Outpatient Hospital Compare Preview Report Help Guide

Transcription

1 Outpatient Hospital Compare Preview Report Help Guide The target audience for this publication is hospitals. The document scope is limited to instructions for hospitals on how to access and understand the data provided on the preview report prior to publication of data on Hospital Compare. February Preview/April 2018 Hospital Compare Release

2 February 2018 Preview/April 2018 Hospital Compare Release - Outpatient TABLE OF CONTENTS Section 1: Overview... 3 Hospital Compare... 3 Hospital Outpatient Quality Reporting (OQR) Program... 3 Preview Period... 3 Section 2: Preview Report Access... 4 Access Preview Report... 4 Run Preview Report... 5 View Preview report... 6 Section 3: General Information... 8 Preview Report Eligibility... 8 Notice of Participation (NOP) Information... 8 Rounding Rules... 8 Section 4: Preview Report Details Overall Hospital Quality Star Rating Web Based Measures Clinical Process Measures AMI Cardiac Care Measures Outpatient Imaging Efficiency Measures Emergency Department Measures Pain Management Measure Stroke Measure Endoscopy/Polyp Surveillance Measures Cataract Surgery Measure External Beam Radiotherapy (EBRT) Measure Healthcare Personnel (HCP) Influenza Vaccination Influenza Vaccination Adherence Percentage Outcome Measure Section 5: Questions Section 2: Preview Report Access Page 2 of 28

3 February 2018 Preview/April 2018 Hospital Compare Release - Outpatient Section 1: Overview Outpatient Hospital Compare Preview Report Help Guide Hospital Compare The Centers for Medicare & Medicaid Services (CMS) publicly reports hospital quality performance information on the Hospital Compare website, Hospital Compare presents hospital performance data in a consistent, unified manner to ensure the availability of credible information about the care delivered in the nation s hospitals, including outpatient care. Participating hospitals submit quality of care measure data as part of the Hospital Outpatient Quality Reporting (OQR) Program. Hospitals that do not meet program requirements, as required by statute, will be subject to a two percent reduction of their Outpatient Prospective Payment System (OPPS) Payment Update. Hospital Outpatient Quality Reporting (OQR) Program The Hospital OQR Program was mandated under the Tax Relief and Healthcare Act (TRCHA) of Initial program implementation was finalized in the Calendar Year (CY) 2008 OPPS/Ambulatory Surgical Center (ASC) Final Rule with Comment Period released November 1, Under the Hospital OQR Program, hospitals that meet full program requirements, including the reporting of data for standardized measures on the quality of hospital outpatient care, will receive their full OPPS Payment Update. Reporting is used to encourage hospitals and clinicians to improve quality of care and to empower Medicare beneficiaries and other consumers with quality of care information to make more informed decisions about healthcare. Preview Period Prior to the release of data on Hospital Compare, hospitals are given the opportunity to preview their data during a 30-day preview period via the QualityNet Secure Portal, the only CMS-approved website for secure healthcare quality data exchange, at Section 2: Preview Report Access Page 3 of 28

4 February 2018 Preview/April 2018 Hospital Compare Release - Outpatient Section 2: Preview Report Access The preview report can be accessed through the QualityNet Secure Portal. Note: Users must be enrolled and identity-proofed in the QualityNet Secure Portal in order to access the preview report. To access a preview report, the user must be: 1) Registered as a QualityNet user a) Registration Instructions for Outpatient are available on the QualityNet home page by selecting the [Hospitals - Outpatient] link under the QualityNet Registration header in the left-hand navigation bar at: FQnetBasic&cid= ) Enrolled for access to the QualityNet Secure Portal a) Detailed enrollment and login instructions can be found on the QualityNet home page under the Log in to QualityNet Secure Portal header. Select [Portal Resources] at: FQnetBasic&cid= ) Assigned the Hospital Reporting Feedback-Outpatient role a) This role is assigned by a hospital s QualityNet Security Administrator (SA). Access Preview Report Follow the instructions below to access the preview report: 1) Access the public website for QualityNet at 2) Select [Login], under the Log in to QualityNet Secure Portal header. 3) Enter your QualityNet User ID, Password, and Security Code. Select [Submit]. 4) Read the Terms and Conditions statement and select [I Accept] to proceed. Note: If [I Decline] is selected, the program closes. Section 2: Preview Report Access Page 4 of 28

5 February 2018 Preview/April 2018 Hospital Compare Release - Outpatient Run Preview Report 1) Select [Run Reports] from the My Reports drop-down. 2) Select [OQR] from the Report Program drop-down. 3) Select [Public Reporting Preview Reports] from the list in the Report Category drop-down. Section 2: Preview Report Access Page 5 of 28

6 February 2018 Preview/April 2018 Hospital Compare Release - Outpatient 4) Select [View Reports]; the selected report will display under Report Name. 5) Select [Public Reporting Preview reports] under Report Name. 6) Select [Run Reports]. View Preview report Section 2: Preview Report Access Page 6 of 28

