Measures and current data collection periods

Transcription

1 10/24/2016 s and current data s s and current data s Send general questions regarding Hospital and the data to Hospital@hsag.com. Download the data and get information on when the data was last revised from data.medicare.gov Hospital overall ratings: Data s The Hospital overall ratings include more than 60 of the over 100 measures reported on Hospital. The hospital overall ratings are based on data reported in October Data s vary by measure. The table above lists the data collection periods for each measure. as posted General information Structural measures SM PART CARD Participation in a systematic database for cardiac surgery Cardiac Surgery Registry December 1/1/ /31/2014 SM PART NURSE Participation in a systematic database for nursing sensitive care Nursing Care Registry December 1/1/ /31/2014 ACS REGISTRY Participation in a multispecialty surgical registry Multispecialty Surgical Registry Semi, December 10/1/2014 9/30/ d.html# 1/23

2 10/24/2016 s and current data s as posted SM PART GEN SURG Participation in general surgery registry General Surgery Registry December 1/1/ /31/2014 OP 12 The Ability for Providers with HIT to Receive Laboratory Data Electronically Directly into their ONC Certified EHR System as Discrete Searchable Data Able to receive lab results electronically 1/1/ /31/2014 OP 17 Tracking Clinical Results between Visits Able to track patients lab results, tests, and referrals electronically between visits 1/1/ /31/2014 OP 25 Safe surgery checklist use (outpatient) Uses outpatient safe surgery checklist 1/1/ /31/2014 SM SS CHECK Safe surgery checklist use (inpatient) Uses inpatient safe surgery checklist December 1/1/ /31/2014 Survey of patient's experiences Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) 1 A P Communication with nurses (composite that their nurses "Always" communicated well 1 U P Communication with nurses (composite that their nurses "Usually" communicated well d.html# 2/23

3 10/24/2016 s and current data s as posted 1 SN P Communication with nurses (composite that their nurses "Sometimes" or "Never" communicated well 2 A P Communication with doctors (composite that their doctors "Always" communicated well 2 U P Communication with doctors (composite that their doctors "Usually" communicated well 2 SN P Communication with doctors (composite that their doctors "Sometimes" or "Never" communicated well 3 A P Responsiveness of hospital staff (composite that they "Always" received help as soon as they wanted 3 U P Responsiveness of hospital staff (composite that they "Usually" received help as soon as they wanted 3 SN P Responsiveness of hospital staff (composite that they "Sometimes" or "Never" received help as soon as they wanted d.html# 3/23

4 10/24/2016 s and current data s as posted 4 A P Pain management (composite that their pain was "Always" well controlled 4 U P Pain management (composite that their pain was "Usually" well controlled 4 SN P Pain management (composite that their pain was "Sometimes" or "Never" well controlled 5 A P Communication about medicines (composite that staff "Always" explained about medicines before giving it to them 5 U P Communication about medicines (composite that staff "Usually" explained about medicines before giving it to them 5 SN P Communication about medicines (composite that staff "Sometimes" or "Never" explained about medicines before giving it to them H CLEAN HSP A P Cleanliness of hospital environment (individual that their room and bathroom were "Always" clean d.html# 4/23

5 10/24/2016 s and current data s as posted H CLEAN HSP U P Cleanliness of hospital environment (individual that their room and bathroom were "Usually" clean H CLEAN HSP SN P Cleanliness of hospital environment (individual that their room and bathroom were "Sometimes" or "Never" clean H QUIET HSP A P Quietness of hospital environment (individual that the area around their room was "Always" quiet at night H QUIET HSP U P Quietness of hospital environment (individual that the area around their room was "Usually" quiet at night H QUIET HSP SN P Quietness of hospital environment (individual that the area around their room was "Sometimes" or "Never" quiet at night 6 Y P Discharge information (composite that YES, they were given information about what to do during their recovery at home 6 N P Discharge information (composite that NO, they were not given information about what to do during their recovery at home d.html# 5/23

