About the Quality Ratings

Hospital Quality Ratings

Avoidable Hospital Stays

Hospital Quality Ratings

Childbirth
When both the mother and the newborn do not have injuries after childbirth then good results are achieved. Childbirth practice patterns includes quality ratings on how often and when both C-sections and vaginal births are performed.
Results of care: Information on what happened to patients while being cared for in the hospital or after leaving the hospital. These ratings are sometimes called outcome measures.
Newborns with a birth injury or infection (2011-2013)
How often a newborn infant experiences a problem during the birth process (labor or delivery) such as a broken collarbone, an infection, or a head injury.
  • A lower score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • Figures presented are events per 1,000 cases.
  • Numbers in the measure details table are not scaled. These are raw statistics.

Clinical Title: Birth Trauma — Injury to Neonate

Measure Code: PSI17

Statistics Available: Numerator, Denominator, Observed Rate and CI

Measure Source: AHRQ Quality Indicator

Obstetric injury after a vaginal delivery with medical instruments (2011-2013)
How often a woman experiences a tear (trauma) to her perineum - the area between her vagina and rectum - while giving birth when a health care provider is helping to deliver her baby using a forceps or other medical instrument. Such tears are often preventable.
  • A lower score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • Figures presented are events per 1,000 cases.
  • Numbers in the measure details table are not scaled. These are raw statistics.

Clinical Title: Obstetric Trauma Rate — Vaginal Delivery With Instrument

Measure Code: PSI18

Statistics Available: Numerator, Denominator, Observed Rate and CI

Measure Source: AHRQ Quality Indicator

Obstetric injury after vaginal delivery without medical instruments (2011-2013)
How often a woman experiences a tear (trauma) to her perineum - the area between her vagina and rectum - while giving birth. Such tears, which can happen even when medical instruments are not used, are often preventable.
  • A lower score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • Figures presented are events per 1,000 cases.
  • Numbers in the measure details table are not scaled. These are raw statistics.

Clinical Title: Obstetric Trauma Rate — Vaginal Delivery Without Instrument

Measure Code: PSI19

Statistics Available: Numerator, Denominator, Observed Rate and CI

Measure Source: AHRQ Quality Indicator

Practice patterns: Information on the types of care provided in the hospital. This type of quality rating often shows information about the numbers of surgeries or procedures that a hospital performs.
Percentage of births (deliveries) that are C-sections (2011-2013)
How often babies in the hospital are delivered using cesarean section, which involves an operation, instead of by normal/vaginal delivery.
  • A lower score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • Figures presented are events per 100 cases.
  • Numbers in the measure details table are not scaled. These are raw statistics.

Clinical Title: Cesarean Delivery Rate

Measure Code: IQI21

Statistics Available: Numerator, Denominator, Observed Rate and CI

Measure Source: AHRQ Quality Indicator

Uncomplicated vaginal births performed after C-section (2011-2013)
How often babies in the hospital are delivered normally - meaning with a vaginal birth - when the mother previously delivered by cesarean section (involving an operation).
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • Figures presented are events per 100 cases.
  • Numbers in the measure details table are not scaled. These are raw statistics.

Clinical Title: Vaginal Birth After Cesarean (VBAC) Delivery Rate, Uncomplicated

Measure Code: IQI22

Statistics Available: Numerator, Denominator, Observed Rate and CI

Measure Source: AHRQ Quality Indicator

Primary Cesarean Deliver Rate (2011-2013)
How often babies in the hospital are delivered using cesarean section, which involves an operation, instead of by normal/vaginal delivery - where this is the mother's first birth.
  • A lower score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • Figures presented are events per 100 cases.
  • Numbers in the measure details table are not scaled. These are raw statistics.

Clinical Title: Primary Cesarean Delivery Rate

Measure Code: IQI33

Statistics Available: Numerator, Denominator, Observed Rate and CI

Measure Source: AHRQ Quality Indicator

Vaginal birth after a previous C-section (2011-2013)
How often babies in the hospital are delivered normally - meaning with a vaginal birth - where the mother has previously delivered by cesarean section (involving an operation). The difference between this indicator and the one above it is that this one counts all VBACs, even those where a complication occurred during childbirth.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • Figures presented are events per 100 cases.
  • Numbers in the measure details table are not scaled. These are raw statistics.

Clinical Title: Vaginal Birth After Cesarean (VBAC) Rate, All

Measure Code: IQI34

Statistics Available: Numerator, Denominator, Observed Rate and CI

Measure Source: AHRQ Quality Indicator

Composites
Measures that combine more than one measure into one score. Composite measures provide a summary of quality or performance.
Deaths:
Combined measure: Dying in the hospital following eight major surgeries (2011-2013)
Patients who died in the hospital after having one of eight major surgeries.
  • A lower score is better.
  • Hospital scores presented are risk-standardized ratios summed across all conditions. The expected overall score is 1.0.
    • A score of less than 1 means that the hospital had fewer deaths due to these conditions than other hospitals nationwide with a similar case mix. For example, an overall score of 0.5 means that half as many patients died as expected.
    • A score of 1 means that the hospital had the same number of deaths due to these conditions as other hospitals nationwide with a similar case mix.
    • A score of more than 1 means the hospital had more deaths due to these conditions than other hospitals nationwide with a similar case mix. For example, an overall score of 2.0 means that twice as many patients died as expected.
  • Each individual component of this score takes into account how sick patients were before they went to the hospital (the components are risk-adjusted).
  • Ratings include a significance test.
  • Figures presented are ratios of observed to expected.
  • Numbers in the measure details table are not scaled. These are raw statistics.

Clinical Title: Mortality for selected procedures (esophageal resection, pancreatic resection, AAA repair, CABG, craniotomy, hip replacement, percutaneous transluminal coronary angioplasty (PTCA), and carotid endarterectom)

Measure Code: IQIProc

Statistics Available: Composite Ratio and CI

Measure Source: AHRQ Quality Indicator

Combined measure: Dying in the hospital for six conditions (2011-2013)
Patients who died in the hospital after having one of six common conditions or procedures.
  • A lower score is better.
  • Hospital scores presented are risk-standardized ratios summed across all conditions. The expected overall score is 1.0.
    • A score of less than 1 means that the hospital had fewer deaths due to these conditions than other hospitals nationwide with a similar case mix. For example, an overall score of 0.5 means that half as many patients died as expected.
    • A score of 1 means that the hospital had the same number of deaths due to these conditions as other hospitals nationwide with a similar case mix.
    • A score of more than 1 means the hospital had more deaths due to these conditions than other hospitals nationwide with a similar case mix. For example, an overall score of 2.0 means that twice as many patients died as expected.
  • Each individual component of this score takes into account how sick patients were before they went to the hospital (the components are risk-adjusted).
  • Ratings include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are ratios of observed to expected.
  • Numbers in the measure details table are not scaled. These are raw statistics.

Clinical Title: Mortality for selected conditions (AMI, CHF, stroke, hemorrhage, hip fracture, and pneumonia)

Measure Code: IQICond

Statistics Available: Composite Ratio and CI

Measure Source: AHRQ Quality Indicator

Patient safety:
Combined measure: Eight patient safety problems (2011-2013)
Patients who had one of eight common patient safety problems in the hospital.
  • A lower score is better.
  • Hospital scores presented are risk-standardized ratios summed across all conditions. The expected overall score is 1.0.
    • A score of less than 1 means that the hospital had fewer selected patient safety events than other hospitals nationwide with a similar case mix. For example, an overall score of 0.5 means that half as many discharges involved complications as expected.
    • A score of 1 means that the hospital had the same number of selected patient safety events as other hospitals nationwide with a similar case mix.
    • A score of more than 1 means the hospital had more selected patient safety events than other hospitals nationwide with a similar case mix. For example, an overall score of 2.0 means that twice as many discharges involved complications as expected.
  • Each individual component of this score takes into account how sick patients were before they went to the hospital (the components are risk-adjusted).
  • Ratings include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are ratios of observed to expected.
  • Numbers in the measure details table are not scaled. These are raw statistics.

Clinical Title: Patient safety composite for selected indicators (decibutus ulcer, iatrogenic pneumothorax, infection due to medical care, postoperative hip fracture, postoperative PV or DVT, postoperative sepsis, postoperative wound dehiscence, accidental puncture/laceration)

Measure Code: PSIComp

Statistics Available: Composite Ratio and CI

Measure Source: AHRQ Quality Indicator

Deaths and readmissions
A readmission happens when a patient has to return to the hospital. A higher number of deaths or readmissions may mean the hospital is not treating people effectively. Measures provide information on the number of deaths and readmissions oragnized by Health Topic.
Heart surgeries and procedures:
Dying in the hospital during or after having a surgery to bypass a blocked blood vessel in the heart (2011-2013)
Deaths in the hospital following a coronary artery bypass graft, or CABG, which is designed to provide a way around clogged arteries in the heart.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • Figures presented are events per 100 cases.

Clinical Title: Coronary Artery Bypass Graft (CABG) Mortality Rate

Measure Code: IQI12

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Dying in the hospital during or after a procedure to open up blocked vessels in the heart (angioplasty) (2011-2013)
Deaths in the hospital following a percutaneous transluminal coronary angioplasty, or PTCA, a surgery in which clogged arteries of the heart are opened up and then kept open using wire mesh tubes or stents.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • Figures presented are events per 100 cases.