7 February 2018 Preview/April 2018 Hospital Compare Release - Outpatient Select the [Search Reports] tab. The report requested will display, as well as the report status. A green check mark will display in the Status column when the report is complete. Once complete, the report can be viewed or downloaded. Section 2: Preview Report Access Page 7 of 28

8 Section 3: General Information Preview Report Eligibility Hospitals without a Hospital OQR Program Notice of Participation (NOP), and/or hospitals that submitted data only for quality improvement purposes, will receive a report, which displays only the CMS Certification Number (CCN) and hospital name along with the following message: An active OQR Notice of Participation is required to view the preview report or, if a voluntary reporter, an election has been made to withhold data from being publicly reported. Questions regarding your Hospital OQR Program may be submitted to the OQR Outreach and Education Support Contractor through the Outpatient Questions and Answers tool at or by calling, toll-free, weekdays from 7 a.m. to 6 p.m. ET. Notice of Participation (NOP) Information Reporting of measure data is based on your hospital s NOP status. Hospital OQR Program eligible hospitals with an active NOP will have submitted data publicly reported. Publicly Reportable Quarters Table Calendar Year NOP Publicly Reportable Quarters of Clinical Process Measure Data Publicly Reportable Quarters of Imaging Efficiency Measure Data Q15 3Q15-2Q Q15 3Q15-2Q Q16 3Q15-2Q Q16 3Q16-2Q Q16 3Q16-2Q Q16 3Q16-2Q Q17 3Q16-2Q Q17 3Q17-2Q Q17 3Q17-2Q Q17 3Q17-2Q Q18 3Q17-2Q18 Rounding Rules All percentage and median time calculations (provider, state, and national) are rounded to the nearest whole number using the following rounding logic, unless otherwise stated: Above [x.5], round up to the nearest whole number. Section 3: General Information Page 8 of 29

9 Below [x.5], round down to the nearest whole number. October 2017 Preview/December 2017 Hospital Compare Release - Outpatient Exactly [x.5] and x is an even number, round down to the nearest whole, even number. (Rounding to the even number is a statistically accepted methodology.) Exactly [x.5] and x is an odd number, round up to the nearest whole, even number. (Rounding to the even number is a statistically accepted methodology.) Page 9 of 29

10 Section 4: Preview Report Details The preview report displays your hospital characteristics information at the top of each section. Your hospital CCN and name display above the hospital characteristics information. Hospital characteristics include your hospital s address, city, state, ZIP code, telephone number, county name, type of facility, type of ownership, and emergency service provided status. Type of ownership is not publicly reported; however, it is available in the downloadable database on Hospital Compare. If the hospital characteristics displayed are incorrect, your hospital should contact your state survey agency CASPER coordinator to complete the information. The state survey agency CASPER contact list is available from the Hospital Compare home page by selecting the [Resources] button located between the [About the Data] and [Help] buttons directly above the Find a Hospital selection area. Once the screen refreshes, select the CASPER/ASPEN contacts link from the left-side navigation pane at When your hospital s state survey agency is unable to make the needed change, your hospital should contact its CMS regional office. Preview Report Overall Hospital Quality Star Rating Overall Hospital Quality Star Rating The Overall Hospital Quality Star Rating provides a summary of hospital quality data reported on the Hospital Compare website. These ratings reflect up to 57 measures across seven aspects of quality currently captured by existing measures on Hospital Compare: mortality; safety of care; readmission; excess days in acute care; patient experience; effectiveness of care; timeliness of care; and efficient use of medical imaging. The methodology used to calculate the Star Rating is scientifically rigorous and a valid way to summarize the quality information available on Hospital Compare. The Star Rating is intended to supplement rather than replace the information on Hospital Compare. Star Ratings are generally updated on a bi-annual schedule and are anticipated to be updated with the July and December Hospital Compare releases using the data reported for that release. The Star Ratings for April and October Hospital Compare releases will generally maintain the same rating reported from the previous quarter s release unless otherwise noted. Hospitals will receive a Star Rating (1, 2, 3, 4, or 5 stars) and be assigned a performance category for each of the measure groups (above the national average; same as the national average; or below the national average). The Preview Report also contains supplemental information for hospitals to help them understand the calculation of the Star Rating. Calculations for the ratings include: a summary score (the weighted average of a hospital s available group scores); the hospital s group scores; the Page 10 of 29

11 national group score for each of the seven groups; the number of measures included in the hospital s calculation of the group scores; and the weighting of each group used to calculate the summary score. Please refer to the Hospital Compare Star Rating methodology resources on QualityNet.org ( > Hospitals-Inpatient > Hospital Star Ratings > Methodology Resources or > Hospitals-Outpatient > Hospital Star Ratings > Methodology Resources) for a detailed discussion of the rating calculations. The Hospital Compare Preview Report has two overall rating sections (separate from the HCAHPS Star Rating): Overall Hospital Quality Star Rating Overall Hospital Quality Star Rating Group Scores Hospital Compare Overall Hospital Quality Star Rating section: Your Hospital s Overall Star Rating 1, 2, 3, 4 or 5 stars. A hospital will only receive a Star Rating if it has at least three group scores (of which one must be an outcomes measure group mortality, safety of care, or readmission) with at least three measures in each group. Your Hospital s Summary Score the weighted average of the hospital s group scores. This score is recalculated for the July and December releases only. It is not recalculated for the April and October releases. Hospital Compare Star Rating Group Scores section: Group Hospital quality is represented by several dimensions, including clinical care processes, initiatives focused on care transitions, and patient experiences. The Hospital Compare Star Rating includes seven groups: o Mortality o Safety of care o Readmission o Patient experience o Effectiveness of care o Timeliness of care o Efficient use of medical imaging Page 11 of 29

