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Measures and current data collection periods on Hospital CompareMeasures and current data collection periods on Hospital CompareMeasure identifierTechnical measure titleMeasure as posted on Hospital CompareUpdate frequencyCurrent data collection periodFromThroughGeneral information- Structural measuresSM-PART-NURSEParticipation in a systematic database for nursing sensitive careNursing Care RegistryAnnually December1/1/201512/31/2015ACS-REGISTRYParticipation in a multispecialty surgical registryMultispecialty Surgical RegistryQuarterly 10/1/20159/30/2016SM-PART-GEN-SURGParticipation in general surgery registryGeneral Surgery RegistryAnnually December1/1/201512/31/2015OP-12The Ability for Providers with HIT to Receive Laboratory Data Electronically Directly into their ONC-Certified EHR System as Discrete Searchable DataAble to receive lab results electronicallyAnnually December1/1/201512/31/2015OP-17Tracking Clinical Results between VisitsAble to track patients’ lab results, tests, and referrals electronically between visitsAnnually December1/1/201512/31/2015OP-25Safe surgery checklist use (outpatient)Uses outpatient safe surgery checklistAnnually December1/1/201512/31/2015SM-SS-CHECKSafe surgery checklist use (inpatient)Uses inpatient safe surgery checklist Annually December1/1/201512/31/2015Survey of patient's experiences- Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS)H-COMP-1-A-PCommunication with nurses (composite measure)Patients who reported that their nurses "Always" communicated wellQuarterly 1/1/201612/31/2016H-COMP-1-U-PCommunication with nurses (composite measure)Patients who reported that their nurses "Usually" communicated wellQuarterly 1/1/201612/31/2016H-COMP-1-SN-PCommunication with nurses (composite measure)Patients who reported that their nurses "Sometimes" or "Never" communicated wellQuarterly 1/1/201612/31/2016H-COMP-2-A-PCommunication with doctors (composite measure)Patients who reported that their doctors "Always" communicated wellQuarterly 1/1/201612/31/2016H-COMP-2-U-PCommunication with doctors (composite measure)Patients who reported that their doctors "Usually" communicated wellQuarterly 1/1/201612/31/2016H-COMP-2-SN-PCommunication with doctors (composite measure)Patients who reported that their doctors "Sometimes" or "Never" communicated wellQuarterly 1/1/201612/31/2016H-COMP-3-A-PResponsiveness of hospital staff (composite measure)Patients who reported that they "Always" received help as soon as they wantedQuarterly 1/1/201612/31/2016H-COMP-3-U-PResponsiveness of hospital staff (composite measure)Patients who reported that they "Usually" received help as soon as they wantedQuarterly 1/1/201612/31/2016H-COMP-3-SN-PResponsiveness of hospital staff (composite measure)Patients who reported that they "Sometimes" or "Never" received help as soon as they wantedQuarterly 1/1/201612/31/2016H-COMP-4-A-PPain management (composite measure)Patients who reported that their pain was "Always" well controlledQuarterly 1/1/201612/31/2016H-COMP-4-U-PPain management (composite measure)Patients who reported that their pain was "Usually" well controlledQuarterly 1/1/201612/31/2016H-COMP-4-SN-PPain management (composite measure)Patients who reported that their pain was "Sometimes" or "Never" well controlledQuarterly 1/1/201612/31/2016H-COMP-5-A-PCommunication about medicines (composite measure)Patients who reported that staff "Always" explained about medicines before giving it to themQuarterly 1/1/201612/31/2016H-COMP-5-U-PCommunication about medicines (composite measure)Patients who reported that staff "Usually" explained about medicines before giving it to themQuarterly 1/1/201612/31/2016H-COMP-5-SN-PCommunication about medicines (composite measure)Patients who reported that staff "Sometimes" or "Never" explained about medicines before giving it to themQuarterly 1/1/201612/31/2016H-CLEAN-HSP-A-PCleanliness of hospital environment (individual measure)Patients who reported that their room and bathroom were "Always" cleanQuarterly 1/1/201612/31/2016H-CLEAN-HSP-U-PCleanliness of hospital environment (individual measure)Patients who reported that their room and bathroom were "Usually" cleanQuarterly 1/1/201612/31/2016H-CLEAN-HSP-SN-PCleanliness of hospital environment (individual measure)Patients who reported that their room and bathroom were "Sometimes" or "Never" cleanQuarterly 1/1/201612/31/2016H-QUIET-HSP-A-PQuietness of hospital environment (individual measure)Patients who reported that the area around their room was "Always" quiet at nightQuarterly 1/1/201612/31/2016H-QUIET-HSP-U-PQuietness of hospital environment (individual measure)Patients who reported that the area around their room was "Usually" quiet at nightQuarterly 1/1/201612/31/2016H-QUIET-HSP-SN-PQuietness of hospital environment (individual measure)Patients who reported that the area around their room was "Sometimes" or "Never" quiet at nightQuarterly 1/1/201612/31/2016H-COMP-6-Y-PDischarge information (composite measure)Patients who reported that YES, they were given information about what to do during their recovery at homeQuarterly 1/1/201612/31/2016H-COMP-6-N-PDischarge information (composite measure)Patients who reported that NO, they were not given information about what to do during their recovery at homeQuarterly 1/1/201612/31/2016H-COMP-7-SACare Transition (composite measure)Patients who "Strongly Agree" they understood their care when they left the hospitalQuarterly 1/1/201612/31/2016H-COMP-7-ACare Transition (composite measure)Patients who “Agree” they understood their care when they left the hospitalQuarterly 1/1/201612/31/2016H-COMP-7-D-SDCare Transition (composite measure)Patients who “Disagree” or “Strongly Disagree” they understood their care when they left the hospitalQuarterly 1/1/201612/31/2016H-HSP-RATING-9-10Overall rating of hospital (global measure)Patients who gave their hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest)Quarterly 1/1/201612/31/2016H-HSP-RATING-7-8Overall rating of hospital (global measure)Patients who gave their hospital a rating of 7 or 8 on a scale from 0 (lowest) to 10 (highest)Quarterly 1/1/201612/31/2016H-HSP-RATING-0-6Overall rating of hospital (global measure)Patients who gave their hospital a rating of 6 or lower on a scale from 0 (lowest) to 10 (highest)Quarterly 1/1/201612/31/2016H-RECMND-DYWillingness to recommend the hospital (global measure)Patients who reported YES, they would definitely recommend the hospitalQuarterly 1/1/201612/31/2016H-RECMND-PYWillingness to recommend the hospital (global measure)Patients who reported YES, they would probably recommend the hospitalQuarterly 1/1/201612/31/2016H-RECMND-DNWillingness to recommend the hospital (global measure)Patients who reported NO, they would probably not or definitely not recommend the hospitalQuarterly 1/1/201612/31/2016Timely & effective care- Cataract surgery outcomeOP-31Improvement in Patient’s Visual Function within 90 Days Following Cataract SurgeryPercentage of patients who had cataract surgery and had improvement in visual function within 90 days following the surgery Annually December1/1/201512/31/2015Timely & effective care- Colonoscopy follow-upOP-29Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patientsPercentage of patients receiving appropriate recommendation for follow-up screening colonoscopyAnnually December1/1/201512/31/2015OP-30Endoscopy/polyp surveillance: colonoscopy interval for patients with a history of adenomatous polyps - avoidance of inappropriate usePercentage of patients with history of polyps receiving follow-up colonoscopy in the appropriate timeframeAnnually December1/1/201512/31/2015Timely & effective care- Heart attackOP-3bMedian time to transfer to another facility for acute coronary interventionAverage (median) number of minutes before outpatients with chest pain or possible heart attack who needed