• Posted on 04/10/2018
  • 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
2018 50.00 19.00 N/A 0.00 28.57 24.39 11% -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
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
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 9 9 7 7.5500 -1%
2016 07/01/2012 06/30/2014 5.0000 01/01/2013 12/31/2014 7.3333 8 6 8 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 N/A N/A N/A 7.6750 -1%

Timely & Effective Care

Cancer Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
OP-33. External Beam Radiotherapy for Bone Metastases 92   66% 82% 84%

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 96% 100%

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 166   95% 85% 82%
OP-30. Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use 165   97% 90% 89%

Timely Heart Attack Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
OP-1. Median Time to Fibrinolysis N/A 7 N/A 28 minutes 25 minutes
OP-2. Fibrinolytic Therapy received within 30 minutes N/A 7 N/A 59% 65%
OP-3b. Median Time to transfer patients for Acute Coronary Intervention N/A 1 N/A 57 minutes 54 minutes
OP-4. Aspirin at Arrival 25   100% 95% 96%
OP-5. Median Time to ECG 26   6 minutes 7 minutes 7 minutes

Timely Emergency Department Care

Measure Number of Patients Footnotes Hospital Score National Average State Average
ED-1b. Average (median) time patients spent in the emergency department, before they were admitted to the hospital as an inpatient 679 2 336 minutes 281 minutes 257 minutes
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 room 665 2 135 minutes 102 minutes 82 minutes
OP-18b. Average time patients spent in the emergency department before being sent home 423   172 minutes 140 minutes 141 minutes
OP-20. Average time patients spent in the emergency department before they were seen by a healthcare professional 431   35 minutes 20 minutes 21 minutes
OP-21. Average time patients who came to the emergency department with broken bones had to wait before receiving pain medication 483   23 minutes 49 minutes 48 minutes
OP-22. Percentage of patients who left the emergency department before being seen 267,931   4% 2% 2%
OP-23. Percentage of patients who came to the emergency department with stroke symptoms who received brain scan results within 45 minutes of arrival 19   58% 72% 67%

Preventive Care

Measure Number of Patients Footnotes Hospital Score National Average State Average
IMM-2. Patients assessed and given influenza vaccination 543 2 93% 93% 93%
IMM-3-OP-27-FAC-ADHPCT. Healthcare workers given influenza vaccination 14,541   76% 88% 83%

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-6. Patients who developed blood clots who did not receive preventative treatment 94 2 3% 2% 4%

Pregnancy and Delivery Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
PC-01. Women who had elective deliveries 1-3 weeks early when not medically necessary 367 2 3% 2% 3%

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 79% Usually 17% Sometimes 4% ***..
Doctors communicated well Always 79% Usually 17% Sometimes 4% ***..
Help received quickly Always 62% Usually 27% Sometimes 11% **...
Pain controlled well Always 69% Usually 24% Sometimes 7% ***..
Staff explained medicines Always 61% Usually 18% Sometimes 21% **...
Room and bath kept clean Always 64% Usually 24% Sometimes 12% **...
Area quiet at night Always 57% Usually 31% Sometimes 12% ***..
Given discharge instructions Yes 87% No 13%   ***..
Patient understood care Strongly Agree 51% Agree 44% Disagree 5% ***..
Overall hospital rating High 70% Medium 21% Low 9% ***..
Would recommend hospital Definitely 71% Probably 23% No 6% ***..
Summary Star Rating   ***..

Readmissions, Complications and Deaths

30-Day Risk Adjusted Mortality Rates

Measure Hospital Predicted Range National Average
Number Patients Mortality Rate from to
CABG 289 5.0% 3.1% 7.8% 3.2%
Heart Attack 989 13.3% 11.4% 15.3% 13.6%
Heart Failure 1,686 10.4% 9.1% 12.0% 11.9%
Pneumonia 2,426 15.6% 14.2% 17.0% 15.9%
COPD 1,152 6.8% 5.7% 8.3% 8.0%
Stroke 1,020 14.4% 12.6% 16.6% 14.6%