12 Number of Measures the number of measures used to calculate the hospital s group scores is based on the data reported by the hospital. The Star Rating aims to be as inclusive as possible of measures on Hospital Compare. However, the following types of measures will not be incorporated into the hospital Star Rating: (1) measures suspended, retired, or delayed from public reporting on Hospital Compare; (2) measures with no more than 100 hospitals reporting performance publicly; (3) structural measures; (4) measures for which it is unclear whether a higher or lower score is better (non-directional); (5) measures no longer required for the IQR Program or OQR Program; and (6) duplicative measures (e.g., individual measures that make up a composite measure that is already reported; or measures that are identical to another measure). The table below includes a full list of the measures included in each group that, if reported by the hospital, are used in calculating the Star Rating. Mortality (N=7) Measure MORT-30-AMI MORT-30-CABG MORT-30-COPD MORT-30-HF MORT-30-PN MORT-30-STK PSI-4-SURG- COMP Description Acute Myocardial Infarction (AMI) 30-Day Mortality Rate Coronary Artery Bypass Graft (CABG) 30-Day Mortality Rate Chronic Obstructive Pulmonary Disease (COPD) 30-Day Mortality Rate Heart Failure (HF) 30-Day Mortality Rate Pneumonia (PN) 30-Day Mortality Rate Acute Ischemic Stroke (STK) 30-Day Mortality Rate Death Among Surgical Patients with Serious Treatable Complications Safety of Care (N=8) Measure HAI-1 HAI-2 HAI-3 HAI-4 HAI-5 HAI-6 COMP-HIP-KNEE PSI-90-Safety Description Central-Line Associated Bloodstream Infection (CLABSI) Catheter-associated Urinary Tract Infection (CAUTI) Surgical Site Infection from colon surgery (SSI-colon) Surgical Site Infection from abdominal hysterectomy (SSI-abdominal hysterectomy) Methicillin-Resistant Staphylococcus aureus (MRSA) Bacteremia Clostridium Difficile (C. difficile) Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) Complication/Patient Safety for Selected Indicators (PSI) Page 12 of 29

13 Readmission (N=9) Measure READM-30-CABG READM-30-COPD READM-30-Hip- Knee READM-30-PN READM-30-STK READM-30-HOSP- WIDE EDAC-30-AMI EDAC-30-HF OP-32 Description Coronary Artery Bypass Graft (CABG) 30-Day Readmission Rate Chronic Obstructive Pulmonary Disease (COPD) 30-Day Readmission Rate Hospital-Level 30-Day All-Cause Risk-Standardized Readmission Rate (RSRR) Following Elective Total Hip Arthroplasty (THA)/Total Knee Arthroplasty (TKA) Pneumonia (PN) 30-Day Readmission Rate Stroke (STK) 30-Day Readmission Rate Hospital-Wide All-Cause Unplanned Readmission (HWR) Excess Days in Acute Care (EDAC) after hospitalization for Acute Myocardial Infarction (AMI) Excess Days in Acute Care (EDAC) after hospitalization for Heart Failure (HF) Facility 7-Day Risk Standardized Hospital Visit Rate after Outpatient Colonoscopy Patient Experience (N=11) Measure Description H-CLEAN-HSP Cleanliness of Hospital Environment (Q8) H-COMP-1 Nurse Communication (Q1, Q2, Q3) H-COMP-2 Doctor Communication (Q5, Q6, Q7) H-COMP-3 Responsiveness of Hospital Staff (Q4, Q11) H-COMP-4 Pain management (Q13, Q14) H-COMP-5 Communication About Medicines (Q16, Q17) H-COMP-6 Discharge Information (Q19, Q20) H-HSP-RATING Overall Rating of Hospital (Q21) H-QUIET-HSP Quietness of Hospital Environment (Q9) H-RECMND Willingness to Recommend Hospital (Q22) H-COMP-7 HCAHPS 3 Item Care Transition Measure (CTM-3) Effectiveness of Care (N=10) Measure Description IMM-2 Influenza Immunization IMM-3/OP-27 Healthcare Personnel (HCP) Influenza Vaccination OP-4 Aspirin at Arrival Page 13 of 29

