please help me with this data analysis question.

Thank you.

You are a decision support analyst at Sunshine General Hospital. The Director of the medical unit has asked for a report on readmissions for medical conditions at the facility (both overall and for certain CMGs). Specifically, the Director wants to know how Sunshine General Hospital compares to its peer hospitals in the region. Where is Sunshine General Hospital doing well, and where are the opportunities for improvement?

Facility Name	Clinical Cohorts	Fiscal Year
2017/18	2018/19	2019/20	2020/21
Hospital 1	Cardiovascular	N/A	N/A	N/A	N/A
	Congestive Heart Failure	N/A	N/A	43.8%	0.0%
	COPD	0.0%	0.0%	N/A	N/A
	Cerebrovascular Accident	N/A	0.0%	N/A	N/A
	Diabetes mellitus	N/A	0.0%	N/A	0.0%
	Gastrointestinal	11.8%	15.8%	11.8%	13.3%
	Pneumonia	N/A	N/A	0.0%	N/A
Hospital 2	Cardiovascular	10.6%	15.7%	10.9%	12.1%
	Congestive Heart Failure	24.3%	23.7%	27.8%	16.7%
	COPD	24.0%	25.3%	20.8%	26.6%
	Cerebrovascular Accident	0.0%	N/A	N/A	N/A
	Diabetes mellitus	N/A	N/A	N/A	N/A
	Gastrointestinal	18.8%	19.7%	14.1%	19.4%
	Pneumonia	23.3%	23.3%	21.2%	16.2%
Hospital 3	Cardiovascular	N/A	N/A	N/A	N/A
	Congestive Heart Failure	N/A	19.2%	N/A	38.9%
	COPD	N/A	23.8%	N/A	12.0%
	Cerebrovascular Accident	0.0%	N/A	N/A	N/A
	Diabetes mellitus	N/A	N/A	N/A	N/A
	Gastrointestinal	23.0%	16.4%	13.2%	16.1%
	Pneumonia	31.6%	7.7%	13.6%	0.0%
Hospital 4	Cardiovascular	N/A	N/A	N/A	0.0%
	Congestive Heart Failure	N/A	26.3%	N/A	N/A
	COPD	N/A	56.0%	0.0%	16.7%
	Cerebrovascular Accident	N/A	N/A	N/A	N/A
	Diabetes mellitus	N/A	N/A	N/A	0.0%
	Gastrointestinal	28.9%	26.1%	20.0%	N/A
	Pneumonia	0.0%	N/A	N/A	N/A
Hospital 5	Cardiovascular	12.0%	13.2%	N/A	11.1%
	Congestive Heart Failure	N/A	N/A	N/A	N/A
	COPD	20.8%	20.4%	20.0%	23.7%
	Cerebrovascular Accident	N/A	0.0%	N/A	N/A
	Diabetes mellitus	N/A	N/A	0.0%	N/A
	Gastrointestinal	16.0%	17.1%	16.9%	21.7%
	Pneumonia	18.2%	17.9%	N/A	18.9%
Hospital 6	Diabetes mellitus	7.1%	0.0%	2.0%	2.1%
	Gastrointestinal	7.5%	11.1%	9.5%	8.8%
	Pneumonia	8.1%	8.9%	4.6%	6.3%
Hospital 7	Cardiovascular	18.8%	11.4%	18.3%	16.7%
	Congestive Heart Failure	16.7%	19.3%	20.9%	21.7%
	COPD	18.0%	14.1%	13.2%	20.2%
	Cerebrovascular Accident	N/A	10.8%	N/A	N/A
	Diabetes mellitus	N/A	N/A	17.7%	N/A
	Gastrointestinal	16.7%	11.3%	13.5%	11.9%
	Pneumonia	11.7%	13.1%	8.6%	10.7%
Hospital 8	Cardiovascular	17.4%	16.5%	12.2%	21.9%
	Congestive Heart Failure	14.3%	29.8%	21.6%	22.8%
	COPD	23.3%	17.4%	21.3%	20.8%
	Cerebrovascular Accident	12.2%	N/A	N/A	N/A
	Diabetes mellitus	12.7%	18.1%	12.5%	23.4%
	Gastrointestinal	14.0%	14.6%	17.1%	15.8%
