Quality Data Refresh on CMS Hospital Compare

The following is a summary of the latest quality data updated on CMS Hospital Compare. Data was updated on July 25, 2018.

1. Structural measures (8 measures)

• 7 measures (SM_SS_CHECK, SM-HS-PATIENT-SAF, SM-PART-NURSE, SM-PART-GEN-SURG, OP_25, OP_12, OP-17) reporting data through 16Q1_16Q4
• 1 measure (ACS Registery) data updated to report data through 16Q3_17Q2 (data updated annually in December)

2. HCAPHS: (32 measures) data updated to report data through 16Q4_17Q3

3. Timely & effective care: Sepsis care (1 measure) (new)

• 1 measure (SEP-1) reporting data 17Q1_17Q3

4. Timely & effective care: Cataract surgery outcome (1 measure)

• 1 measure (OP-31) reporting data through 16Q1_16Q4 (data updated annually in December)

5. Timely & effective care – Colonoscopy follow-up (2 measures)

• 2 measures (OP-29, OP-30) reporting data through 16Q1_16Q4 (data updated annually in December)

6. Timely & effective care: Heart Attack (4 measures)

• 4 measures (OP-3b, OP-5, OP_4 OP_2) data updated to report data through 16Q4_17Q3

7. Timely & effective care – Emergency Department (8 measures)

• 2 measures (EDV, OP-22) reporting data through 16Q1_16Q4 (data updated annually in December)
• 6 measures (ED-1b, ED-2b, OP-18b, OP-20, OP-21, OP-23) data updated to report data through 16Q4_17Q3

8. Timely & effective care – Preventive care (2 measures)

• 1 measure (IMM-2) reporting data through 16Q4_17Q1 (data updated annually in December)
• 1 measure (IMM-3) reporting data through 16Q4_17Q1 (data updated annually in October)

9. Timely & effective care – Blood clot prevention & treatment (1 measure)

• 1 measure (VTE-6) data updated to report data through 16Q4_17Q3.

10. Timely & effective care – Pregnancy & delivery care (1 measure)

• 1 measure (PC-01) data updated to report data through 16Q4_17Q3

11. Timely and Effective Care – Cancer care (1 measure)

• 1 measure (OP-33) reporting data for 16Q1_16Q4 (data updated annually in December)

12. Complications – Surgical complications (13 measures)

• 1 measure (COMP-HIP-KNEE) reporting data through 14Q2_17Q1 (data updated annually in July)
• 12 measures (PSI-90-SAFETY, PSI-3-ULCER, PSI-4-SURG-COMP, PSI-6-IAT-PTX, PSI-7-CVCBI, PSI-8-POST-HIP, PSI-9-POST-HEM, PSI-10-POST-KIDNEY, PSI-11-POST-RESP, PSI-12-POSTOP-PULMEMB-DVT, PSI-13-POST-SEPSIS, PSI-14-POSTOP-DEHIS, PSI-15-ACC-LAC) reporting data through 15Q4_17Q2 (data updated annually in July)

13. Complications & deaths – Infections (6 measures)

• 6 measures (HAI-1, HAI-2, HAI-3, HAI-4, HAI-5, HAI-6) data updated to report data through 16Q4_17Q3

14. Unplanned Hospital Visits – including 30 day rates of readmission (11 measures)

• 1 measure (OP-32) reporting data for 16Q1_16Q4 (data updated annually in December)
• 8 measures (READM-30-COPD, READM-30-AMI, READM-30-HF, READM-30-PN, READM-30-STK, READM-30-CABG, READM-30-HIP-KNEE, EDAC-30-AMI) reporting data through 14Q3_16Q2 (data updated annually in July)
• 1 measure (EDAC-30-PN) reporting data through 14Q3_16Q2 (data updated annually in December)
• 1 measure (READM-30-HOSP-WIDE) reporting data through 16Q3_17Q2 (data updated annually in July)

15. Complications & deaths – 30 day death rates (6 measures)

• 6 measures (MORT-30-COPD, MORT-30-AMI, MORT-30-HF, MORT-30-PN, MORT-30-STK, MORT-30-CABG) reporting data through 14Q3_17Q2 (data updated annually in July)

16. Use of medical imaging – Outpatient imaging efficiency (6 measures)

• 6 measures (OP-8, OP-9, OP-10, OP-11, OP-13, OP-14) reporting data through 16Q3_17Q2 (data updated annually in July)

17. Payment & value of care (5 measures)

• 1 measure (MSPB-1) reporting data through 16Q1_16Q4 (data updated annually in December)
• 3 measures (PAYM_30_AMI, PAYM_30_HF, PAYM_30_PN) reporting data through 14Q3_17Q2 (data is updated annually in July)
• 1 measure ( PAYM-90-HIP-KNEE) reporting data through 14Q2_17Q1 (data updated annually in July)

Note: Diagnosis coding switched from ICD-9 to ICD-10 in 2015. Data for the FY 2019 CMS PSI measures only represent the 21-month performance period of ICD-10 claims (10/1/2015 to 6/30/2017).

Measures and current data collection periods for VHA hospitals

1. Complications – Surgical complications (12 measures)

• 12 measures (PSI-4-SURG-COMP, PSI-6-IAT-PTX, PSI-7-CVCBI, PSI-8-POST-HIP, PSI-12-POSTOP-PULMEMB-DVT, PSI-13-POST-SEPSIS, PSI-14-POSTOP-DEHIS, PSI-15-ACC-LAC, PSI-3, PSI-9, PSI-10, PSI-11) reporting data through 15Q4_17Q3 (data updated Quarterly (until 36 months of data) then Annually July)

2. Readmissions & deaths- 30 day rates of readmission (4 measures)

• 4 measures (READM-30-COPD, READM-30-AMI, READM-30-HF, READM-30-PN) reporting data through 14Q3_17Q2 (data updated annually in July)

3. Readmissions & deaths- 30-day death (mortality) rates (4 measures)

• 4 measures (MORT-30-COPD, MORT-30-AMI, MORT-30-HF, MORT-30-PN) reporting data through 14Q3_16Q2 (data updated annually in July)