Quality Report

  • Posted on 07/27/2026
  • Collection Periods
  • Report is based on information from Hospital Compare, a website created through the efforts of the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (DHHS) along with the Hospital Quality Alliance (HQA).  The HQA is a public-private collaboration established to promote reporting on hospital quality of care.

Sample Hospital

Louisville, KY  11111
CMS Certification Number: 000000
Sample Report | Order Information

Quality Measures Linked to Payment

Value-Based Purchasing Program

Federal
Fiscal
Year		 Clinical Process of Care Domain Patient Experience of Care Domain Outcome Domain Efficiency Domain Safety Domain Total
Performance
Score		 National
Percentile		 Payment
Adjustment
2026 15.00 32.00 N/A 0.00 15.00 15.50 6% -0.93%
2025 10.00 14.00 N/A 0.00 18.00 10.50 7% -1.06%
2024 11.67 13.00 N/A 0.00 8.00 8.17 4% -1.22%
2023 34.00 N/A N/A 0.00 N/A *N/A * *0.00%
2022 46.67 N/A N/A N/A N/A *N/A * *0.00%
2021 44.00 26.00 N/A 10.00 8.00 22.00 14% -0.59%
2020 57.50 24.00 N/A 0.00 28.33 27.46 16% -0.46%
2019 60.00 23.00 N/A 0.00 26.67 27.42 17% -0.44%
2018 50.00 19.00 N/A 0.00 28.57 24.39 12% -0.59%
2017 25.00 17.00 56.67 0.00 16.67 23.00 13% -0.59%
2016 28.57 24.00 45.71 0.00 N/A 27.14 13% -0.43%
2015 48.18 26.00 52.00 0.00 N/A 33.04 25% -0.22%
2014 45.83 26.00 40.00 N/A N/A 38.43 24% -0.24%
2013 47.27 31.00 N/A N/A N/A 42.39 19% -0.22%

Readmission Reduction Program

Federal
Fiscal
Year		 Heart Attack Heart Failure Pneumonia COPD CABG Hip/Knee Readmissions
Adjustment
Factor		 Payment
Adjustment
Excess
Ratio		 Cases Excess
Ratio		 Cases Excess
Ratio		 Cases Excess
Ratio		 Cases Excess
Ratio		 Cases Excess
Ratio		 Cases
2026 1.1967 642 1.0261 1,668 1.0224 1,690 1.0902 474 1.0031 216 1.1180 89 0.9923 -0.77%
2025 1.1315 559 1.0190 1,393 0.9643 1,305 1.0646 357 1.0251 195 1.2344 53 0.9945 -0.55%
2024 1.0277 454 1.0080 1,208 1.0129 1,150 1.0774 330 1.0311 162 0.9104 255 0.9967 -0.33%
2023 0.9736 521 0.9917 1,551 * * 1.0414 605 1.0063 173 1.0289 842 0.9984 -0.16%
2022 0.9828 689 0.9833 2,065 1.0146 2,302 1.0220 1,040 1.0199 249 1.0744 1,489 0.9951 -0.49%
2021 1.0106 853 0.9866 2,510 0.9872 2,669 1.0322 1,707 1.1160 293 1.0716 1,871 0.9944 -0.56%
2020 0.9859 901 0.9868 2,340 1.0366 2,615 1.0070 1,730 1.0544 301 1.0494 1,836 0.9949 -0.51%
2019 0.9954 978 0.9750 2,165 1.0134 2,537 1.0631 1,651 1.0349 284 1.0121 1,691 0.9963 -0.37%
2018 0.9992 1,029 0.9713 2,036 1.0151 2,658 1.0631 1,386 1.0283 277 1.0371 1,623 0.9966 -0.34%
2017 0.9927 1,031 0.9533 1,974 0.9991 2,467 1.0831 1,441 1.1213 268 1.0435 1,555 0.9959 -0.41%
2016 1.0517 965 0.9394 1,928 0.9784 1,650 1.0193 1,449 N/A N/A 0.9756 1,532 0.9983 -0.17%
2015 1.0268 911 0.9639 1,990 1.0515 1,630 0.9962 1,476 N/A N/A 0.9475 1,520 0.9982 -0.18%
2014 1.0244 780 0.9838 1,822 1.0333 1,502 N/A N/A N/A N/A N/A N/A 0.9988 -0.12%
2013 1.0255 741 0.9686 1,729 1.0374 1,342 N/A N/A N/A N/A N/A N/A 0.9985 -0.15%