6 10/24/2016 s and current data s as posted 7 SA Care Transition (composite Patients who "Strongly Agree" they understood their care when they left the hospital 7 A Care Transition (composite Patients who Agree they understood their care when they left the hospital 7 D SD Care Transition (composite Patients who Disagree or Strongly Disagree they understood their care when they left the hospital H HSP RATING 9 10 Overall rating of hospital (global Patients who gave their hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest) H HSP RATING 7 8 Overall rating of hospital (global Patients who gave their hospital a rating of 7 or 8 on a scale from 0 (lowest) to 10 (highest) H HSP RATING 0 6 Overall rating of hospital (global Patients who gave their hospital a rating of 6 or lower on a scale from 0 (lowest) to 10 (highest) H RECMND DY Willingness to recommend the hospital (global YES, they would definitely recommend the hospital d.html# 6/23

7 10/24/2016 s and current data s as posted H RECMND PY Willingness to recommend the hospital (global YES, they would probably recommend the hospital H RECMND DN Willingness to recommend the hospital (global NO, they would probably not or definitely not recommend the hospital Timely & effective care Colonoscopy follow up OP 29 Endoscopy/polyp surveillance: appropriate follow up interval for normal colonoscopy in average risk patients Percentage of patients receiving appropriate recommendation for follow up screening colonoscopy A higher percentage is better December 4/1/ /31/2014 OP 30 Endoscopy/polyp surveillance: colonoscopy interval for patients with a history of adenomatous polyps avoidance of inappropriate use Percentage of patients with history of polyps receiving follow up colonoscopy in the appropriate timeframe December 4/1/ /31/2014 Timely & effective care Heart attack OP 3b Median time to transfer to another facility for acute coronary intervention Average (median) number of minutes before outpatients with chest pain or possible heart attack who needed specialized care were transferred to another hospital d.html# 7/23

8 10/24/2016 s and current data s as posted OP 5 Median time to ECG Average (median) number of minutes before outpatients with chest pain or possible heart attack got an ECG OP 2 Fibrinolytic therapy received within 30 minutes of emergency department arrival Outpatients with chest pain or possible heart attack who got drugs to break up blood clots within 30 minutes of arrival OP 4 Aspirin at arrival Outpatients with chest pain or possible heart attack who received aspirin within 24 hours of arrival or before transferring from the emergency department AMI 7a Fibrinolytic therapy received within 30 minutes of hospital arrival Heart attack patients who got drugs to break up blood clots within 30 minutes of arrival AMI 8a Primary percutaneous coronary intervention (PCI) received within 90 minutes of hospital arrival Heart attack patients given a procedure to open blocked blood vessels within 90 minutes of arrival Timely & effective care Heart failure (HF) HF 2 Evaluation of LVS function Heart failure patients given an evaluation of left ventricular systolic (LVS) function d.html# 8/23

9 10/24/2016 s and current data s as posted Timely & effective care Pneumonia (PN) PN 6 Initial antibiotic for community acquired pneumonia (CAP) in immunocompetent patient Pneumonia patients given the most appropriate initial antibiotic(s) Timely & effective care Surgical Care Improvement Project (SCIP) SCIP Inf 1a Prophylactic antibiotic received within one hour prior to surgical incision Surgery patients who were given an antibiotic at the right time (within one hour before surgery) to help prevent infection SCIP Inf 3a Prophylactic antibiotics discontinued within 24 hours after surgery end time Surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery) SCIP VTE 2 Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery 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 d.html# 9/23

10 10/24/2016 s and current data s as posted SCIP CARD 2 Surgery patients on betablocker therapy prior to arrival who received a beta blocker during the perioperative period Surgery patients who were taking heart drugs called beta blockers before coming to the hospital, who were kept on the beta blockers during the period just before and after their surgery SCIP Inf 2a Prophylactic antibiotic selection for surgical patients Surgery patients who were given the right kind of antibiotic to help prevent infection SCIP INF 9 Urinary catheter removed on postoperative day 1 (POD 1) or postoperative day 2 (POD 2) with day of surgery being day zero Surgery patients whose urinary catheters were removed on the first or second day after surgery Timely & effective care Emergency department (ED) throughput EDV Emergency department volume Emergency department volume 1/1/ /31/2014 ED 1b Median time from emergency department arrival to emergency department departure for admitted emergency department patients Average (median) time patients spent in the emergency department, before they were admitted to the hospital as an inpatient d.html# 10/23

