Latest Quality Data Refresh on CMS Hospital Compare

Hospital quality data updated on CMS Hospital Compare on October 30, 2019 as follows:

1. Structural measures (6 measures)
   • 5 measures (SM_SS_CHECK, SM-HS-PATIENT-SAF, OP_25, OP_12, OP-17) data unchanged, reporting data through 17Q1_17Q4 (data updated annually in January)
   • 1 measure (ACS-Registry) data updated to report data through 17Q4_18Q3 (data updated quarterly)
2. HCAPHS: (29 measures) data updated to report data through 18Q1_18Q4 (data updated quarterly)
3. Timely & effective care: Sepsis care (1 measure) 1 measure (SEP-1)
   • data updated to report data 18Q1_18Q4 (data updated quarterly)
4. Timely & effective care: Cataract surgery outcome (1 measure)
   • 1 measure (OP-31) data unchanged, 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) data unchanged, 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 18Q1_18Q4 (data updated quarterly)
7. Timely & effective care – Emergency Department (6 measures)
   • 2 measures (EDV, OP-22) data unchanged, 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 18Q1_18Q4 (data updated quarterly)
8. Timely & effective care – Preventive care (2 measures)
   • 1 measure (IMM-2) data unchanged, reporting data through 17Q4_18Q1 (data updated annually in January)
   • 1 measure (IMM-3-OP-27-FAC-ADHPCT) data updated to report data through 18Q4_19Q1 (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 18Q1_18Q4 (data updated quarterly)
10. Timely & effective care – Pregnancy & delivery care (1 measure)
    • 1 measure (PC-01) data updated to report data through 18Q1_18Q4 (data updated quarterly)
11. Timely and Effective Care – Cancer care (1 measure)
    • 1 measure (OP-33) data unchanged, 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 unchanged, reporting data through 17Q3_18Q2 (data updated annually in July)
13. Complications – Surgical complications (13 measures)
    • 1 measure (COMP-HIP-KNEE) data unchanged, 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) data unchanged, 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 18Q1_18Q4 (data updated quarterly)
15. Unplanned Hospital Visits – including 30 day rates of readmission (11 measures)
    • 1 measure (OP-32) data unchanged, 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) data unchanged, reporting data through 15Q3_18Q2 (data updated annually in July)
    • 1 measure (READM-30-HOSP-WIDE) data unchanged, reporting data through 16Q3_17Q2 (data updated annually in July)
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) data unchanged, reporting data through 15Q3_18Q2 (data updated annually in July)
17. Psychiatric unit services – Preventive care and screening (5 measures)
    • 3 measures (SMD, SUB-1, TOB-1) data unchanged, reporting data through 17Q1_17Q4 (data updated annually in January)
    • 2 measures (IPFQR-IMM-2, FLUVAC-HCP) data unchanged, reporting data through 17Q1_18Q1 (data updated annually in January)
18. Psychiatric unit services – Substance use treatment (8 measures)
    • 8 measures (SUB-2, SUB-2A, SUB-3, SUB-3A, TOB-2, TOB-2A, TOB-3, TOB-3A) data unchanged, reporting data through 17Q1-_17Q4 (data updated annually in January)
19. Psychiatric unit services- Patient safety (2 measures)
    • 2 measures (HBIPS-2, HBIPS-3) data unchanged, reporting data through 17Q1_17Q4 (data updated annually in January)
20. Psychiatric unit services- Patient experience of care (1 measure)
    • 1 measure (PEOC) data unchanged, reporting data through 17Q1_17Q4 (data updated annually in January)
21. Psychiatric unit services- Facility use of technology (2 measures)
    • 2 measures (EHR, EHR-HISP) data unchanged, reporting data through 17Q1_17Q4 (data updated annually in January)
22. Psychiatric unit services- Follow up care (5 measures)
    • 3 measures (TR-1, TR-2, HBIPS-5) data unchanged, reporting data through 17Q1_17Q4 (data updated annually in January)
    • 2 measures (FUH-30, FUH-7) data unchanged, reporting data through 16Q3_17Q2 (data updated annually in January)
23. Psychiatric unit services- Unplanned readmissions (1 measure)
    • 1 measure (READM-30-IPF) data unchanged, reporting data through 15Q3_17Q2 (data updated annually in January)
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) data unchanged, reporting data through 17Q1_17Q4 (data updated annually in January)
25. Payment & value of care – Medicare Spending Per Beneficiary (1 measure)
    • 1 measure (MSPB-1) data unchanged, reporting data through 17Q1_17Q4 (data updated annually in January)
26. Payment & value of care – Payment Measures
    • 3 measures (PAYM_30_AMI, PAYM_30_HF, PAYM_30_PN) data unchanged, reporting data through 15Q3_18Q2 (data is updated annually in July)
    • 1 measure (PAYM-90-HIP-KNEE) data unchanged, reporting data through 15Q2_18Q1 (data updated annually in July)

Note: Measures not included in this update (October) or previous update (July)
1. Structural measures – 2 measures (SM-PART-NURSE, SM-PART-GEN-SURG)
2. Timely & effective care – Heart Attack: 2 measures (OP-4 and OP-1)
3. Unplanned Hospital Visits including 30 day rate of readmission – 1 measure (READM-30-STK)