Hospital-Acquired Condition (HAC) Reduction Program

Federal
Fiscal
Year
Domain 1
Serious Complications
(AHRQ PSI 90 Composite Score)
Domain 2
Central Line-Associated Blood Stream Infections (CLABSI)
Catheter-Associated Urinary Tract Infections (CAUTI)
Surgical Site Infections - Colon Surgeries and Abdominal Hysterectomies (SSI)
Methicillin-Resistant Staphylococcus Aureus (MRSA)
Clostridium difficile (C.diff.) Infection (CDI)
 Total
HAC
Score		 Payment
Adjustment
From To Score From To Score CLABSI Score CAUTI Score SSI Score MRSA Score CDI Score
2026 07/01/2022 06/30/2024 1.0815 01/01/2023 12/31/2024 0.854 0.4730 1.6790 0.8440 0.3960 0.4739 -1%
2025 07/01/2021 06/30/2023 1.0181 01/01/2022 12/31/2023 0.821 0.5420 1.7960 0.8580 0.5730 0.3938 -1%
2024 01/01/2021 06/30/2022 1.0609 01/01/2022 12/31/2022 0.867 0.6850 1.4410 0.8570 0.6660 0.3570 0%
2023 N/A N/A N/A 01/01/2021 12/31/2021 0.9900 0.8450 1.5710 1.0600 0.5010 *0.0000 *0%
2022 07/01/2018 12/31/2019 -1.2647 01/01/2019 12/31/2019 -0.0786 0.4914 0.8136 0.4182 0.6883 0.1780 0%
2021 07/01/2017 06/30/2019 -1.3599 01/01/2018 12/31/2019 -0.0398 0.2840 1.2604 -0.0568 0.5019 0.0983 0%
2020 07/01/2016 06/30/2018 -0.4891 01/01/2017 12/31/2018 0.1036 -0.1900 1.6372 -0.0772 0.0628 0.1746 0%
2019 10/01/2015 06/30/2017 1.0070 01/01/2016 12/31/2017 0.482 0.0505 -0.0427 1.6686 0.6828 0.0508 0.5607 -1%
2018 07/01/2014 09/30/2015 2.0928 01/01/2015 12/31/2016 0.6696 0.1938 0.3272 1.6380 0.8686 0.3205 0.8831 -1%
2017 07/01/2013 06/30/2015 5.0000 01/01/2014 12/31/2015 8.0000 8 7.0000 9.0000 9.0000 7.0000 7.5500 -1%
2016 07/01/2012 06/30/2014 5.0000 01/01/2013 12/31/2014 7.3333 8 6.0000 8.0000 N/A N/A 6.7500 0%
2015 07/01/2011 06/30/2013 8.0000 01/01/2012 12/31/2013 7.5000 8 7.0000 N/A N/A N/A 7.6750 -1%

Timely & Effective Care

Cataract Surgery Outcome

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
OP-31. Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery N/A 5 N/A 97.0% N/A

Colonoscopy Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
OP-29. Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients 165   100.0% 93.0% 96.0%

Sepsis Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
SEP-1. Appropriate care for severe sepsis and septic shock 555 2 60.0% 65.0% 68.0%
SEP-SH-3HR. Septic Shock 3-Hour Bundle 194 2 68.0% 73.0% 77.0%
SEP-SH-6HR. Septic Shock 6-Hour Bundle 108 2 90.0% 87.0% 88.0%
SEV_SEP_3HR. Severe Sepsis 3-Hour Bundle 556 2 78.0% 81.0% 82.0%
SEV_SEP_6HR. Severe Sepsis 6-Hour Bundle 292 2 92.0% 93.0% 95.0%