30-Day Risk Adjusted Readmission Rates

Measure Hospital Predicted Range National Average
Number Patients Readmission Rate from to
Colonoscopy 1,647 15.8% 12.1% 20.9% 16.4%
CABG 277 14.4% 11.6% 17.8% 13.8%
Heart Attack 1,028 16.2% 14.4% 18.2% 16.3%
Heart Failure 2,029 21.0% 19.5% 22.7% 21.6%
Pneumonia 2,655 17.3% 16.1% 18.7% 16.9%
COPD 1,384 20.9% 19.1% 22.9% 19.8%
Hip/Knee Surgery 1,623 4.5% 3.7% 5.4% 4.4%
Stroke 1,028 12.4% 10.7% 14.3% 12.2%
Hospital-wide 12,533 15.8% 15.2% 16.3% 15.3%

Surgical Complications

Measure Hospital Predicted Range National Average
Number Patients Rate from to
Complications for Hip/Knee Replacements 1,538 2.60% 2.00% 3.40% 2.80%
PSI-3. Pressure sores 15,489 0.25% 0.00% 0.51% 0.26%
PSI-4. Death from serious treatable complications after surgery 299 16.12% 13.05% 19.20% 13.91%
PSI-6. Collapsed lung due to medical treatment 21,610 0.32% 0.12% 0.53% 0.40%
PSI-8. Broken hip from a fall after surgery 16,449 0.14% 0.07% 0.21% 0.10%
PSI-9. Postoperative Hemorrhage or Hematoma Rate 6,665 5.47% 4.06% 6.89% 4.78%
PSI-10. Postoperative Acute Kidney Injury Rate 3,867 1.98% 1.23% 2.73% 1.12%
PSI-11. Postoperative Respiratory Failure Rate 3,275 16.77% 13.53% 20.02% 11.89%
PSI-12. Serious blood clots after surgery 6,968 5.87% 4.42% 7.31% 4.35%
PSI-13. Blood stream infection after surgery 3,738 5.93% 3.72% 8.15% 5.94%
PSI-14. A wound that splits open after surgery 954 3.48% 1.62% 5.35% 2.26%
PSI-15. Accidental cuts and tears from medical treatment 1,064 0.63% 0.00% 1.67% 0.88%
PSI-90. Serious Complications N/A 1.24% 1.08% 1.40% 1.00%

Healthcare Associated Infections

Measure Hospital Score State Score
HAI-1-SIR. Central Line Associated Blood Stream Infections (CLABSI) 0.887 0.746
HAI-2-SIR. Catheter Associated Urinary Tract Infections (CAUTI) 0.936 0.784
HAI-3-SIR. Surgical Site Infections from colon surgery (SSI: Colon) 1.487 0.895
HAI-4-SIR. Surgical Site Infections from abdominal hysterectomy (SSI: Hysterectomy) 2.152 1.106
HAI-5-SIR. Methicillin-resistant Staphylococcus aureus (or MRSA) blood infections 1.387 1.087
HAI-6-SIR. Clostridium difficile (or C.diff.) Infections (intestinal infections) 0.772 0.769

Payment and Value of Care

Use of Medical Imaging

Measure Hospital Footnotes Hospital Score National Average State Average
OP-8. MRI Lumbar Spine for Low Back Pain 38.1% 39.8% 39.7%
OP-9. Mammography Follow-up Rates 7.6% 8.8% 7.9%
OP-10. Abdomen CT - Use of Contrast Material 7.9% 7.8% 8.3%
OP-11. Thorax CT - Use of Contrast Material 0.5% 1.8% 3.0%
OP-13. Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery 5.0% 4.8% 4.7%
OP-14. Outpatients with brain CT scans who got a sinus CT scan at the same time 1.5% 1.6% 1.8%

Medicare Spending Per Beneficiary

Measure Hospital Score National Average State Average
MSPB. Medicare Spending per Beneficiary 1.01 0.98 0.99

Measures of Psychiatric Facilities

Inpatient Psychiatric Facility Quality Reporting (IPFQR)

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