11 10/24/2016 s and current data s as posted ED 2b Admit decision time to emergency department departure time for admitted patient 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 OP 18b Median time from emergency department arrival to emergency department departure for discharged emergency department patients Average (median) time patients spent in the emergency department before leaving from the visit OP 20 Door to diagnostic evaluation by a qualified medical professional Average (median) time patients spent in the emergency department before they were seen by a healthcare professional OP 21 Median time to pain medication for long bone fractures Average (median) time patients who came to the emergency department with broken bones had to wait before getting pain medication OP 22 Patient left without being seen Percentage of patients who left the emergency department before being seen 1/1/ /31/ d.html# 11/23

12 10/24/2016 s and current data s as posted OP 23 Head CT scan results for acute ischemic stroke or hemorrhagic stroke who received head CT scan interpretation within 45 minutes of arrival Percentage of patients who came to the emergency department with stroke symptoms who received brain scan results within 45 minutes of arrival Timely & effective care Preventive care IMM 2 Immunization for influenza Patients assessed and given influenza vaccination 10/1/2014 3/31/2015 IMM 3 OP 27 FAC ADHPCT Influenza Vaccination Coverage among Healthcare Personnel Healthcare workers given influenza vaccination October 10/1/2015 3/31/2016 Timely & effective care Children's asthma care (CAC) CAC 3 Home management plan of care (HMPC) document given to patient/caregiver Children and their caregivers who received a home management plan of care document while hospitalized for asthma Timely & effective care Stroke care STK 4 Thrombolytic Therapy Ischemic stroke patients who got medicine to break up a blood clot within 3 hours after symptoms started d.html# 12/23

13 10/24/2016 s and current data s as posted STK 5 Antithrombotic Therapy by End of Hospital Day 2 Ischemic stroke patients who received medicine known to prevent complications caused by blood clots within 2 days of hospital admission STK 1 Venous Thromboembolism (VTE) Prophylaxis Ischemic or hemorrhagic stroke patients who received treatment to keep blood clots from forming anywhere in the body within 2 days of hospital admission STK 2 Discharged on Antithrombotic Therapy Ischemic stroke patients who received a prescription for medicine known to prevent complications caused by blood clots at discharge STK 3 Anticoagulation Therapy for Atrial Fibrillation/Flutter Ischemic stroke patients with a type of irregular heartbeat who were given a prescription for a blood thinner at discharge STK 6 Discharged on Statin Medication Ischemic stroke patients needing medicine to lower bad cholesterol, who were given a prescription for this medicine at discharge d.html# 13/23

14 10/24/2016 s and current data s as posted STK 8 Stroke Education Ischemic or hemorrhagic stroke patients or caregivers who received written educational materials about stroke care and prevention during the hospital stay STK 10 Assessed for Rehabilitation Ischemic or hemorrhagic stroke patients who were evaluated for rehabilitation services Timely & effective care Blood clot prevention & treatment VTE 1 Venous thromboembolism prophylaxis Patients who got treatment to prevent blood clots on the day of or day after hospital admission or surgery VTE 2 ICU venous thromboembolism prophylaxis Patients who got treatment to prevent blood clots on the day of or day after being admitted to the intensive care unit (ICU) VTE 6 Hospital acquired potentially preventable venous thromboembolism Patients who developed a blood clot while in the hospital who did not get treatment that could have prevented it d.html# 14/23

