Quality Definitions and Methodology
Hospital Compare Footnotes
- The number of cases is too
small (n<25) for purposes of reliably predicting
For each measure, the rate is
displayed as a percent of the number of patients for
whom the measured treatment is appropriate. For
hospitals with small numbers of patients for whom the
measured treatment is appropriate during the reporting
period (fewer than 25 patients), the calculated rate may
not be predictive of the hospital's future performance.
As the quality data base is expanded to a full rolling
four quarters of data for each measure, the number of
cases used to determine hospitals' rates will likely
increase, thereby increasing the reliability and
stability of the rates. Note: This footnote does not
necessarily reflect hospital size or overall patient
- Measure reflects the
hospital's indication that its submission was based upon
a sample of its relevant discharges.
Rates are based on the cases reported by hospitals. A
rate may be based upon the total number of cases treated
by a hospital, or for a facility with a large caseload,
a rate may be based on a random sample of the cases the
hospital treated. This footnote indicates that a
hospital chose to submit data for a sample of its total
cases (following specific rules for how to the select
- Rate reflects fewer than the
maximum possible quarters of data for the measure.
Each rate reflects the care provided over a specific
time period, up to a maximum of four quarters. For the
ten measures in the "Starter Set", the maximum number of
quarters for which the hospital could have provided data
was four quarters. For the seven additional measures
that were first reported in April 2005, the maximum
number of quarters for which a hospital could have
provided data was three quarters (April - December
2004). For the three additional measures reported in
September 2005, the maximum number of quarters a
hospital could have provided data was two quarters (July
- December 2004). This footnote indicates that the rate
was calculated based on fewer than the maximum possible
number of quarters for the measure.
- Inaccurate information
submitted and suppressed for one or more quarters.
Hospitals are required to submit accurate, reportable
data to the Centers for Medicare and Medicaid Services
(CMS). The rates for these measures were calculated by
excluding data that had been suppressed for one or more
quarters because they were identified as inaccurate.
- No data is available from the
hospital for this measure.
Hospitals volunteer to provide data for reporting on
Hospital Compare. This footnote is applied when the
hospital did not submit any cases for a measure.
- Fewer than 100 patients completed the HCAHPS survey. Use these rates with caution, as the number of surveys may be too low to reliably assess hospital performance.
The number of completed surveys the hospital or its vendor provided to CMS is less than 100.
- This displays less than 9 months of accurate data.
This footnote is applied when CMS opts to display HCAHPS results on fewer than the required months of survey data.
- Survey results are not available for this period.
This footnote is applied when a hospital did not participate in HCAHPS, did not collect sufficient HCAHPS data for public reporting purposes, or chose to suppress their HCAHPS results.
- No patients were eligible for the HCAHPS Survey.
This footnote is applied when a hospital has no patients eligible to participate in the HCAHPS survey.
- A state average was not calculated because too few hospitals in the state submitted data.
This footnote is applied when too few hospitals submitted data.