Quality Report

  • Posted on 04/07/2024
  • 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
2024 11.67 13.00 N/A 0.00 8.00 8.17 4% -1.22%
2023 34.00 N/A N/A 0.00 N/A *N/A * *0.00%
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 12% -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
2024 1.0277 454 1.0080 1,208 1.0129 1,150 1.0774 330 1.0311 162 0.9104 255 0.9967 -0.33%
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
2024 01/01/2021 06/30/2022 1.0609 01/01/2022 12/31/2022 0.867 0.685 1.441 0.857 0.666 0.3570 0%
2023 N/A N/A N/A 01/01/2021 12/31/2021 0.9900 0.8450 1.5710 1.0600 0.5010 *0.0000 *0%
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 97.0% N/A

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% 92.0% 88.0%

Sepsis Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
SEP-1. Appropriate care for severe sepsis and septic shock 407 2 40.0% 60.0% 59.0%
SEP-SH-3HR. Septic Shock 3-Hour Bundle 111 2 51.0% 69.0% 68.0%
SEP-SH-6HR. Septic Shock 6-Hour Bundle 46 2 74.0% 85.0% 83.0%
SEV_SEP_3HR. Severe Sepsis 3-Hour Bundle 408 2 67.0% 79.0% 78.0%
SEV_SEP_6HR. Severe Sepsis 6-Hour Bundle 194 2 79.0% 90.0% 92.0%

Timely Heart Attack Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
No Data are available for this hospital.

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 421   204 minutes 162 minutes 151 minutes
OP-18c. Average (median) time patients spent in the emergency department before leaving from the visit- Psychiatric/Mental Health Patients. N/A 1 N/A 268 minutes 216 minutes
OP-22. Percentage of patients who left the emergency department before being seen 280,817   6.0% 3.0% 3.0%
OP-23. Percentage of patients who came to the emergency department with stroke symptoms who received brain scan results within 45 minutes of arrival 49   65.0% 69.0% 67.0%

Healthcare Personnel Vaccination

Measure Number of Patients Footnotes Hospital Score National Average State Average
HCP-COVID-19. Percentage of healthcare personnel who completed COVID-19 primary vaccination series 21,995   91.3% 90.5% 87.2%
IMM-3. Healthcare workers given influenza vaccination 26,778   77.0% 81.0% 82.0%

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-05. Exclusive Breast Milk Feeding N/A 5 N/A  
PC-01. Women who had elective deliveries 1-3 weeks early when not medically necessary 553   3.0% 2.0% 2.0%
SM-7. Maternal Morbidity Structural Measure N/A   Yes  

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 75% Usually 20% Sometimes 5% ***..
Doctors communicated well Always 77% Usually 18% Sometimes 5% ***..
Help received quickly Always 57% Usually 29% Sometimes 14% ***..
Staff explained medicines Always 57% Usually 18% Sometimes 25% ***..
Room and bath kept clean Always 62% Usually 23% Sometimes 15% **...
Area quiet at night Always 59% Usually 29% Sometimes 12% ***..
Given discharge instructions Yes 86% No 14%   ***..
Patient understood care Strongly Agree 50% Agree 43% Disagree 7% ***..
Overall hospital rating High 67% Medium 23% Low 10% ***..
Would recommend hospital Definitely 69% Probably 25% No 6% ****.
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 204 4.1% 2.4% 6.6% 2.9%
COPD 360 8.5% 6.4% 11.2% 9.2%
Heart Attack 546 12.1% 10.2% 14.3% 12.6%
Heart Failure 1,380 13.9% 12.3% 15.6% 11.8%
Pneumonia 1,372 18.9% 16.9% 20.9% 18.2%
Stroke 716 14.7% 12.8% 16.7% 13.9%

30-Day Risk Adjusted Readmission Rates

Measure Hospital Predicted Range National Average
Number Patients Readmission Rate from to
CABG 197 11.6% 9.1% 14.7% 11.0%
Colonoscopy 4,254 11.3% 9.0% 14.1% 13.2%
COPD 398 21.4% 18.4% 24.6% 19.3%
Heart Attack 566 14.2% 12.2% 16.5% 14.0%
Heart Failure 1,524 20.3% 18.5% 22.1% 20.2%
Hip/Knee Surgery 276 3.7% 2.6% 5.3% 4.3%
Hospital-wide 8,008 15.0% 14.4% 15.7% 14.6%
Pneumonia 1,405 17.4% 15.7% 19.1% 16.9%

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 958 5.0% 4.0% 6.2% 5.4%
OP-35-ADM. Rate of inpatient admissions for patients receiving outpatient chemotherapy 958 12.9% 11.3% 14.8% 10.3%
OP-36. Ratio of unplanned hospital visits after hospital outpatient surgery 2,316 0.9% 0.8% 1.1% N/A

Hospital Return Days

Measure Hospital Predicted Range National Average
Number Patients Readmission Rate from to
Heart Attack 566 14.0% 0.7% 29.3% N/A
Heart Failure 1,524 23.7% 11.9% 37.0% N/A
Pneumonia 1,405 26.2% 14.9% 38.0% N/A

Surgical Complications

Measure Hospital Predicted Range National Average
Number Patients Rate from to
Complications for Hip/Knee Replacements 313 3.10% 2.00% 4.80% 3.20%
PSI-3. Pressure sores 21,343 0.25% 0.00% 0.55% 0.59%
PSI-4. Death from serious treatable complications after surgery 448 16.00% 13.32% 18.67% 16.79%
PSI-6. Collapsed lung due to medical treatment 24,284 0.17% 0.04% 0.31% 0.25%
PSI-8. Broken hip from a fall after surgery 25,811 0.09% 0.03% 0.14% 0.09%
PSI-9. Postoperative Hemorrhage or Hematoma Rate 6,697 1.95% 0.99% 2.91% 2.52%
PSI-10. Postoperative Acute Kidney Injury Rate 2,999 1.88% 0.83% 2.92% 1.57%
PSI-11. Postoperative Respiratory Failure Rate 2,949 8.87% 6.00% 11.74% 8.86%
PSI-12. Serious blood clots after surgery 7,069 4.45% 3.26% 5.63% 3.63%
PSI-13. Blood stream infection after surgery 2,906 7.12% 5.05% 9.19% 5.28%
PSI-14. A wound that splits open after surgery 1,561 1.75% 0.23% 3.26% 2.01%
PSI-15. Accidental cuts and tears from medical treatment 4,987 1.38% 0.65% 2.11% 1.10%
PSI-90. Serious Complications N/A 1.02% 0.86% 1.18% 1.00%

Healthcare Associated Infections

Measure Hospital Score State Score
HAI-1-SIR. Central Line Associated Blood Stream Infections (CLABSI) 0.762 0.932
HAI-2-SIR. Catheter Associated Urinary Tract Infections (CAUTI) 0.523 0.612
HAI-3-SIR. Surgical Site Infections from colon surgery (SSI: Colon) 2.066 0.985
HAI-4-SIR. Surgical Site Infections from abdominal hysterectomy (SSI: Hysterectomy) 1.613 1.093
HAI-5-SIR. Methicillin-resistant Staphylococcus aureus (or MRSA) blood infections 0.933 1.005
HAI-6-SIR. Clostridium difficile (or C.diff.) Infections (intestinal infections) 0.595 0.491

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 33.8% 37.1% 34.1%
OP-10. Abdomen CT - Use of Contrast Material 6.8% 6.0% 6.9%
OP-13. Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery 3.6% 3.8% 3.5%
OP-39. Breast Cancer Screening Recall Rates 8.1% 9.2% 7.3%

Medicare Spending Per Beneficiary

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