Hospital Public Reporting
The consumer website called Hospital Compare,
www.hospitalcompare.hhs.gov,
was unveiled on April 1, 2005. This resource provides instant,
objective, easy-to-use and free information about the quality of
hospital care in Colorado and nationwide. Under the Hospital Quality
Initiative, hospitals voluntarily submit quality of care information so
that consumers can compare care and make better-informed decisions.
Hospital Compare was created by the Centers for Medicare & Medicaid
Services (CMS) and the Hospital Quality Alliance, a public-private
collaboration.
Quality Measures
The 24 quality measures, which are based on established guidelines,
have gone through years of extensive testing for validity and
reliability by CMS and the Medicare quality improvement organizations (QIOs),
the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO), and researchers. The National Quality Forum (NQF), a voluntary
standard-setting consensus-building organization representing providers,
consumers, purchasers, and researchers, has endorsed these measures.
Heart Attack Process of Care Measures
For more
information about Heart Attack,
Click here
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Brief Explanation
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Percent of Heart Attack Patients Given Aspirin at Arrival
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Aspirin can help keep blood clots from forming and dissolve blood clots that can cause heart attacks.
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Percent of Heart Attack Patients Given Aspirin at Discharge
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Taking aspirin may help prevent further heart attacks.
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Percent of Heart Attack Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)
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ACE (angiotensin converting enzyme) inhibitors and ARBs (angiotensin receptor blockers) are medicines used to treat heart attacks, heart failure, or a decreased function of the heart.
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Percent of Heart Attack Patients Given Smoking Cessation Advice/Counseling
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Smoking is linked to heart attacks. Quitting may help prevent another heart attack.
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Percent of Heart Attack Patients Given Beta Blocker at Discharge
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Beta blockers are a type of medicine used to lower blood pressure, treat chest pain (angina) and heart failure, and to help prevent a heart attack.
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Percent of Heart Attack Patients Given Fibrinolytic Medication Within 30 Minutes Of Arrival
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Blood clots can cause heart attacks. Doctors may give this medicine, or perform a procedure to open the blockage, and in some cases, may do both.
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Percent of Heart Attack Patients Given PCI Within 90 Minutes Of Arrival
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The procedures called Percutaneous Coronary Interventions (PCI) are among those that are the most effective for opening blocked blood vessels that cause heart attacks. Doctors may perform PCI, or give medicine to open the blockage, and in some cases, may do both.
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Heart Failure Process of Care Measures For more
information about Heart Failure,
Click here
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Brief Explanation
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Percent of Heart Failure Patients Given Discharge Instructions
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The staff at the hospital should provide you with information to help you manage your heart failure symptoms when you are discharged.
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Percent of Heart Failure Patients Given an Evaluation of Left Ventricular Systolic (LVS) Function
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An evaluation of the LVS function checks how the left chamber of the heart is pumping.
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Percent of Heart Failure Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)
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ACE (angiotensin converting enzyme) inhibitors and ARBs (angiotensin receptor blockers) are medicines used to treat heart attacks, heart failure, or a decreased function of the heart.
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Percent of Heart Failure Patients Given Smoking Cessation Advice/Counseling
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Smoking is linked to heart failure. Quitting may help improve your condition.
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Pneumonia Process of Care Measures For more
information about Pneumonia,
Click here
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Brief Explanation
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Percent of Pneumonia Patients Given Oxygenation Assessment
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Having enough oxygen in your blood is important to your health.
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Percent of Pneumonia Patients Assessed and Given Pneumococcal Vaccination
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A pneumonia (pneumococcal) shot can help prevent pneumonia in the future, even for patients who have been hospitalized for pneumonia.
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Percent of Pneumonia Patients Whose Initial Emergency Room Blood Culture Was Performed Prior To The Administration Of The First Hospital Dose Of Antibiotics
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A blood culture tells what kind of medicine will work best to treat your pneumonia.
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Percent of Pneumonia Patients Given Smoking Cessation Advice/Counseling
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Smoking is linked to pneumonia. Quitting may help prevent you from getting pneumonia again.
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Percent of Pneumonia Patients Given Initial Antibiotic(s) within 6 Hours After Arrival
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Timely use of antibiotics can improve the treatment of pneumonia caused by bacteria.
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Percent of Pneumonia Patients Given the Most Appropriate Initial Antibiotic(s)
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Antibiotics are medicines that treat infection, and each one is different. Hospitals should choose the antibiotics that best treat the infection type for each pneumonia patient.
