• Posted on 06/17/2020
  • 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
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
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
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 101   95.0% 89.0% 91.0%

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 99.0% 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   93.0% 89.0% 89.0%
OP-30. Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use 168   97.0% 93.0% 94.0%

Sepsis Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
SEP-1. Appropriate care for severe sepsis and septic shock 624 2 49.0% 59.0% 57.0%
SEP-SH-3HR. Septic Shock 3-Hour Bundle 323 2 78.0% 86.0% 85.0%
SEP-SH-6HR. Septic Shock 6-Hour Bundle 84 2 54.0% 68.0% 67.0%
SEV_SEP_3HR. Severe Sepsis 3-Hour Bundle 468 2 76.0% 79.0% 77.0%
SEV_SEP_6HR. Severe Sepsis 6-Hour Bundle 260 2 87.0% 88.0% 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 3, 7 N/A 58.0% 70.0%
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
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 667 2 119 minutes 102 minutes 84 minutes
OP-18b. Average time patients spent in the emergency department before being sent home 421   172 minutes 141 minutes 147 minutes
OP-18c. Average (median) time patients spent in the emergency department before leaving from the visit- Psychiatric/Mental Health Patients. 16   326 minutes 239 minutes 196 minutes
OP-22. Percentage of patients who left the emergency department before being seen 266,303   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 13   54.0% 72.0% 74.0%

Preventive Care

Measure Number of Patients Footnotes Hospital Score National Average State Average
IMM-3. Healthcare workers given influenza vaccination 16,591   93.0% 90.0% 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 591   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 15% Sometimes 5% ***..
Help received quickly Always 64% Usually 27% Sometimes 9% ***..
Staff explained medicines Always 62% Usually 18% 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 43% Disagree 4% ***..
Overall hospital rating High 71% Medium 21% Low 8% ***..
Would recommend hospital Definitely 72% Probably 22% 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 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 5,075 14.5% 12.0% 17.7% 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 953 4.7% 3.7% 6.0% 6.0%
Rate of inpatient admissions for patients receiving outpatient chemotherapy 953 15.5% 13.8% 17.5% 12.5%
Ratio of unplanned hospital visits after hospital outpatient surgery 2,072 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) 0.638 0.628
HAI-2-SIR. Catheter Associated Urinary Tract Infections (CAUTI) 0.995 0.675
HAI-3-SIR. Surgical Site Infections from colon surgery (SSI: Colon) 1.388 1.020
HAI-4-SIR. Surgical Site Infections from abdominal hysterectomy (SSI: Hysterectomy) 1.184 0.947
HAI-5-SIR. Methicillin-resistant Staphylococcus aureus (or MRSA) blood infections 0.727 1.037
HAI-6-SIR. Clostridium difficile (or C.diff.) Infections (intestinal infections) 0.822 0.636

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 1.01 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.