• Posted on 07/08/2022
  • 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
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% 0.00%
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
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
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 1.007 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
No Data are available for this hospital.

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 96.0% 98.0%

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 153   100.0% 90.0% 89.0%

Sepsis Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
SEP-1. Appropriate care for severe sepsis and septic shock 354 2 46.0% 57.0% 55.0%
SEP-SH-3HR. Septic Shock 3-Hour Bundle 179 2 76.0% 82.0% 80.0%
SEP-SH-6HR. Septic Shock 6-Hour Bundle 35 2 83.0% 83.0% 77.0%
SEV_SEP_3HR. Severe Sepsis 3-Hour Bundle 354 2 69.0% 78.0% 77.0%
SEV_SEP_6HR. Severe Sepsis 6-Hour Bundle 148 2 81.0% 89.0% 89.0%

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 7 N/A 53.0% 67.0%
OP-3b. Median Time to transfer patients for Acute Coronary Intervention N/A 1 N/A 61 minutes 55 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   210 minutes 155 minutes 156 minutes
OP-18c. Average (median) time patients spent in the emergency department before leaving from the visit- Psychiatric/Mental Health Patients. 16   288 minutes 254 minutes 202 minutes
OP-22. Percentage of patients who left the emergency department before being seen 216,639   2.0% 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 25   64.0% 71.0% 72.0%

Preventive Care

Measure Number of Patients Footnotes Hospital Score National Average State Average
IMM-3. Healthcare workers given influenza vaccination 25,414   77.0% 86.0% 86.0%

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 625   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 79% Usually 16% Sometimes 5% ***..
Help received quickly Always 61% Usually 28% Sometimes 11% ***..
Staff explained medicines Always 63% Usually 17% Sometimes 20% ***..
Room and bath kept clean Always 66% Usually 22% Sometimes 12% ***..
Area quiet at night Always 59% Usually 31% Sometimes 10% ***..
Given discharge instructions Yes 87% No 13%   ****.
Patient understood care Strongly Agree 53% Agree 42% Disagree 5% ***..
Overall hospital rating High 74% Medium 17% Low 9% ****.
Would recommend hospital Definitely 75% Probably 20% 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 213 3.5% 2.0% 5.9% 2.9%
COPD 586 8.7% 6.8% 10.8% 8.4%
Heart Attack 601 11.7% 9.8% 14.0% 12.4%
Heart Failure 1,637 11.0% 9.6% 12.6% 11.3%
Pneumonia * N/A * N/A * N/A * N/A * N/A
Stroke 814 13.4% 11.7% 15.3% 13.6%
  • * Some claims-based measure data will not appear in the July 2022 release. CMS plans to release these results at a later date.

30-Day Risk Adjusted Readmission Rates

Measure Hospital Predicted Range National Average
Number Patients Readmission Rate from to
CABG 208 12.3% 9.6% 15.8% 11.9%
Colonoscopy * N/A * N/A * N/A * N/A * N/A
COPD 671 20.8% 18.3% 23.4% 19.8%
Heart Attack 634 14.6% 12.6% 16.7% 15.0%
Heart Failure 1,871 21.2% 19.5% 22.9% 21.3%
Hip/Knee Surgery 863 4.1% 3.2% 5.2% 4.1%
Hospital-wide 9,107 15.9% 15.1% 16.4% 15.0%
Pneumonia * N/A * N/A * N/A * N/A * N/A
  • * Some claims-based measure data will not appear in the July 2022 release. CMS plans to release these results at a later date.

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 * N/A * N/A * N/A * N/A * N/A
OP-35-ADM. Rate of inpatient admissions for patients receiving outpatient chemotherapy * N/A * N/A * N/A * N/A * N/A
OP-36. Ratio of unplanned hospital visits after hospital outpatient surgery 1,110 0.9% 0.7% 1.1% N/A
  • * Some claims-based measure data will not appear in the July 2022 release. CMS plans to release these results at a later date.

Hospital Return Days

Measure Hospital Predicted Range National Average
Number Patients Readmission Rate from to
Heart Attack 634 -4.8% -15.9% 7.6% N/A
Heart Failure 1,871 13.5% 2.5% 24.5% N/A
Pneumonia 1,872 11.0% 1.0% 20.8% N/A

Surgical Complications

Measure Hospital Predicted Range National Average
Number Patients Rate from to
Complications for Hip/Knee Replacements 897 3.30% 2.50% 4.40% 2.40%
PSI-3. Pressure sores * N/A * N/A * N/A * N/A * N/A
PSI-4. Death from serious treatable complications after surgery * N/A * N/A * N/A * N/A * N/A
PSI-6. Collapsed lung due to medical treatment * N/A * N/A * N/A * N/A * N/A
PSI-8. Broken hip from a fall after surgery * N/A * N/A * N/A * N/A * N/A
PSI-9. Postoperative Hemorrhage or Hematoma Rate * N/A * N/A * N/A * N/A * N/A
PSI-10. Postoperative Acute Kidney Injury Rate * N/A * N/A * N/A * N/A * N/A
PSI-11. Postoperative Respiratory Failure Rate * N/A * N/A * N/A * N/A * N/A
PSI-12. Serious blood clots after surgery * N/A * N/A * N/A * N/A * N/A
PSI-13. Blood stream infection after surgery * N/A * N/A * N/A * N/A * N/A
PSI-14. A wound that splits open after surgery * N/A * N/A * N/A * N/A * N/A
PSI-15. Accidental cuts and tears from medical treatment * N/A * N/A * N/A * N/A * N/A
PSI-90. Serious Complications * N/A * N/A * N/A * N/A * N/A
  • * Some claims-based measure data will not appear in the July 2022 release. CMS plans to release these results at a later date.

Healthcare Associated Infections

Measure Hospital Score State Score
HAI-1-SIR. Central Line Associated Blood Stream Infections (CLABSI) 0.898 1.040
HAI-2-SIR. Catheter Associated Urinary Tract Infections (CAUTI) 0.767 0.809
HAI-3-SIR. Surgical Site Infections from colon surgery (SSI: Colon) 1.775 0.887
HAI-4-SIR. Surgical Site Infections from abdominal hysterectomy (SSI: Hysterectomy) 1.956 1.239
HAI-5-SIR. Methicillin-resistant Staphylococcus aureus (or MRSA) blood infections 1.186 1.480
HAI-6-SIR. Clostridium difficile (or C.diff.) Infections (intestinal infections) 0.544 0.511

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 46.6% 45.2% 44.3%
OP-10. Abdomen CT - Use of Contrast Material 5.6% 6.2% 6.2%
OP-13. Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery 4.6% 3.9% 3.7%
OP-39. Breast Cancer Screening Recall Rates 8.3% 9.4% 8.0%

Medicare Spending Per Beneficiary

Measure Hospital Score National Average State Average
MSPB. Medicare Spending per Beneficiary 1.03 0.99 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.