Clinical Title: Percutaneous Transluminal Coronary Angioplasty (PTCA) Mortality Rate

Measure Code: IQI30

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Heart attack and chest pain:
Dying in the hospital after heart attack (2011-2013)
Deaths in the hospital of patients who came in because they had a heart attack.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Acute Myocardial Infarction (AMI) Mortality Rate

Measure Code: IQI15

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Dying in the hospital after heart attack (excludes patients transferred to another hospital) (2011-2013)
AMI mortality, without transfer cases.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • Figures presented are events per 100 cases.

Clinical Title: Acute Myocardial Infarction (AMI) Mortality Rate, Without Transfer Cases

Measure Code: IQI32

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Dying within 30-days after getting care in the hospital for a heart attack (2008-2012)
Hospitals keep track of how many of their patients died soon after getting care for a heart attack (this is called a death rate). These rates show how many patients died within 30 days of going to the hospital for a heart attack, and takes into account how sick patients were before they went to the hospital.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Hospital 30-Day Death (Mortality) Rates for Heart Attack Compared to US Rate

Measure Code: 30DAY_MORT_HA

Statistics Available: Denominator, Risk-Adjusted Rate and CI

Data Source: CMS Hospital Compare

Returning to the hospital after getting care for a heart attack (2008-2012)
Hospitals keep track of how many of their patients had to go back to the hospital soon after getting care for a heart attack (this is called a readmission rate). These rates show how many patients had to go back to a hospital within 30 days of their original stay. The patients may have needed hospital care because of their heart attack or for a different reason.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Hospital 30-Day Readmission Rates for Heart Attack Compared to US Rate

Measure Code: 30DAY_READM_HA

Statistics Available: Denominator, Risk-Adjusted Rate and CI

Data Source: CMS Hospital Compare

Heart failure:
Dying in the hospital after heart failure (2011-2013)
Deaths in the hospital of patients who came in because they had heart failure.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Congestive Heart Failure (CHF) Mortality Rate

Measure Code: IQI16

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Dying within 30-days after getting care in the hospital for heart failure (2008-2012)
Hospitals keep track of how many of their patients died soon after getting care for heart failure (this is called a death rate). These rates show how many patients died within 30 days of going to the hospital for heart failure.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Hospital 30-Day Death (Mortality) Rates for Heart Failure Compared to US Rate

Measure Code: 30DAY_MORT_HF

Statistics Available: Denominator, Risk-Adjusted Rate and CI

Data Source: CMS Hospital Compare

Returning to the hospital after getting care for heart failure (2008-2012)
Hospitals keep track of how many of their patients had to go back to the hospital soon after getting care for heart failure (this is called a readmission rate). These rates show how many patients had to go back to a hospital within 30 days of their original stay. The patients may have needed hospital care because of their heart failure or for a different reason.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Hospital 30-Day Readmission Rates for Heart Failure Compared to US Rate

Measure Code: 30DAY_READM_HF

Statistics Available: Denominator, Risk-Adjusted Rate and CI

Data Source: CMS Hospital Compare

Other surgeries:
Dying in the hospital during or after surgery on the esophagus (2011-2013)
How often patients died in the hospital after an operation to remove part of their esophagus (the tube leading from the throat to the stomach).
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Esophageal Resection Mortality Rate

Measure Code: IQI8

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Dying in the hospital during or after pancreas surgery (2011-2013)
How often patients died in the hospital after an operation to remove part of their pancreas (a digestive organ).
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Pancreatic Resection Mortality Rate

Measure Code: IQI9

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Dying in the hospital during or after a surgical repair of an aortic aneurysm (2011-2013)
How often patients died in the hospital after an operation to repair an abnormally enlarged blood vessel supplying blood to the stomach, pelvis and legs (called abdominal aortic aneurysm repair).
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Abdominal Aortic Aneurism (AAA) Repair Mortality Rate

Measure Code: IQI11

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Dying in the hospital during or after brain surgery (2011-2013)
How often patients died in the hospital following brain surgery (called craniotomy).
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • Figures presented are events per 100 cases.

Clinical Title: Craniotomy Mortality Rate

Measure Code: IQI13

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Dying in the hospital during or after hip replacement (2011-2013)
How often patients died in the hospital after an operation to replace a bad hip.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • Figures presented are events per 100 cases.

Clinical Title: Hip Replacement Mortality Rate

Measure Code: IQI14

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Stroke:
Dying in the hospital after stroke (2011-2013)
How often patients died in the hospital who came in after having a stroke.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Acute Stroke Mortality Rate

Measure Code: IQI17

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Pneumonia:
Dying in the hospital while getting care for pneumonia (2011-2013)
Deaths in the hospital of patients who came in with pneumonia.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Pneumonia Mortality Rate

Measure Code: IQI20

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Dying within 30-days after getting care in the hospital for pneumonia (2008-2012)
Deaths in the hospital of patients who came in with pneumonia.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Hospital 30-Day Death (Mortality) Rates for Pneumonia Compared to US Rate

Measure Code: 30DAY_MORT_PN

Statistics Available: Denominator, Risk-Adjusted Rate and CI

Data Source: CMS Hospital Compare

Returning to the hospital after getting care for pneumonia (2008-2012)
Hospitals keep track of how many of their patients had to go back to the hospital soon after getting care for pneumonia (this is called a readmission rate). These rates show how many patients had to go back to a hospital within 30 days of their original stay. The patients may have needed hospital care because of their pneumonia or for a different reason.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Hospital 30-Day Readmission Rates for Pneumonia Compared to US Rate

Measure Code: 30DAY_READM_PN

Statistics Available: Denominator, Risk-Adjusted Rate and CI

Data Source: CMS Hospital Compare

Other patient safety:
Dying in the hospital after bleeding from stomach or intestines (2011-2013)
How often patients died after they came in with heavy bleeding in their stomach or intestines.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • Figures presented are events per 100 cases.

Clinical Title: Gastrointestinal Hemorrhage Mortality Rate

Measure Code: IQI18

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Dying in the hospital after fractured hip (2011-2013)
How often patients died in the hospital who came in with a broken hip.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Hip Fracture Mortality Rate

Measure Code: IQI19

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Dying in the hospital while getting care for a condition that rarely results in death (2011-2013)
How often patients died in the hospital when they had been admitted for a health problem that rarely results in death.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 1,000 cases.

Clinical Title: Death Rate in Low-Mortality Diagnosis Related Groups (DRGs)

Measure Code: PSI2

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Surgical patient safety:
Dying in the hospital because a serious condition was not identified and treated (2011-2013)
How often patients died after developing a complication that should have been identified quickly and treated.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 1,000 cases.

Clinical Title: Death Rate Among Surgical Inpatients With Serious Treatable Complications

Measure Code: PSI4

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Heart attack and chest pain
A heart attack (also called an AMI or an acute myocardial infarction) happens when the arteries leading to the heart become blocked and the blood supply is slowed or stops.
Results of care: Information on what happened to patients while being cared for in the hospital or after leaving the hospital. These ratings are sometimes called outcome measures.
Dying in the hospital after heart attack (2011-2013)
Deaths in the hospital of patients who came in because they had a heart attack.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Acute Myocardial Infarction (AMI) Mortality Rate

Measure Code: IQI15

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Dying in the hospital after heart attack (excludes patients transferred to another hospital) (2011-2013)
AMI mortality, without transfer cases.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • Figures presented are events per 100 cases.

Clinical Title: Acute Myocardial Infarction (AMI) Mortality Rate, Without Transfer Cases

Measure Code: IQI32

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Dying within 30-days after getting care in the hospital for a heart attack (2008-2012)
Hospitals keep track of how many of their patients died soon after getting care for a heart attack (this is called a death rate). These rates show how many patients died within 30 days of going to the hospital for a heart attack, and takes into account how sick patients were before they went to the hospital.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Hospital 30-Day Death (Mortality) Rates for Heart Attack Compared to US Rate

Measure Code: 30DAY_MORT_HA

Statistics Available: Denominator, Risk-Adjusted Rate and CI

Data Source: CMS Hospital Compare

Returning to the hospital after getting care for a heart attack (2008-2012)
Hospitals keep track of how many of their patients had to go back to the hospital soon after getting care for a heart attack (this is called a readmission rate). These rates show how many patients had to go back to a hospital within 30 days of their original stay. The patients may have needed hospital care because of their heart attack or for a different reason.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Hospital 30-Day Readmission Rates for Heart Attack Compared to US Rate

Measure Code: 30DAY_READM_HA

Statistics Available: Denominator, Risk-Adjusted Rate and CI

Data Source: CMS Hospital Compare

Recommended care - Inpatient: Information on how many patients got the care they needed such as the right medicine, surgery, or advice. These ratings are sometimes called process measures.
Aspirin given when patient gets to the hospital (2010-2012)
Doctors should give aspirin to heart attack patients when they get to the hospital because it can help keep blood clots from forming. It also helps break up blood clots that may cause another heart attack.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Patients given aspirin at arrival

Measure Code: AMI-1

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Aspirin prescribed before leaving the hospital (2010-2012)
Doctors should give heart attack patients a prescription for aspirin before they leave the hospital. For most patients, taking aspirin can keep blood clots from forming, improve the chances of survival, and help prevent another heart attack.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Heart Attack Patients Given Aspirin at Discharge

Measure Code: AMI-2

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Medicine to help the heart work better given before leaving the hospital (2010-2012)
For heart attack patients with a problem on the left side of their heart, Doctors should give them a special prescription for medicine that lowers blood pressure and makes it easier for the heart to work.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Patients Given ACE Inhibitor or ARB for LVSD

Measure Code: AMI-3

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Advice to stop smoking (2010-2012)
Hospital staff should talk to heart attack patients who smoke about quitting, as smoking increases the chance of another heart attack, heart disease, and stroke. Patients who get even brief advice to quit smoking are more likely to stop.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • Figures presented are events per 100 cases.