15 10/24/2016 s and current data s as posted VTE 3 Anticoagulation overlap therapy Patients with blood clots who got treatment, which includes using two different blood thinner medicines at the same time VTE 4 Unfractionated heparin with dosages/platelet count monitoring Patients with blood clots who were treated with an intravenous blood thinner, and then were checked to determine if the blood thinner caused unplanned complications VTE 5 Warfarin therapy discharge instructions Patients with blood clots who were discharged on a blood thinner medicine and received written instructions about that medicine Timely & effective care Pregnancy & delivery care PC 01 Elective delivery Percent of mothers whose deliveries were scheduled too early (1 2 weeks early), when a scheduled delivery was not medically necessary Complications Surgical complications d.html# 15/23

16 10/24/2016 s and current data s as posted COMP HIP KNEE Hospital level riskstandardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) Rate of complications for hip/knee replacement patients 4/1/2012 3/31/2015 PSI 90 SAFETY Complication/patient safety for selected indicators (composite) Serious complications 7/1/2013 6/30/2015 PSI 3 ULCER Pressure ulcer rate (Data will not be posted on Hospital but will be available on Data.Medicare.Gov) Pressure sores 7/1/2013 6/30/2015 PSI 4 SURG COMP Death rate among surgical inpatients with serious treatable complications Deaths among patients with serious treatable complications after surgery 7/1/2013 6/30/2015 PSI 6 IAT PTX Iatrogenic pneumothorax rate (Data will not be posted but will be available on Data.Medicare.Gov) Collapsed lung due to medical treatment 7/1/2013 6/30/2015 PSI 7 CVCBI Central venous catheterrelated bloodstream infection rate (Data will not be posted but will be available on Data.Medicare.Gov) Infections from a large venous catheter 7/1/2013 6/30/ d.html# 16/23

17 10/24/2016 s and current data s as posted PSI 8 POST HIP Postoperative hip fracture rate (Data will not be posted but will be available on Data.Medicare.Gov) Broken hip from a fall after surgery 7/1/2013 6/30/2015 PSI 12 POSTOP PULMEMB DVT Perioperative pulmonary embolism or deep vein thrombosis rate (Data will not be posted but will be available on Data.Medicare.Gov) Serious blood clots after surgery 7/1/2013 6/30/2015 PSI 13 POST SEPSIS Postoperative sepsis rate (Data will not be posted but will be available on Data.Medicare.Gov) Blood stream infection after surgery 7/1/2013 6/30/2015 PSI 14 POSTOP DEHIS Postoperative wound dehiscence rate (Data will not be posted but will be available on Data.Medicare.Gov) A wound that splits open after surgery on the abdomen or pelvis 7/1/2013 6/30/2015 PSI 15 ACC LAC Accidental puncture or laceration rate (Data will not be posted but will be available on Data.Medicare.Gov) Accidental cuts and tears from medical treatment 7/1/2013 6/30/2015 Complications Healthcare associated infections (HAI) d.html# 17/23

18 10/24/2016 s and current data s as posted HAI 1 Central line associated bloodstream infections (CLABSI) in ICUs and select wards Central line associated bloodstream infections (CLABSI) in ICUs and select wards HAI 1a Central line associated bloodstream infection (CLABSI) in ICUs only Central line associated bloodstream infections (CLABSI) in ICUs only HAI 2 Catheter associated urinary tract infections (CAUTI) in ICUs and select wards Catheter associated urinary tract infections (CAUTI) in ICUs and select wards HAI 2a Catheter associated urinary tract infection (CAUTI) in ICUs only Catheter associated urinary tract infections (CAUTI) in ICUs only HAI 3 Surgical site infections from colon surgery (SSI: Colon) Surgical site infections from colon surgery (SSI: Colon) HAI 4 Surgical site infections from abdominal hysterectomy (SSI: Hysterectomy) Surgical site infections from abdominal hysterectomy (SSI: Hysterectomy) HAI 5 Methicillin resistant Staphylococcus Aureus (or MRSA) blood infections Methicillin resistant Staphylococcus Aureus (MRSA) Blood Laboratory identified Events (Bloodstream infections) d.html# 18/23

