• Posted on 01/27/2021
  • 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
2021 44.00 26.00 N/A 10.00 8.00 22.00 13% -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 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
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
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 1.007 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 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 123   95.0% 91.0% 89.0%

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 11.0% 100.0%

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 168   98.0% 91.0% 91.0%

Sepsis Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
SEP-1. Appropriate care for severe sepsis and septic shock 626   50.0% 60.0% 58.0%
SEP-SH-3HR. Septic Shock 3-Hour Bundle 439 2 78.0% 86.0% 85.0%
SEP-SH-6HR. Septic Shock 6-Hour Bundle 107 2 54.0% 69.0% 68.0%
SEV_SEP_3HR. Severe Sepsis 3-Hour Bundle 628 2 78.0% 80.0% 77.0%
SEV_SEP_6HR. Severe Sepsis 6-Hour Bundle 348 2 86.0% 89.0% 90.0%

Timely Heart Attack Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
OP-2. Fibrinolytic Therapy received within 30 minutes N/A 3, 7 N/A 57.0% 67.0%
OP-3b. Median Time to transfer patients for Acute Coronary Intervention N/A 1, 3 N/A 58 minutes 50 minutes

Timely Emergency Department Care

Measure Number of Patients Footnotes Hospital Score National Average State Average
OP-18b. Average time patients spent in the emergency department before being sent home 422   174 minutes 142 minutes 148 minutes
OP-18c. Average (median) time patients spent in the emergency department before leaving from the visit- Psychiatric/Mental Health Patients. 16   269 minutes 242 minutes 200 minutes
OP-22. Percentage of patients who left the emergency department before being seen 276,330   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 12   58.0% 72.0% 74.0%

Preventive Care

Measure Number of Patients Footnotes Hospital Score National Average State Average
IMM-3. Healthcare workers given influenza vaccination N/A 5 N/A 91.0% 92.0%

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
No Data are available for this hospital.

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 647   2.0% 2.0% 2.0%

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 80% Usually 16% Sometimes 4% ****.
Doctors communicated well Always 80% Usually 16% Sometimes 4% ***..
Help received quickly Always 65% Usually 26% Sometimes 9% ***..
Staff explained medicines Always 63% Usually 17% Sometimes 20% ***..
Room and bath kept clean Always 69% Usually 21% Sometimes 10% **...
Area quiet at night Always 60% Usually 29% Sometimes 11% ***..
Given discharge instructions Yes 87% No 13%   ***..
Patient understood care Strongly Agree 53% Agree 42% Disagree 5% ***..
Overall hospital rating High 72% Medium 20% Low 8% ***..
Would recommend hospital Definitely 72% Probably 23% No 5% ***..
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 298 3.0% 1.8% 5.2% 3.0%
COPD 1,427 8.6% 7.3% 10.0% 8.4%
Heart Attack 833 12.1% 10.3% 14.1% 12.7%
Heart Failure 2,111 9.9% 8.7% 11.2% 11.3%
Pneumonia 2,481 14.9% 13.5% 16.3% 15.4%
Stroke 1,042 14.2% 12.3% 16.3% 13.6%

30-Day Risk Adjusted Readmission Rates

Measure Hospital Predicted Range National Average
Number Patients Readmission Rate from to
CABG 293 14.3% 11.3% 17.8% 12.7%
Colonoscopy 5,196 14.7% 12.2% 17.6% 16.4%
COPD 1,699 20.4% 18.8% 22.2% 19.6%
Heart Attack 852 16.5% 14.4% 18.6% 16.1%
Heart Failure 2,503 21.8% 20.3% 23.4% 21.9%
Hip/Knee Surgery 1,871 4.2% 3.5% 5.1% 4.0%
Hospital-wide 12,718 16.4% 15.7% 16.9% 15.6%
Pneumonia 2,665 16.5% 15.2% 17.8% 16.6%

Visit Rates Following OP Procedure

Measure Hospital Predicted Range National Average
Number Patients Readmission Rate from to
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy 932 4.7% 3.7% 6.0% 5.9%
Rate of inpatient admissions for patients receiving outpatient chemotherapy 932 12.8% 11.2% 14.6% 12.0%
Ratio of unplanned hospital visits after hospital outpatient surgery 2,152 1.1% 0.9% 1.2% N/A

Hospital Return Days

Measure Hospital Predicted Range National Average
Number Patients Readmission Rate from to
Heart Attack 852 14.9% 2.8% 27.4% N/A
Heart Failure 2,503 4.9% -4.3% 14.2% N/A
Pneumonia 2,665 16.1% 7.9% 24.7% N/A

Surgical Complications

Measure Hospital Predicted Range National Average
Number Patients Rate from to
Complications for Hip/Knee Replacements 1,818 3.10% 2.40% 3.80% 2.40%
PSI-3. Pressure sores 28,208 0.10% 0.00% 0.40% 0.60%
PSI-4. Death from serious treatable complications after surgery 465 18.22% 15.25% 21.19% 16.42%
PSI-6. Collapsed lung due to medical treatment 34,403 0.27% 0.13% 0.41% 0.25%
PSI-8. Broken hip from a fall after surgery 30,607 0.13% 0.06% 0.19% 0.11%
PSI-9. Postoperative Hemorrhage or Hematoma Rate 10,815 2.43% 1.65% 3.20% 2.49%
PSI-10. Postoperative Acute Kidney Injury Rate 6,113 1.11% 0.31% 1.91% 1.36%
PSI-11. Postoperative Respiratory Failure Rate 5,191 6.66% 4.63% 8.70% 6.15%
PSI-12. Serious blood clots after surgery 11,352 3.81% 2.74% 4.87% 3.76%
PSI-13. Blood stream infection after surgery 5,935 3.40% 1.81% 4.99% 4.79%
PSI-14. A wound that splits open after surgery 3,051 0.80% 0.23% 1.37% 0.91%
PSI-15. Accidental cuts and tears from medical treatment 6,848 0.76% 0.07% 1.45% 1.26%
PSI-90. Serious Complications Not Applicable 0.79% 0.64% 0.94% 1.00%

Healthcare Associated Infections

Measure Hospital Score State Score
HAI-1-SIR. Central Line Associated Blood Stream Infections (CLABSI) 0.616 0.689
HAI-2-SIR. Catheter Associated Urinary Tract Infections (CAUTI) 0.949 0.654
HAI-3-SIR. Surgical Site Infections from colon surgery (SSI: Colon) 1.210 0.955
HAI-4-SIR. Surgical Site Infections from abdominal hysterectomy (SSI: Hysterectomy) 1.421 0.967
HAI-5-SIR. Methicillin-resistant Staphylococcus aureus (or MRSA) blood infections 1.015 1.021
HAI-6-SIR. Clostridium difficile (or C.diff.) Infections (intestinal infections) 0.765 0.614

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 41.3% 39.0% 37.7%
OP-10. Abdomen CT - Use of Contrast Material 8.6% 6.4% 6.6%
OP-13. Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery 4.4% 4.2% 4.0%

Medicare Spending Per Beneficiary

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

Measures of Psychiatric Facilities

Inpatient Psychiatric Facility Quality Reporting (IPFQR)

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