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Hospital Compare Preview Reports now available

January 11, 2010

March 2010 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 preview reports will be available from January 11 through February 9. To access the reports, you must be a registered QualityNet user and have been assigned the QIO Clinical Warehouse Feedback Report role. The data 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. The Hospital Compare release is tentatively scheduled for mid-March 2010.

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 March 2010 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.) Hospitals are encouraged to carefully review the information found in the Help Summary document.

The Preview Reports include data for:

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

Structural Measure

The Structural Measure “Participation in a Systematic Database for Cardiac Surgery” data was collected from July 1, 2009, through August 15, 2009, and included participation during First Quarter 2009 and Second Quarter 2009.

Clinical Process Measures

The Clinical Process Measures—Acute Myocardial Infarction (AMI), Heart Failure (HF), Pneumonia (PN), and Surgical Care Improvement Project (SCIP)—reflect data submitted to the QIO Clinical Warehouse for discharges from Third Quarter 2008 through Second Quarter 2009. The Clinical Process Measures no longer display the hospital's quarterly rates. The measure rates display as an aggregate rate of the four quarters of data.

Reporting of measures is in accordance with a hospital’s pledge status. Hospitals may enroll in the HQA and/or RHQDAPU initiatives at any time. To meet RHQDAPU requirements, data from PN-5b must be submitted for discharges through Fourth Quarter 2008. In order for Third Quarter 2008 and Fourth Quarter 2008 data to be included in the aggregate rate, hospitals must have an active HQA pledge. If a hospital has a RHQDAPU pledge but no HQA pledge, only First Quarter 2009 and Second Quarter 2009 data will be included in the aggregate rate.

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 AMI, HF, and PN include three years of administrative data from hospitalized, fee-for-service Medicare beneficiaries discharged between July 1, 2005, and June 30, 2008. This data is only refreshed for the June release.

For questions regarding the 30-Day Risk-Standardized Mortality Measures or 30-Day Risk-Standardized Readmission Measures, contact 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 Third Quarter 2008 through Second Quarter 2009 discharges.

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 non-IPPS hospitals will continue to have the option of withholding their HCAHPS results from being publicly reported.

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 February 9, 2010. It is recommended that hospitals alert their QIO Hospital Reporting Contact when faxing the request. A withholding request is applicable only for the current reporting period; therefore, hospitals that suppressed data for one or more measures during the previous reporting period must submit a new form in order to continue suppression of the same measure(s).

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