Clinical Title: Patients Given Smoking Cessation Advice/Counseling

Measure Code: AMI-4

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Medicine to lower blood pressure before leaving the hospital (2010-2012)
Doctors should give heart attack patients a prescription for medicine called beta blockers. Taking this medicine lowers blood pressure, treats chest pain and heart failure, and can help prevent a future heart attack.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Patients Given Beta Blocker at Discharge

Measure Code: AMI-5

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Heart Attack Patients Given a Prescription for a Statin at Discharge (2010-2012)
Doctors should prescribe cholesterol lowering drugs to heart attack patients when they leave the hospital.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Heart Attack Patients Given a Prescription for a Statin at Discharge

Measure Code: AMI-10

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Medicine to reduce blood clots given within 30 minutes of getting to the hospital (2010-2012)
Doctors should give heart attack patients a medicine within 30 minutes of getting to the hospital to help break up blood clots and improve blood flow to the heart.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Patients Given Fibrinolytic Medication Within 30 Minutes Of Arrival

Measure Code: AMI-7a

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Procedure to open blood vessels done within 90 minutes of getting to the hospital (2010-2012)
Doctors should do a procedure on heart attack patients within 90 minutes of getting to the hospital to help blood flow to the heart by opening blocked blood vessels. Blood vessels carry blood through the body.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Patients Given PCI Within 90 Minutes of Arrival

Measure Code: AMI-8a

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Recommended care - Outpatient: Information on how many patients got the care they needed such as the right medicine, surgery, or advice. These ratings are sometimes called process measures.
Average length of time to receive clot-dissolving medication
The average number of minutes it takes for heart attack patients to receive a medicine after getting to the hospital. The medicine helps break up blood clots and improve blood flow to the heart. Patients should receive this medicine within 30 minutes.
  • A lower score is better.
  • This is an outpatient measure.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are in minutes.

Clinical Title: Median Time to Fibrinolysis

Measure Code: OP-1

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Clot-dissolving medication received within 30 minutes
Doctors should give heart attack patients a medicine within 30 minutes of getting to the hospital. The medicine helps break up blood clots and improve blood flow to the heart.
  • A higher score is better.
  • This is an outpatient measure.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Fibrinolytic Therapy Received Within 30 Minutes

Measure Code: OP-2

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Average length of time for transfer to another hospital to receive a procedure for heart attack
If a hospital does not have the facilities to provide specialized heart attack care, it should quickly transfer patients with possible heart attack to another hospital that can give them this care. This measure shows the average (mean) number of minutes it takes for these hospitals to transfer possible heart attack patients from the emergency department to another hospital.
  • A lower score is better.
  • This is an outpatient measure.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are in minutes.

Clinical Title: Median Time to Transfer to Another Facility for Acute Coronary Intervention

Measure Code: OP-3

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Received aspirin on arrival to the hospital
Doctors should give aspirin to heart attack patients when they get to the hospital because it can help keep blood clots from forming. It also helps break up blood clots that may cause another heart attack.
  • A higher score is better.
  • This is an outpatient measure.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Aspirin at Arrival

Measure Code: OP-4

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Average length of time to receive an ECG (a test that can detect heart damage following heart attack)
An electrocardiogram, sometimes called an ECG or EKG, is a test that can help doctors determine whether patients are having a heart attack. Doctors should give this test to possible heart attack patients within 10 minutes of getting to the hospital.
  • A lower score is better.
  • This is an outpatient measure.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are in minutes.

Clinical Title: Median Time to ECG

Measure Code: OP-5

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Heart failure
Ratings about care for heart failure. Heart failure or congestive heart failure is a weakening of the heart's pumping power that prevents the body from getting enough oxygen and nutrients to meet its needs.
Results of care: Information on what happened to patients while being cared for in the hospital or after leaving the hospital. These ratings are sometimes called outcome measures.
Dying in the hospital after heart failure (2011-2013)
Deaths in the hospital of patients who came in because they had heart failure.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Congestive Heart Failure (CHF) Mortality Rate

Measure Code: IQI16

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Dying within 30-days after getting care in the hospital for heart failure (2008-2012)
Hospitals keep track of how many of their patients died soon after getting care for heart failure (this is called a death rate). These rates show how many patients died within 30 days of going to the hospital for heart failure.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Hospital 30-Day Death (Mortality) Rates for Heart Failure Compared to US Rate

Measure Code: 30DAY_MORT_HF

Statistics Available: Denominator, Risk-Adjusted Rate and CI

Data Source: CMS Hospital Compare

Returning to the hospital after getting care for heart failure (2008-2012)
Hospitals keep track of how many of their patients had to go back to the hospital soon after getting care for heart failure (this is called a readmission rate). These rates show how many patients had to go back to a hospital within 30 days of their original stay. The patients may have needed hospital care because of their heart failure or for a different reason.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Hospital 30-Day Readmission Rates for Heart Failure Compared to US Rate

Measure Code: 30DAY_READM_HF

Statistics Available: Denominator, Risk-Adjusted Rate and CI

Data Source: CMS Hospital Compare

Recommended care: Information on how many patients got the care they needed such as the right medicine, surgery, or advice. These ratings are sometimes called process measures.
Instructions for follow-up care given before leaving the hospital (2010-2012)
Hospital staff should give follow-up care instructions to heart failure patients before they leave the hospital to help patients manage their symptoms and lower the chance of getting other health problems.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Patients Given Discharge Instructions

Measure Code: HF-1

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Test of how well the heart is able to pump blood (2010-2012)
Doctors should give heart failure patients a test that shows how well the heart is pumping blood. The test results tell doctors which parts of the heart are not working well, and they can then treat the heart failure based on these results.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Patients Given an Evaluation of LVS Function

Measure Code: HF-2

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Medicine to make the heart work better given before leaving the hospital (2010-2012)
Doctors should give heart failure patients a prescription for medicine to improve how the heart works before they leave the hospital. This medicine can lower blood pressure and make it easier for the heart to pump.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)

Measure Code: HF-3

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Advice to stop smoking (2010-2012)
Hospital staff should talk to heart failure patients who smoke about quitting, Smoking increases the chance of another heart attack, heart disease, and stroke. Patients who get even brief advice to quit smoking are more likely to stop.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • Figures presented are events per 100 cases.

Clinical Title: Patients Given Smoking Cessation Advice/Counseling

Measure Code: HF-4

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Heart surgeries and procedures
Ratings about surgeries and procedures related to the heart such as angioplasty and coronary bypass surgery.
Results of care: Information on what happened to patients while being cared for in the hospital or after leaving the hospital. These ratings are sometimes called outcome measures.
Dying in the hospital during or after having a surgery to bypass a blocked blood vessel in the heart (2011-2013)
Deaths in the hospital following a coronary artery bypass graft, or CABG, which is designed to provide a way around clogged arteries in the heart.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • Figures presented are events per 100 cases.

Clinical Title: Coronary Artery Bypass Graft (CABG) Mortality Rate

Measure Code: IQI12

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Number of surgeries to bypass blocked blood vessels in the heart (2011-2013)
How often a hospital does an operation called a coronary artery bypass graft, or CABG, which is designed to restore the natural flow of blood in the heart.
  • Hospitals are not rated for this measure because there are currently no nationally agreed upon standards.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • Figures presented are counts.
  • Numbers in the measure details table are not scaled. These are raw statistics.

Clinical Title: Coronary Artery Bypass Graft (CABG) Volume

Measure Code: IQI5

Statistics Available: Volume of Procedures

Measure Source: AHRQ Quality Indicator

Dying in the hospital during or after a procedure to open up blocked vessels in the heart (angioplasty) (2011-2013)
Deaths in the hospital following a percutaneous transluminal coronary angioplasty, or PTCA, a surgery in which clogged arteries of the heart are opened up and then kept open using wire mesh tubes or stents.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • Figures presented are events per 100 cases.

Clinical Title: Percutaneous Transluminal Coronary Angioplasty (PTCA) Mortality Rate

Measure Code: IQI30

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Number of procedures to open up blocked blood vessels in heart (angioplasty)
How often a hospital does an operation called a percutaneous transluminal coronary angioplasty, or PTCA. This is a procedure in which clogged arteries of the heart are opened up and then kept open using wire mesh tubes or stents.
  • Hospitals are not rated for this measure because there are currently no nationally agreed upon standards.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • Figures presented are counts.
  • Numbers in the measure details table are not scaled. These are raw statistics.

Clinical Title: Percutaneous Coronary Intervention (PCI) Volume

Measure Code: IQI6

Statistics Available: Volume of Procedures

Measure Source: AHRQ Quality Indicator

Recommended care: Information on how many patients got the care they needed such as the right medicine, surgery, or advice. These ratings are sometimes called process measures.
Number of times a procedure is used to find blocked blood vessels in the heart on both sides of the heart instead of on only one side of the heart which is known to lead to fewer complications. (2011-2013)
Many patients undergo a "cardiac catheterization" to learn how well the heart is working. Usually, this is done by putting tubes in the arteries on one side of the heart. This indicator shows how many patients getting this procedure have tubes put into the arteries on both sides of the heart (called bilateral cardiac catheterization), which experts believe puts them at greater risk for complications.
  • A lower score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.
  • Numbers in the measure details table are not scaled. These are raw statistics.

