• Posted on 04/25/2017
  • 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
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
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
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

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 87% 92%

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 175   91% 80% 79%
OP-30. Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use 143   92% 87% 88%

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 59% 64%
OP-3b. Median Time to transfer patients for Acute Coronary Intervention N/A 1 N/A 59 minutes 52 minutes
OP-4. Aspirin at Arrival 17   100% 96% 96%
OP-5. Median Time to ECG 18   6 minutes 7 minutes 6 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 657 2 294 minutes 279 minutes 252 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 643 2 111 minutes 99 minutes 79 minutes
OP-18b. Average time patients spent in the emergency department before being sent home 328   179 minutes 140 minutes 137 minutes
OP-20. Average time patients spent in the emergency department before they were seen by a healthcare professional 328   34 minutes 21 minutes 22 minutes
OP-21. Average time patients who came to the emergency department with broken bones had to wait before receiving pain medication 291   24 minutes 52 minutes 52 minutes
OP-22. Percentage of patients who left the emergency department before being seen 259,318   3% 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 14   86% 70% 68%

Preventive Care

Measure Number of Patients Footnotes Hospital Score National Average State Average
IMM-2. Patients assessed and given influenza vaccination 535 2 95% 94% 95%
IMM-3-OP-27-FAC-ADHPCT. Healthcare workers given influenza vaccination 20,388   80% 86% 83%

Stroke Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
STK-4. Ischemic stroke patients who received t-PA within 3 hours of symptoms 47   74% 87% 85%

Blood Clot Prevention and Treatment

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
VTE-5. Patients with blood clots who were discharged on blood thinners and received educational instructions at discharge 169 2 67% 93% 90%
VTE-6. Patients who developed blood clots who did not receive preventative treatment 100 2 3% 2% 2%

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 561 2 4% 2% 4%

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 16% Sometimes 5% ***..
Doctors communicated well Always 79% Usually 16% Sometimes 5% ***..
Help received quickly Always 64% Usually 26% Sometimes 10% ***..
Pain controlled well Always 69% Usually 24% Sometimes 7% ***..
Staff explained medicines Always 61% Usually 19% Sometimes 20% **...
Room and bath kept clean Always 66% Usually 22% Sometimes 12% **...
Area quiet at night Always 58% Usually 29% Sometimes 13% ***..
Given discharge instructions Yes 86% No 14%   ***..
Patient understood care Strongly Agree 52% Agree 43% Disagree 5% ***..
Overall hospital rating High 70% Medium 22% Low 8% ***..
Would recommend hospital Definitely 72% Probably 22% 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 279 4.0% 2.3% 6.5% 3.2%
Heart Attack 996 13.3% 11.6% 15.2% 14.1%
Heart Failure 1,641 10.5% 9.2% 12.1% 12.1%
Pneumonia 2,294 16.7% 15.2% 18.1% 16.3%
COPD 1,212 7.8% 6.5% 9.3% 8.0%
Stroke 938 14.4% 12.5% 16.6% 14.9%

30-Day Risk Adjusted Readmission Rates

Measure Hospital Predicted Range National Average
Number Patients Readmission Rate from to
CABG 268 16.1% 13.1% 19.5% 14.4%
Heart Attack 1,030 17.0% 15.2% 18.9% 16.8%
Heart Failure 1,966 21.1% 19.5% 22.8% 21.9%
Pneumonia 2,464 17.2% 15.9% 18.5% 17.1%
COPD 1,438 21.5% 19.8% 23.4% 20.0%
Hip/Knee Surgery 1,555 4.7% 3.9% 5.7% 4.6%
Stroke 924 12.9% 11.0% 14.8% 12.5%
Hospital-wide 12,001 16.0% 15.4% 16.5% 15.6%

Surgical Complications

Measure Hospital Predicted Range National Average
Number Patients Rate from to
Complications for Hip/Knee Replacements 1,491 2.70% 2.10% 3.40% 3.00%
PSI-3. Pressure sores 13,164 0.35% 0.00% 0.74% 0.48%
PSI-4. Death from serious treatable complications after surgery 534 14.47% 11.83% 17.11% 13.65%
PSI-6. Collapsed lung due to medical treatment 32,176 0.29% 0.10% 0.48% 0.41%
PSI-7. Infections from a large venous catheter 22,102 0.32% 0.17% 0.48% 0.17%
PSI-8. Broken hip from a fall after surgery 5,801 0.06% 0.06% 0.06% 0.06%
PSI-12. Serious blood clots after surgery 10,699 6.25% 4.89% 7.61% 5.31%
PSI-13. Blood stream infection after surgery 1,561 7.96% 3.91% 12.01% 10.21%
PSI-14. A wound that splits open after surgery 1,490 3.03% 1.34% 4.72% 2.32%
PSI-15. Accidental cuts and tears from medical treatment 32,808 1.10% 0.72% 1.49% 1.43%
PSI-90. Serious Complications N/A 0.86% 0.73% 1.00% 0.90%

Healthcare Associated Infections

Measure Hospital Score State Score
HAI-1-SIR. Central Line Associated Blood Stream Infections (CLABSI) N/A N/A
HAI-2-SIR. Catheter Associated Urinary Tract Infections (CAUTI) 1.013 0.904
HAI-3-SIR. Surgical Site Infections from colon surgery (SSI: Colon) 1.763 0.945
HAI-4-SIR. Surgical Site Infections from abdominal hysterectomy (SSI: Hysterectomy) 1.973 0.976
HAI-5-SIR. Methicillin-resistant Staphylococcus aureus (or MRSA) blood infections 1.487 1.346
HAI-6-SIR. Clostridium difficile (or C.diff.) Infections (intestinal infections) 1.025 0.971

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 39.8% 39.5% 39.4%
OP-9. Mammography Follow-up Rates 7.6% 8.9% 7.9%
OP-10. Abdomen CT - Use of Contrast Material 8.1% 8.4% 9.0%
OP-11. Thorax CT - Use of Contrast Material 0.5% 2.1% 4.7%
OP-13. Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery 6.2% 4.8% 4.9%
OP-14. Outpatients with brain CT scans who got a sinus CT scan at the same time 3.0% 2.9% 3.1%

Medicare Spending Per Beneficiary

Measure Hospital Score National Average State Average
MSPB. Medicare Spending per Beneficiary 1.02 0.99 0.97

Measures of Psychiatric Facilities

Inpatient Psychiatric Facility Quality Reporting (IPFQR)

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