Quality Report

  • Posted on 01/13/2025
  • Collection Periods
  • Report is based on information from Hospital Compare, a website created through the efforts of the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (DHHS) along with the Hospital Quality Alliance (HQA).  The HQA is a public-private collaboration established to promote reporting on hospital quality of care.

Sample Hospital

Louisville, KY  11111
CMS Certification Number: 000000
Sample Report | Order Information

Quality Measures Linked to Payment

Value-Based Purchasing Program

Federal
Fiscal
Year		 Clinical Process of Care Domain Patient Experience of Care Domain Outcome Domain Efficiency Domain Safety Domain Total
Performance
Score		 National
Percentile		 Payment
Adjustment
2024 11.67 13.00 N/A 0.00 8.00 8.17 4% -1.22%
2023 34.00 N/A N/A 0.00 N/A *N/A * *0.00%
2022 46.67 N/A N/A N/A N/A *N/A * *0.00%
2021 44.00 26.00 N/A 10.00 8.00 22.00 14% -0.59%
2020 57.50 24.00 N/A 0.00 28.33 27.46 16% -0.46%
2019 60.00 23.00 N/A 0.00 26.67 27.42 17% -0.44%
2018 50.00 19.00 N/A 0.00 28.57 24.39 12% -0.59%
2017 25.00 17.00 56.67 0.00 16.67 23.00 13% -0.59%
2016 28.57 24.00 45.71 0.00 N/A 27.14 13% -0.43%
2015 48.18 26.00 52.00 0.00 N/A 33.04 25% -0.22%
2014 45.83 26.00 40.00 N/A N/A 38.43 24% -0.24%
2013 47.27 31.00 N/A N/A N/A 42.39 19% -0.22%

Readmission Reduction Program

Federal
Fiscal
Year		 Heart Attack Heart Failure Pneumonia COPD CABG Hip/Knee Readmissions
Adjustment
Factor		 Payment
Adjustment
Excess
Ratio		 Cases Excess
Ratio		 Cases Excess
Ratio		 Cases Excess
Ratio		 Cases Excess
Ratio		 Cases Excess
Ratio		 Cases
2024 1.0277 454 1.0080 1,208 1.0129 1,150 1.0774 330 1.0311 162 0.9104 255 0.9967 -0.33%
2023 0.9736 521 0.9917 1,551 * * 1.0414 605 1.0063 173 1.0289 842 0.9984 -0.16%
2022 0.9828 689 0.9833 2,065 1.0146 2,302 1.0220 1,040 1.0199 249 1.0744 1,489 0.9951 -0.49%
2021 1.0106 853 0.9866 2,510 0.9872 2,669 1.0322 1,707 1.1160 293 1.0716 1,871 0.9944 -0.56%
2020 0.9859 901 0.9868 2,340 1.0366 2,615 1.0070 1,730 1.0544 301 1.0494 1,836 0.9949 -0.51%
2019 0.9954 978 0.9750 2,165 1.0134 2,537 1.0631 1,651 1.0349 284 1.0121 1,691 0.9963 -0.37%
2018 0.9992 1,029 0.9713 2,036 1.0151 2,658 1.0631 1,386 1.0283 277 1.0371 1,623 0.9966 -0.34%
2017 0.9927 1,031 0.9533 1,974 0.9991 2,467 1.0831 1,441 1.1213 268 1.0435 1,555 0.9959 -0.41%
2016 1.0517 965 0.9394 1,928 0.9784 1,650 1.0193 1,449 N/A N/A 0.9756 1,532 0.9983 -0.17%
2015 1.0268 911 0.9639 1,990 1.0515 1,630 0.9962 1,476 N/A N/A 0.9475 1,520 0.9982 -0.18%
2014 1.0244 780 0.9838 1,822 1.0333 1,502 N/A N/A N/A N/A N/A N/A 0.9988 -0.12%
2013 1.0255 741 0.9686 1,729 1.0374 1,342 N/A N/A N/A N/A N/A N/A 0.9985 -0.15%

