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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 January 29, 2020.

1. Structural measures (3 measures)

  • 3 measures (ACS-Registry, OP-12, OP-17) data updated to report data through 18Q1_18Q4 (ACS-Registry data updated quarterly, OP-12, OP-17 data updated annually in January)

Note: 3 measures (SM_SS_CHECK, SM-HS-PATIENT-SAF, OP_25) not included in this update

2. HCAPHS: (29 measures) data updated to report data through 18Q2_19Q1 (data updated quarterly)

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

  • 1 measure (SEP-1) data updated to report data 18Q2_19Q1  (data updated quarterly)

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

  • 1 measure (OP-31) data updated to report data through 18Q1_18Q4 (data updated annually in January)

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

  • 2 measures (OP-29, OP-30) data updated to report data through 18Q1_18Q4 (data updated annually in January)

6. Timely & effective care: Heart Attack (3 measures)

  • 3 measures (OP-3b, OP-5,  OP-2) data updated to report data through 18Q2_19Q1 (data updated quarterly)

7. Timely & effective care – Emergency Department (6 measures)

  • 2 measures (EDV, OP-22) data update to report data through 18Q1_18Q4 (data updated annually in January)
  • 4 measures (ED-2b, OP-18b, OP-18c, OP-23) data updated to report data through 18Q1_18Q4 (data updated quarterly)

Note: 1 measure ED-1b not included in this update. 1 measure OP-18c (Average (median) time psychiatric or other mental health patients spent in the emergency department before leaving from the visit) data not posted on Hospital Compare, but available on data.medicare.gov

8. Timely & effective care – Preventive care (1 measure)

  • 1 measure (IMM-3-OP-27-FAC-ADHPCT) data unchanged, reporting data through 18Q4_19Q1 (data updated annually in October)

Note: 1 measure (IMM-2) not included in this update

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

  • 1 measure (PC-01) data updated to report data through 18Q2_19Q1 (data updated quarterly)

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

  • 1 measure (OP-33) data updated to report data for 18Q1_18Q4 (data updated annually in January)

11. 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)

12. 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)

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 18Q2_19Q1 (data updated quarterly)

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

  • 1 measure (OP-32) data updated to report data through 16Q1_18Q4 (data updated annually in January)
  • 3 measures (OP-35-ADM, OP-35-ED, OP-36) data updated to report data through 18Q1_18Q4 (New measures)
  • 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)

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) data unchanged, reporting data through 15Q3_18Q2 (data updated annually in July)

16. Psychiatric unit services – Preventive care and screening (2 measures)

  • 1 measure (SMD) data updated to report data through 18Q1_18Q4 (data updated annually in January)
  • 1 measure (IPFQR-IMM-2) data updated to report data through 18Q4_19Q1 (data updated annually in January)

Note: 3 measures (SUB-1, TOB-1, FLUVAC-HCP) not included in this update

17. 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 updated to report data through 18Q1_18Q4 (data updated annually in January)

18. Psychiatric unit services- Patient safety (2 measures)

  • 2 measures (HBIPS-2, HBIPS-3) data updated to reportdata through 18Q1_18Q4 (data updated annually in January)

19. Psychiatric unit services- Follow up care (5 measures)

  • 3 measures (TR-1, TR-2, HBIPS-5) data updated, reporting data through 18Q1_18Q4 (data updated annually in January)
  • 2 measures (FUH-30, FUH-7) data updated, reporting data through 17Q3_18Q2 (data updated annually in January)

20. Psychiatric unit services- Unplanned readmissions (1 measure)

  • 1 measure (READM-30-IPF) data updated, reporting data through 16Q3_18Q2 (data updated annually in January)

21. Payment & value of care – Medicare Spending Per Beneficiary (1 measure)

  • 1 measure (MSPB-1) data updated, reporting data through 18Q1_18Q4  (data updated annually in January)

22. Payment & value of care – Payment Measures (4 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)

Measures not included in this update (January)

  • Structural measures – 3 measures (SM_SS_CHECK, SM-HS-PATIENT-SAF, OP_25)
  • Timely & effective care – Blood clot prevention & treatment: 1 measures (VTE-6)
  • Timely & effective care – Emergency Department: 1 measure ED-1b
  • Timely & effective care – Preventive care: 1 measure IMM-2
  • Psychiatric unit services- Preventive care and screening: 3 measures (SUB-1, TOB-1, FLUVAC-HCP)
  • Psychiatric unit services- Patient experience of care: 1 measure PEOC
  • Psychiatric unit services- Facility use of technology: 2 measures EHR, EHR-HISP
  • Payment & value of care – Clinical Episode-Based Payment: 6 measures – CEB

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One Comment

  1. Martina Dolan Post author | January 30, 2020

    More on this topic:

    CMS.gov: CMS Announces Updated Quality Information Including Star Ratings on Hospital Compare – https://www.cms.gov/blog/cms-announces-updated-quality-information-including-star-ratings-hospital-compare

    Modern Healthcare: CMS updates Hospital Compare star ratings ahead of methodology changes – https://www.modernhealthcare.com/safety-quality/cms-updates-hospital-compare-star-ratings-ahead-methodology-changes

    American Hospital Association: CMS updates overall hospital star ratings – https://www.aha.org/news/headline/2020-01-29-cms-updates-overall-hospital-star-ratings

    Kaiser Health News: Hospital Star Ratings Get Refresh Despite Pushback From Industry That Methodology Is Flawed – https://khn.org/morning-breakout/hospital-star-ratings-get-refresh-despite-pushback-from-industry-that-methodology-is-flawed/

    Becker’s Hospital Review: 228 hospitals with a 1 star rating from CMS – https://www.beckershospitalreview.com/quality/228-hospitals-with-a-1-star-rating-from-cms.html

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