Timely Emergency Department Care

Measure Number of Patients Footnotes Hospital Score National Average State Average
OP-18a. Average (median) time all patients spent in the emergency department before leaving from the visit, including psychiatric/mental health patients and patients who were transferred to another facility. 657   194 minutes 168 minutes 155 minutes
OP-18b. Average time patients spent in the emergency department before being sent home 630   192 minutes 162 minutes 150 minutes
OP-18c. Average (median) time patients spent in the emergency department before leaving from the visit- Psychiatric/Mental Health Patients. 25   225 minutes 257 minutes 210 minutes
OP-18d. Average (median) time transfer patients spent in the emergency department before leaving from the visit N/A 1 N/A 287 minutes 277 minutes
OP-22. Percentage of patients who left the emergency department before being seen 281,857   3.0% 2.0% 2.0%
OP-23. Percentage of patients who came to the emergency department with stroke symptoms who received brain scan results within 45 minutes of arrival 31   52.0% 69.0% 68.0%

Healthcare Personnel Vaccination

Measure Number of Patients Footnotes Hospital Score National Average State Average
IMM-3. Healthcare workers given influenza vaccination 34,031   78.0% 78.0% 80.0%

Safe Use of Opioids

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
Safe Use of Opioids 19,877   13.0% 15.0% 15.0%

Stroke Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
No Data are available for this hospital.

Blood Clot Prevention and Treatment

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
VTE-1. Patients who received treatment to prevent blood clots within one day of admission or the day after surgery N/A 5 N/A
VTE-2. ICU patients who received treatment to prevent blood clots within one day of admission, within one day of transfer to the ICU, or within one day following surgery N/A 5 N/A

Pregnancy and Delivery Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
SM-7. Maternal Morbidity Structural Measure N/A   Yes  

Patient Survey Results

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

Survey question Measure Percent Measure Percent Measure Percent Star Rating
Nurses communicated well Always 77% Usually 18% Sometimes 5% ***..
Doctors communicated well Always 76% Usually 18% Sometimes 6% ***..
Staff explained medicines Always 59% Usually 19% Sometimes 22% **...
Room and bath kept clean Always 67% Usually 21% Sometimes 12% ***..
Area quiet at night Always 56% Usually 33% Sometimes 11% ***..
Given discharge instructions Yes 87% No 13%   ****.
Overall hospital rating High 71% Medium 19% Low 10% ***..
Would recommend hospital Definitely 73% Probably 20% No 7% ****.
Summary Star Rating   ***..

Unplanned Hospital Visits, Complications and Deaths

30-Day Risk Adjusted Mortality Rates

Measure Hospital Predicted Range National Average
Number Patients Mortality Rate from to
CABG 198 1.7% 0.7% 4.1% 2.4%
COPD 500 9.5% 5.5% 15.2% 8.6%
Heart Attack 591 10.6% 7.7% 14.2% 11.9%
Heart Failure 1,530 11.8% 7.3% 18.1% 11.1%
Pneumonia 1,778 17.7% 12.2% 25.0% 15.2%
Stroke 1,303 13.3% 8.9% 19.9% 11.9%
Hospital-Wide 13,078 4.7% 3.8% 5.7% 3.9%

30-Day Risk Adjusted Readmission Rates

Measure Hospital Predicted Range National Average
Number Patients Readmission Rate from to
CABG 275 13.7% 9.7% 18.9% 11.0%
Colonoscopy 5,185 1.2% 1.0% 1.5% 1.3%
COPD 1,246 20.6% 17.3% 24.6% 20.0%
Heart Attack 951 14.0% 11.4% 17.0% 14.4%
Heart Failure 2,901 21.7% 18.3% 25.4% 21.3%
Hip/Knee Surgery 139 6.5% 4.2% 10.0% 5.8%
Pneumonia 2,941 18.1% 15.2% 21.3% 17.3%
Hospital-Wide N/A N/A N/A N/A N/A

