Quality of Indicators three years compairson report

Jewish Renaissance Medical Center Quality of Care Indicators Three Years Comparison Dr. Nonkulie Dladla, M.D., M.S. Chief Medical Officer

The Jewish Renaissance Medical Center is proud topresent our most recent Quality of Indicators ThreeYear Comparison Report. Our report includesvarious clinical data collected from 2014-2016.This report reflects both our commitment to PatientCentered Medical Home (PCMH) standards andour efforts towards building a transparentrelationship with our patients and community.

Jewish Renaissance Medical Center Early Entry into Prenatal Care 70.00% 66.62% 60.00% 61.85% 61.73% 50.00% 40.00% 32.68% 33.02% 30.00% 28.40% 20.00% 5.47% 7.87% Year 2014 10.00% 4.98% Year 2015 Year 2016 0.00% First Trimester Second Trimester Third Trimester` YEAR Women Having First Visit with Grantee ( a ) Women Having First Visit with Another Provider Percentage First Trimester Second Trimester Third Trimester First Trimester Second( bTr)imester Third Trimester First Trimester Second Trimester Third TrimesterYear 2014 413 222 38 28 11 1 61.85% 32.68% 5.47%Year 2015 395 177 33 46 11 0 66.62% 28.40% 4.98%Year 2016 371 197 34 29 17 0 61.73% 33.02% 7.87%

Jewish Renaissance Medical Center Childhood Immunization80.00%70.00%60.00%50.00% 75.30%40.00% 62.86%30.00% 34.29%20.00%10.00%0.00% Year 2014 Year 2015 Year 2016Childhood ImmunizationYEAR Total Patients with Number Charts Sampled Number of Patients Percentage 2nd Birthday (a ) or EHR total (b ) Immunized (c ) MMEAESSUARUE:REP:erPceerncteangetaogfecohifldcrheinld2reynea2rsyeofarasgeofwahgoerewcheoiveredcaegieveadppargoepraiaptpervoapcrciiantees vbayctchineiers2bndybtihrtehidra2ynd birthdayYear 2014 486 70 44 62.86%Year 2015 417 417 314 75.30%Year 2016 452 70 24 34.29%

Jewish Renaissance Medical Center Cervical Cancer Screening64.00% 63.06%63.00%62.00% 60.70%61.00%60.00% 59.68%59.00%58.00%57.00% Year 2014 Year 2015 Year 2016Cervical Cancer ScreeningYEAR Total Female Patients Number Charts Sampled Number of Patients Tested Percentage 23-64 years of Age (a ) or EHR Total (b ) (c ) MEASURE:Percentage of women 23-64 years of age, who received one or more Pap tests to screen for cervical cancerYear 2014 6,031 6,031 3,599 59.68%Year 2015 5,664 5,664 3,572 63.06%Year 2016 6,158 6,158 3,738 60.70%

Jewish Renaissance Medical Center Child and Adolescent Weight Assessment and Counseling100.00% 92.86% 90.00% 80.00% 82.86% 71.43% 70.00% Year 2014 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Year 2015 Year 2016Child and Adolescent Weight Assessment and CounselingYEAR Total Patients Aged Number Charts Sampled Number of Patients with Counseling Percentage 3 – 17 (a ) or EHR Total (b ) and BMI Documented (c ) MMEEASSUARUER:EP:ePrceerncteangteaogfePoafticehntilsdargeend 23 ytheraorusgohf1a7gweitwhhCoournesceeliinvgeadnadgBeMaI pDporcoumpreinattse vaccines by their 2nd birthdayYear 2014 6,440 70 58 82.86%Year 2015 71.43%Year 2016 6,884 70 50 92.86% 6,563 70 65