	Pneumonia	11.2%	10.8%	9.7%	16.9%
Hospital 9	Cardiovascular	N/A	N/A	N/A	N/A
	Congestive Heart Failure	0.0%	41.7%	N/A	0.0%
	COPD	N/A	14.7%	N/A	15.8%
	Cerebrovascular Accident	N/A	0.0%	N/A	N/A
	Diabetes mellitus	N/A	0.0%	N/A	N/A
	Gastrointestinal	25.0%	N/A	28.0%	21.7%
	Pneumonia	0.0%	N/A	N/A	0.0%
Hospital 10	Cardiovascular	15.6%	19.1%	18.9%	13.7%
	Congestive Heart Failure	25.7%	23.1%	18.5%	24.0%
	COPD	21.8%	14.0%	16.8%	16.0%
	Cerebrovascular Accident	7.5%	4.9%	11.5%	6.5%
	Diabetes mellitus	14.3%	22.2%	21.2%	18.1%
	Gastrointestinal	13.0%	15.3%	11.3%	11.5%
	Pneumonia	16.9%	14.2%	15.2%	15.3%
Hospital 11	Cardiovascular	15.7%	17.7%	18.0%	16.0%
	Congestive Heart Failure	36.1%	20.7%	30.3%	N/A
	COPD	21.1%	20.7%	16.4%	8.9%
	Cerebrovascular Accident	N/A	0.0%	0.0%	N/A
	Diabetes mellitus	N/A	N/A	23.8%	N/A
	Gastrointestinal	15.3%	13.1%	15.1%	16.2%
	Pneumonia	N/A	18.2%	10.9%	N/A
Hospital 12	Cardiovascular	16.4%	18.5%	20.0%	20.4%
	Congestive Heart Failure	23.6%	19.0%	30.6%	26.8%
	COPD	15.1%	18.2%	10.0%	16.1%
	Cerebrovascular Accident	N/A	N/A	N/A	N/A
	Diabetes mellitus	0.0%	N/A	N/A	N/A
	Gastrointestinal	14.1%	21.2%	17.8%	17.3%
	Pneumonia	N/A	17.2%	N/A	N/A
Hospital 13	Cardiovascular	25.0%	N/A	0.0%	N/A
	Congestive Heart Failure	17.2%	34.5%	17.9%	22.2%
	COPD	20.7%	16.2%	25.6%	20.2%
	Cerebrovascular Accident	N/A	N/A	0.0%	0.0%
	Diabetes mellitus	0.0%	N/A	N/A	N/A
	Gastrointestinal	21.9%	20.8%	25.0%	34.1%
	Pneumonia	26.9%	11.6%	15.8%	N/A
Sunshine General Hospital	Cardiovascular	24.1%	20.2%	20.2%	15.7%
	Congestive Heart Failure	14.6%	14.0%	20.4%	28.9%
	COPD	20.2%	16.1%	18.4%	23.1%
	Cerebrovascular Accident	N/A	0.0%	0.0%	N/A
	Diabetes mellitus	N/A	N/A	N/A	N/A
	Gastrointestinal	20.7%	19.1%	13.9%	13.4%
	Pneumonia	N/A	N/A	9.8%	12.3%
Hospital 15	Cardiovascular	21.1%	17.7%	14.0%	17.3%
	Congestive Heart Failure	22.1%	22.2%	23.5%	21.1%
	COPD	18.0%	17.3%	19.4%	20.2%
	Cerebrovascular Accident	8.2%	9.4%	9.4%	10.2%
	Diabetes mellitus	15.3%	16.8%	17.2%	14.7%
	Gastrointestinal	16.4%	18.9%	16.8%	18.7%
	Pneumonia	16.6%	11.7%	17.7%	14.7%
Hospital 16	Cardiovascular	10.5%	9.3%	9.8%	12.2%
	Congestive Heart Failure	22.5%	14.6%	17.0%	24.6%
	COPD	N/A	N/A	N/A	N/A
	Cerebrovascular Accident	N/A	0.0%	N/A
	Diabetes mellitus	N/A	N/A
	Gastrointestinal	N/A	N/A	N/A	N/A
	Pneumonia	0.0%	N/A	N/A	N/A
Hospital 17	Cardiovascular	12.0%	13.8%	8.6%	19.4%
	Congestive Heart Failure	21.4%	23.5%	24.3%	27.8%
	COPD	13.8%	19.5%	16.3%	13.8%
	Cerebrovascular Accident	N/A	8.5%	N/A	N/A
	Diabetes mellitus	47.1%	30.0%	32.4%	19.3%
	Gastrointestinal	14.5%	17.5%	18.8%	15.2%
	Pneumonia	9.0%	8.4%	13.5%	9.1%