Hospital-Acquired Condition (HAC) Reduction Program

Federal
Fiscal
Year
Domain 1
Serious Complications
(AHRQ PSI 90 Composite Score)
Domain 2
Central Line-Associated Blood Stream Infections (CLABSI)
Catheter-Associated Urinary Tract Infections (CAUTI)
Surgical Site Infections - Colon Surgeries and Abdominal Hysterectomies (SSI)
Methicillin-Resistant Staphylococcus Aureus (MRSA)
Clostridium difficile (C.diff.) Infection (CDI)
 Total
HAC
Score		 Payment
Adjustment
From To Score From To Score CLABSI Score CAUTI Score SSI Score MRSA Score CDI Score
2024 01/01/2021 06/30/2022 1.0609 01/01/2022 12/31/2022 0.867 0.685 1.441 0.857 0.666 0.3570 0%
2023 N/A N/A N/A 01/01/2021 12/31/2021 0.9900 0.8450 1.5710 1.0600 0.5010 *0.0000 *0%
2022 07/01/2018 12/31/2019 -1.2647 01/01/2019 12/31/2019 -0.0786 0.4914 0.8136 0.4182 0.6883 0.1780 0%
2021 07/01/2017 06/30/2019 -1.3599 01/01/2018 12/31/2019 -0.0398 0.2840 1.2604 -0.0568 0.5019 0.0983 0%
2020 07/01/2016 06/30/2018 -0.4891 01/01/2017 12/31/2018 0.1036 -0.1900 1.6372 -0.0772 0.0628 0.1746 0%
2019 10/01/2015 06/30/2017 1.007 01/01/2016 12/31/2017 0.482 0.0505 -0.0427 1.6686 0.6828 0.0508 0.5607 -1%
2018 07/01/2014 09/30/2015 2.0928 01/01/2015 12/31/2016 0.6696 0.1938 0.3272 1.6380 0.8686 0.3205 0.8831 -1%
2017 07/01/2013 06/30/2015 5.0000 01/01/2014 12/31/2015 8.0000 8 7 9 9 7 7.5500 -1%
2016 07/01/2012 06/30/2014 5.0000 01/01/2013 12/31/2014 7.3333 8 6 8 N/A N/A 6.7500 0%
2015 07/01/2011 06/30/2013 8.0000 01/01/2012 12/31/2013 7.5000 8 7 N/A N/A N/A 7.6750 -1%

Timely & Effective Care

Cancer Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
No Data are available for this hospital.

Cataract Surgery Outcome

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
OP-31. Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery N/A 5 N/A 98.0% N/A

Colonoscopy Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
OP-29. Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients 168   97.0% 92.0% 89.0%

Sepsis Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
SEP-1. Appropriate care for severe sepsis and septic shock 472 2 49.0% 62.0% 63.0%
SEP-SH-3HR. Septic Shock 3-Hour Bundle 144 2 58.0% 71.0% 73.0%
SEP-SH-6HR. Septic Shock 6-Hour Bundle 70 2 84.0% 85.0% 85.0%
SEV_SEP_3HR. Severe Sepsis 3-Hour Bundle 472 2 70.0% 80.0% 79.0%
SEV_SEP_6HR. Severe Sepsis 6-Hour Bundle 215 2 88.0% 91.0% 93.0%

Timely Heart Attack Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
No Data are available for this hospital.

Timely Emergency Department Care

Measure Number of Patients Footnotes Hospital Score National Average State Average
OP-18b. Average time patients spent in the emergency department before being sent home 421   186 minutes 163 minutes 153 minutes
OP-18c. Average (median) time patients spent in the emergency department before leaving from the visit- Psychiatric/Mental Health Patients. 14   282 minutes 267 minutes 214 minutes
OP-22. Percentage of patients who left the emergency department before being seen 278,683   4.0% 2.0% 2.0%
OP-23. Percentage of patients who came to the emergency department with stroke symptoms who received brain scan results within 45 minutes of arrival 54   72.0% 70.0% 70.0%

Healthcare Personnel Vaccination

Measure Number of Patients Footnotes Hospital Score National Average State Average
HCP-COVID-19. Percentage of healthcare personnel who completed COVID-19 primary vaccination series 25,840   9.3% 15.6% 8.7%
IMM-3. Healthcare workers given influenza vaccination 52,508   87.0% 80.0% 84.0%

Stroke Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
No Data are available for this hospital.

Blood Clot Prevention and Treatment

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
No Data are available for this hospital.

Pregnancy and Delivery Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
PC-05. Exclusive Breast Milk Feeding N/A 5 N/A  
PC-01. Women who had elective deliveries 1-3 weeks early when not medically necessary 553   3.0%  
SM-7. Maternal Morbidity Structural Measure N/A   Yes  

Patient Survey Results

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

Survey question Measure Percent Measure Percent Measure Percent Star Rating
Nurses communicated well Always 76% Usually 18% Sometimes 6% ***..
Doctors communicated well Always 77% Usually 17% Sometimes 6% ***..
Help received quickly Always 58% Usually 28% Sometimes 14% ***..
Staff explained medicines Always 57% Usually 18% Sometimes 25% ***..
Room and bath kept clean Always 63% Usually 24% Sometimes 13% **...
Area quiet at night Always 61% Usually 27% Sometimes 12% ***..
Given discharge instructions Yes 86% No 14%   ***..
Patient understood care Strongly Agree 52% Agree 42% Disagree 6% ***..
Overall hospital rating High 70% Medium 20% Low 10% ***..
Would recommend hospital Definitely 71% Probably 22% No 7% ***..
Summary Star Rating   ***..