Jewish Renaissance Medical Center Body Mass Index (BMI) Screening and Follow-Up 78.57% 78.57%80.00%70.00%60.00% 48.57%50.00%40.00%30.00%20.00%10.00%0.00% Year 2014 Year 2015 Year 2016Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-UpYEAR Total Patients 18 Number Charts Sampled Number of Patients with BMI Charted and Percentage and Over (a ) or EHR Total (b ) Follow-Up Plan Documented as Appropriate (c )MMEEAASUSURER:EP:PeercrceenntatgaegeofoPf aPtaietinetns tasgaegde1d81a8nadnodveorvweritwh i(t1h) (B1M) IBdMocI udmoceunmteedtaendda(n2d) f(o2l)lofowl-luopwp-ulapnpdloacnudmoecnutmedeinf tBeMdI iifsBoMutIsiidseounotsrimdaelnpoarrmamael tpearrsametersYear 2014 10,562 70 34 48.57%Year 2015 10,791 70 55 78.57%Year 2016 11,314 70 55 78.57%

Jewish Renaissance Medical Center Tobacco Use Screening and Cessation Intervention100.00% 91.94% 94.93% 90.00% 80.00% 75.74% 70.00% Year 2014 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Year 2015 Year 2016Tobacco Use Screening and Cessation InterventionYEAR Total Patients 18 Number Charts Sampled NNuummbbeerr ooff PpaattieienntstsAsAssessesesdsdfofroTroTboabccaocUcoseUse Percentage and Over (a ) or EHR Total (b ) anadndPrPorvoivdideeddIInntteerrvveennttioionnififaaToTboabcbcaocUoseUrs(ecr) (c )MEASURE: PMeErAceSnUtRaEg:ePeorfcePnattaiegnetosfapgaetdie1n8tsaangdedol1d8eyrewahrsoa(n1d) owledreer wschreoe(1n)ewdefroer stcorbeaecnceoduosfer toonbeacocromuosereotniemoersmwoitrheintim24esmwointthhins intervention 24 months ianntedrivfeindteionntifainedditfoidbeentaiftioebdatcocboeuasetorb(a2c)croeuceseivre(d2)creescseaitvieodn cceosusnasteiolnincgounselingYear 2014 9,823 9,823 7,440 75.74%Year 2015 9,812 9,812 9,021 91.94%Year 2016 8,565 8,565 8,131 94.93%

Jewish Renaissance Medical Center Asthma Treatment Plan 98.42% 10.980.96 94.29%0.940.92 88.73% 0.90.880.860.840.82 Year 2014 Year 2015 Year 2016Asthma Treatment PlanYEAR ToTtaotlaPlaPtaiteiennytss AAggeedd55tthhrorouguhgh6464 Number Charts Sampled Number Nouf mPabteiernotfsPwaittihenAtcscwepitthable Plan Percentage wwiitthh PPeerrssiisstteennt tAAstshymham(aa) (a) or EHR Total (b ) Aceptab(lce)Plan (c )MMEEAASSUURREE::PPeerrcceennttaaggee ooff PPaattiieennttssaaggeedd51t8hraonudghov64erwwitihthPe(1rs)iBstMenItdAosctuhmmeatwehdoahnadd(a2n) fAoclcloepwt-aubplepTlarenadtmoceunmt Pelnanted if BMI is outside normal parametersYear 2014 143 70 66 94.29%Year 2015 71 71 63 88.73%Year 2016 317 317 312 98.42%

