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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 October 31, 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 January)

2. HCAPHS: (29 measures) data updated to report data through 17Q1_17Q4
Note: CMS is no longer reporting the HCAHPS pain measure from Hospital Compare and the downloadable databases, and has excluded it from the calculation of the HCAHPS Summary Star Rating. (Visit  https://www.hcahpsonline.org/en/  for more information relating New Communication About Pain Composite Measure Released: Beginning with patients discharged in January 2018, CMS will replace the current Pain Management questions (items 12, 13 and 14 on the HCAHPS Survey) with three new questions that focus on communication about pain.

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

  • 1 measure (SEP-1) reporting data 17Q1_17Q4

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

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

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

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

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

  • 4 measures (OP-3b, OP-5, OP_4 OP_2) data updated to report data through 17Q1_17Q4

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

  • 2 measures (EDV, OP-22) reporting data through 16Q1_16Q4 (data updated annually in January)
  • 6 measures (ED-1b, ED-2b, OP-18b, OP-20, OP-21, OP-23) data updated to report data through 17Q1_17Q4

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

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

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

  • 1 measure (VTE-6) data updated to report data through 17Q1_17Q4.

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

  • 1 measure (PC-01) data updated to report data through 17Q1_17Q4

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

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

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 17Q1_17Q4.

14. Unplanned Hospital Visits – including 30 day rates of readmission (12 measures)

  • 1 measure (OP-32) reporting data for 16Q1_16Q4 (data updated annually in January)
  • 11 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, EDAC-30-HF, EDAC-30-PN) reporting data through 14Q3_17Q2 (data updated annually in July)
  • 1 measure (READM-30-HOSP-WIDE) reporting data through 16Q3_17Q2 (data updated annually in July)

*note: new measure on hospital return days for patients with pneumonia (READM-30-PN)

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 January)
  • 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)