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Hospital Compare Preview Reports now available

April 10, 2009

June 2009 Hospital Compare Preview Reports for the Hospital Quality Alliance (HQA) and Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) initiatives are now available on My QualityNet for participating hospitals and Quality Improvement Organizations (QIOs).

The “HQA Preview Reports” will be available from April 10 through May 9, 2009. (To access the reports, you must be a registered My QualityNet user and have been assigned the QIO Clinical Warehouse Feedback Report role.) The data that displays in the Preview Reports will be reported on Hospital Compare, the Centers for Medicare & Medicaid Services' (CMS) website for Medicare beneficiaries and the general public, tentatively in June 2009.

Report information

For more information on the reporting of the Clinical Process Measures, 30-Day Risk-Standardized Mortality and Readmission Measures, and HCAHPS Survey Measures, refer to the June 2009 Preview Report Help Summary, PDF. (The Help Summary can also be accessed by a registered My QualityNet user from the “Need Help” link that displays when users run an “HQA Preview Report” on My QualityNet.)

The Preview Reports include data for:

• Clinical Process Measures
• 30-day Risk-Standardized Mortality Measures
• 30-day Risk-Standardized Readmission Measures
• HCAHPS (Hospital Consumer Assessment of Healthcare Providers & Systems) Survey Measures

Clinical Process Measures

The Clinical Process Measures reflect data submitted to the QIO Clinical Warehouse for discharges from Fourth Quarter 2007 through Third Quarter 2008. “AMI- 6, Beta-Blocker at Arrival” was removed from Hospital Compare effective January 15, 2009; however, it is required to be submitted for RHQDAPU requirements for discharges through First Quarter 2009. Data for SCIP-Inf-4 and SCIP-Inf-6 began being reported with First Quarter 2008. The Preview Report will display “N/A” for Fourth Quarter 2007.

To meet RHQDAPU requirements, data from PN-5b must be submitted. For public reporting purposes, PN-5c results are being calculated from the PN-5b data. All hospitals may suppress PN-5c. PN-5b will not display on the Preview Report and will not be reported on Hospital Compare.

Hospitals may contact their QIO Hospital Reporting Contact for questions regarding the Clinical Process Measures.

Outcome Measures

The data for the 30-Day Risk-Standardized Mortality Measures and 30-Day Risk-Standardized Readmission Measures for acute myocardial infarction (AMI), heart failure (HF), and pneumonia (PN) include three years of administrative data from hospitalized, fee-for-service Medicare beneficiaries discharged between Third Quarter 2005 and Second Quarter 2008.

Participating hospitals with eligible cases will receive Hospital-Specific Reports (HSRs) with information on the 30-Day Risk-Standardized Mortality and 30-Day Risk-Standardized Readmission Measures for AMI, HF and PN via their My QualityNet inbox. Detailed methodology, answers to frequently asked questions and other resources for these measures are available on the Mortality Measures and Readmission Measures pages of QualityNet.

To access the HSRs, each registered QualityNet user must be assigned two roles: 1) QIO Clinical Warehouse Feedback Report role, in order to receive the report; and 2) File Exchange & Search role, in order to download the report from My QualityNet.

Submit questions regarding the 30-Day Risk-Standardized Mortality Measures or 30-Day Risk-Standardized Readmission Measures to the Outcomes Measures implementation team at mortalitymeasures@mathematica-mpr.com or readmissionmeasures@mathematica-mpr.com.

HCAHPS (Hospital Consumer Assessment of Healthcare Providers & Systems) Survey Measures

HCAHPS data reflects four quarters of HCAHPS survey data, for discharges Fourth Quarter 2007 through Third Quarter 2008.

Note: Beginning with the March 2009 Hospital Compare release, HCAHPS results from all Inpatient Prospective Payment System (IPPS) hospitals participating in the RHQDAPU program will be published on the Hospital Compare website. All hospitals will continue to receive a Preview Report prior to public reporting, and Critical Access Hospitals will continue to have the option of withholding their HCAHPS results from public reporting.

For information related to the HCAHPS Measures, contact the HCAHPS Project Team at hcahps@azqio.sdps.org.

Data Suppression

To suppress data, hospitals must complete the Hospital Compare Request for Withholding Data from Public Reporting form and submit it to their QIO Hospital Reporting Contact no later than the QIO's close of business on May 9, 2009. It is recommended that hospitals alert their QIO Hospital Reporting Contact when faxing the request. Because a withholding request is applicable only for the current reporting period, HQA hospitals that suppressed data for one or more measures in March 2009 must submit a new form in order to continue suppression of the same measure(s).