Final Quality Project
4508 Final Quality Project
Part 3: Core Measures
The Hospital Inpatient Quality Reporting Program was originally mandated by Section 501(b) of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. This section of the MMA authorized CMS to pay hospitals that successfully report designated quality measures a higher annual update to their payment rates. Initially, the MMA provided for a 0.4 percentage point reduction in the annual market basket (the measure of inflation in costs of goods and services used by hospitals in treating Medicare patients) update for hospitals that did not successfully report. The Deficit Reduction Act of 2005 increased that reduction to 2.0 percentage points. This was modified by the American Recovery and Reinvestment Act of 2009 and the Affordable Care Act of 2010, which provided that beginning in fiscal year (FY) 2015, the reduction would be by one-quarter of such applicable annual payment rate update if all Hospital Inpatient Quality Reporting Program requirements are not met. Under the Hospital Inpatient Quality Reporting Program, CMS collects quality data from hospitals paid under the Inpatient Prospective Payment System, with the goal of driving quality improvement through measurement and transparency by publicly displaying data to help consumers make more informed decisions about their health care. It is also intended to encourage hospitals and clinicians to improve the quality and cost of inpatient care provided to all patients. The data collected through the program are available to consumers and providers on the Hospital Compare. Data for selected measures are also used for paying a portion of hospitals based on the quality and efficiency of care, including the Hospital Value-Based Purchasing Program, Hospital-Acquired Condition Reduction Program, and Hospital Readmissions Reduction Program. Additional measures are selected with wide agreement from CMS, the hospital industry and public stakeholders like The Joint Commission (TJC), the National Quality Forum (NQF), and the Agency for Healthcare Research and Quality (AHRQ). Hospital Compare is a consumer-oriented website that provides information on how well hospitals provide recommended care to their patients. This information can help consumers make informed decisions about where to go for health care. Hospital Compare allows consumers to select multiple hospitals and directly compare performance measure information related to heart attack, heart failure, pneumonia, surgery and other conditions. These results are organized by:
• General information • Survey of patients’ experiences • Timely & effective care • Complications • Readmissions & deaths • Use of medical imaging • Payment & value of care
Hospital Compare was created through the efforts of Medicare and the Hospital Quality Alliance (HQA). The HQA: Improving Care Through Information was created in December 2002. The HQA was a public-private collaboration established in December 2002 to promote reporting on hospital quality of care. The HQA consisted of organizations that represented consumers, hospitals, providers, employers, accrediting organizations, and federal agencies. The HQA effort was intended to make it easier for consumers to make informed health care decisions and to support efforts to improve quality in U.S. hospitals. Since it’s inception, many new measures and topics have been displayed in the site.
• In 2005, the first set of 10 “core” process of care measures were displayed on such topics as heart attack, heart failure, pneumonia and surgical care.
• In March 2008, data from the Hospital Consumer Assessment of Healthcare Providers and
Systems (HCAHPS) survey, also known as the CAHPS Hospital Survey, was added to Hospital Compare. HCAHPS provides a standardized instrument and data collection methodology for measuring patient’s perspectives on hospital care. Also in 2008, data on hospital 30- day mortality for heart attack and heart failure was displayed. Later in 2008, mortality rates for pneumonia was added.
• In 2009, CMS added data on hospital outpatient facilities, which included outpatient
imaging efficiency data as well as emergency department and surgical process of care measures.
• 2010 saw the addition of 30-day readmission measures for heart attack, heart failure and
pneumonia patients.
• In 2011, CMS began posting data on Hospital Associated Infections (HAIs) received from the Centers for Disease Control and Preventions (CDC) National Healthcare Safety Network (NHNS). The measure sets have been expanded to include ICU’s and other hospital wards.
• In 2012, we added the CMS readmission reduction program and measures that were
voluntarily submitted by hospitals participating the American College of Surgeons National Surgical Quality Improvement Program. The three measures are:
o Lower Extremity Bypass surgical outcomes o Outcomes in Surgeries for Patients 65 Years of Age or Older o Colon Surgery Outcomes
• Hospital Compare saw the addition of the Hospital Value Based Purchasing program data in
2013. CMS continues to evolve the website, with the addition of the Overall Hospital Quality Star Rating in July 2016 and the re-introduction of measure data from Veterans Health Administration Hospitals.
After reading and following the directions, you will be provided with 10 questions. The key performance data that you will discover is readily available to the general public, your health care competitors, insurance companies and managed care organizations, and all stakeholders in your organization. Hospital administrators (e.g., CEO, CFO, COO) must be aware of this data, read it, understand it, and act on it to improve the quality of care provided in their organizations, which is necessary to best serve their communities and maintain their institution’s financial success and competitive edge. DIRECTIONS:
• Go to https://www.medicare.gov/hospitalcompare/ and read through the general information provided.
• Under the title “Hospital Compare,” type in the location Orlando, FL.
• Click on “Find Hospitals.”
• When the hospitals within this area appear, select to compare “Orlando Health Orlando
Regional Medical Center,” “AdventHealth Orlando,” and “Health Central,” then COMPARE.
• From the data displayed, locate the answers to the following 10 questions:
1. From the complications and death measures, which of the following three hospitals scored “Better than U.S. National Rate” on “Death Rate for COPD Patients”?
a. Orlando Health Orlando Regional Medical Center b. AdventHealth Orlando c. Health Central
2. From the timely and effective care measures, which of the following three hospitals scored 90% on the process of care measure for “Healthcare Workers Given Influenza Vaccination”?
a. Orlando Health Orlando Regional Medical Center b. AdventHealth Orlando c. Health Central
3. From the survey of patients’ hospital experiences, in comparing the three hospitals, what did you find was the national average for all reporting hospitals in the United States for the “percent of patients who reported that their nurses ‘always’ communicated well.”
a. 77% b. 76% c. 81% d. 78% e. 79%
4. From the timely and effective measures, which of the following three hospitals scored the highest on the process of care measure for percent of ““Percentage of patients who received appropriate care for severe sepsis and septic shock”?
a. Orlando Health Orlando Regional Medical Center b. AdventHealth Orlando c. Orlando Health
5. From the survey of patients’ hospital experiences, which of the following three hospitals scored the lowest percentage on “Patients who reported YES, they would definitely recommend the hospital (to friends and family).”?
a. Orlando Health Orlando Regional Medical Center b. AdventHealth Orlando c. Health Central
6. From the complications of care measures, which of the following three hospitals scored Better
than the National Benchmark for “Surgical site infections (SSI) from colon surgery”? a. Orlando Health Orlando Regional Medical Center b. AdventHealth Orlando c. Health Central
7. From the timely and effective measures, which of the following three hospitals had the lowest
percentage on the measure for percent of “Outpatients who had a follow-up mammogram, breast ultrasound, or breast MRI within the 45 days after a screening mammogram ”?
a. Orlando Health Orlando Regional Medical Center b. AdventHealth Orlando c. Health Central
8. From the payment and value of care measures, which of the following three hospitals had
Greater than the National Average Payment on the measure for “Payment for heart attack patients”?
a. Orlando Health Orlando Regional Medical Center b. AdventHealth Orlando c. Health Central
9. From the unplanned hospital visits measures, what did you find was the national rate for all
reporting hospitals in the United States for the “Rate of readmission after discharge from hospital (hospital-wide).”
a. 15.3% b. 16.3% c. 14.3%
10. From the timely and effective care measures, what did you find was the rate for the state of Florida for all reporting hospitals for the “Percent of mothers whose deliveries were scheduled too early (1-2 weeks early), when a scheduled delivery was not medically necessary.”
a. 0% b. 1% c. 2%