14 Measure OP-22 OP-23 OP-29 OP-30 OP-33 PC-01 VTE-6 Description Left Without Being Seen Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients Who Received Head CT or MRI Scan Interpretation Within 45 minutes of ED Arrival Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients Colonoscopy Interval for Patients with a History of Adenomatous Polyps Avoidance of Inappropriate Use External Beam Radiotherapy for Bone Metastases Elective Delivery Prior to 39 Completed Weeks Gestation: Percentage of Babies Electively Delivered Prior to 39 Completed Weeks Gestation Hospital Acquired Potentially-Preventable Venous Thromboembolism Timeliness of Care (N=7) Measure ED-1b ED-2b OP-3 OP-5 OP-18b/ED-3 OP-20 OP-21 Description Median Time from Emergency Department (ED) Arrival to ED Departure for Admitted ED Patients Admit Decision Time to ED Departure Time for Admitted Patients Median Time to Transfer to Another Facility for Acute Coronary Intervention Median Time to ECG Median Time from ED Arrival to ED Departure for Discharged ED Patients Door to Diagnostic Evaluation by a Qualified Medical Professional Median Time to Pain Management for Long Bone Fracture Efficient Use of Medical Imaging (N=5) Measure OP-8 OP-10 OP-11 OP-13 OP-14 Description MRI Lumbar Spine for Low Back Pain Abdomen Computed Tomography (CT) Use of Contrast Material Thorax CT Use of Contrast Material Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac, Low-Risk Surgery Simultaneous Use of Brain Computed Tomography (CT) and Sinus Computed Tomography (CT) Page 14 of 29

15 Measures with less than 100 hospitals reporting are not included in the Hospital Compare Star Rating calculation. A complete list of the measures that will be individually reported, including the measures excluded from the Hospital Compare Star Rating, is available on QualityNet. NOTE: For hospitals reporting the Healthcare Personnel Influenza Vaccination measure in both IQR (IMM-3) and OQR (OP-27), only one program s measure scores will be used, as they are equal scores. For hospitals participating in IQR only, the IMM-3 score will be used. For hospitals participating in OQR only, the OP-27 score will be used. Weight The weight used for the specified group to calculate the hospital s summary score, which is then translated into the hospital s Star Rating. CMS assigns a weight to each group score to calculate a hospital summary score. The following criteria were applied to determine how each measure group is weighted: o Measure importance, including prioritizing outcome measures over process measures o Consistency with other CMS programs, such as Hospital Value-Based Purchasing o Alignment with CMS priorities, as outlined in the CMS Quality Strategy o Stakeholder input, including the prioritization of measure groups by the Technical Expert Panel (TEP), public comment periods, the hospital dry run, and additional sources of patient and consumer feedback o If a hospital does not report at least one measure for a given group, the weight (or percentage) assigned to that group is redistributed proportionally among the groups with a sufficient number of measures Group Score The estimate of the latent variable model used to produce a group score for each group. National Average Group Score The national average group score for each group based on the distribution of group scores across all hospitals. Category The group performance category provides a hospital with a national comparison across a three-point scale for each of the hospital s available group scores. These performance categories are: above the national average, same as the national average, and below the national average. Hospital Compare Star Rating Hospital-Specific Reports (HSRs) HSRs are provided to support the bi-annual, July and December, Star Rating updates. The Star Rating HSR contains hospital-specific rating and national results, hospital-specific measure group score results, hospital-specific measure score results, and measure loadings for the reporting period. Hospitals are encouraged to review their Hospital Compare Star Rating HSRs along with the Hospital Inpatient and Outpatient Quality Reporting preview reports. Hospital Compare Star Rating Footnotes Number Description Application 4 Data suppressed by CMS for one or more quarters Reserved for CMS use Page 15 of 29

16 Number Description Application 16 There are too few measures or measure groups reported to calculate an overall rating or measure group score This footnote is applied when a hospital: reported data for fewer than three measures in any measure group used to calculate overall ratings; or reported data for fewer than three of the measure groups used to calculate ratings; or did not report data for at least one outcomes measure group 17 This hospital s overall rating only includes data reported on inpatient services 23 The data are based on claims that the hospital or facility submitted to CMS. The hospital or facility has reported discrepancies in their claims data. This footnote is applied when a hospital only reports data for inpatient hospital services This footnote is applied when a hospital or facility alerts CMS of a possible issue with the claims data used to calculate results for this measure. Calculations are based on a snapshot of the administrative claims data and changes that hospitals or facilities make to their claims after the snapshot are not reflected in the data. Issues with claims data include but are not limited to the use of incorrect billing codes or inaccurate dates of service. Questions Regarding the Hospital Compare Star Rating Questions regarding the Hospital Compare Star Rating may be directed to the Hospital Compare Quality Star Rating Team by at: cmsstarratings@lantanagroup.com. Web-based Measures The Web-based measures section follows the Star Rating section. The data in this section are based on the data entered by your hospital into the web-based data collection tool on QualityNet from January 1 through May 15. The data are updated annually and have been changed to update with the December Hospital Compare release. Other Web-based measures reported in separate sections of the preview report include OP-29, OP-30 and OP-31. The Web-based measures section includes: OP-12: The Ability for Providers with HIT to Receive Laboratory Data Electronically Directly into their ONC-Certified EHR System as Discrete Searchable Data OP-17: Tracking Clinical Results between Visits OP-25: Safe Surgery Checklist Use OP-26: Hospital Outpatient Volume on Selected Outpatient Surgical Procedures (Gastrointestinal, Genitourinary, Nervous System, Musculoskeletal, Cardiovascular, Eye, Skin, Respiratory and Other) Page 16 of 29

