Quality Definitions and Methodology

Quality Data Collection Periods as Posted on Hospital Compare on 09/21/2018

Measure Collection Period
From To
Readmission Reduction
READM-30-AMI-HRRP. Heart Attack7/1/20136/30/2016
READM-30-HF-HRRP. Heart Failure7/1/20136/30/2016
READM-30-PN-HRRP. Pneumonia7/1/20136/30/2016
READM-30-COPD-HRRP. COPD7/1/20136/30/2016
READM-30-HIP-KNEE-HRRP. Hip/Knee Surgery7/1/20136/30/2016
Timely Heart Attack Care
OP-1. Median Time to Fibrinolysis1/1/201712/31/2017
OP-2. Fibrinolytic Therapy received within 30 minutes1/1/201712/31/2017
OP-3b. Median Time to transfer patients for Acute Coronary Intervention1/1/201712/31/2017
OP-4. Aspirin at Arrival1/1/201712/31/2017
OP-5. Median Time to ECG1/1/201712/31/2017
Timely Emergency Department Care
ED-1b. Average (median) time patients spent in the emergency department, before they were admitted to the hospital as an inpatient1/1/201712/31/2017
ED-2b. Average (median) time patients spent in the emergency department, after the doctor decided to admit them as an inpatient before leaving the emergency department for their inpatient room1/1/201712/31/2017
OP-18b. Average time patients spent in the emergency department before being sent home1/1/201712/31/2017
OP-18c. Average (median) time patients spent in the emergency department before leaving from the visit- Psychiatric/Mental Health Patients.1/1/201712/31/2017
OP-20. Average time patients spent in the emergency department before they were seen by a healthcare professional1/1/201712/31/2017
OP-21. Average time patients who came to the emergency department with broken bones had to wait before receiving pain medication1/1/201712/31/2017
OP-22. Percentage of patients who left the emergency department before being seen1/1/201612/31/2016
OP-23. Percentage of patients who came to the emergency department with stroke symptoms who received brain scan results within 45 minutes of arrival1/1/201712/31/2017
Preventive Care
IMM-2. Patients assessed and given influenza vaccination10/1/20163/31/2017
Pregnancy and Delivery Care
PC-01. Women who had elective deliveries 1-3 weeks early when not medically necessary1/1/201712/31/2017
Survey of Patient Hospital Experiences
HCAHPS. Patient Survey Results1/1/201712/31/2017
30-Day Risk Adjusted Mortality Rates
MORT-30-CABG. CABG7/1/20146/30/2017
MORT-AMI. Heart Attack7/1/20146/30/2017
MORT-HF. Heart Failure7/1/20146/30/2017
MORT-PN. Pneumonia7/1/20146/30/2017
MORT-30-COPD. COPD7/1/20146/30/2017
MORT-30-STK. Stroke7/1/20146/30/2017
30-Day Risk Adjusted Readmission Rates
OP-32. Colonoscopy1/1/201612/31/2016
READM-30-CABG. CABG7/1/20146/30/2017
READM-AMI. Heart Attack7/1/20146/30/2017
READM-HF. Heart Failure7/1/20146/30/2017
READM-PN. Pneumonia7/1/20146/30/2017
READM-30-COPD. COPD7/1/20146/30/2017
READM-30-HIP-KNEE. Hip/Knee Surgery7/1/20146/30/2017
READM-30-STK. Stroke7/1/20146/30/2017
READM-30-HOSPWIDE. Hospital-wide7/1/20166/30/2017
Surgical Complications
Complications for Hip/Knee Replacements4/1/20143/31/2017
PSI-4. Death from serious treatable complications after surgery10/1/20156/30/2017
PSI-6. Collapsed lung due to medical treatment10/1/20156/30/2017
PSI-12. Serious blood clots after surgery10/1/20156/30/2017
PSI-14. A wound that splits open after surgery10/1/20156/30/2017
PSI-15. Accidental cuts and tears from medical treatment10/1/20156/30/2017
PSI-90. Serious Complications10/1/20156/30/2017
Healthcare Associated Infections
HAI-1-SIR. Central Line Associated Blood Stream Infections (CLABSI)1/1/201712/31/2017
HAI-2-SIR. Catheter Associated Urinary Tract Infections (CAUTI)1/1/201712/31/2017
HAI-3-SIR. Surgical Site Infections from colon surgery (SSI: Colon)1/1/201712/31/2017
HAI-4-SIR. Surgical Site Infections from abdominal hysterectomy (SSI: Hysterectomy)1/1/201712/31/2017
HAI-5-SIR. Methicillin-resistant Staphylococcus aureus (or MRSA) blood infections1/1/201712/31/2017
HAI-6-SIR. Clostridium difficile (or C.diff.) Infections (intestinal infections)1/1/201712/31/2017
Use of Medical Imaging
OP-8. MRI Lumbar Spine for Low Back Pain7/1/20166/30/2017
OP-9. Mammography Follow-up Rates7/1/20166/30/2017
OP-10. Abdomen CT - Use of Contrast Material7/1/20166/30/2017
OP-11. Thorax CT - Use of Contrast Material7/1/20166/30/2017
OP-13. Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery7/1/20166/30/2017
OP-14. Outpatients with brain CT scans who got a sinus CT scan at the same time7/1/20166/30/2017
Medicare Spending Per Beneficiary
MSPB. Medicare Spending per Beneficiary1/1/201612/31/2016
Cataract Surgery Outcome
OP-31. Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery1/1/201612/31/2016
Colonoscopy care
OP-29. Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients1/1/201612/31/2016
OP-30. Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use1/1/201612/31/2016
OP-25. Safe Surgery Checklist Use1/1/201612/31/2016
OP-26. Hospital Outpatient Volume Data on Selected Outpatient Surgical Procedures1/1/201612/31/2016
SM_PART_GEN_SURG. General Surgery Registry1/1/201612/31/2016
HBIPS-2. Hours of physical-restraint use1/1/201612/31/2016
HBIPS-3. Hours of seclusion1/1/201612/31/2016
HBIPS-5. Patients discharged on multiple antipsychotic medications with appropriate justification1/1/201612/31/2016
FUH-30. Follow-Up After Hospitalization for Mental Illness within 30 days7/1/20156/30/2016
FUH-7. Follow-Up After Hospitalization for Mental Illness within 7 days7/1/20156/30/2016