19 10/24/2016 s and current data s as posted HAI 6 Clostridium difficile (C.diff.) infections Clostridium difficile (C.diff.) Laboratoryidentified Events (Intestinal infections) Readmissions & deaths 30 day rates of readmission READM 30 COPD Chronic obstructive pulmonary disease (COPD) 30 day readmission rate Rate of readmission for chronic obstructive pulmonary disease (COPD) patients READM 30 AMI Acute myocardial infarction (AMI) 30 day readmission rate Rate of readmission for heart attack patients READM 30 HF Heart failure (HF) 30 day readmission rate Rate of readmission for heart failure patients READM 30 PN Pneumonia (PN) 30 day readmission rate Rate of readmission for pneumonia patients READM 30 STK Stroke 30 day readmission rate Rate of readmission for stroke patients READM 30 CABG Coronary artery bypass graft (CABG) surgery 30 day readmission rate Rate of readmission for coronary artery bypass graft (CABG) surgery patients READM 30 HIP KNEE 30 day readmission rate following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) Rate of readmission after hip/knee replacement d.html# 19/23

20 10/24/2016 s and current data s as posted READM 30 HOSP WIDE 30 day hospital wide allcause unplanned readmission (HWR) Rate of readmission after discharge from hospital (hospital wide) 7/1/2014 6/30/2015 Readmissions & deaths 30 day death (mortality) rates MORT 30 COPD COPD 30 day mortality rate Death rate for COPD patients MORT 30 AMI Acute myocardial infarction (AMI) 30 day mortality rate Death rate for heart attack patients MORT 30 HF Heart failure (HF) 30 day mortality rate Death rate for heart failure patients MORT 30 PN Pneumonia (PN) 30 day mortality rate Death rate for pneumonia patients MORT 30 STK Stroke 30 day mortality rate Death rate for stroke patients MORT 30 CABG Coronary artery bypass graft (CABG) surgery 30 day mortality rate Death rate for CABG surgery patients Use of medical imaging Outpatient imaging efficiency d.html# 20/23

21 10/24/2016 s and current data s as posted OP 8 MRI Lumbar Spine for Low Back Pain Outpatients with lowback pain who had an MRI without trying recommended treatments (such as physical therapy) first 7/1/2014 6/30/2015 If a number is high, it may mean the facility is doing too many unnecessary MRIs for low back pain. OP 9 Mammography Follow Up Rates Outpatients who had a follow up mammogram, breast ultrasound, or breast MRI within the 45 days after a screening mammogram. 7/1/2014 6/30/2015 OP 10 Abdomen CT Use of Contrast Material Outpatient CT scans of the abdomen that were combination (double) scans 7/1/2014 6/30/2015 If a number is high, it may mean that too many patients have a double scan when a single scan is all they need. d.html# 21/23

22 10/24/2016 s and current data s as posted OP 11 Thorax Computed Tomography (CT) Use of Contrast Material Outpatient CT scans of the chest that were combination (double) scans 7/1/2014 6/30/2015 If a number is high, it may mean that too many patients have a double scan when a single scan is all they need. OP 13 Cardiac Imaging for Preoperative Risk Assessment for Non Cardiac Low Risk Surgery Outpatients who got cardiac imaging stress tests before low risk outpatient surgery If a number is high, it may mean that too many cardiac scans were done prior to lowrisk surgeries. 7/1/2014 6/30/2015 OP 14 Simultaneous Use of Brain Computed Tomography (CT) and Sinus CT Outpatients with brain CT scans who got a sinus CT scan at the same time 7/1/2014 6/30/2015 If a number is high, it may mean that too many patients have both a brain and sinus scan, when a single scan is all they need. Payment & value of care MSPB 1 Medicare hospital spending per patient Medicare Spending per Beneficiary October d.html# 22/23

23 10/24/2016 s and current data s as posted PAYM 30 AMI Heart attack payment Payment for heart attack patients PAYM 30 HF Heart failure payment Payment for heart failure patients PAYM 30 PN Pneumonia payment Payment for pneumonia patients d.html# 23/23