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Sample Hospital Louisville, KY 11111 CMS Certification Number: 000000 |
Sample Report | Order Information
Quality Report |
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% | 83% | |
OP-30. Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use | 165 | 97% | 89% | 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 | 26 minutes |
OP-2. Fibrinolytic Therapy received within 30 minutes | N/A | 7 | N/A | 57% | 65% |
OP-3b. Median Time to transfer patients for Acute Coronary Intervention | N/A | 1 | N/A | 58 minutes | 56 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 | 672 | 2 | 330 minutes | 282 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 | 658 | 2 | 130 minutes | 102 minutes | 81 minutes |
OP-18b. Average time patients spent in the emergency department before being sent home | 427 | 168 minutes | 138 minutes | 140 minutes | |
OP-20. Average time patients spent in the emergency department before they were seen by a healthcare professional | 432 | 35 minutes | 20 minutes | 22 minutes | |
OP-21. Average time patients who came to the emergency department with broken bones had to wait before receiving pain medication | 507 | 24 minutes | 49 minutes | 49 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 | 21 | 57% | 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 | 93 | 2 | 2% | 2% | 3% |
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 | 280 | 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 | 63% | Usually | 26% | Sometimes | 11% | ![]() ![]() ![]() ![]() ![]() |
Pain controlled well | Always | 69% | Usually | 25% | Sometimes | 6% | ![]() ![]() ![]() ![]() ![]() |
Staff explained medicines | Always | 62% | Usually | 17% | 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 | 86% | No | 14% | ![]() ![]() ![]() ![]() ![]() |
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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) | 0.764 | 0.722 |
HAI-2-SIR. Catheter Associated Urinary Tract Infections (CAUTI) | 0.964 | 0.785 |
HAI-3-SIR. Surgical Site Infections from colon surgery (SSI: Colon) | 1.541 | 0.967 |
HAI-4-SIR. Surgical Site Infections from abdominal hysterectomy (SSI: Hysterectomy) | 1.915 | 1.064 |
HAI-5-SIR. Methicillin-resistant Staphylococcus aureus (or MRSA) blood infections | 1.639 | 1.173 |
HAI-6-SIR. Clostridium difficile (or C.diff.) Infections (intestinal infections) | 0.911 | 0.799 |
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. |