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Quality Data Refreshed on CMS Hospital Compare

The following is a summary of the latest quality data updated on CMS Hospital Compare.  Data was updated on July 30, 2019.

1. Structural measures (6 measures)
6 measures (ACS Registery, SM_SS_CHECK,  SM-HS-PATIENT-SAF, OP_25, OP_12, OP-17) reporting data through 17Q1_17Q4 (data updated annually in January)
Note: 2 measures (SM-PART-NURSE, SM-PART-GEN-SURG) were not included in this update

2. HCAPHS: (29 measures) data updated to report data through 17Q4_18Q3

3.Timely & effective care: Sepsis care  (1 measure)
1 measure (SEP-1) reporting data 17Q4_18Q3  

4.Timely & effective care: Cataract surgery outcome (1 measure)
1 measure (OP-31) reporting data through 17Q1_17Q4 (data updated annually in January)

5. Timely & effective care – Colonoscopy follow-up (2 measures)
2 measures (OP-29, OP-30) reporting data through 17Q1_17Q4 (data updated annually in January)

6. Timely & effective care: Heart Attack (3 measures)
3 measures (OP-3b, OP-5,  OP-2, OP-1) data updated to report data through 17Q4_18Q3
Note: 2 measures (OP-4 and OP-1) were not included in this update.

7. Timely & effective care – Emergency Department (6 measures)
2 measures (EDV, OP-22) reporting data through 17Q1_17Q4 (data updated annually in January)
4 measures (ED-1b, ED-2b, OP-18b, OP-23) data updated to report data through 17Q4_18Q3

8. Timely & effective care – Preventive care (2 measures)
2 measures (IMM-2) through 17Q4_18Q1 (data updated annually in January (IMM-2); October (IMM-3-OP-27-FAC-ADHPCT))

9. Timely & effective care – Blood clot prevention & treatment (1 measure)
1 measure (VTE-6) data updated to report data through 17Q4_18Q3.  

10. Timely & effective care – Pregnancy & delivery care (1 measure)
1 measure (PC-01) data remains unchanged, reporting data through 17Q4_18Q3

11. Timely and Effective Care – Cancer care (1 measure)
1 measure (OP-33) reporting data for 17Q1_17Q4 (data updated annually in January)

12. Timely and Effective Care – Use of medical imaging (6 measures)
 6 measures (OP-8, OP-9,  OP-10, OP-11, OP-13, OP-14) data updated to report data through 17Q3_18Q2 (data updated annually in July)

13. Complications – Surgical complications (13 measures)
1 measure (COMP-HIP-KNEE) reporting data through 15Q2_18Q1 (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 16Q3_18Q2 (data updated annually in July)

14. 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 17Q4_18Q3.

15. Unplanned Hospital Visits – including 30 day rates of readmission (11 measures)
1 measure (OP-32) reporting data for 17Q1_17Q4 (data updated annually in January)
9 measures (READM-30-COPD, READM-30-AMI, READM-30-HF, READM-30-PN, READM-30-CABG, READM-30-HIP-KNEE, EDAC-30-AMI, EDAC-30-HF, EDAC-30-PN) reporting data through 15Q3_18Q2 (data updated annually in July)
1 measure (READM-30-HOSP-WIDE) reporting data through 16Q3_17Q2 (data updated annually in July)
Note – 1 measure (READM-30-STK) not included in this update

16. 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 15Q3_18Q2 (data updated annually in July)

17. Psychiatric unit services – Preventive care and screening (5 measures) *(new)
New measures:
SMD Screening for metabolic disorders
SUB-1 Alcohol use screening
TOB-1 Tobacco use screening
IPFQR-IMM-2 Influenza immunization
FLUVAC-HCP Influenza vaccination coverage among healthcare personnel

3 measures (SMD, SUB-1, TOB-1) reporting data through 17Q1_17Q4 (data updated annually in January)
2 measures (IPFQR-IMM-2, FLUVAC-HCP) reporting data through 17Q1_18Q1 (data updated annually in January)

18. Psychiatric unit services – Substance use treatment (8 measures) *(new)
New measures:
SUB-2 Alcohol use brief intervention provided or offered
SUB-2A Alcohol use brief intervention
SUB-3 Alcohol and other drug use disorder treatment provided or offered at discharge
SUB-3A Alcohol and other drug use disorder treatment at discharge
TOB-2 Tobacco use treatment provided or offered
TOB-2A Tobacco use treatment (during the hospital stay)
TOB-3 Tobacco use treatment provided or offered at discharge
TOB-3A Tobacco use treatment at discharge

8 measures (SUB-2, SUB-2A, SUB-3, SUB-3A, TOB-2, TOB-2A, TOB-3, TOB-3A) reporting data through 17Q1-_17Q4 (data updated annually in January)

19. Psychiatric unit services- Patient safety (2 measures) *(new)
New measures:
HBIPS-2 Hours of physical-restraint use
HBIPS-3 Hours of seclusion

2 measures (HBIPS-2, HBIPS-3) reporting data through 17Q1_17Q4 (data updated annually in January)

20. Psychiatric unit services- Patient experience of care (1 measure) *(new)
New measure:
PEOC Assessment of patient experience of care

1 measure (PEOC) reporting data through 17Q1_17Q4 (data updated annually in January)

21. Psychiatric unit services- Facility use of technology (2 measures) *(new)
New measures:
EHR Use of an Electronic Health Record (EHR)
EHR-HISP Use of an Electronic Health Record (EHR)

2 measures (EHR, EHR-HISP) reporting data through 17Q1_17Q4 (data updated annually in January)

22. Psychiatric unit services- Follow up care (5 measures) *(new)
New measures:
TR-1 Transition record with specified elements received by discharged patients
TR-2 Timely transmission of transition record
HBIPS-5 Patients discharged on multiple antipsychotic medications with appropriate justification
FUH-30 Follow-up after hospitalization for mental illness
FUH-7 Follow-up after hospitalization for mental illness

3 measures (TR-1, TR-2, HBIPS-5) reporting data through 17Q1_17Q4 (data updated annually in January)
2 measures (FUH-30, FUH-7) reporting data through 16Q3_17Q2

23. Psychiatric unit services- Unplanned readmissions (1 measure) *(new)
New measure:
READM-30-IPF 30-day all-cause unplanned readmission following psychiatric hospitalization in an inpatient psychiatric facility (IPF)

1 measure (READM-30-IPF) reporting data through 15Q3_17Q2

24. Payment & value of care – Clinical Episode-Based Payment (6 measures)
6 measures (CEBP-AA, CEBP-CELLULITIS, CEBP-CHOLE-CDE, CEBP-GI, CEBP-KIDNEY-UTI, CEBP-SFUSION) reporting data through 17Q1_17Q4  (data updated annually in January)

18. Payment & value of care – Medicare Spending Per Beneficiary (1 measure)
1 measure (MSPB-1)  reporting data through 17Q1_17Q4  (data updated annually in January)

19. Payment & value of care – Payment Measures
3 measures (PAYM_30_AMI, PAYM_30_HF, PAYM_30_PN) reporting data through 15Q3_18Q2   (data is updated annually in July)
1 measure (PAYM-90-HIP-KNEE) reporting data through 15Q2_18Q1   (data updated annually in July)

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