3 Quality Weight: The Quality Weight for each Participant is based on each of the following three quality categories: Healthcare-Associated Infections (35%), Core Measures (20%), and Patient Experience (45%) (as defined below). For performance at or below the minimum acceptable (threshold) level of performance with respect to each individual quality metric, a Participant will not receive a payout for that metric. For target level of performance with respect to each individual quality metric, a Participant may receive 100% of the Quality-weighted portion of the PEP Opportunity tied to that individual quality metric. Payouts for performance above the threshold and below the target levels of quality metric performance for Participants will be calculated by the Committee in its sole discretion using straight-line interpolation.
In the event the Company exceeds its consolidated target level of EBITDA adopted by the Committee with respect to the EBITDA measure, the Committee shall multiply the payout percentage calculated for each individual quality metric which qualifies for 100% payout as described above by the EBITDA payout percentage. In the event the Companys actual EBITDA is less than 90% of the target level of EBITDA set by the Committee, there will be no payout with respect to the quality-weighted portion of PEP opportunity.
Healthcare Associated Infections metrics are Central Line-Associated Blood Stream Infection (CLABSI), Catheter-Associated Urinary Tract Infection (CAUTI), Surgical Site Infections (SSI), Methicillin Resistant Staphylococcus Aureus (MRSA) and Clostridium difficile (C. diff ) for the Centers for Medicare and Medicaid Services (CMS) reportable patient populations as defined by the Centers for Disease Control and Preventions National Healthcare Safety Network (CDC NHSN).
The Core Measures metric includes the following inpatient core measures: Sepsis Bundle (SEP-1) and Early Elective Delivery (PC-01) as developed by The Joint Commission and the Centers for Medicare and Medicaid Services (CMS) and set forth in the Specifications Manual for National Hospital Inpatient Quality Measures.
The Patient Experience metric for inpatients is the CMS Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) overall rating top box score (CMS defines the top box score for the overall rating question to be a response of nine or ten on the CMS HCAHPS survey). The Patient Experience metric for emergency room patients is the Press Ganey Emergency Room overall rating top box score (Press Ganey defines the top box score for the overall question to be a response of Very Good on the Patient Experience Emergency Room survey).
In the event the applicable governmental agency adjusts any of the definitions of the quality metrics set forth above during the performance period, appropriate adjustments shall be made to the targets, or results, or both, to properly account for such changes, in the Committees sole discretion.
In the event the Company acquires or opens new facilities during the measurement period, the newly opened or acquired facilities will be excluded for purposes of calculating the Companys performance on the quality weighted metrics.
The threshold, target and maximum EBITDA performance levels and other goals shall be set by the Committee in its sole discretion. The maximum dollar amount that may be paid to any Participant under the Program with respect to the Fiscal Year shall not exceed the amount set forth in Section 5(f)(iii) of the 2006 Plan.