Quality Definitions and Methodology

Quality Data Collection Periods as Posted on Hospital Compare on 12/05/2017

Measure Collection Period
From To
Readmission Reduction
READM-30-AMI-HRRP. Heart Attack07/01/201306/30/2016
READM-30-HF-HRRP. Heart Failure07/01/201306/30/2016
READM-30-PN-HRRP. Pneumonia07/01/201306/30/2016
READM-30-COPD-HRRP. COPD07/01/201306/30/2016
READM-30-HIP-KNEE-HRRP. Hip/Knee Surgery07/01/201306/30/2016
Timely Heart Attack Care
OP-1. Median Time to Fibrinolysis04/01/201603/31/2017
OP-2. Fibrinolytic Therapy received within 30 minutes04/01/201603/31/2017
OP-3b. Median Time to transfer patients for Acute Coronary Intervention04/01/201603/31/2017
OP-4. Aspirin at Arrival04/01/201603/31/2017
OP-5. Median Time to ECG04/01/201603/31/2017
Timely Emergency Department Care
ED-1b. Average (median) time patients spent in the emergency department, before they were admitted to the hospital as an inpatient04/01/201603/31/2017
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 room04/01/201603/31/2017
OP-18b. Average time patients spent in the emergency department before being sent home04/01/201603/31/2017
OP-20. Average time patients spent in the emergency department before they were seen by a healthcare professional04/01/201603/31/2017
OP-21. Average time patients who came to the emergency department with broken bones had to wait before receiving pain medication04/01/201603/31/2017
OP-22. Percentage of patients who left the emergency department before being seen01/01/201612/31/2016
OP-23. Percentage of patients who came to the emergency department with stroke symptoms who received brain scan results within 45 minutes of arrival04/01/201603/31/2017
Preventative Care
IMM-2. Patients assessed and given influenza vaccination10/01/201603/31/2017
Blood Clot Prevention
VTE-6. Patients who developed blood clots who did not receive preventative treatment04/01/201603/31/2017
Pregnancy and Delivery Care
PC-01. Women who had elective deliveries 1-3 weeks early when not medically necessary04/01/201603/31/2017
Survey of Patient Hospital Experiences
HCAHPS. Patient Survey Results04/01/201603/31/2017
30-Day Risk Adjusted Mortality Rates
MORT-30-CABG. CABG07/01/201306/30/2016
MORT-AMI. Heart Attack07/01/201306/30/2016
MORT-HF. Heart Failure07/01/201306/30/2016
MORT-PN. Pneumonia07/01/201306/30/2016
MORT-30-COPD. COPD07/01/201306/30/2016
MORT-30-STK. Stroke07/01/201306/30/2016
30-Day Risk Adjusted Readmission Rates
OP-32. Colonoscopy01/01/201612/31/2016
READM-30-CABG. CABG07/01/201306/30/2016
READM-AMI. Heart Attack07/01/201306/30/2016
READM-HF. Heart Failure07/01/201306/30/2016
READM-PN. Pneumonia07/01/201306/30/2016
READM-30-COPD. COPD07/01/201306/30/2016
READM-30-HIP-KNEE. Hip/Knee Surgery07/01/201306/30/2016
READM-30-STK. Stroke07/01/201306/30/2016
READM-30-HOSPWIDE. Hospital-wide07/01/201506/30/2016
Surgical Complications
Complications for Hip/Knee Replacements04/01/201303/31/2016
PSI-4. Death from serious treatable complications after surgery07/01/201409/30/2015
PSI-6. Collapsed lung due to medical treatment07/01/201409/30/2015
PSI-12. Serious blood clots after surgery07/01/201409/30/2015
PSI-14. A wound that splits open after surgery07/01/201409/30/2015
PSI-15. Accidental cuts and tears from medical treatment07/01/201409/30/2015
PSI-90. Serious Complications07/01/201409/30/2015
Healthcare Associated Infections
HAI-1-SIR. Central Line Associated Blood Stream Infections (CLABSI)04/01/201603/31/2017
HAI-2-SIR. Catheter Associated Urinary Tract Infections (CAUTI)04/01/201603/31/2017
HAI-3-SIR. Surgical Site Infections from colon surgery (SSI: Colon)04/01/201603/31/2017
HAI-4-SIR. Surgical Site Infections from abdominal hysterectomy (SSI: Hysterectomy)04/01/201603/31/2017
HAI-5-SIR. Methicillin-resistant Staphylococcus aureus (or MRSA) blood infections04/01/201603/31/2017
HAI-6-SIR. Clostridium difficile (or C.diff.) Infections (intestinal infections)04/01/201603/31/2017
Use of Medical Imaging
OP-8. MRI Lumbar Spine for Low Back Pain07/01/201506/30/2016
OP-9. Mammography Follow-up Rates07/01/201506/30/2016
OP-10. Abdomen CT - Use of Contrast Material07/01/201506/30/2016
OP-11. Thorax CT - Use of Contrast Material07/01/201506/30/2016
OP-13. Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery07/01/201506/30/2016
OP-14. Outpatients with brain CT scans who got a sinus CT scan at the same time07/01/201506/30/2016
Medicare Spending Per Beneficiary
MSPB. Medicare Spending per Beneficiary01/01/201612/31/2016
Cataract Surgery Outcome
OP-31. Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery01/01/201612/31/2016
Colonoscopy care
OP-29. Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients01/01/201612/31/2016
OP-30. Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use01/01/201612/31/2016
OP-25. Safe Surgery Checklist Use01/01/201612/31/2016
OP-26. Hospital Outpatient Volume Data on Selected Outpatient Surgical Procedures01/01/201612/31/2016
SM_PART_GEN_SURG. General Surgery Registry01/01/201612/31/2016
HBIPS-2. Hours of physical-restraint use01/01/201612/31/2016
HBIPS-3. Hours of seclusion01/01/201612/31/2016
HBIPS-5. Patients discharged on multiple antipsychotic medications with appropriate justification01/01/201612/31/2016
FUH-30. Follow-Up After Hospitalization for Mental Illness within 30 days07/01/201506/30/2016
FUH-7. Follow-Up After Hospitalization for Mental Illness within 7 days07/01/201506/30/2016
IMM-2. Influenza Immunization10/01/201603/31/2017