Jewish Renaissance Medical Center CCoorroonaryy AArrtteerryyDDisieseasaese(C(ACDA)D: )L:ipLidpiTdhTehraeprypay92.00%91.00%90.00%89.00%88.00% 91.03%87.00%86.00% 87.14%85.00% 86.30%84.00%83.00% Year 2014 Year 2015 Year 2016CoCroornoanrayryAArtretreyryDDisieseasaese(C(CAADD):):LiLpiipdidThTehrepraypyYEAR TToottaall PPaattiieennttssAAggeedd1188 aanndd Number Charts Sampled NuNmubmebreor fofPPataiteiennttssPPrreessccrriibbeedd a Percentage OOvveerr wwiitthh CCAADD DDiiaaggnnoossissis(a()a ) or EHR Total (b ) LAipLiidpidLoLwoweerirninggTThheerrpaapyy((cc)) 87.14% 86.30%MEMAESAUSRUER:EP:ePrecercnetnatgaegeofoPf aPtaiteinentstsaaggeedd1188aannddoollddeerrwwiitthh adidaigangonsoissoisfoCfACDAwDhwo hwoerweeprreespcrreibsecrdibaeldipaidlilpoiwdelroiwngetrhinegratphyerpy 91.03%Year 2014 87 70 61 63Year 2015 73 73 71Year 2016 78 78

Jewish Renaissance Medical Center IIsscchheemmiicc VVaassccuullaarr DDiisseeaassee ((IIVVDD))::UUsseeooffAAssppiirriinnoorrAAnnttitithhrroommbboottiiccTThheerpraapyy 1 98.44%0.980.960.940.92 89.70% 0.9 87.95%0.880.860.840.82 Year 2014 Year 2015 Year 2016IsIcshcehmemiciVcaVsacusclaurlDarisDeaisseea(sIeVD(I)V: DU)s:eUosfeAospfiArisnpoirriAnnotrithArnotmitbhorotimc TbhoetricpaTyherapyYEAR TTootatal lPPaatiteiennttssAAggeedd 1188 aanndd OOvveerr wwiitthhIIVVDD Number Charts Sampled NumNubemrboefrPoaftiPenattsiewnittshwAistphirAinspoirrionther Percentage DiDagiangonsossis or AMMI,I,CCAABBGG, ,oorrPPTTCCAAPProrocecdeudruere(a()a ) or EHR Total (b ) or otheArntAitnhirtohmrobmotoicticThTehrearppyay (c ) MEASURE: Percentage of PaMtiEeAntSsUaRgEe:dPe1r8ceanndtaogledeorfwPiathtiedniatgsnaogseisdo1f 8IVaDnodroAldMeI,rCwAiBtGh,aodriPaCgnI porsoisceodfuIrVeDwoitrhAaMspI,irCinABorGa, nother antithrombotic or PCI procedure with aspiritnheorraapny owthhoerwaenretitphrreoscmribboetdicatlhipeirdplaoywwerhinogwtheererappryescribed a lipid lowering therpyYear 2014 233 233 209 89.70%Year 2015 87.95%Year 2016 224 224 197 98.44% 257 257 253

Jewish Renaissance Medical Center CoClorloercetcatlaCl CanancecerlSSccrreeening 50.00% 27.08% 48.57% 27.73% 45.00% Year 2014 Year 2015 Year 2016 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00%CoCloolroercetcatlaClaCnacencl eScrrSecerneienngingYEAR Total Patients Aged 50 through 75 Number Charts Sampled NNuummbbeerrooffPPaattiieennttsswwiitthh aapppprroopprriiaate Percentage (a ) or EHR Total (b ) sSccrreeeennininggffoorrCCoolloorreeccttal Cancceerr(c ) 27.08% 48.57% MEASURMEE:APSeUrRcEe:nPteargceenotfaPgeatoiefnPtastiaegnetds a5g0etdh5r0ouagnhd7th5ryoeuagrhs7o5fyaegaerswohfoagheadwahpophraodpraipapterospcrrieaetenisncgrefeonricnogloforreccotalol rceacntaclecrancer 27.73%Year 2014 3,180 3,180 861Year 2015Year 2016 3,002 70 34 3,329 3,329 923

