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Quality Definitions and Methodology

Quality Data Collection Periods as Posted on Hospital Compare on 04/25/2017

Measure Collection Period
From To
Readmission Reduction
READM-30-AMI-HRRP. Heart Attack7/1/20126/30/2015
READM-30-HF-HRRP. Heart Failure7/1/20126/30/2015
READM-30-PN-HRRP. Pneumonia7/1/20126/30/2015
READM-30-COPD-HRRP. COPD7/1/20126/30/2015
READM-30-HIP-KNEE-HRRP. Hip/Knee Surgery7/1/20126/30/2015
Timely Heart Attack Care
OP-1. Median Time to Fibrinolysis7/1/20153/31/2016
OP-2. Fibrinolytic Therapy received within 30 minutes7/1/20153/31/2016
OP-3b. Median Time to transfer patients for Acute Coronary Intervention7/1/20153/31/2016
OP-4. Aspirin at Arrival7/1/20153/31/2016
OP-5. Median Time to ECG7/1/20153/31/2016
Timely Emergency Department Care
ED-1b. Average (median) time patients spent in the emergency department, before they were admitted to the hospital as an inpatient7/1/20156/30/2016
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 room7/1/20156/30/2016
OP-18b. Average time patients spent in the emergency department before being sent home7/1/20153/31/2016
OP-20. Average time patients spent in the emergency department before they were seen by a healthcare professional7/1/20153/31/2016
OP-21. Average time patients who came to the emergency department with broken bones had to wait before receiving pain medication7/1/20153/31/2016
OP-22. Percentage of patients who left the emergency department before being seen1/1/201512/31/2015
OP-23. Percentage of patients who came to the emergency department with stroke symptoms who received brain scan results within 45 minutes of arrival7/1/20153/31/2016
Preventative Care
IMM-2. Patients assessed and given influenza vaccination10/1/20153/31/2016
Timely Stroke Care
STK-4. Ischemic stroke patients who received t-PA within 3 hours of symptoms7/1/20156/30/2016
Blood Clot Prevention
VTE-5. Patients with blood clots who were discharged on blood thinners and received educational instructions at discharge7/1/20156/30/2016
VTE-6. Patients who developed blood clots who did not receive preventative treatment7/1/20156/30/2016
Pregnancy and Delivery Care
PC-01. Women who had elective deliveries 1-3 weeks early when not medically necessary7/1/20156/30/2016
Survey of Patient Hospital Experiences
HCAHPS. Patient Survey Results7/1/20156/30/2016
30-Day Risk Adjusted Mortality Rates
MORT-30-CABG. CABG7/1/20126/30/2015
MORT-AMI. Heart Attack7/1/20126/30/2015
MORT-HF. Heart Failure7/1/20126/30/2015
MORT-PN. Pneumonia7/1/20126/30/2015
MORT-30-COPD. COPD7/1/20126/30/2015
MORT-30-STK. Stroke7/1/20126/30/2015
30-Day Risk Adjusted Readmission Rates
READM-30-CABG. CABG7/1/20126/30/2015
READM-AMI. Heart Attack7/1/20126/30/2015
READM-HF. Heart Failure7/1/20126/30/2015
READM-PN. Pneumonia7/1/20126/30/2015
READM-30-COPD. COPD7/1/20126/30/2015
READM-30-HIP-KNEE. Hip/Knee Surgery7/1/20126/30/2015
READM-30-STK. Stroke7/1/20126/30/2015
READM-30-HOSPWIDE. Hospital-wide7/1/20146/30/2015
Surgical Complications
Complications for Hip/Knee Replacements4/1/20123/31/2015
PSI-4. Death from serious treatable complications after surgery7/1/20136/30/2015
PSI-6. Collapsed lung due to medical treatment7/1/20136/30/2015
PSI-12. Serious blood clots after surgery7/1/20136/30/2015
PSI-14. A wound that splits open after surgery7/1/20136/30/2015
PSI-15. Accidental cuts and tears from medical treatment7/1/20136/30/2015
PSI-90. Serious Complications7/1/20136/30/2015
Healthcare Associated Infections
HAI-1-SIR. Central Line Associated Blood Stream Infections (CLABSI)7/1/20156/30/2016
HAI-2-SIR. Catheter Associated Urinary Tract Infections (CAUTI)7/1/20156/30/2016
HAI-3-SIR. Surgical Site Infections from colon surgery (SSI: Colon)7/1/20156/30/2016
HAI-4-SIR. Surgical Site Infections from abdominal hysterectomy (SSI: Hysterectomy)7/1/20156/30/2016
HAI-5-SIR. Methicillin-resistant Staphylococcus aureus (or MRSA) blood infections7/1/20156/30/2016
HAI-6-SIR. Clostridium difficile (or C.diff.) Infections (intestinal infections)7/1/20156/30/2016
Use of Medical Imaging
OP-8. MRI Lumbar Spine for Low Back Pain7/1/20146/30/2015
OP-9. Mammography Follow-up Rates7/1/20146/30/2015
OP-10. Abdomen CT - Use of Contrast Material7/1/20146/30/2015
OP-11. Thorax CT - Use of Contrast Material7/1/20146/30/2015
OP-13. Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery7/1/20146/30/2015
OP-14. Outpatients with brain CT scans who got a sinus CT scan at the same time7/1/20146/30/2015
Medicare Spending Per Beneficiary
MSPB. Medicare Spending per Beneficiary1/1/201512/31/2015
Cataract Surgery Outcome
OP-31. Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery1/1/201512/31/2015
Colonoscopy care
OP-29. Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients1/1/201512/31/2015
OP-30. Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use1/1/201512/31/2015
General
OP-25. Safe Surgery Checklist Use1/1/201512/31/2015
OP-26. Hospital Outpatient Volume Data on Selected Outpatient Surgical Procedures1/1/201512/31/2015
SM_PART_GEN_SURG. General Surgery Registry1/1/201512/31/2015
IPFQR
HBIPS-2. Hours of physical-restraint use1/1/201512/31/2015
HBIPS-3. Hours of seclusion1/1/201512/31/2015
HBIPS-5. Patients discharged on multiple antipsychotic medications with appropriate justification1/1/201512/31/2015
HBIPS-6. Post-discharge continuing care plan created1/1/201512/31/2015
HBIPS-7. Post-discharge continuing care plan transmitted to the next level of care provider upon discharge1/1/201512/31/2015
FUH-30. Follow-Up After Hospitalization for Mental Illness within 30 days7/1/20146/30/2015
FUH-7. Follow-Up After Hospitalization for Mental Illness within 7 days7/1/20146/30/2015
IMM-2. Influenza Immunization10/1/20153/31/2016