17 Clinical Process Measures These measures are listed as Clinical Process Measures on the preview report and can be found in the Timely and Effective Care tab on Hospital Compare. The AMI Cardiac Care section of the preview report displays the AMI Cardiac Care clinical process measures. The measures contain up to four quarters of data and display as an aggregate rate or median time. The clinical process measures are calculated from Medicare and Non-Medicare patient encounter data submitted by your hospital into the clinical warehouse. Each measure displays: Your Hospital Performance for All Quarters (when submitted); 10% of All Hospitals Submitting Data Performed Equal to or Better Than (i.e., 90 th percentile); State Performance; and National Performance AMI Cardiac Care Measures AMI Cardiac Care measures include: OP-1: Median Time to Fibrinolysis (Measure data displayed on the preview report will be available through the download process but will be excluded from display on Hospital Compare); OP-2: Fibrinolytic Therapy Received Within 30 Minutes of ED Arrival; OP-3b: Median Time to Transfer to Another Facility for Acute Coronary Intervention; OP-4: Aspirin at Arrival, including both chest pain and heart attack patients; and OP-5: Median Time to ECG, including both chest pain and heart attack patients Page 17 of 29

18 State and National Performance Rates The state and national performance rates for the clinical process measures are calculated based on the all publicly reported data in the warehouse. State Performance: The state performance rate is derived by summing the numerators for all cases in the state that are publicly reported, then dividing by the sum of the denominators in the state. Median times are identified using all cases in the state. National Performance: The national performance rate is derived by summing the numerators for all cases that are publicly reported in the nation, then dividing by the sum of the denominators in the nation. Median times are identified using all cases in the nation. The 90 th percentile is calculated for each measure using the un-weighted average or median for each eligible hospital and identifying the top 10 percent of hospitals. Footnotes Clinical Process Measures Footnote Table # Description Application The number of cases/patients is too few to report. Results are based on a shorter time period than required. Data suppressed by CMS for one or more quarters. Results are not available for this reporting period. No cases met the criteria for this measure. Applied to any measure rate where the denominators are greater than 0 and less than 11. Data will not display on Hospital Compare. Applied when a hospital elected not to submit data, had no data to submit, or did not successfully submit data to the warehouse for a measure for one or more but not all possible quarters. Reserved for CMS use. Applied when a hospital either elected not to submit data or the hospital had no data to submit for a particular measure for all quarters represented in the current preview period. Applied when a hospital treated patients in a topic but no patients met the criteria for inclusion in the measure calculation. Outpatient Imaging Efficiency Measures The Outpatient Imaging Efficiency (OIE) section of the preview report displays the Outpatient Imaging Efficiency measures. Imaging Efficiency measures are calculated by CMS using calendar year Medicare Fee-For-Service (FFS) paid claims. The data are updated annually with the July Hospital Compare release. Some rates or ratios for hospitals will not be displayed due to minimum case counts not being met. Imaging Efficiency measures include: OP-8: MRI Lumbar Spine for Low Back Pain; OP-9: Mammography Follow-up Rates; Page 18 of 29

19 OP-10: Abdomen CT Use of Contrast Material; OP-11: Thorax CT Use of Contrast Material; October 2017 Preview/December 2017 Hospital Compare Release - Outpatient OP-13: Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac, Low-Risk Surgery; and OP-14: Simultaneous Use of Brain Computed Tomography (CT) and Sinus Computed Tomography (CT). Each measure displays: Your Hospital Performance for All Quarters (when submitted); 10% of All Hospitals Submitting Data Performed Equal to or Better Than (OIE measures display N/A for this column); State Performance; and National Performance State and National Performance Rates The state and national performance weighted average rates for each Imaging Efficiency measure are calculated based on Medicare claims data, regardless of whether providers elected to opt out of publicly reporting their data. Footnotes Imaging Efficiency Measures Footnote Table # Description Application The number of cases/patients is too few to report. Data suppressed by CMS for one or more quarters. Results are not available for this reporting period. Applied to any measure rate or ratio where the minimum case count was not met. Reserved for CMS use. Applied to the hospital performance rate for instances in which a hospital did not have claims data for a particular measure. Page 19 of 29