Jewish Renaissance Medical Center Patient Screened for Depression and Follow-Up0.6 51.78%0.5 40.87%0.40.30.2 5.71%0.1 0 Year 2014 Year 2015 Year 2016Patient Screened for Depression and Follow-UpYEAR Total Patients Aged 12 and Older Number Charts Sampled Number pf Patients Screened for Depression and Percentage (a ) or EHR Total (b ) and Follow-Up Plan Documented as Appropriate (c ) 5.71% 40.87% MEASURE:Percentage of Patients aged 12 and older who were (1) screened for depression with a standardized tool 51.78% and if screening was positive (2) had a follow-up plan documentedYear 2014 14,365 70 4Year 2015Year 2016 13,501 13,501 5,518 14,463 14,463 7,489

Jewish Renaissance Medical Center Dental Sealants 35.00% 30.00% 25.00% 33.51% 20.00% 15.00% 24.07% 10.00% 5.00% 0.00% Year 2015 Year 2016Dental SealantsYEAR ToTtaoltaPlaPtiaetinetnstsAAgegedd66ThTrhorouugghh99IdIdeennttiiffiieedd Number Charts Sampled Number ofPatients with Sealants to First Molars Percentage asaMs Mooddeerraattee ttoo HHiigghhRRiisskkffoorrCCaavritieiess((aa)) or EHR Total (b ) (c ) 33.51% 24.07% MEASURE:MPeEArcSeUnRtEa:gPeeorcfePnattaigeentosfaPgaetdie6ntTshargoeudgh509 aIdnedntthifrioeudgahs7M5oydeearrastoeftaogHeiwghhoRihskadfoarpCparovpitriieastewsitchreSeenailnagntfsortocoFliorsret cMtaollacrasncerYear 2014 185 185 62Year 2015 1,043 1,043 251Year 2016

Jewish Renaissance Medical Center Deliveries and Birth Weight 870 823900800700600 397 466 384 482500400300200100 08 1 54 Year 2014 Live Births: <1500 grams 18 14 Year 2015 0 Year 2016 Live Births: 1500-2499 Live Births: =>2500 grams Patients Who Delivered grams Patients who Delivered Live Births: <1500 grams Live Births: 1500-2499 grams Live Births: =>2500 gramsYear 2014 482 0 18 466Year 2015 870 8 54 823Year 2016 397 1 14 384

Jewish Renaissance Medical Center Hypertension3,000 2,577 2,5772,500 1,966 2,054 1,966 2,0542,0001,500 1,2961,000 1,091 1,112500 0 Number Charts Sampled Patients with HTN Controlled Total Hypertensive Patients Year 2014 Year 2015 Year 2016HypertensionYEAR Total Hypertensive Patients Number Charts Sampled Patients with HTN Controlled (a) or EHR Total (b ) (c ) 1,091Year 2014 1,966 1,966 1,112Year 2015 2,054 2,054 1,296 2,577Year 2016 2,577

Jewish Renaissance Medical Center Diabetes : Hemoglobin A1c Poor Control 1,4711,6001,400 1,042 1,0821,2001,000 665 590 564 800 456 600 514 452 400 200 0 Patients with Hba1c<8% Patients with Hba1c >9% Number Charts Sampled Year 2014 Year 2015 Year 2016Diabetes : Hemoglobin A1c Poor Control YEAR Total Patients with Diabetes Number Charts Sampled Patients with Hba1c<8% Patients with Hba1c >9% (a) or EHR Total (b ) (d)Year 2014 1,042 (c) 590Year 2015 1,082 456Year 2016 1,471 1,042 452 564 1,082 514 1,471 665

Jewish Renaissance Medical Center Seasonal Flu vaccine30,000 25,182 25,38225,00020,000 23,87015,00010,000 2,895 2,710 3,744 5,000 0 Total of Patients Number of Seasonal Flu vaccine Patients Year 2014 Year 2015 Year 2016Seasonal Flu vaccineYEAR Total of Patients Number of Seasonal Flu vaccine Patients PercentageYear 2014 25,182 2,895 11.50% 10.68%Year 2015 25,382 2,710 15.68%Year 2016 23,870 3,744

Jewish Renaissance Medical Center Thank You !