Page 44 - COPR- April2018

KPI Name System Leader Measure Definition

Inpatient
Numerator: Number of top-box responses
Denominator: Total responses
Based on the Press Ganey survey question rating hospitals from 0 to 10.
Ratings of 9 or 10 are considered “top-box.” The system and region scores
Inpatient & ED Phyllis Doulaveris are averages of the individual hospital scores, weighted by hospital volume.
Pat Davis-Hagens Emergency Department (ED)
Patient Experience
Numerator: Number of top-box responses
Denominator: Total responses
Based on the Press Ganey survey question rating ED care. The top-box
score is a rating of 5. The system and region scores are averages of the
individual ED scores, weighted by ED volume.
Press Ganey calculates the composite patient satisfaction percentile
ranking which compares Mercy’s patient satisfaction survey responses with
those of other clients in the Press Ganey national database. The patient
Staci Lucius satisfaction percentile ranking is a composite score reflective of survey
Medical Practice Dr. Marvin responses from each of Press Ganey’s Medical Practice survey domains:
Patient Experience
Narcelles Access, Moving Through Your Visit, Nurse/Assistant, Care Provider,
Personal Issues, and Overall Assessment.
This metric is intended to reflect the overall experience ranking of patient
satisfaction within Mercy Health Physicians.

Acute care total reimbursement for direct care minus total costs (direct and
Profit/Loss per Daniel Hurry indirect). Measures the difference between Medicare reimbursement for
Medicare Patient direct costs and indirect/fixed costs in the acute care setting for 5
by Condition Dr. Michael Hooker diagnostic groups, including: heart failure, sepsis, vascular surgery,
general surgery, and total joint replacement (TJR).

Admits per 1,000 MSSP members (continuously assigned) for the following
conditions: heart failure, COPD, acute care composite - dehydration,
Ambulatory Care
Sensitive Deirdre Beluan pneumonia, and urinary tract infection (UTI).
Dr. S. Ramalingam Successfully managing ACSC admissions will drive results in value-based
Conditions
care contracts and performance in CPC+ by reducing the total cost of care
and improving both quality of care and quality of life.
Numerator: Rolling 12 months of domestic admissions for the at risk
Medicare Advantage Plans (including ED admits)
Domestic Denominator: Rolling 12 months of total admissions for the at risk Medicare
Admissions to Deirdre Beluan Advantage Plans (including ED admits)
Dr. Matt Owens
Improve Quality This metric reflects the benefits of maintaining a high level of in-network
utilization to improve quality, lower cost, reduce redundancy of testing, and
enhance care coordination.
Numerator: Population Health Patients (inpatient) with an Epic
7 Day Follow Up Cathy Follmer Readmission Risk Score of 14% or greater, discharged to home, and had
(high readmission Amy Baldridge a follow up visit scheduled to occur within a 7 day discharge
risk PHP) Denominator: Population Health Patients (inpatient) with an Epic
Readmission Risk Score of 14% or greater, discharged to home.

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