20 # Description Application 7 No cases met the criteria for this measure. 23 The data are based on claims that the hospital or facility submitted to CMS. The hospital or facility has reported discrepancies in their claims data. Applied to the hospital performance rate for instances in which a hospital did not have claims data for a particular measure. This footnote is applied when a hospital or facility alerts CMS of a possible issue with the claims data used to calculate results for this measure. Calculations are based on a snapshot of the administrative claims data and changes that hospitals or facilities make to their claims after the snapshot are not reflected in the data. Issues with claims data include but are not limited to the use of incorrect billing codes or inaccurate dates of service. Emergency Department Measures The Emergency Department section of the preview report displays the Emergency Department measures. The measures OP-18b and OP-20 contain up to four quarters of data and display as a median time. The measures are calculated from Medicare and Non-Medicare patient encounter data submitted by your hospital. OP-22 data is entered annually into a web-based tool on QualityNet by your hospital. Emergency Department measures include: OP-18b: Median Time from ED Arrival to ED Departure for Discharged ED Patients; OP-20: Door to Diagnostic Evaluation by a Qualified Medical Professional; and OP-22: Left without Being Seen The Emergency Department Volume (EDV) measure displays based on the volume of patients submitted by a hospital as the denominator used for the measure OP-22: Left without Being Seen. Category assignments are: Very High values of 60,000 or greater patients per year; Page 20 of 29

21 High values ranging from 40,000 to 59,999 patients per year; Medium values ranging from 20,000 to 39,999 patients per year; and Low values below 19,999 or less patients per year State and National Performance Rates The state and national performance rates for the Emergency Department measures are calculated based on the all publicly reported data in the warehouse. State Performance: Median times are identified using all cases that are publicly reported in the state. OP-18b and OP-20 display the state average minutes for hospitals that fall in the Low, Medium, High, Very High, and Overall EDV categories. National Performance: Median times are identified using all cases that are publicly reported in the nation. The 90 th percentile is calculated for each measure using the median for each eligible hospital and identifying the top 10 percent of hospitals. OP-18b and OP-20 display the national average minutes for hospitals that fall in the Low, Medium, High, Very High, and Overall EDV categories. Footnotes Emergency Department Measures Footnote Table # Description Application The number of cases/patients is too few to report. Results are based on a shorter time period than required. Data suppressed by CMS for one or more quarters. Results are not available for this reporting period. No cases met the criteria for this measure. Applied to any measure rate where the denominators are greater than 0 and less than 11. Data will not display on Hospital Compare. Applied when a hospital elected not to submit data, had no data to submit, or did not successfully submit data to the warehouse for a measure for one or more but not all possible quarters. Reserved for CMS use. Applied when a hospital either elected not to submit data or the hospital had no data to submit for a particular measure for all quarters represented in the current preview period. Applied when a hospital treated patients in a topic but no patients met the criteria for inclusion in the measure calculation. Page 21 of 29

22 Pain Management Measure The Pain Management section of the preview report displays the measure OP-21, Median Time to Pain Management for Long Bone Fracture. This measure contains up to four quarters of data and displays as a median time. The measure is calculated from Medicare and Non-Medicare patient encounter data submitted by the hospital. This measure displays: Your Hospital Performance for All Quarters (when submitted); 10% of All Hospitals Submitting Data Performed Equal to or Better Than; State Performance; and National Performance State and National Performance Rates The state and national performance rates for the Pain Management measure are calculated based on the all publicly reported data in the warehouse. State Performance: Median times are identified using all cases that are publicly reported in the state. National Performance: Median times are identified using all cases that are publicly reported in the nation. The 90 th percentile is calculated for each measure using the median for each eligible hospital and identifying the top 10 percent of hospitals. Footnotes Pain Management Measure Footnote Table # Description Application The number of cases/patients is too few to report. Results are based on a shorter time period than required. Data suppressed by CMS for one or more quarters. Results are not available for this reporting period. Applied to any measure rate where the denominators are greater than 0 and less than 11. Data will not display on Hospital Compare. Applied when a hospital elected not to submit data, had no data to submit, or did not successfully submit data to the warehouse for a measure for one or more but not all possible quarters. Reserved for CMS use. Applied when a hospital either elected not to submit data or the hospital had no data to submit for a particular measure for all quarters represented in the current preview period. Page 22 of 29

23 # Description Application 7 No cases met the criteria for this measure. Applied when a hospital treated patients in a topic but no patients met the criteria for inclusion in the measure calculation. Stroke Measure The Stroke section of the preview report displays the measure OP-23, Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients who Received Head CT or MRI Scan Interpretation Within 45 minutes of ED Arrival. This measure displays: Your Hospital Performance for All Quarters (when submitted); 10% of All Hospitals Submitting Data Performed Equal to or Better Than; State Performance; and National Performance State and National Performance Rates The state and national performance rates for the Stroke measure are calculated based on the all publicly reported data in the warehouse. State Performance: The state performance rate is derived by summing the numerators for all cases that are publicly reported in the state, divided by the sum of the denominators in the state. National Performance: The national performance rate is derived by summing the numerators for all cases that are publicly reported in the nation, divided by the sum of the denominators in the nation. The 90 th percentile is calculated for each measure using the un-weighted average for each eligible hospital and identifying the top 10 percent of hospitals. Footnotes Stroke Measure Footnote Table # Description Application 1 3 The number of cases/patients is too few to report. Results are based on a shorter time period than required. Applied to any measure rate where the denominators are greater than 0 and less than 11. Data will not display on Hospital Compare. Applied when a hospital elected not to submit data, had no data to submit, or did not successfully submit data to the warehouse for a measure for one or more but not all possible quarters. Page 23 of 29