specialized care were transferred to another hospitalQuarterly 1/1/201612/31/2016OP-5Median time to ECGAverage (median) number of minutes before outpatients with chest pain or possible heart attack got an ECGQuarterly 1/1/201612/31/2016OP-2Fibrinolytic therapy received within 30 minutes of emergency department arrivalOutpatients with chest pain or possible heart attack who got drugs to break up blood clots within 30 minutes of arrivalQuarterly 1/1/201612/31/2016OP-4Aspirin at arrivalOutpatients with chest pain or possible heart attack who received aspirin within 24 hours of arrival or before transferring from the emergency departmentQuarterly 1/1/201612/31/2016Timely & effective care- Emergency department (ED) throughputEDVEmergency department volumeEmergency department volumeAnnually December1/1/201512/31/2015ED-1bMedian time from emergency department arrival to emergency department departure for admitted emergency department patientsAverage (median) time patients spent in the emergency department, before they were admitted to the hospital as an inpatientQuarterly 1/1/201612/31/2016ED-2bAdmit decision time to emergency department departure time for admitted patientAverage (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 roomQuarterly 1/1/201612/31/2016OP-18bMedian time from emergency department arrival to emergency department departure for discharged emergency department patientsAverage (median) time patients spent in the emergency department before leaving from the visitQuarterly 1/1/201612/31/2016OP-20Door to diagnostic evaluation by a qualified medical professionalAverage (median) time patients spent in the emergency department before they were seen by a healthcare professionalQuarterly 1/1/201612/31/2016OP-21Median time to pain medication for long bone fracturesAverage (median) time patients who came to the emergency department with broken bones had to wait before getting pain medicationQuarterly 1/1/201612/31/2016OP-22Patient left without being seenPercentage of patients who left the emergency department before being seenAnnually December1/1/201512/31/2015OP-23Head CT scan results for acute ischemic stroke or hemorrhagic stroke who received head CT scan interpretation within 45 minutes of arrivalPercentage of patients who came to the emergency department with stroke symptoms who received brain scan results within 45 minutes of arrivalQuarterly 1/1/201612/31/2016Timely & effective care- Preventive careIMM-2Immunization for influenzaPatients assessed and given influenza vaccinationAnnually December10/1/20153/31/2016IMM-3-OP-27-FAC-ADHPCTInfluenza Vaccination Coverage among Healthcare PersonnelHealthcare workers given influenza vaccinationAnnually October10/1/20163/31/2017Timely & effective care- Stroke careSTK-4Thrombolytic TherapyIschemic stroke patients who got medicine to break up a blood clot within 3 hours after symptoms started Quarterly 1/1/201612/31/2016Timely & effective care- Blood clot prevention & treatmentVTE-6Hospital acquired potentially preventable venous thromboembolismPatients who developed a blood clot while in the hospital who did not get treatment that could have prevented it Quarterly 1/1/201612/31/2016VTE-5Warfarin therapy discharge instructionsPatients with blood clots who were discharged on a blood thinner medicine and received written instructions about that medicine Quarterly 1/1/201612/31/2016Timely & effective care- Pregnancy & delivery carePC-01Elective deliveryPercent of mothers whose deliveries were scheduled too early (1-2 weeks early), when a scheduled delivery was not medically necessaryQuarterly 1/1/201612/31/2016Complications & deaths- Surgical complicationsCOMP-HIP-KNEEHospital level risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and total knee arthroplasty (TKA)Rate of complications for hip/knee replacement patientsAnnually July4/1/20133/31/2016PSI-90-SAFETYComplication/patient safety for selected indicators (composite)Serious complicationsAnnually