• Posted on 04/10/2019
  • 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
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
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
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 93   89.0% 86.0% 88.0%

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 95.0% 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   96.0% 88.0% 88.0%
OP-30. Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use 169   95.0% 90.0% 93.0%

Sepsis Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
SEP-1. Appropriate care for severe sepsis and septic shock 507 2 40.0% 53.0% 52.0%

Timely Heart Attack Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
OP-2. Fibrinolytic Therapy received within 30 minutes 0 3, 7 N/A 59.0% 68.0%
OP-3b. Median Time to transfer patients for Acute Coronary Intervention N/A 1, 3 N/A 62 minutes 54 minutes
OP-5. Median Time to ECG 29   10 minutes 8 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 684 2 334 minutes 256 minutes 242 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 677 2 137 minutes 86 minutes 73 minutes
OP-18b. Average time patients spent in the emergency department before being sent home 425   181 minutes 137 minutes 140 minutes
OP-18c. Average (median) time patients spent in the emergency department before leaving from the visit- Psychiatric/Mental Health Patients. 13   282 minutes 212 minutes 189 minutes
OP-22. Percentage of patients who left the emergency department before being seen 261,419   4.0% 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 21   52.0% 73.0% 70.0%

Preventive Care

Measure Number of Patients Footnotes Hospital Score National Average State Average
IMM-2. Patients assessed and given influenza vaccination 568 2 90.0% 93.0% 94.0%
IMM-3-OP-27-FAC-ADHPCT. Healthcare workers given influenza vaccination 17,203   94.0% 89.0% 90.0%

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
VTE-6. Patients who developed blood clots who did not receive preventative treatment 77 2 5.0% 3.0% 4.0%

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 617 2 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 79% Usually 17% Sometimes 4% ***..
Doctors communicated well Always 80% Usually 15% Sometimes 5% ****.
Help received quickly Always 64% Usually 26% Sometimes 10% ***..
Staff explained medicines Always 62% Usually 18% Sometimes 20% ***..
Room and bath kept clean Always 68% Usually 22% Sometimes 10% **...
Area quiet at night Always 58% Usually 30% Sometimes 12% ***..
Given discharge instructions Yes 87% No 13%   ***..
Patient understood care Strongly Agree 54% Agree 41% Disagree 5% ****.
Overall hospital rating High 72% Medium 20% Low 8% ****.
Would recommend hospital Definitely 73% Probably 22% No 5% ***..
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 294 5.0% 3.0% 7.8% 3.1%
Heart Attack 960 13.1% 11.3% 15.1% 13.2%
Heart Failure 1,879 10.2% 9.0% 11.6% 11.7%
Pneumonia 2,372 16.4% 15.1% 17.9% 15.7%
COPD 1,376 8.3% 7.0% 9.7% 8.3%
Stroke 1,045 14.9% 13.1% 16.9% 14.3%

30-Day Risk Adjusted Readmission Rates

Measure Hospital Predicted Range National Average
Number Patients Readmission Rate from to
Colonoscopy 1,669 13.4% 10.2% 17.6% 14.8%
CABG 284 14.0% 11.1% 17.5% 13.2%
Heart Attack 977 15.7% 13.8% 17.8% 16.0%
Heart Failure 2,156 21.0% 19.4% 22.7% 21.7%
Pneumonia 2,535 17.0% 15.7% 18.3% 16.7%
COPD 1,648 20.9% 19.2% 22.6% 19.6%
Hip/Knee Surgery 1,691 4.2% 3.4% 5.0% 4.2%
Stroke 1,052 12.0% 10.4% 13.7% 11.9%
Hospital-wide 12,404 16.1% 15.4% 16.6% 15.3%

Surgical Complications

Measure Hospital Predicted Range National Average
Number Patients Rate from to
Complications for Hip/Knee Replacements 1,588 2.30% 1.70% 3.00% 2.60%
PSI-3. Pressure sores 25,611 0.08% 0.00% 0.31% 0.41%
PSI-4. Death from serious treatable complications after surgery 440 15.85% 12.88% 18.83% 16.17%
PSI-6. Collapsed lung due to medical treatment 29,996 0.24% 0.08% 0.39% 0.29%
PSI-8. Broken hip from a fall after surgery 26,702 0.10% 0.04% 0.17% 0.11%
PSI-9. Postoperative Hemorrhage or Hematoma Rate 9,569 2.79% 1.93% 3.66% 2.60%
PSI-10. Postoperative Acute Kidney Injury Rate 5,615 1.67% 0.80% 2.54% 1.32%
PSI-11. Postoperative Respiratory Failure Rate 4,808 14.08% 11.80% 16.37% 7.88%
PSI-12. Serious blood clots after surgery 10,039 4.46% 3.33% 5.59% 3.86%
PSI-13. Blood stream infection after surgery 5,525 4.98% 3.24% 6.71% 5.23%
PSI-14. A wound that splits open after surgery 3,044 1.27% 0.47% 2.06% 0.86%
PSI-15. Accidental cuts and tears from medical treatment 6,421 0.95% 0.27% 1.63% 1.29%
PSI-90. Serious Complications N/A 1.13% 0.98% 1.27% 1.00%

Healthcare Associated Infections

Measure Hospital Score State Score
HAI-1-SIR. Central Line Associated Blood Stream Infections (CLABSI) 0.666 0.696
HAI-2-SIR. Catheter Associated Urinary Tract Infections (CAUTI) 0.785 0.765
HAI-3-SIR. Surgical Site Infections from colon surgery (SSI: Colon) 1.758 1.096
HAI-4-SIR. Surgical Site Infections from abdominal hysterectomy (SSI: Hysterectomy) 1.628 0.927
HAI-5-SIR. Methicillin-resistant Staphylococcus aureus (or MRSA) blood infections 0.762 0.957
HAI-6-SIR. Clostridium difficile (or C.diff.) Infections (intestinal infections) 0.726 0.736

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 40.7% 39.3% 38.8%
OP-9. Mammography Follow-up Rates 6.8% 8.9% 8.0%
OP-10. Abdomen CT - Use of Contrast Material 10.1% 7.8% 7.7%
OP-11. Thorax CT - Use of Contrast Material 0.7% 1.5% 2.7%
OP-13. Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery 4.6% 4.6% 4.5%
OP-14. Outpatients with brain CT scans who got a sinus CT scan at the same time 0.7% 1.1% 1.2%

Medicare Spending Per Beneficiary

Measure Hospital Score National Average State Average
MSPB. Medicare Spending per Beneficiary 1.02 0.99 0.98

Measures of Psychiatric Facilities

Inpatient Psychiatric Facility Quality Reporting (IPFQR)

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