24 # Description Application Data suppressed by CMS for one or more quarters. Results are not available for this reporting period. No cases met the criteria for this measure. Reserved for CMS use. Applied when a hospital either elected not to submit data or the hospital had no data to submit for a particular measure for all quarters represented in the current preview period. Applied when a hospital treated patients in a topic but no patients met the criteria for inclusion in the measure calculation. Endoscopy/Polyp Surveillance Measures The Endoscopy/Polyp Surveillance section of the preview report displays OP-29, Appropriate Followup Interval for Normal Colonoscopy in Average Risk Patients, and OP-30, Colonoscopy interval for Patients with a History of Adenomatous Polyps Avoidance of Inappropriate Use. These measures display: Your Hospital Performance for All Quarters (when submitted); 10% of All Hospitals Submitting Data Performed Equal to or Better Than; State Performance; and National Performance State and National Performance Rates The state and national performance rates for the Endoscopy/Polyp Surveillance measures are calculated based on the all publicly reported data in the warehouse. State Performance: The state performance rate is derived by summing the numerators for all cases that are publicly reported in the state, then dividing by the sum of the denominators in the state. National Performance: The national performance rate is derived by summing the numerators for all cases that are publicly reported in the nation, then dividing by the sum of the denominators in the nation. The 90 th percentile is calculated for each measure using the un-weighted average for each eligible hospital and identifying the top 10 percent of hospitals. Page 24 of 29

25 Footnotes Endoscopy/Polyp Surveillance Measure Footnote Table October 2017 Preview/December 2017 Hospital Compare Release - Outpatient # Description Application The number of cases/patients is too few to report. Data suppressed by CMS for one or more quarters. Results are not available for this reporting period. No cases met the criteria for this measure. Cataract Surgery Measure Applied to any measure rate where the denominators are greater than 0 and less than 11. Data will not display on Hospital Compare. Reserved for CMS use. Applied when a hospital either elected not to submit data or the hospital had no data to submit for a particular measure for all quarters represented in the current preview period. Applied when a hospital treated patients in a topic but no patients met the criteria for inclusion in the measure calculation. The Cataract surgery measure section of the preview report displays OP-31 Cataracts - Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery The measure displays: Your Hospital Performance for All Quarters (when submitted); 10% of All Hospitals Submitting Data Performed Equal to or Better Than; State Performance; and National Performance State and National Performance Rates The state and national performance rates for the Cataract surgery measure are calculated based on the all publicly reported data in the warehouse. State Performance: The state performance rate is derived by summing the numerators for all cases that are publicly reported in the state, then dividing by the sum of the denominators in the state. National Performance: The national performance rate is derived by summing the numerators for all cases that are publicly reported in the nation, then dividing by the sum of the denominators in the nation. The 90 th percentile is calculated for each measure using the un-weighted average for each eligible hospital and identifying the top 10 percent of hospitals. Footnotes Cataract Surgery Measure Footnote Table Page 25 of 29

26 # Description Application The number of cases/patients is too few to report. Data suppressed by CMS for one or more quarters. Results are not available for this reporting period. No cases met the criteria for this measure. Applied to any measure rate where the denominators are greater than 0 and less than 11. Data will not display on Hospital Compare. Reserved for CMS use. Applied when a hospital either elected not to submit data or the hospital had no data to submit for a particular measure for all quarters represented in the current preview period. Applied when a hospital treated patients in a topic but no patients met the criteria for inclusion in the measure calculation. External Beam Radiotherapy (EBRT) Measure The EBRT measure section of the preview report displays OP-33 External Beam Radiotherapy for Bone Metastases. Data will display the percentage of patients regardless of age, with a diagnosis of bone metastases and no previous radiation who receive EBRT with an acceptable fractionation scheme. The measure displays: Your Hospital Performance for All Quarters (when submitted); 10% of All Hospitals Submitting Data Performed Equal to or Better Than; State Performance; and National Performance State and National Performance Rates The state and national performance rates for the EBRT measure are calculated based on the all publicly reported data in the warehouse. State Performance: The state performance rate is derived by summing the numerators for all cases that are publicly reported in the state, then dividing by the sum of the denominators in the state. National Performance: The national performance rate is derived by summing the numerators for all cases that are publicly reported in the nation, then dividing by the sum of the denominators in the nation. The 90 th percentile is calculated for each measure using the un-weighted average for each eligible hospital and identifying the top 10 percent of hospitals. Page 26 of 29