Facility Name	Hospital Type	2020 Calendar Year
Index Cases	# Readmitted To Any Hospital	# Expected Readmissions to Any Hospital (Evidence Based Target)	Ratio - Readmission To Any Hospital	Ratio - Expected Readmissions to Any Hospital (Evidence Based Target)
Hospital 1	Small	104	12	15.31	11.5%	14.7%
Hospital 2	Small	375	71	57.68	18.9%	15.4%
Hospital 3	Small	193	29	29.05	15.0%	15.1%
Hospital 4	Small	96	10	12.92	10.4%	13.5%
Hospital 5	Small	208	38	29.41	18.3%	14.1%
Hospital 6	Specialty Chld	571	43	59.41	7.5%	10.4%
Hospital 7	Large Community	1,096	167	164.41	15.2%	15.0%
Hospital 8	Large Community	1,080	198	155.37	18.3%	14.4%
Hospital 9	Small	115	17	18.61	14.8%	16.2%
Hospital 10	Large Community	1,666	240	242.43	14.4%	14.6%
Hospital 11	Large Community	329	43	50.95	13.1%	15.5%
Hospital 12	Large Community	386	61	57.68	15.8%	14.9%
Hospital 13	Small	222	42	36.16	18.9%	16.3%
Sunshine General Hospital	Large Community	462	79	69.11	17.1%	15.0%
Hospital 15	Teaching	3,962	698	609.63	17.6%	15.4%
Hospital 16	Teaching	435	68	59.30	15.6%	13.6%
Hospital 17	Large Community	1,245	193	185.63	15.5%	14.9%

Facility Name	Hospital Type	FY2019/20	FY2020/21
Q1	Q2	Q3	Q4	Q1
# Readmissions	# Index Cases	%	# Readmissions	# Index Cases	%	# Readmissions	# Index Cases	%	# Readmissions	# Index Cases	%	# Readmissions	# Index Cases	%
Hospital 1	Small	<5	26	N/A	<5	17	N/A	<5	21	N/A	<5	18	N/A	<5	34	N/A
Hospital 2	Small	19	100	19.0%	12	74	16.2%	20	113	17.7%	17	102	16.7%	17	92	18.5%
Hospital 3	Small	5	45	11.1%	<5	33	N/A	7	56	12.5%	7	52	13.5%	5	46	10.9%
Hospital 4	Small	<5	24	N/A	<5	21	N/A	5	29	17.2%	7	32	21.9%	7	27	25.9%
Hospital 5	Small	11	53	20.8%	8	39	20.5%	9	61	14.8%	16	66	24.2%	9	50	18.0%
Hospital 6	Specialty Chld	12	137	8.8%	11	132	8.3%	6	153	3.9%	14	160	8.8%	8	141	5.7%
Hospital 7	Large Community	52	298	17.4%	48	249	19.3%	39	283	13.8%	49	283	17.3%	41	303	13.5%
Hospital 8	Large Community	62	291	21.3%	49	248	19.8%	43	238	18.1%	45	272	16.5%	61	288	21.2%
Hospital 9	Small	<5	22	N/A	<5	36	N/A	5	32	15.6%	<5	14	N/A	<5	31	N/A
Hospital 10	Large Community	69	463	14.9%	60	373	16.1%	56	423	13.2%	59	459	12.9%	69	440	15.7%
Hospital 11	Large Community	6	80	7.5%	6	64	9.4%	13	92	14.1%	10	98	10.2%	10	96	10.4%
Hospital 12	Large Community	17	91	18.7%	13	96	13.5%	11	96	11.5%	18	107	16.8%	13	109	11.9%
Hospital 13	Small	12	50	24.0%	11	46	23.9%	7	65	10.8%	7	63	11.1%	6	47	12.8%
Sunshine General Hospital	Large Community	15	123	12.2%	23	119	19.3%	26	111	23.4%	17	96	17.7%	8	92	8.7%
Hospital 15	Teaching	165	1016	16.2%	190	980	19.4%	182	1026	17.7%	168	994	16.9%	195	1067	18.3%
Hospital 16	Teaching	22	118	18.6%	11	87	12.6%	13	103	12.6%	9	95	9.5%	16	110	14.5%
Hospital 17	Large Community	53	336	15.8%	46	277	16.6%	42	292	14.4%	34	294	11.6%	57	310	18.4%