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Quality Data Refresh on CMS Hospital Compare

Hospital quality data was updated on CMS Hospital Compare as part of the quarterly data refresh on April 22, 2020. The following is a summary of the refresh:

1. Structural measures (3 measures)

  • 3 measures (ACS-Registry, OP-12, OP-17) data updated to report data through 18Q2_19Q1 (ACS-Registry data updated quarterly, OP-12, OP-17 data updated annually in January)

2. HCAPHS: (29 measures) data updated to report data through 18Q3_19Q2 (data updated quarterly)

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

  • 1 measure (SEP-1) data updated to report data 18Q3_19Q2  (data updated quarterly)

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

  • 1 measure (OP-31) remains unchanged reporting data through 18Q1_18Q4 (data updated annually in January)

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

  • 2 measures (OP-29, OP-30) remains unchanged reporting data through 18Q1_18Q4 (data updated annually in January)

6. Timely & effective care: Heart Attack (2 measures)

  • 2 measures (OP-3b, OP-2) data updated to report data through 18Q3_19Q2 (data updated quarterly)

Note: data not reported for 1 measure OP-5

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

  • 2 measures (EDV, OP-22) data remains unchanged reporting 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 18Q3_19Q2 (data updated quarterly)

Note: 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-FAC-ADHPCT) data unchanged, reporting data through 18Q4_19Q1 (data updated annually in October)

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

  • 1 measure (PC-01) data updated to report data through 18Q3_19Q2 (data updated quarterly)

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

  • 1 measure (OP-33) data remains unchanged reporting 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 18Q3_19Q2 (data updated quarterly)

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

  • 1 measure (OP-32) data unchanged reporting data through 16Q1_18Q4 (data updated annually in January)
  • 3 measures (OP-35-ADM, OP-35-ED, OP-36) data unchanged reporting data through 18Q1_18Q4 
  • 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 unchanged reporting data through 18Q1_18Q4 (data updated annually in January)
  • 1 measure (IPFQR-IMM-2) data unchanged reporting data through 18Q4_19Q1 (data updated annually in January)

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 unchanged reporting data through18Q1_18Q4 (data updated annually in January)

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

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

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

  • 1 measure (READM-30-IPF) data unchanged 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 unchanged 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 (April)
1. Timely & effective care: Heart Attack – P-5: Median Time to ECG

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