Carolina Cardenas

Valley Regional Medical Center NPI1679810378

Performance

Public Reporting for Performance Scores

More Details

Final MIPS Score

89.35 out of 100

Score Breakdown

Quality Category Score 79.96
PI Category Score 0

 

IA Category Score 40
Cost Category Score 0
Total Patients: 0
Source of Scores: group

Performance Details

Measure Code Measure Title Performance Rate Patient Count Star Value Five Star Benchmark Collection Type
IA_EC_BE_22 Improved Practices that Engage Patients Pre-Visit
IA_EC_AHE_6 Provide Education Opportunities for New Clinicians
IA_EC_BE_13 Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.
IA_EC_CC_8 Implementation of documentation improvements for practice/process improvements
IA_EC_PM_7 Use of QCDR for feedback reports that incorporate population health
IA_EC_PSPA_16 Use of decision support and standardized treatment protocols
IA_EC_EPA_1 Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record
IA_EC_PM_11 Regular Review Practices in Place on Targeted Patient Population Needs
IA_EC_PSPA_19 Implementation of formal quality improvement methods, practice changes, or other practice improvement processes
IA_EC_PSPA_2 Participation in MOC Part IV
IA_EC_PSPA_11 Participation in CAHPS or other supplemental questionnaire
IA_EC_PSPA_20 Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes
IA_EC_PSPA_28 Completion of an Accredited Safety or Quality Improvement Program
IA_EC_PSPA_7 Use of QCDR data for ongoing practice assessment and improvements
IA_EC_PSPA_8 Use of Patient Safety Tools
MIPS_EC_424_overall Perioperative Temperature Management 100 65 REG
MIPS_EC_430_overall Prevention of Post-Operative Nausea and Vomiting (PONV) Combination Therapy 100 57 REG
QCDR_EC_AQI62_overall Obstructive Sleep Apnea: Patient Education 98 86 QCDR