July**7/1/20149/30/2015PSI-3-ULCER*Pressure ulcer rate (Data will not be posted on Hospital Compare but will be available on Data.)Pressure soresAnnually July**7/1/20149/30/2015PSI-4-SURG-COMP*Death rate among surgical inpatients with serious treatable complicationsDeaths among patients with serious treatable complications after surgeryAnnually July**7/1/20149/30/2015PSI-6-IAT-PTX*Iatrogenic pneumothorax rate (Data will not be posted on Hospital Compare but will be available on Data.)Collapsed lung due to medical treatmentAnnually July**7/1/20149/30/2015PSI-8-POST-HIP*Postoperative hip fracture rate (Data will not be posted on Hospital Compare but will be available on Data.)Broken hip from a fall after surgeryAnnually July**7/1/20149/30/2015PSI-9-POST-HEM*Perioperative hemorrhage or hematoma rate (Data will not be posted on Hospital Compare but will be available on Data.)Bleeding or bruising during surgeryAnnually July**7/1/20149/30/2015PSI-10-POST-KIDNEY*Postoperative acute kidney injury requiring dialysis rate (Data will not be posted on Hospital Compare but will be available on Data.)Kidney and diabetic complications after surgeryAnnually July**7/1/20149/30/2015PSI-11-POST-RESP*Postoperative respiratory failure rate (Data will not be posted on Hospital Compare but will be available on Data.)Respiratory failure after surgeryAnnually July**7/1/20149/30/2015PSI-12-POSTOP-PULMEMB-DVT*Perioperative pulmonary embolism or deep vein thrombosis rate (Data will not be posted on Hospital Compare but will be available on Data.)Serious blood clots after surgeryAnnually July**7/1/20149/30/2015PSI-13-POST-SEPSIS*Postoperative sepsis rate (Data will not be posted on Hospital Compare but will be available on Data.)Blood stream infection after surgeryAnnually July**7/1/20149/30/2015PSI-14-POSTOP-DEHIS*Postoperative wound dehiscence rate (Data will not be posted on Hospital Compare but will be available on Data.)A wound that splits open after surgery on the abdomen or pelvisAnnually July**7/1/20149/30/2015PSI-15-ACC-LAC*Accidental puncture or laceration rate (Data will not be posted on Hospital Compare but will be available on Data.)Accidental cuts and tears from medical treatmentAnnually July**7/1/20149/30/2015Complications & deaths- Healthcare-associated infections (HAI)HAI-1Central line-associated bloodstream infections (CLABSI) in ICUs and select wardsCentral line-associated bloodstream infections (CLABSI) in ICUs and select wardsQuarterly 1/1/201612/31/2016HAI-2Catheter-associated urinary tract infections (CAUTI) in ICUs and select wardsCatheter-associated urinary tract infections (CAUTI) in ICUs and select wardsQuarterly 1/1/201612/31/2016HAI-3Surgical site infections from colon surgery (SSI: Colon)Surgical site infections from colon surgery (SSI: Colon)Quarterly 1/1/201612/31/2016HAI-4Surgical site infections from abdominal hysterectomy (SSI: Hysterectomy)Surgical site infections from abdominal hysterectomy (SSI: Hysterectomy)Quarterly 1/1/201612/31/2016HAI-5Methicillin-resistant Staphylococcus Aureus (or MRSA) blood infectionsMethicillin-resistant Staphylococcus Aureus (MRSA) Blood Laboratory-identified Events (Bloodstream infections)Quarterly 1/1/201612/31/2016HAI-6Clostridium difficile (C.diff.) infectionsClostridium difficile (C.diff.) Laboratory-identified Events (Intestinal infections)Quarterly 1/1/201612/31/2016Complications & deaths- 30-day death ratesMORT-30-COPD*COPD 30-day mortality rateDeath rate for COPD patientsAnnually July7/1/20136/30/2016MORT-30-AMI*Acute myocardial infarction (AMI) 30-day mortality rateDeath rate for heart attack patientsAnnually July7/1/20136/30/2016MORT-30-HF*Heart failure (HF) 30-day mortality rateDeath rate for heart failure patientsAnnually July7/1/20136/30/2016MORT-30-PN*Pneumonia (PN) 30-day mortality rateDeath rate for pneumonia patientsAnnually July7/1/20136/30/2016MORT-30-STKStroke 30-day mortality rateDeath rate for stroke patientsAnnually