Clinical Title: Bilateral Cardiac Catheterization Rate

Measure Code: IQI25

Statistics Available: Numerator, Denominator, Observed Rate and CI

Measure Source: AHRQ Quality Indicator

Blood sugar level controlled after heart surgery (2010-2012)
Hospital staff should help surgery patients keep their blood sugar as close to normal as possible after their surgery, because this can lower their chances of infections, heart attack, and brain, kidney, lung, and stomach problems.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Cardiac Surgery Patients with Controlled 6AM Postoperative Blood Glucose

Measure Code: SCIP-INF-4

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Other surgeries
Brain surgery (craniotomy) and hip replacement are examples of other surgeries.
Results of care: Information on what happened to patients while being cared for in the hospital or after leaving the hospital. These ratings are sometimes called outcome measures.
Dying in the hospital during or after surgery on the esophagus (2011-2013)
How often patients died in the hospital after an operation to remove part of their esophagus (the tube leading from the throat to the stomach).
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Esophageal Resection Mortality Rate

Measure Code: IQI8

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Number of surgeries to remove part of the esophagus (2010-2012)
How often a hospital did an operation to remove a diseased portion of the esophagus (the tube leading from the throat to the stomach), usually due to cancer.
  • Hospitals are not rated for this measure because there are currently no nationally agreed upon standards.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are counts.
  • Numbers in the measure details table are not scaled. These are raw statistics.

Clinical Title: Esophageal Resection Volume

Measure Code: IQI1

Statistics Available: Volume of Procedures

Measure Source: AHRQ Quality Indicator

Dying in the hospital during or after pancreas surgery (2011-2013)
How often patients died in the hospital after an operation to remove part of their pancreas (a digestive organ).
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Pancreatic Resection Mortality Rate

Measure Code: IQI9

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Number of surgeries to remove part of the pancreas (2011-2013)
How often a hospital did an operation to remove a diseased portion of the pancreas (a digestive organ), usually due to cancer.
  • Hospitals are not rated for this measure because there are currently no nationally agreed upon standards.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are counts.
  • Numbers in the measure details table are not scaled. These are raw statistics.

Clinical Title: Pancreatic Resection Volume

Measure Code: IQI2

Statistics Available: Volume of Procedures

Measure Source: AHRQ Quality Indicator

Dying in the hospital during or after a surgical repair of an aortic aneurysm (2011-2013)
How often patients died in the hospital after an operation to repair an abnormally enlarged blood vessel supplying blood to the stomach, pelvis and legs (called abdominal aortic aneurysm repair).
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Abdominal Aortic Aneurism (AAA) Repair Mortality Rate

Measure Code: IQI11

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Number of surgical repairs of an aortic aneurysm (2011-2013)
How often a hospital did an operation involving repair of an abnormally enlarged blood vessel supplying blood to the stomach, pelvis and legs ((called abdominal aortic aneurysm repair).
  • Hospitals are not rated for this measure because there are currently no nationally agreed upon standards.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are counts.
  • Numbers in the measure details table are not scaled. These are raw statistics.

Clinical Title: Abdominal Aortic Aneurysm (AAA) Repair Volume

Measure Code: IQI4

Statistics Available: Volume of Procedures

Measure Source: AHRQ Quality Indicator

Dying in the hospital during or after brain surgery (2011-2013)
How often patients died in the hospital following brain surgery (called craniotomy).
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • Figures presented are events per 100 cases.

Clinical Title: Craniotomy Mortality Rate

Measure Code: IQI13

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Dying in the hospital during or after hip replacement (2011-2013)
How often patients died in the hospital after an operation to replace a bad hip.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • Figures presented are events per 100 cases.

Clinical Title: Hip Replacement Mortality Rate

Measure Code: IQI14

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Recommended care: Information on how many patients got the care they needed such as the right medicine, surgery, or advice. These ratings are sometimes called process measures.
Healthy appendix removed in the elderly (2011-2013)
How often a healthy appendix was removed from an elderly person in the hospital during surgery for another medical problem (called an incidental appendectomy). Health experts believe this should be avoided, but some surgeons still do it.
  • A lower score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.
  • Numbers in the measure details table are not scaled. These are raw statistics.

Clinical Title: Incidental Appendectomy in the Elderly Rate

Measure Code: IQI24

Statistics Available: Numerator, Denominator, Observed Rate and CI

Measure Source: AHRQ Quality Indicator

Practice patterns: Information on the types of care provided in the hospital. This type of quality rating often shows information about the numbers of surgeries or procedures that a hospital performs.
Gallbladder was removed using a minimally-invasive procedure (2011-2013)
How often a hospital did an operation to remove a patient's gallbladder using a "laparoscopic" approach. This approach involves less cutting and is considered a better choice where possible since it results in fewer complications and a faster and less painful recovery.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • Figures presented are events per 100 cases.
  • Numbers in the measure details table are not scaled. These are raw statistics.

Clinical Title: Laparoscopic Cholecystectomy Rate

Measure Code: IQI23

Statistics Available: Numerator, Denominator, Observed Rate and CI

Measure Source: AHRQ Quality Indicator

Imaging
Ratings about imaging procedures including magnetic resonance imaging (MRI), mammography, and computerized axial tomography (CAT scans).
Practice patterns: Information on how many patients got the care they needed such as the right medicine, surgery, or advice.
MRI for lower back pain (2010-2012)
Outpatients with low back pain who had an MRI without trying recommended treatments first, such as physical therapy. If a number is high, it may mean the facility is doing too many unnecessary MRIs for low back pain.
  • A lower score is better.
  • This is an outpatient measure.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: MRI Lumbar Spine for Low Back Pain

Measure Code: OP-8

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Contrast material (dye) used during abdominal CT scan
Outpatient CT scans of the abdomen that were "combination" (or double) scans performed both with and without contrast material (dye). A number close to 100% may mean that too many patients are being given a double scan when a single scan is all they need.
  • A lower score is better.
  • This is an outpatient measure.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • Figures presented are events per 100 cases.

Clinical Title: Abdomen CT - Use of Contrast Material

Measure Code: OP-10

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Contrast material (dye) used during chest CT scan
Outpatient CT scans of the chest that were "combination" (or double) scans performed both with and without contrast material (dye). A number close to 100% may mean that too many patients are being given a double scan when a single scan is all they need.
  • A lower score is better.
  • This is an outpatient measure.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Thorax CT - Use of Contrast Material

Measure Code: OP-11

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Cardiac imaging for preoperative risk assessment CT scan
Outpatient CT scans of the chest that were "combination" (or double) scans performed both with and without contrast material (dye). A number close to 100% may mean that too many patients are being given a double scan when a single scan is all they need.
  • A lower score is better.
  • This is an outpatient measure.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Cardiac CT - Use of Contrast Material

Measure Code: OP-13

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Simultaneous use of brain CT and sinus CT
Outpatient CT scans of the chest that were "combination" (or double) scans performed both with and without contrast material (dye). A number close to 100% may mean that too many patients are being given a double scan when a single scan is all they need.
  • A lower score is better.
  • This is an outpatient measure.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Brain CT - Simultaneous use of brain CT and sinus CT

Measure Code: OP-14

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Nursing sensitive care
Ratings about nursing sensitive care. Nurses and the care they provide exert a great deal of influence over healthcare quality, patient safety, and patient outcomes.
Results of care - Complications: Information on what happened to patients while being cared for in the hospital or after leaving the hospital. These ratings are sometimes called outcome measures.
Severe bloodstream infection after surgery (2011-2013)
How often hospital patients got a serious bloodstreem infection following an operation.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • Figures presented are events per 1,000 cases.

Clinical Title: Postoperative Sepsis Rate

Measure Code: PSI13

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Blood infection that patients with catheters developed while in the hospital (2011-2013)
How often patients got a variety of infections as a result of the care they received in the hospital.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • Figures presented are events per 1,000 cases.

Clinical Title: Central Venous Catheter-Related Blood Stream Infections Rate

Measure Code: PSI7

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Developing a bed sore in the hospital (2011-2013)
How often patients developed a bed sore, which is a sore or wound on the skin. This can occur because people are lying in one position for too long.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • Figures presented are events per 1,000 cases.

Clinical Title: Pressure Ulcer Rate

Measure Code: PSI3

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Hip fracture after surgery (2011-2013)
How often hospital patients broke a hip bone from a fall following any kind of surgery.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • Figures presented are events per 1,000 cases.

Clinical Title: Postoperative Hip Fracture Rate

Measure Code: PSI8

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Abnormal changes in internal body functions after surgery (2011-2013)
How often hospital patients experienced abnormal changes in basic bodily functions such as digestion, breathing, body temperature and blood circulation, after having an operation.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • Figures presented are events per 1,000 cases.

Clinical Title: Postoperative Physiologic and Metabolic Derangement Rate

Measure Code: PSI10

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Blood clot in the lung or leg vein after surgery (2011-2013)
How often hospital patients developed a blood clot that ends up in the lungs (called pulmonary embolism) or in a large vein ( called deep vein thrombosis) after an operation.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 1,000 cases.

Clinical Title: Postoperative Pulmonary Embolism or Deep Vein Thrombosis Rate

Measure Code: PSI12

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Results of care - Deaths: Information on what happened to patients while being cared for in the hospital or after leaving the hospital. These ratings are sometimes called outcome measures.
Dying in the hospital while getting care for a condition that rarely results in death (2011-2013)
How often patients died in the hospital when they had been admitted for a health problem that rarely results in death.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 1,000 cases.

