-resistant Staphylococcus aureus 0.799 0.000

Measure Baseline Performance Threshold Score* MSPB-1 Medicare spending per beneficiary

Measure Baseline Performance Threshold Achieve Pts Improve Pts Score* AMI-7a Fibrinolytic agent received w ithin 30 minutes of hospital arrival IMM-2 Influenza Immunization 0.951607 0.997739 PC-01 Elective Delivery Prior to 39 Completed Weeks Gestation

0.031250 0.000000

Measure Baseline Performance Threshold Benchmark Achieve Pts Score* 30-day mortality, acute myocardial infarction 0.851458 0.871669 30-day mortality, heart failure 0.881794 0.903985 30-day mortality, pneumonia 0.882986 0.908124

Clinical Care Outcome Measures Earned Points

Your Total Performance Score^ State National

Base Operating DRG Payment Reduction

Safety earned points

Value-Based Incentive

Value-Based Incentive Payment Adjustment Factor

Safety (20%)

Your Net Change in Base Operating DRG Payment

1Baseline: 10/01/2010–06/30/2012 Performance: 10/01/2013–06/30/2015 2Baseline: 01/01/2013-12/31/2013 Performance: 01/01/2015-12/31/2015

Clinical Care (30%)

VALUE-BASED PURCHASING PERFORMANCE SCORE****

Efficiency and Cost Reduction (25%)

Outcomes Measures (25%)

Fiscal Year 2017 Value-Based Purchasing Report

****Total Score = Patient Experience Score*25% + Safety Score*20% + Eff iciency and Cost Score*25% + Clinical Process Score*5% + Clinical Outcome Score*25%

Patient- and Caregiver-Centered Experience of Care/Care Coordination (25%)

Baseline: 01/01/2013–12/31/2013 Performance: 01/01/2015–12/31/2015

Process Measures (5%)

Efficiency Earned Points

Clinical Care Process Measures Earned Points

Patient Experience Earned Points (max 80)

Baseline: 01/01/2013–12/31/2013 Performance: 01/01/2015–12/31/2015

October 1, 2016–September 30, 2017. Baseline and Performance Periods vary by domain and are detailed below.

Achievement Points: awarded by comparing a hospital’s performance period rates with all hospitals’ baseline period rates

• Rate at or above the benchmark = 10 points• Rate less than achievement threshold = 0 points• Rate at or above the threshold but less than the benchmark =

1–9 points

Improvement Points: awarded by comparing a hospital’s baseline and performance rates

• Rate at or above the benchmark = 9 points (hospitals that haverates at or better than the benchmark but do not improve from their baseline period rate will receive 0 improvement points, as no improvement was actually observed)

• Rate less than or equal to baseline period rate = 0 points• Rate between the baseline period rate and the benchmark = 0–9

points

Measure Score: the greater of the achievement points and improvement points for a measure (for a measure to be considered “eligible,” it must meet the minimum case requirements during the performance period)

Unweighted Domain Score: CMS normalizes domain scores by converting a hospital’s earned points (sum of the measure scores) to a percentage of total points that were possible based on the number of eligible measures

Benchmark: Average (mean) performance of the top ten percent ofhospitals during the baseline period

Achievement Threshold: performance at the 50th percentile (median) of hospitals during the baseline period

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Understanding My Value-Based Purchasing Report

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•

This material was prepared by Health Services Advisory Group, Inc., the Quality Improvement Organization for Florida under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. QN-11SOW-D.1-09152016-01

Patient Experience of Care Consistency Score: = (20 x lowest dimension score) – 0.5

Lowest Dimension Score: (performance period rate – floor) / (achievement threshold – floor) Floor: rate of lowest performing hospitals during baseline period

SSI Scores: at least one of the two strata (abdominal hysterectomy or colon surgery) must have at least one predicted infection

Combined SSI Score: a weighted average is computed based on the number of predicted infections and the points awarded to each stratum

Efficiency Measure: claims-based; includes risk-adjusted and price-standardized payments for Part A and Part B services provided three days prior to hospital admission through 30 days after hospital discharge

Base Operating DRG Payment Reduction: the FY17 VBP Program is funded through a 2.00% reduction from participating hospitals’ base operating DRG payment amounts

Value-Based Incentive Payment Percentage: portion of the base operating DRG payment amount your hospital earned back. This can be less than, equal to, or greater than the original 2.00% withhold.