July7/1/20136/30/2016MORT-30-CABGCoronary artery bypass graft (CABG) surgery 30-day mortality rateDeath rate for CABG surgery patientsAnnually July7/1/20136/30/2016Hospital returns- 30-day unplanned readmissions & hospital return daysMSPB-1Medicare hospital spending per patientMedicare Spending per BeneficiaryAnnually December1/1/201512/31/2015EDAC-30-AMIAMI excess days in acute care (EDAC)Hospital return days for heart attack patientsAnnually July7/1/20136/30/2016EDAC-30-HFHF excess days in acute care (EDAC)Hospital return days for heart failure patientsAnnually July7/1/20136/30/2016READM-30-COPD*Chronic obstructive pulmonary disease (COPD) 30-day readmission rateRate of readmission for chronic obstructive pulmonary disease (COPD) patientsAnnually July7/1/20136/30/2016READM-30-AMI*Acute myocardial infarction (AMI) 30-day readmission rateRate of readmission for heart attack patientsAnnually July7/1/20136/30/2016READM-30-HF*Heart failure (HF) 30-day readmission rateRate of readmission for heart failure patientsAnnually July7/1/20136/30/2016READM-30-PN*Pneumonia (PN) 30-day readmission rateRate of readmission for pneumonia patientsAnnually July7/1/20136/30/2016READM-30-STKStroke 30-day readmission rateRate of readmission for stroke patientsAnnually July7/1/20136/30/2016READM-30-CABGCoronary artery bypass graft (CABG) surgery 30-day readmission rateRate of readmission for coronary artery bypass graft (CABG) surgery patientsAnnually July7/1/20136/30/2016READM-30-HIP-KNEE30-day readmission rate following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA)Rate of readmission after hip/knee replacementAnnually July7/1/20136/30/2016READM-30-HOSP-WIDE30-day hospital-wide all- cause unplanned readmission (HWR)Rate of readmission after discharge from hospital (hospital-wide)Annually July7/1/20156/30/2016Use of medical imaging- Outpatient imaging efficiencyOP-8MRI Lumbar Spine for Low Back PainOutpatients with low-back pain who had an MRI without trying recommended treatments (such as physical therapy) first?(if a number is high, it may mean the facility is doing too many unnecessary MRIs for low-back pain).?(if a number is high, it may mean the facility is doing too many unnecessary MRIs for low-back pain)Annually July7/1/20156/30/2016OP-9Mammography Follow-Up RatesOutpatients who had a follow-up mammogram, breast ultrasound, or breast MRI within the 45 days after a screening mammogram?(a follow-up rate near 0% may indicate missed cancer; a rate higher than 14% may mean there is unnecessary follow-up)Annually July7/1/20156/30/2016OP-10Abdomen CT - Use of Contrast MaterialOutpatient CT scans of the abdomen that were “combination” (double) scans?(if a number is high, it may mean that too many patients have a double scan when a single scan is all they need)Annually July7/1/20156/30/2016OP-11Thorax CT - Use of Contrast MaterialOutpatient CT scans of the chest that were “combination” (double) scans(if a number is high, it may mean that too many patients have a double scan when a single scan is all they need)Annually July7/1/20156/30/2016OP-13Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac Low-Risk SurgeryOutpatients 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 low-risk surgeries)Annually July7/1/20156/30/2016OP-14Simultaneous Use of Brain Computed Tomography (CT) and Sinus CTOutpatients with brain CT scans who got a sinus CT scan at the same time?(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)Annually July7/1/20156/30/2016Payment & value of carePAYM-30-AMIHeart attack paymentPayment for heart attack patientsAnnually July7/1/20136/30/2016PAYM-30-HFHeart failure paymentPayment for heart failure patientsAnnually July7/1/20136/30/2016PAYM-30-PNPneumonia paymentPayment for pneumonia patientsAnnually July7/1/20136/30/2016PAYM-90-HIP-KNEEHip/knee replacement paymentPayment for hip/knee replacement patientsAnnually July4/1/20133/31/2016 ................
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