Clinical Title: Death Rate in Low-Mortality Diagnosis Related Groups (DRGs)

Measure Code: PSI2

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Dying in the hospital because a serious condition was not identified and treated (2011-2013)
How often patients died after developing a complication that should have been identified quickly and treated.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 1,000 cases.

Clinical Title: Death Rate Among Surgical Inpatients With Serious Treatable Complications

Measure Code: PSI4

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Patient experiences
Ratings from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS, pronounced "H-caps"). HCAHPS is a national, standardized survey of hospital patients that asks patients about their experiences during a recent hospital stay.
Communication: These ratings show how satisfied patients say they are with the way hospital staff communicated with them. Good communication means that hospital staff explained things clearly, listened carefully, and treated patients with courtesy and respect. These ratings are collected from patient surveys.
How Often Did Doctors Communicate Well with Patients? (2010-2012)
The survey asked patients about communication with their doctors. Good communication means that doctors explained things clearly, listened carefully, and treated patients with courtesy and respect.
  • A good score indicates patients often answered "always" - higher is better.
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: How Often Did Doctors Communicate Well with Patients?

Measure Code: H_COMP_2_A_P

Statistics Available: Observed (by answer type), Response Rate (collapsed)

Data Source: CMS Hospital Compare

How Often Did Nurses Communicate Well with Patients? (2010-2012)
The survey asked patients about communication with nurses. Good communication means that nurses explained things clearly, listened carefully, and treated patients with courtesy and respect.
  • A good score indicates patients often answered "always" - higher is better.
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: How Often Did Nurses Communicate Well with Patients?

Measure Code: H_COMP_1_A_P

Statistics Available: Observed (by answer type), Response Rate (collapsed)

Data Source: CMS Hospital Compare

How Often Did Staff Explain about Medicines Before Giving Them to Patients? (2010-2012)
The survey asked patients if they were told about new medicines and possible side effects.
  • A good score indicates patients often answered "always" - higher is better.
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: How Often Did Staff Explain about Medicines Before Giving Them to Patients?

Measure Code: H_COMP_5_A_P

Statistics Available: Observed (by answer type), Response Rate (collapsed)

Data Source: CMS Hospital Compare

Were Patients Given Information About What to Do During Their Recovery at Home? (2010-2012)
The survey asked patients about the information they got before they left the hospital. Hospital staff should talk to patients about the care they will need at home and give them information on symptoms and health problems to watch for.
  • A good score indicates patients often answered "yes" - higher is better.
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Were Patients Given Information About What to Do During Their Recovery at Home?

Measure Code: H_COMP_6_Y_P

Statistics Available: Observed (by answer type), Response Rate (collapsed)

Data Source: CMS Hospital Compare

Environment: These ratings show how satisfied patients say they are with the physical environment in the hospital. A good physical environment means that patients received help quickly, their pain was well-controlled, and the patient room was clean and quiet. This type of quality rating appears only in the "Patient Experiences" health topic. These ratings are collected from patient surveys.
How Often Did Patients Receive Help Quickly from Hospital Staff? (2010-2012)
The survey asked patients about the timeliness of help when they used the call button and when they needed help getting to the bathroom or using a bedpan.
  • A good score indicates patients often answered "always" - higher is better.
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: How Often Did Patients Receive Help Quickly from Hospital Staff?

Measure Code: H_COMP_3_A_P

Statistics Available: Observed (by answer type), Response Rate (collapsed)

Data Source: CMS Hospital Compare

How Often Was Patients' Pain Well-Controlled? (2010-2012)
The survey asked patients who needed pain medicine about the control of that pain and the helpfulness of hospital staff.
  • A good score indicates patients often answered "always" - higher is better.
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: How Often Was Patients' Pain Well-Controlled?

Measure Code: H_COMP_4_A_P

Statistics Available: Observed (by answer type), Response Rate (collapsed)

Data Source: CMS Hospital Compare

How Often Was the Area Around Patients' Rooms Kept Quiet at Night? (2010-2012)
The survey asked patients about noise at night in the area around their hospital room.
  • A good score indicates patients often answered "always" - higher is better.
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: How Often Was the Area Around Patients' Rooms Kept Quiet at Night?

Measure Code: H_QUIET_HSP_A_P

Statistics Available: Observed (by answer type), Response Rate (collapsed)

Data Source: CMS Hospital Compare

How Often Were the Patients' Rooms and Bathrooms Kept Clean? (2010-2012)
The survey asked patients about the cleanliness of their hospital room and bathroom.
  • A good score indicates patients often answered "always" - higher is better.
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: How Often Were the Patients' Rooms and Bathrooms Kept Clean?

Measure Code: H_CLEAN_HSP_A_P

Statistics Available: Observed (by answer type), Response Rate (collapsed)

Data Source: CMS Hospital Compare

Satisfaction overall: These ratings show how satisfied patients say they are with their recent hospital stay overall. This type of quality rating appears only in the "Patient Experiences" health topic. These ratings are collected from patient surveys.
How Do Patients Rate the Hospital Overall? (2010-2012)
The survey asked patients to rate the hospital on a scale of 0 to 10 (a 10 is the best score).
  • A good score indicates patients often rated a hospital as a 9 or a 10 - higher is better.
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: How Do Patients Rate the Hospital Overall?

Measure Code: H_HSP_RATING_9_10

Statistics Available: Observed (by answer type), Response Rate (collapsed)

Data Source: CMS Hospital Compare

Would Patients Recommend the Hospital to Friends and Family? (2010-2012)
The survey asked patients if they would recommend the hospital to friends and family.
  • A good score indicates patients often answered "yes" - higher is better.
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Would Patients Recommend the Hospital to Friends and Family?

Measure Code: H_RECMND_DY

Statistics Available: Observed (by answer type), Response Rate (collapsed)

Data Source: CMS Hospital Compare

Pneumonia
Pneumonia is a serious lung infection that causes difficulty breathing, fever, cough and fatigue.
Results of care: Information on what happened to patients while being cared for in the hospital or after leaving the hospital. These ratings are sometimes called outcome measures.
Dying in the hospital while getting care for pneumonia (2011-2013)
Deaths in the hospital of patients who came in with pneumonia.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Pneumonia Mortality Rate

Measure Code: IQI20

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Dying within 30-days after getting care in the hospital for pneumonia (2008-2012)
Deaths in the hospital of patients who came in with pneumonia.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Hospital 30-Day Death (Mortality) Rates for Pneumonia Compared to US Rate

Measure Code: 30DAY_MORT_PN

Statistics Available: Denominator, Risk-Adjusted Rate and CI

Data Source: CMS Hospital Compare

Returning to the hospital after getting care for pneumonia (2008-2012)
Hospitals keep track of how many of their patients had to go back to the hospital soon after getting care for pneumonia (this is called a readmission rate). These rates show how many patients had to go back to a hospital within 30 days of their original stay. The patients may have needed hospital care because of their pneumonia or for a different reason.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Hospital 30-Day Readmission Rates for Pneumonia Compared to US Rate

Measure Code: 30DAY_READM_PN

Statistics Available: Denominator, Risk-Adjusted Rate and CI

Data Source: CMS Hospital Compare

Recommended care: Information on how many patients got the care they needed such as the right medicine, surgery, or advice. These ratings are sometimes called process measures.
Pneumonia shot given (if needed)
Hospital staff should check if pneumonia patients have gotten a pneumonia shot recently. If patients have not already gotten this shot, they should get it during their hospital stay because it still may prevent or lower the chance of getting pneumonia again.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • Figures presented are events per 100 cases.

Clinical Title: Patients Assessed and Given Pneumococcal Vaccination

Measure Code: PN-2

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Blood test done before getting antibiotics (2010-2012)
Doctors should give pneumonia patients a blood test before they get any antibiotics to help find out which bacteria may have caused the pneumonia. Different antibiotics work for different kinds of bacteria, so knowing the kind of bacteria will allow doctors to pick the right medicine.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Patients Whose Initial Emergency Room Blood Culture Was Performed Prior to the Administration of the First Hospital Dose of Antibiotics

Measure Code: PN-3B

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Advice to stop smoking
Hospital staff should talk to pneumonia patients who smoke about quitting, as smoking increases the chance of getting pneumonia or other lung disease. Patients who get even brief advice to quit smoking are more likely to stop.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • Figures presented are events per 100 cases.

Clinical Title: Patients Given Smoking Cessation Advice/Counseling

Measure Code: PN-4

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Antibiotics given within 6 hours of getting to the hospital
Hospital staff should give pneumonia patients an antibiotic to fight infection within 6 hours of getting to the hospital. Taking antibiotics early can cure pneumonia caused by bacteria and reduce the chance of complications.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Patients Given Initial Antibiotic(s) within 6 Hours After Arrival

Measure Code: PN-5C

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Right antibiotics given (2010-2012)
Doctors should give patients the right antibiotic for the type of pneumonia they have, as different antibiotics are used to treat different kinds of bacteria that cause pneumonia.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Patients Given the Most Appropriate Initial Antibiotic

Measure Code: PN-6

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Flu shot given (if needed)
Hospital staff should check if pneumonia patients have gotten a flu shot recently. If patients have not already gotten this shot, they should get it during their hospital stay because it helps protect pneumonia patients from other lung infections, lowers the chances of getting the flu, and prevents the spread of flu. It is most important for pneumonia patients 50 and older.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Pneumonia Patients Assessed and Given Influenza Vaccination

Measure Code: PN-7

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Stroke
A stroke happens when the blood supply to the brain stops. This topic includes carotid endarterectomy surgery, an operation intended to prevent stroke.
Results of care: Information on what happened to patients while being cared for in the hospital or after leaving the hospital. These ratings are sometimes called outcome measures.
Dying in the hospital after stroke (2011-2013)
How often patients died in the hospital who came in after having a stroke.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Acute Stroke Mortality Rate

Measure Code: IQI17

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Dying in the hospital during or after a procedure to open up blocked blood vessels leading to the brain (2011-2013)
Deaths in the hospital during or after a carotid endarterectomy, or CEA, which is designed to open up blocked blood vessels leading to the brain.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • Figures presented are events per 100 cases.