Net Change in Base Operating DRG Payment Amount: amount your FY17 base operating DRG payment amounts will be changed = value-based incentive payment percentage – 2.00%

Value-Based Incentive Payment Adjustment Factor: value used to translate a hospital’s Total Performance Score into the value based incentive payment. This is what every claim amount is multiplied by to get the final payment amount.

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Total Performance Score: Sum of weighted domain scores; requires “scores from” at least 3 of 4 domains.

Measure Baseline Performance Floor (%) Threshold (%) Benchmark (%) Achieve Pts Improve Pts Score* Communication w ith nurses 58.14 78.19 86.61 Communication w ith doctors 63.58 80.51 88.80 Responsiveness of hospital staff 37.29 65.05 80.01 Pain management 49.53 70.28 78.33 Communication about medications 41.42 62.88 73.36 Cleanliness and quietness 44.32 65.30 79.39 Discharge information 64.09 85.91 91.23 Overall rating of hospital 35.99 70.02 84.60

Measure Baseline Performance Threshold Benchmark Achieve Pts Improve Pts Score* 1AHRQ PSI-90 Composite 0.777936 0.547889 2CLABSI Central line associated BSI 0.457 0.000 2CAUTI Catheter associated UTI 0.845 0.000 2SSI Colon 0.751 0.000 2SSI Abdominal hysterectomy 0.698 0.000 2Composite SSI 2Clostridium difficile 0.750 0.000 2Methicillin-resistant Staphylococcus aureus 0.799 0.000

Measure Baseline Performance Threshold Benchmark Achieve Pts Improve Pts Score* MSPB-1 Medicare spending per beneficiary

Measure Baseline Performance Threshold Benchmark Achieve Pts Improve Pts Score* AMI-7a Fibrinolytic agent received w ithin 30 minutes of hospital arrival

0.954545 1.000000

IMM-2 Influenza Immunization 0.951607 0.997739 PC-01 Elective Delivery Prior to 39 Completed Weeks Gestation

0.031250 0.000000

Measure Baseline Performance Threshold Benchmark Achieve Pts Improve Pts Score* 30-day mortality, acute myocardial infarction 0.851458 0.871669 30-day mortality, heart failure 0.881794 0.903985 30-day mortality, pneumonia 0.882986 0.908124

Clinical Care Outcome Measures Earned Points

Your Total Performance Score^ State National

Base Operating DRG Payment Reduction

Safety earned points

Value-Based Incentive

Value-Based Incentive Payment Adjustment Factor

Safety (20%)

Your Net Change in Base Operating DRG Payment

1Baseline: 10/01/2010–06/30/2012 Performance: 10/01/2013–06/30/2015 2Baseline: 01/01/2013-12/31/2013 Performance: 01/01/2015-12/31/2015

Clinical Care (30%)

VALUE-BASED PURCHASING PERFORMANCE SCORE****

Efficiency and Cost Reduction (25%)

Outcom es Measures (25%) Baseline: 10/01/2010–06/30/2012 Performance: 10/01/2013–06/30/2015

Fiscal Year 2017 Value-Based Purchasing Report

****Total Score = Patient Experience Score*25% + Safety Score*20% + Eff iciency and Cost Score*25% + Clinical Process Score*5% + Clinical Outcome Score*25%

Patient- and Caregiver-Centered Experience of Care/Care Coordination (25%)

Baseline: 01/01/2013–12/31/2013 Performance: 01/01/2015–12/31/2015

Process Measures (5%) Baseline: 01/01/2013–12/31/2013 Performance: 01/01/2015–12/31/2015

Clinical Care Domain Score (earned pts/potential pts)***

Patient Experience Consistency Points (max 20) Patient Experience Domain Score (earned pts + consistency pts)/100

Efficiency Score (points earned/potential points)

Efficiency Earned Points

Clinical Care Process Measures Earned Points

Patient Experience Earned Points (max 80)

Baseline: 01/01/2013–12/31/2013 Performance: 01/01/2015–12/31/2015

Safety Score (points earned/potential points)**