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Percent of Pneumonia Patients Assessed and Given Influenza Vaccination
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An influenza shot can help prevent influenza in the future, even for patients who have been hospitalized for pneumonia.
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Surgical Care Improvement Project Process of Care Measures For more
information about Surgical Care Improvement Project,
Click here
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Brief Explanation
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Preventing Blood Clots
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Percent of surgery patients whose doctors ordered treatments to prevent blood clots after certain types of surgeries
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Certain types of surgery can increase patients’ risk of having blood clots after surgery. For these types of surgery, this measure tells how often treatment to help prevent blood clots was ordered by the doctor.
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Percent of patients who got treatment at the right time (within 24 hours before or after their surgery) to help prevent blood clots after certain types of surgery
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This measure tells how often patients having certain types of surgery received treatment to prevent blood clots in the period from 24 hours before surgery to 24 hours after surgery.
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Preventing Infection
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Percent of surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery)
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Taking preventive antibiotics for more than 24 hours after routine surgery is usually not necessary. This measure shows how often hospitals stopped giving antibiotics to surgery patients when they were no longer needed to prevent surgical infection.
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Percent of all heart surgery patients whose blood sugar (blood glucose) is kept under good control in the days right after surgery
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All heart surgery patients get their blood sugar checked after surgery. Any patient who has high blood sugar after heart surgery has a greater chance of getting an infection. This measure tells how often the blood sugar of heart surgery patients was kept under good control in the days right after their surgery.
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Percent of surgery patients needing hair removed from the surgical area before surgery, who had hair removed using a safer method (electric clippers or hair removal cream – not a razor)
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For those patients who needed to have hair removed to prepare for surgery, this measure tells how often one of the safer methods was used (electric clippers or hair removal cream).
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Percent of surgery patients who were given an antibiotic at the right time (within one hour before surgery) to help prevent infection
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Getting an antibiotic within one hour before surgery reduces the risk of wound infections. This measure shows how often hospital staff make sure surgery patients get antibiotics at the right time.
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Percent of surgery patients who were given the right kind of antibiotic to help prevent infection
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Some antibiotics work better than others to prevent wound infections for certain types of surgery. This measure shows how often hospital staff make sure patients get the right kind of preventive antibiotic medication for their surgery.
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Benefits of Participation
Hospitals benefit from publicly reporting quality of care
information in several ways. Participation helps hospitals to
highlight their successes and to identify and focus on areas for
improvement in quality of care, as well as using national and local
benchmarks to assess performance. Hospitals also have the
opportunity to give consumers important information about quality of
care to help them compare and make informed decisions. In addition
to these benefits, hospitals receive technical assistance and
hands-on training in submitting data and improving quality from
quality improvement organizations (QIOs).
Which Hospitals Should Participate?
Most hospitals are subject to the RHQDAPU Initiative. They are
designated as 'subsection d hospitals' and are defined in the Social
Security Act under Section 1886(d)(1)(B).
Data is now available on Hospital Compare at
www.medicare.gov
or
www.hospitalcompare.hhs.gov (links opens new windows).
Hospital Quality Alliance (HQA)
The American Hospital Association (AHA), the Federation of American
Hospitals (FAH), and the Association of American Medical Colleges (AAMC)
have launched a national voluntary initiative to collect and report
hospital quality performance information. This effort is intended to
make critical information about hospital performance accessible to
the public and to inform and invigorate efforts to improve quality.
Voluntary reporting is an essential first step to realize this goal.
This project builds upon previous CMS and QIO strategies to identify
illnesses and/or clinical conditions that affect Medicare
beneficiaries in order to: promote the best medical practices
associated with the targeted clinical disorders; prevent or reduce
further instances of these selected clinical disorders; and prevent
related complications.
How to Participate in HQA >
Mission of the HQA
The Hospital Quality Alliance facilitates continuous improvement in
patient care through:
- Implementing measures that portray the quality, cost and value
of hospital care;
- Developing and using measure reporting in the nation's
hospitals; and
- Sharing useful hospital performance information with the public.