Clinical Title: Carotid Endarterectomy Mortality Rate

Measure Code: IQI31

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Number of operations to remove blockage in brain arteries (2011-2013)
How often a hospital did an operation to remove blockage in the arteries leading to the brain (called carotid endarterectomy).
  • Hospitals are not rated for this measure because there are currently no nationally agreed upon standards.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • Figures presented are counts.
  • Numbers in the measure details table are not scaled. These are raw statistics.

Clinical Title: Carotid Endarterectomy Volume

Measure Code: IQI7

Statistics Available: Volume of Procedures

Measure Source: AHRQ Quality Indicator

Surgical patient safety
  • Hospital quality ratings for recommended care before surgery and after surgery, and results of surgical care.
  • Recommended care before surgery: Information on how many patients got the care they needed such as the right medicine, surgery, or advice.
  • Recommended care after surgery: Information on how many patients got the care they needed such as the right medicine, surgery, or advice after a surgery.
Results of care: Information on what happened to patients while being cared for in the hospital or after leaving the hospital. These ratings are sometimes called outcome measures.
Dying in the hospital because a serious condition was not identified and treated (2011-2013)
How often patients died after developing a complication that should have been identified quickly and treated.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 1,000 cases.

Clinical Title: Death Rate Among Surgical Inpatients With Serious Treatable Complications

Measure Code: PSI4

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Hip fracture after surgery (2011-2013)
How often hospital patients broke a hip bone from a fall following any kind of surgery.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • Figures presented are events per 1,000 cases.

Clinical Title: Postoperative Hip Fracture Rate

Measure Code: PSI8

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Bleeding or bruising after surgery (2011-2013)
How often patients bled too much either within their body or outside their body (hemorrhage), or developed a large bruise or clot (hematoma) after an operation. All of these complications involved another operation to stop the bleeding or remove the blood clots.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • Figures presented are events per 1,000 cases.

Clinical Title: Postoperative Hemorrhage or Hematoma Rate

Measure Code: PSI9

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Abnormal changes in internal body functions after surgery (2011-2013)
How often hospital patients experienced abnormal changes in basic bodily functions such as digestion, breathing, body temperature and blood circulation, after having an operation.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • Figures presented are events per 1,000 cases.

Clinical Title: Postoperative Physiologic and Metabolic Derangement Rate

Measure Code: PSI10

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Breathing failure after surgery (2011-2013)
How often patients became unable to breathe on their own following an operation, and needed a ventilator (a machine that helps someone breathe), at least temporarily.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 1,000 cases.

Clinical Title: Postoperative Respiratory Failure Rate

Measure Code: PSI11

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Blood clot in the lung or leg vein after surgery (2011-2013)
How often hospital patients developed a blood clot that ends up in the lungs (called pulmonary embolism) or in a large vein ( called deep vein thrombosis) after an operation.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 1,000 cases.

Clinical Title: Postoperative Pulmonary Embolism or Deep Vein Thrombosis Rate

Measure Code: PSI12

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Severe bloodstream infection after surgery (2011-2013)
How often hospital patients got a serious bloodstreem infection following an operation.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • Figures presented are events per 1,000 cases.

Clinical Title: Postoperative Sepsis Rate

Measure Code: PSI13

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Surgical wound splits open surgery on stomach or pelvis (2011-2013)
How often a surgical wound in the stomach or pelvic area split open after surgery.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 1,000 cases.

Clinical Title: Postoperative Wound Dehiscence Rate

Measure Code: PSI14

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Recommended care before surgery: Information on how many patients got the care they needed such as the right medicine, surgery, or advice before a surgery.
Antibiotics given one hour before surgery (2010-2012)
Hospital staff should give surgery patients antibiotics within 1 hour before surgery. Antibiotics are medicines that fight infections in your body which, given properly, can greatly lower your chances of getting an infection after surgery.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Surgery Patients Who Received Preventative Antibiotic(s) One Hour Before Incision

Measure Code: SCIP-INF-1

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Right antibiotics given (2010-2012)
Hospital staff should give surgery patients the right kind of antibiotics to lower the chance of infection after surgery. The right antibiotic for a patient depends on the kind of surgery they had.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Surgery Patients Who Received the Appropriate Preventative Antibiotic(s) for Their Surgery

Measure Code: SCIP-INF-2

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Hair removed safely (if needed) (2010-2012)
Hospital staff should use safe methods, such as electric clippers and hair removal cream, if they need to remove a patient's hair from the surgery area. Staff should not use a razor because of the risk of leaving small cuts on the skin.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Surgery Patients with Appropriate Hair Removal

Measure Code: SCIP-INF-6

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Medicine to lower blood pressure given (if needed) (2010-2012)
Hospital staff should give medicine to surgery patients who have heart problems or are at risk for heart problems to lower their blood pressure. These patients may already take this medicine, and should continue to take it because it can lower the risk of death.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: 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 Before and After Their Surgery

Measure Code: SCIP-CARD-2

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Treatment prescribed to prevent blood clots (2010-2012)
Hospital staff should give surgery patients treatment to prevent blood clots within 24 hours before and after certain surgeries. These treatments include blood-thinning medicines and special stockings that help blood move through the body.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Surgery Patients Who Received Treatment to Prevent Blood Clots Within 24 Hours Before or After Selected Surgeries to Prevent Blood Clots

Measure Code: SCIP-VTE-2

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Antibiotics given one hour before surgery (outpatient) (2010-2012)
Hospital staff should give surgery patients antibiotics within 1 hour before surgery. Antibiotics are medicines that fight infections in your body which, given properly, can greatly lower your chances of getting an infection after surgery.
  • A higher score is better.
  • This is an outpatient measure.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Prophylactic Antibiotic Initiated Within One Hour Prior to Surgical Incision

Measure Code: OP-6

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Right antibiotics given (outpatient) (2010-2012)
Hospital staff should give surgery patients the right kind of antibiotics to lower the chance of infection after surgery. The right antibiotic for a patient depends on the kind of surgery they had.
  • A higher score is better.
  • This is an outpatient measure.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Prophylactic Antibiotic Selection for Surgical Patients

Measure Code: OP-7

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Recommended care after surgery: Information on how many patients got the care they needed such as the right medicine, surgery, or advice after a surgery.
Antibiotics stopped within 24 hours after surgery (2010-2012)
Hospital staff should stop giving antibiotics to surgery patients within 24 hours after some surgeries because this increases the chances of side effects such as stomach problems and severe diarrhea.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Surgery Patients Whose Preventative Antibiotics are Stopped Within 24 Hours After Surgery

Measure Code: SCIP-INF-3

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Blood sugar level controlled after heart surgery (2010-2012)
Hospital staff should help surgery patients keep their blood sugar as close to normal as possible after their surgery, because this can lower their chances of infections, heart attack, and brain, kidney, lung, and stomach problems.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Cardiac Surgery Patients with Controlled 6AM Postoperative Blood Glucose

Measure Code: SCIP-INF-4

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Treatment prescribed to prevent blood clots (2010-2012)
Doctors should give surgery patients a prescription for treatment to prevent blood clots from forming after certain surgeries. Blood clots can lead to heart attacks and strokes, and are one of the most common problems that people have related to surgery.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • Figures presented are events per 100 cases.

Clinical Title: Surgery Patients Whose Doctors Ordered Treatments to Prevent Blood Clots (Venous Thromboembolism) For Certain Types of Surgeries

Measure Code: SCIP-VTE-1

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Surgery patients whose urinary catheters were removed on the first or second day after surgery (2010-2012)
Hospital staff should remove urinary catheters from surgery patients on the first or second day after surgery.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Surgery patients whose urinary catheters were removed on the first or second day after surgery

Measure Code: SCIP-INF-9

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Preventing low body temperature during and after surgery (2010-2012)
Hospital staff should manage patients' body temperature during and after surgery.
  • A higher score is better.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Perioperative Temperature Management

Measure Code: SCIP-INF-10

Statistics Available: Denominator, Observed Rate

Data Source: CMS Hospital Compare

Other patient safety
  • Hospital quality ratings for results of surgical and nonsurgical care are provided. These results can occur in either surgical or nonsurgical cases.
  • Recommended Care: Information on how many patients got the care they needed such as the right medicine, surgery, or advice.
  • Results of care: Information on what happened to patients while being cared for in the hospital or after leaving the hospital.
Results of care -- Deaths: Information on what happened to patients while being cared for in the hospital or after leaving the hospital. These ratings are sometimes called outcome measures.
Dying in the hospital while getting care for a condition that rarely results in death (2011-2013)
How often patients died in the hospital when they had been admitted for a health problem that rarely results in death.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 1,000 cases.