Visit Rates Following OP Procedure

Measure Hospital Predicted Range National Average
Number Patients Readmission Rate from to
OP-35-ED. Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy 933 3.7% 2.9% 4.7% 5.4%
OP-35-ADM. Rate of inpatient admissions for patients receiving outpatient chemotherapy 933 12.1% 10.5% 13.8% 10.7%
OP-36. Ratio of unplanned hospital visits after hospital outpatient surgery 2,562 1.1 1.0 1.3 N/A

Hospital Return Days

Measure Hospital Predicted Range National Average
Number Patients Return Days from to
Heart Attack 606 36.6 -31.7 174.7 N/A
Heart Failure 1,362 11.2 -38.0 70.4 N/A
Pneumonia 1,632 16.8 -22.1 72.6 N/A

Surgical Complications

Measure Hospital Predicted Range National Average
Number Patients Rate from to
Complications for Hip/Knee Replacements 141 5.60% 3.10% 10.00% 4.10%
PSI-3. Pressure sores 19,709 0.63% 0.26% 1.01% 0.63%
PSI-4. Death from serious treatable complications after surgery 368 19.91% 16.60% 23.21% 17.33%
PSI-6. Collapsed lung due to medical treatment 22,873 0.18% 0.02% 0.34% 0.21%
PSI-8. Broken hip from a fall after surgery 23,928 0.45% 0.30% 0.60% 0.27%
PSI-9. Postoperative Hemorrhage or Hematoma Rate 6,333 3.01% 2.05% 3.98% 2.34%
PSI-10. Postoperative Acute Kidney Injury Rate 3,013 1.95% 0.81% 3.08% 1.67%
PSI-11. Postoperative Respiratory Failure Rate 2,950 9.22% 6.05% 12.38% 9.42%
PSI-12. Serious blood clots after surgery 6,534 3.19% 1.90% 4.48% 3.52%
PSI-13. Blood stream infection after surgery 2,861 7.02% 4.76% 9.28% 5.27%
PSI-14. A wound that splits open after surgery 1,588 1.63% 0.38% 2.88% 1.77%
PSI-15. Accidental cuts and tears from medical treatment 4,973 0.80% 0.10% 1.50% 1.06%
PSI-90. Serious Complications N/A 1.08% 0.90% 1.26% 1.00%

Healthcare Associated Infections

Measure Hospital Score State Score
HAI-1-SIR. Central Line Associated Blood Stream Infections (CLABSI) 0.915 0.839
HAI-2-SIR. Catheter Associated Urinary Tract Infections (CAUTI) 0.601 0.607
HAI-3-SIR. Surgical Site Infections from colon surgery (SSI: Colon) 1.600 1.073
HAI-4-SIR. Surgical Site Infections from abdominal hysterectomy (SSI: Hysterectomy) 1.348 1.157
HAI-5-SIR. Methicillin-resistant Staphylococcus aureus (or MRSA) blood infections 0.915 0.870
HAI-6-SIR. Clostridium difficile (or C.diff.) Infections (intestinal infections) 0.264 0.321

Payment and Value of Care

Use of Medical Imaging

Measure Hospital Footnotes Hospital Score National Average State Average
OP-10. Abdomen CT - Use of Contrast Material 10.0% 5.8% 7.7%
OP-39. Breast Cancer Screening Recall Rates 5.6% 9.0% 6.6%

Medicare Spending Per Beneficiary

Measure Hospital Score National Average State Average
MSPB. Medicare Spending per Beneficiary 1.00 0.99 1.01

Measures of Psychiatric Facilities

Inpatient Psychiatric Facility Quality Reporting (IPFQR)

Measure Hospital Score Number Patients National Average State Average
No Data are available for this hospital.