HQA Measures
- AMI
- Aspirin at Arrival
- Aspirin at Discharge
- Beta-blocker at Discharge
- ACE or ARB for LVSD
- Percutaneous coronary interventions within 90 minutes of
arrival
- Fibrinolytic therapy received within 30 minutes of
arrival
- Adult smoking cessation advice/counseling
- AMI 30 day mortality (Medicare patients only)
- Heart Failure
- Left ventricular function assessment
- ACE or ARB for LVSD
- Discharge instructions
- Adult smoking cessation advice/counseling
- Heart Failure 30 day mortality (Medicare Patients
Only)
- Pneumonia
- Initial antibiotics received within 6 hours of
hospital arrival
- Pneumococcal vaccination
- Blood culture before antibiotic
- Adult smoking cessation advice/counseling
- Influenza vaccination
- Initial antibiotic selection for CAP in
immunocompetent patient
- Surgical Care
- Prophylactic antibiotic received within 1
hour prior to surgical incision
- Prophylactic antibiotic discontinued within
24 hours after surgery end time
- Prophylactic antibiotic selection for
surgical patients
- Surgery patients with recommended venous
thromboembolism prophylaxis ordered
- Surgery patients who received appropriate
venous thromboembolism prophylaxis within 24
hours prior to surgery to 24 hours after surgery
- Cardiac surgery patients with controlled 6
A.M. postoperative blood glucose
- Surgery patients with appropriate hair
removal
- Surgery patients on Beta-blocker therapy
prior to admission who received a Beta-blocker
during perioperative period
- Accidental puncture or laceration (claims
data)
- Post-op wound dehiscence (claims data)
- AAA mortality (claims data)
- Patient Experience – HCAHPS Survey
Comparison of CMS, JCAHO, and HQA Measures
Data Submission Deadlines Visit
QualityNet for more information on Hospital Public Reporting.
Hospital Patient Perspective on
Care Survey (HCAHPS)
The intent of the HCAHPS initiative is to provide a standardized
survey instrument and data collection methodology for measuring
patients' perspectives on hospital care. While many hospitals currently
collect information on patients' satisfaction with care, there is no
national standard for collecting or publicly reporting this information
that would enable valid comparisons to be made across all hospitals. In
order to make "apples to apples" comparisons to support consumer choice,
it is necessary to introduce a standard measurement approach. HCAHPS can
be viewed as a core set of questions that can be combined with a
broader, customized set of hospital-specific items. HCAHPS is meant to
complement the data hospitals currently collect to support improvements
in internal customer services and quality related activities.
To learn more about HCAHPS, please visit the following website:
http://www.hcahpsonline.org/
For information and technical assistance, contact the Arizona QIO:
hcahps@azqio.sdps.org or 1-888-884-4007.
Reporting Hospital Quality Data
for Annual Payment Update (RHQDAPU)
The Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU)
initiative was initially developed as a result of the Medicare
Prescription Drug, Improvement and Modernization Act (MMA) of 2003.
Section 5001(a) of Pub. 109-171 of the Deficit Reduction Act (DRA) of
2005 set out new requirements for the RQHDAPU program, which build on
the ongoing voluntary Hospital Quality Initiative.
That initiative is intended to equip consumers with quality of care
information to make more informed decisions about their health care,
while encouraging hospitals and clinicians to improve the quality of
inpatient care provided to all patients. The hospital quality of care
information gathered through the initiative is available to consumers on
the Hospital Compare website.
The RHQDAPU initiative requires "sub-section (d)" hospitals to submit
data for specific quality measures for health conditions common among
people with Medicare, and which typically result in hospitalization. For
fiscal year 2010, CMS requires that hospitals submit data regarding 42
quality measures. The data collected encompasses the following
conditions: acute myocardial infarction, heart failure, pneumonia,
surgical care improvement, 30-day mortality rates for acute myocardial
infarction and heart failure patients, readmission measures, structural
measures and the patients experience of
care through the HCAHPS patient survey.
Hospitals that do not participate in the RHQDAPU initiative will receive
a reduction of 2.0 percent in their Medicare Annual Payment Update for
the next fiscal year. To avoid the reduction in their Annual Payment
Update, hospitals must meet specific requirements outlined in the
RHQDAPU Participation Steps.
Visit QualityNet for additional RHQDAPU Information
(link opens a new window).
Questions?
For information on Hospital Public Reporting contact Jean King, Manager of Review Services, at
303.784.5727 or
jking@coqio.sdps.org. The Colorado Foundation for Medical Care (CFMC), the Medicare quality improvement organization for Colorado, prepared this material under
contract with the Centers for Medicare & Medicaid Services (CMS), an
agency of the U.S. Department of Health and Human Services. The contents
do not necessarily reflect CMS Policy.
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