Clinical Title: Death Rate in Low-Mortality Diagnosis Related Groups (DRGs)

Measure Code: PSI2

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Dying in the hospital after bleeding from stomach or intestines (2011-2013)
How often patients died after they came in with heavy bleeding in their stomach or intestines.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • Figures presented are events per 100 cases.

Clinical Title: Gastrointestinal Hemorrhage Mortality Rate

Measure Code: IQI18

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Dying in the hospital after fractured hip (2011-2013)
How often patients died in the hospital who came in with a broken hip.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 100 cases.

Clinical Title: Hip Fracture Mortality Rate

Measure Code: IQI19

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Results of care -- Complications: Information on what happened to patients while being cared for in the hospital or after leaving the hospital. These ratings are sometimes called outcome measures.
Developing a bed sore in the hospital (2011-2013)
How often patients developed a bed sore, which is a sore or wound on the skin. This can occur because people are lying in one position for too long.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • Figures presented are events per 1,000 cases.

Clinical Title: Pressure Ulcer Rate

Measure Code: PSI3

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Surgical tool accidently left in body during surgery (2011-2013)
How often a surgical instrument or tool, such as a scalpel or a sponge, was accidentally left in a patient's body during an operation.
  • Hospitals are not rated for this measure because there are currently no nationally agreed upon standards.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are counts.
  • Numbers in the measure details table are not scaled. These are raw statistics.

Clinical Title: Volume of Foreign Body Left During Procedure

Measure Code: PSI5

Statistics Available: Volume of Procedures

Measure Source: AHRQ Quality Indicator

Accidental puncture of the lung (2011-2013)
How often air leaks out of the lung as a result of a medical procedure or operation (iatrogenic pneumothorax).
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 1,000 cases.

Clinical Title: Iatrogenic Pneumothorax Rate

Measure Code: PSI6

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Blood infection that patients with catheters developed while in the hospital (2011-2013)
How often patients got a variety of infections as a result of the care they received in the hospital.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • Figures presented are events per 1,000 cases.

Clinical Title: Central Venous Catheter-Related Blood Stream Infections Rate

Measure Code: PSI7

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Accidental cut or tear (2011-2013)
How often a patient is accidentally cut, making an unnecessary or dangerous hole or tear in an organ of the body, while receiving medical care.
  • A lower score is better.
  • The rate takes into account how sick patients were before they went to the hospital (it is risk-adjusted).
  • Ratings include a significance test that makes us more confident the hospital rating is accurate.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are events per 1,000 cases.

Clinical Title: Accidental Puncture or Laceration Rate

Measure Code: PSI15

Statistics Available: Numerator, Denominator, Observed Rate and CI, Expected Rate, Risk-Adjusted Rate and CI

Measure Source: AHRQ Quality Indicator

Blood transfusion reaction (2011-2013)
How often a patient in the hospital had a bad reaction to donated blood.
  • Hospitals are not rated for this measure because there are currently no nationally agreed upon standards.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are counts.
  • Numbers in the measure details table are not scaled. These are raw statistics.

Clinical Title: Transfusion Reaction Volume

Measure Code: PSI16

Statistics Available: Volume of Procedures

Measure Source: AHRQ Quality Indicator

Central Line Associated Blood Stream Infections (2010-2012)
A central line is a long, narrow, flexible tube or catheter inserted into a large vein, ending at or close to the heart. The central line is placed in order to give medications, fluids, nutrients or blood products, to obtain blood tests, or to obtain cardiovascular measurements over a long period of time. When not put in correctly or kept clean, central lines can cause serious infections in the blood. These are called central line-associated bloodstream infections (CLABSIs). They can cause hospital stays to be longer and increase the risk of death.

Hospitals can prevent vascular central line-associated infections by choosing the best sites for inserting the catheter, using the right catheter material, keeping the site clean, and removing the catheter when it is no longer needed. Hospitals with high rates of this complication may not be following these recommended procedures.
  • A lower score is better.
  • Hospital scores presented are risk-standardized infection ratios.The expected overall score is 1.0.
    • A score of less than 1 means that the hospital had fewer CLABSI infections than other hospitals nationwide of similar type and size. For example, an overall score of 0.5 means that half as many patients had CLABSI infections as expected.
    • A score of 1 means that the hospital had the same number of CLABSI infections as other hospitals nationwide of similar type and size.
    • A score of more than 1 means the hospital had more CLABSI infections than other hospitals nationwide of similar type and size. For example, an overall score of 2.0 means that twice as many patients had CLABSI infections as expected.
  • This rating takes into account certain factors such as the type and size of a hospital or ICU (it is risk-adjusted).
  • Ratings do not include a significance test.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • Figures presented are ratios of observed to expected.

Clinical Title: Central Line Associated Blood Stream Infections (CLABSI)

Measure Code: HAI-1-SIR

Statistics Available: Measure Ratio

Data Source: CMS Hospital Compare

Avoidable Stays Maps

Chronic Lung Conditions
Asthma in Younger Adults (2011-2013)
Number of admissions for asthma in adults per population.
  • A lower score is better.
  • This is not a measure of hospital quality. Evidence shows these hospital stays are potentially avoidable when patients have access to high quality outpatient care.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • The number of hospital stays is provided for every 100,000 people who reside in that area (i.e., the population).

Clinical Title: Asthma in Younger Adults Admission Rate

Measure Code: PQI15

Statistics Available: Numerator, Denominator, Observed Rate, Risk Adjusted Rate

Measure Source: AHRQ Quality Indicator

Diabetes
Uncontrolled diabetes admission rate (2011-2013)
Number of admissions for uncontrolled diabetes per population.
  • A lower score is better.
  • This is not a measure of hospital quality. Evidence shows these hospital stays are potentially avoidable when patients have access to high quality outpatient care.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • The number of hospital stays is provided for every 100,000 people who reside in that area (i.e., the population).

Clinical Title: Uncontrolled Diabetes Admission Rate

Measure Code: PQI14

Statistics Available: Numerator, Denominator, Observed Rate, Risk Adjusted Rate

Measure Source: AHRQ Quality Indicator

Rate of lower-extremity amputation among patients with diabetes (2011-2013)
Number of admissions for lower-extremity amputation among patients with diabetes per population.
  • A lower score is better.
  • This is not a measure of hospital quality. Evidence shows these hospital stays are potentially avoidable when patients have access to high quality outpatient care.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • The number of hospital stays is provided for every 100,000 people who reside in that area (i.e., the population).

Clinical Title: Rate of Lower-Extremity Amputation Among Patients With Diabetes

Measure Code: PQI16

Statistics Available: Numerator, Denominator, Observed Rate, Risk Adjusted Rate

Measure Source: AHRQ Quality Indicator

Heart Conditions
Angina without procedure admission rate (2011-2013)
Number of admissions for angina without procedure per population.
  • A lower score is better.
  • This is not a measure of hospital quality. Evidence shows these hospital stays are potentially avoidable when patients have access to high quality outpatient care.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • The number of hospital stays is provided for every 100,000 people who reside in that area (i.e., the population).

Clinical Title: Angina Without Procedure Admission Rate

Measure Code: PQI13

Statistics Available: Numerator, Denominator, Observed Rate, Risk Adjusted Rate

Measure Source: AHRQ Quality Indicator

Other Conditions
Dehydration admission rate (2011-2013)
Number of admissions for dehydration per population.
  • A lower score is better.
  • This is not a measure of hospital quality. Evidence shows these hospital stays are potentially avoidable when patients have access to high quality outpatient care.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • The number of hospital stays is provided for every 100,000 people who reside in that area (i.e., the population).

Clinical Title: Dehydration Admission Rate

Measure Code: PQI10

Statistics Available: Numerator, Denominator, Observed Rate, Risk Adjusted Rate

Measure Source: AHRQ Quality Indicator

Bacterial pneumonia admission rate (2011-2013)
Number of admissions for bacterial pneumonia per population.
  • A lower score is better.
  • This is not a measure of hospital quality. Evidence shows these hospital stays are potentially avoidable when patients have access to high quality outpatient care.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • The number of hospital stays is provided for every 100,000 people who reside in that area (i.e., the population).

Clinical Title: Bacterial Pneumonia Admission Rate

Measure Code: PQI11

Statistics Available: Numerator, Denominator, Observed Rate, Risk Adjusted Rate

Measure Source: AHRQ Quality Indicator

Urinary tract infection admission rate (2011-2013)
Number of admissions for urinary infection per population.
  • A lower score is better.
  • This is not a measure of hospital quality. Evidence shows these hospital stays are potentially avoidable when patients have access to high quality outpatient care.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • The number of hospital stays is provided for every 100,000 people who reside in that area (i.e., the population).

Clinical Title: Urinary Tract Infection Admission Rate

Measure Code: PQI12

Statistics Available: Numerator, Denominator, Observed Rate, Risk Adjusted Rate

Measure Source: AHRQ Quality Indicator

Low birth weight rate (2011-2013)
Number of low birth weight births per total births (in an area).
  • A lower score is better.
  • This is not a measure of hospital quality. Evidence shows these hospital stays are potentially avoidable when patients have access to high quality outpatient care.
  • This measure is endorsed by the National Quality Forum, an independent organization that sets standards for health care quality measurement.
  • The number of hospital stays is provided for every 100 births.