27 Footnotes EBRT Measure Footnote Table October 2017 Preview/December 2017 Hospital Compare Release - Outpatient # Description Application The number of cases/patients is too few to report. Data suppressed by CMS for one or more quarters. Results are not available for this reporting period. Applied to any measure rate where the denominators are greater than 0 and less than 11. Data will not display on Hospital Compare. Reserved for CMS use. Applied when a hospital either elected not to submit data or the hospital had no data to submit for a particular measure for all quarters represented in the current preview period. Healthcare Personnel (HCP) Influenza Vaccination The HCP Influenza Vaccination Measure, OP-27, includes the number of HCP contributing towards successful influenza vaccination adherence within the displayed time frame, regardless of clinical responsibility or patient contact. Your hospital s quality measures will include the total number of healthcare personnel in your hospital (Including those in your hospital s outpatient department) who are eligible for vaccination, your hospital s reported adherence percentage, the state reported adherence percentage, and the national reported adherence percentage. Total Number of Healthcare Personnel Eligible for Vaccination represents the total number of healthcare workers in your hospital and your hospital s outpatient department who are eligible to receive the Influenza vaccine for the 2016/2017 flu season, per NHSN protocol. Note: The HCP measure, OP-27, displays on the OP preview report and displays the same data as are displayed for the inpatient measure, IMM-3. To avoid duplication of the measure data in the downloadable files on Hospital Compare, the Measure ID IMM-3_OP-27 will be used to represent IMM-3 and OP-27 rather than listing the data separately. Influenza Vaccination Adherence Percentage The Influenza Vaccination Adherence Percentage is calculated as the total number of healthcare workers contributing to successful vaccination adherence divided by the total number of healthcare workers eligible to receive the Influenza vaccine per NHSN protocol. State Reported Adherence Percentage is calculated as the total number of healthcare workers in the state contributing to successful vaccination adherence divided by the total number of healthcare workers in the state eligible to receive the Influenza vaccine per NHSN protocol. Page 27 of 29

28 National Reported Adherence Percentage is calculated as the total number of healthcare workers in the nation contributing to successful vaccination adherence divided by the total number of healthcare workers in the nation eligible to receive the Influenza vaccine per NHSN protocol. Outcome Measures Following Procedures Facility 7-day Risk-Standardized Hospital Visit after Outpatient Colonoscopy Measure The Outcome Measures Following Procedures section of the preview report displays OP-32 Facility 7- day Risk-Standardized Hospital Visit after Outpatient Colonoscopy Measure. The measure estimates a facility-level rate of risk-standardized, all-cause, unplanned hospital visits within 7 days of an outpatient colonoscopy among Medicare fee-for-services (FFS) patients aged 65 years and older. In addition to your hospital s performance category (Better, No Different, or Worse than the National Rate or Number of cases is too small to report), your hospital s Risk-Standardized Unplanned Hospital Visit (RSHV) Rate for Your Facility, Lower Limit, Upper Limit of 95% Interval Estimates, and Number of Eligible Medicare Cases will display on the Preview Report. Outcome Measures Details The Outcome Measure data for Facility 7-day Risk-Standardized Hospital Visit after Outpatient Colonoscopy Measure will be updated annually during the December Hospital Compare release. Hospitals are not required to submit Outcome Measure data because CMS calculates the measures from claims and enrollment data. The measure is calculated using one year of data. Hospitals with fewer than 25 eligible cases for the measure are assigned to a separate category described as The number of cases is too small (fewer than 25) to reliably tell how well the hospital is performing. and are included in the measure calculation, but will not be reported on Hospital Compare. State and National Rates The Preview Report does not display the state rates for the measure; however, it does provide the national observed result and the number of hospitals in the state and the nation whose performance was categorized as Better, No Different, or Worse than the National Rate or Number of cases is too small to report. Page 28 of 29

29 The Hospital Specific Reports (HSRs) that are distributed to hospitals via the QualityNet Secure Portal do provide the average state risk-standardized outcome rates, national observed (unadjusted) rates for all of the Outcomes Measures. Outcome Measures Footnotes # Description Application 1 The number of cases/patients is too few to report. Applied to any measure rate or ratio where the minimum case count was not met. 4 Data suppressed by CMS for one or more quarters. 5 Results are not available for this reporting period. 7 No cases met the criteria for this measure. 23 The data are based on claims that the hospital or facility submitted to CMS. The hospital or facility has reported discrepancies in their claims data. Reserved for CMS use. Applied when a hospital either elected not to submit data or the hospital had no data to submit for a particular measure for all quarters represented in the current preview period. Applied when a hospital treated patients in a topic but no patients met the criteria for inclusion in the measure calculation. This footnote is applied when a hospital or facility alerts CMS of a possible issue with the claims data used to calculate results for this measure. Calculations are based on a snapshot of the administrative claims data and changes that hospitals or facilities make to their claims after the snapshot are not reflected in the data. Issues with claims data include but are not limited to, the use of incorrect billing codes or inaccurate dates of service. Section 5: Questions Questions regarding the Hospital Compare overall rating may be directed to the Hospital Compare Overall Hospital Rating Team by at: cmsstarratings@lantanagroup.com. Questions may be submitted to the OQR Outreach and Education Support Contractor through the Outpatient Questions and Answers tool at or by calling, toll-free, weekdays from 7 a.m. to 6 p.m. Eastern Time. Questions regarding the registration process, or how to access the QualityNet Secure Portal, may be directed to the QualityNet Help Desk by at qnetsupport@hcqis.org. Page 29 of 29