Clinical Title: Low Birth Weight Rate

Measure Code: PQI9

Statistics Available: Numerator, Denominator, Observed Rate, Risk Adjusted Rate

Measure Source: AHRQ Quality Indicator

Composites
Prevention Quality Indicator Composite - Overall (2011-2013)
This score is based on how often patients were admitted to the hospital for reasons that might have been prevented: short-term diabetes complications, long-term diabetes complications, chronic obstructive pulmonary disease, high blood pressure, heart failure, chest pain, uncontrolled diabetes, adult asthma, diabetes patients with a limb amputated, dehydration, pneumonia, and urinary tract infections. This is not a measure of hospital quality. Evidence shows these hospital stays are potentially avoidable when patients have access to high quality outpatient care.
  • A lower score is better.
  • This is not a measure of hospital quality. Evidence shows these hospital stays are potentially avoidable when patients have access to high quality outpatient care.
  • The number of hospital stays is provided for every 100,000 people who reside in that area (i.e., the population).

Clinical Title: Prevention Quality Indicator Composite - Overall

Measure Code: PQI90

Statistics Available: Numerator, Denominator, Observed Rate, Risk Adjusted Rate

Measure Source: AHRQ Quality Indicator

Prevention Quality Indicator Composite - Chronic Conditions (2011-2013)
This score is based on how often patients were admitted to the hospital for chronic conditions that might have been prevented. Chronic conditions include: short-term diabetes complications, long-term diabetes complications, chronic obstructive pulmonary disease, high blood pressure, heart failure, chest pain, uncontrolled diabetes, adult asthma, and diabetes patients with a limb amputated.
  • A lower score is better.
  • This is not a measure of hospital quality. Evidence shows these hospital stays are potentially avoidable when patients have access to high quality outpatient care.
  • The number of hospital stays is provided for every 100,000 people who reside in that area (i.e., the population).

Clinical Title: Prevention Quality Indicator Composite - Chronic Conditions

Measure Code: PQI92

Statistics Available: Numerator, Denominator, Observed Rate, Risk Adjusted Rate

Measure Source: AHRQ Quality Indicator

Prevention Quality Indicator Composite - Acute Conditions (2011-2013)
This score is based on how often patients were admitted to the hospital for acute conditions that might have been prevented. Acute conditions are sudden and severe, including: dehydration, pneumonia, and urinary tract infections. This is not a measure of hospital quality. Evidence shows these hospital stays are potentially avoidable when patients have access to high quality outpatient care.
  • This is not a measure of hospital quality. Evidence shows these hospital stays are potentially avoidable when patients have access to high quality outpatient care.
  • The number of hospital stays is provided for every 100,000 people who reside in that area (i.e., the population).

Clinical Title: Prevention Quality Indicator Composite - Acute Conditions

Measure Code: PQI91

Statistics Available: Numerator, Denominator, Observed Rate, Risk Adjusted Rate

Measure Source: AHRQ Quality Indicator

Patient Safety
Foreign body left during procedure (2011-2013)
Discharges with foreign body accidentally left in during procedure per population.
  • A lower score is better.
  • This is a measure of patient safety. It captures hospital stays caused by potentially avoidable complications. It also captures hospital stays in which potentially avoidable complications occur.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • The number of hospital stays is provided for every 100,000 people who reside in that area (i.e., the population).

Clinical Title: Rate of Foreign Body Left During Procedure

Measure Code: PSI21

Statistics Available: Numerator, Denominator, Observed Rate, Risk Adjusted Rate

Measure Source: AHRQ Quality Indicator

Iatrogenic pneumothorax rate (2011-2013)
Cases of iatrogenic pneumothorax per population. Excludes trauma, thoracic surgery, lung or pleural biopsy, or cardiac surgery patients.
  • A lower score is better.
  • This is a measure of patient safety. It captures hospital stays caused by potentially avoidable complications. It also captures hospital stays in which potentially avoidable complications occur.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • The number of hospital stays is provided for every 100,000 people who reside in that area (i.e., the population).

Clinical Title: Iatrogenic Pneumothorax Rate

Measure Code: PSI22

Statistics Available: Numerator, Denominator, Observed Rate, Risk Adjusted Rate

Measure Source: AHRQ Quality Indicator

Hospital acquired vascular catheter related infections rate (2011-2013)
Cases of secondary ICD-9-CM codes 9993 or 00662 per population. Excludes patients with immunocompromised state or cancer.
  • A lower score is better.
  • This is a measure of patient safety. It captures hospital stays caused by potentially avoidable complications. It also captures hospital stays in which potentially avoidable complications occur.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • The number of hospital stays is provided for every 100,000 people who reside in that area (i.e., the population).

Clinical Title: Central Venous Catheter-Related Blood Stream Infection Rate

Measure Code: PSI23

Statistics Available: Numerator, Denominator, Observed Rate, Risk Adjusted Rate

Measure Source: AHRQ Quality Indicator

Post-operative wound dehiscence rate (2011-2013)
Cases of reclosure of postoperative disruption of abdominal wall per population. Excludes obstetric admissions.
  • A lower score is better.
  • This is a measure of patient safety. It captures hospital stays caused by potentially avoidable complications. It also captures hospital stays in which potentially avoidable complications occur.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • The number of hospital stays is provided for every 100,000 people who reside in that area (i.e., the population).

Clinical Title: Postoperative Wound Dehiscence Rate

Measure Code: PSI24

Statistics Available: Numerator, Denominator, Observed Rate, Risk Adjusted Rate

Measure Source: AHRQ Quality Indicator

Accidental puncture or laceration rate (2011-2013)
Cases of technical difficulty (e.g., accidental cut or laceration during procedure) per population. Excludes obstetric admissions.
  • A lower score is better.
  • This is a measure of patient safety. It captures hospital stays caused by potentially avoidable complications. It also captures hospital stays in which potentially avoidable complications occur.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • The number of hospital stays is provided for every 100,000 people who reside in that area (i.e., the population).

Clinical Title: Accidental Puncture or Laceration Rate

Measure Code: PSI25

Statistics Available: Numerator, Denominator, Observed Rate, Risk Adjusted Rate

Measure Source: AHRQ Quality Indicator

Transfusion reaction rate (2011-2013)
Cases of transfusion reaction per population.
  • A lower score is better.
  • This is a measure of patient safety. It captures hospital stays caused by potentially avoidable complications. It also captures hospital stays in which potentially avoidable complications occur.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • The number of hospital stays is provided for every 100,000 people who reside in that area (i.e., the population).

Clinical Title: Transfusion Reaction Rate

Measure Code: PSI26

Statistics Available: Numerator, Denominator, Observed Rate, Risk Adjusted Rate

Measure Source: AHRQ Quality Indicator

Post-operative hemorrhage or hematoma rate (2011-2013)
Cases of hematoma or hemorrhage requiring a procedure per population.
  • A lower score is better.
  • This is a measure of patient safety. It captures hospital stays caused by potentially avoidable complications. It also captures hospital stays in which potentially avoidable complications occur.
  • The rate does not take into account how sick patients were before they went to the hospital (it is not risk-adjusted).
  • Ratings do not include a significance test.
  • The number of hospital stays is provided for every 100,000 people who reside in that area (i.e., the population).

Clinical Title: Postoperative Hemorrhage or Hematoma Rate

Measure Code: PSI27

Statistics Available: Numerator, Denominator, Observed Rate, Risk Adjusted Rate

Measure Source: AHRQ Quality Indicator

Procedure Rates
Coronary artery bypass graft rate (2011-2013)
Number of discharges with CABG procedure per population.
  • A lower score is better.
  • This is not a measure of hospital quality. It is a measure of practice patterns in an area. There can be wide variation in practice patterns that might suggest overuse or underuse.
  • The number of hospital stays is provided for every 100,000 people who reside in that area (i.e., the population).

Clinical Title: Coronary Artery Bypass Graft (CABG) Rate

Measure Code: IQI26

Statistics Available: Numerator, Denominator, Observed Rate, Risk Adjusted Rate

Measure Source: AHRQ Quality Indicator

Percutaneous coronary angioplasty rate (2011-2013)
Number of discharges with PTCA procedure per population.
  • A lower score is better.
  • This is not a measure of hospital quality. It is a measure of practice patterns in an area. There can be wide variation in practice patterns that might suggest overuse or underuse.
  • The number of hospital stays is provided for every 100,000 people who reside in that area (i.e., the population).

Clinical Title: Percutaneous Coronary Intervention (PCI) Rate

Measure Code: IQI27

Statistics Available: Numerator, Denominator, Observed Rate, Risk Adjusted Rate

Measure Source: AHRQ Quality Indicator

Hysterectomy rate (2011-2013)
Number of discharges with hysterectomy procedure per population.
  • A lower score is better.
  • This is not a measure of hospital quality. It is a measure of practice patterns in an area. There can be wide variation in practice patterns that might suggest overuse or underuse.
  • The number of hospital stays is provided for every 100,000 people who reside in that area (i.e., the population).

Clinical Title: Hysterectomy Rate

Measure Code: IQI28

Statistics Available: Numerator, Denominator, Observed Rate, Risk Adjusted Rate

Measure Source: AHRQ Quality Indicator

Laminectomy rate (2011-2013)
Number of discharges with laminectomy procedure per population.
  • A lower score is better.
  • This is not a measure of hospital quality. It is a measure of practice patterns in an area. There can be wide variation in practice patterns that might suggest overuse or underuse.
  • The number of hospital stays is provided for every 100,000 people who reside in that area (i.e., the population).

Clinical Title: Laminectomy or Spinal Fusion Rate

Measure Code: IQI29

Statistics Available: Numerator, Denominator, Observed Rate, Risk Adjusted Rate

Measure Source: AHRQ Quality Indicator