Unplanned Hospital Visits, Complications and Deaths

30-Day Risk Adjusted Mortality Rates

Measure Hospital Predicted Range National Average
Number Patients Mortality Rate from to
CABG 235 3.2% 1.8% 5.4% 2.8%
COPD 400 9.0% 6.8% 11.6% 9.4%
Heart Attack 649 12.0% 10.1% 14.2% 12.6%
Heart Failure 1,550 13.9% 12.4% 15.7% 11.9%
Pneumonia 1,536 19.9% 18.0% 21.9% 17.9%
Stroke 786 13.4% 11.7% 15.2% 13.9%

30-Day Risk Adjusted Readmission Rates

Measure Hospital Predicted Range National Average
Number Patients Readmission Rate from to
CABG 230 11.1% 8.7% 13.9% 10.7%
Colonoscopy 5,064 11.3% 9.2% 13.9% 13.0%
COPD 425 20.1% 17.4% 23.2% 18.5%
Heart Attack 671 15.0% 13.1% 17.2% 13.7%
Heart Failure 1,711 20.2% 18.5% 21.9% 19.8%
Hip/Knee Surgery 74 5.1% 3.3% 7.7% 4.5%
Hospital-wide 8,295 15.0% 14.5% 15.6% 14.6%
Pneumonia 1,559 16.4% 14.9% 18.1% 16.4%

Visit Rates Following OP Procedure

Measure Hospital Predicted Range National Average
Number Patients Readmission Rate from to
OP-35-ED. Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy 899 5.1% 4.0% 6.3% 5.5%
OP-35-ADM. Rate of inpatient admissions for patients receiving outpatient chemotherapy 899 11.3% 9.7% 13.1% 10.6%
OP-36. Ratio of unplanned hospital visits after hospital outpatient surgery 2,433 1.1% 0.9% 1.3% N/A

Hospital Return Days

Measure Hospital Predicted Range National Average
Number Patients Readmission Rate from to
Heart Attack 671 26.8% 12.7% 42.3% N/A
Heart Failure 1,711 29.4% 16.4% 43.2% N/A
Pneumonia 1,559 19.6% 8.3% 31.8% N/A

Surgical Complications

Measure Hospital Predicted Range National Average
Number Patients Rate from to
Complications for Hip/Knee Replacements 69 4.70% 2.70% 7.80% 3.50%
PSI-3. Pressure sores 19,358 0.27% 0.00% 0.64% 0.65%
PSI-4. Death from serious treatable complications after surgery 394 17.33% 14.27% 20.40% 17.66%
PSI-6. Collapsed lung due to medical treatment 21,600 0.26% 0.09% 0.43% 0.25%
PSI-8. Broken hip from a fall after surgery 22,628 0.44% 0.28% 0.59% 0.29%
PSI-9. Postoperative Hemorrhage or Hematoma Rate 6,174 2.45% 1.40% 3.49% 2.44%
PSI-10. Postoperative Acute Kidney Injury Rate 2,822 2.64% 1.50% 3.78% 1.69%
PSI-11. Postoperative Respiratory Failure Rate 2,839 11.25% 8.04% 14.45% 10.26%
PSI-12. Serious blood clots after surgery 6,503 3.19% 1.84% 4.55% 3.91%
PSI-13. Blood stream infection after surgery 2,712 7.59% 5.29% 9.90% 5.58%
PSI-14. A wound that splits open after surgery 1,484 1.99% 0.61% 3.36% 1.87%
PSI-15. Accidental cuts and tears from medical treatment 4,728 0.79% 0.19% 1.39% 0.89%
PSI-90. Serious Complications N/A 1.02% 0.85% 1.19% 1.00%

Healthcare Associated Infections

Measure Hospital Score State Score
HAI-1-SIR. Central Line Associated Blood Stream Infections (CLABSI) 0.802 0.842
HAI-2-SIR. Catheter Associated Urinary Tract Infections (CAUTI) 0.453 0.483
HAI-3-SIR. Surgical Site Infections from colon surgery (SSI: Colon) 1.844 1.069
HAI-4-SIR. Surgical Site Infections from abdominal hysterectomy (SSI: Hysterectomy) 1.897 1.080
HAI-5-SIR. Methicillin-resistant Staphylococcus aureus (or MRSA) blood infections 0.957 1.047
HAI-6-SIR. Clostridium difficile (or C.diff.) Infections (intestinal infections) 0.449 0.403

Payment and Value of Care

Use of Medical Imaging

Measure Hospital Footnotes Hospital Score National Average State Average
OP-8. MRI Lumbar Spine for Low Back Pain 35.6% 36.2% 33.7%
OP-10. Abdomen CT - Use of Contrast Material 7.1% 5.8% 7.1%
OP-13. Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery 3.2% 3.7% 3.3%
OP-39. Breast Cancer Screening Recall Rates 6.9% 9.0% 6.8%

Medicare Spending Per Beneficiary

Measure Hospital Score National Average State Average
MSPB. Medicare Spending per Beneficiary 1.02 0.99 1.01

Measures of Psychiatric Facilities

Inpatient Psychiatric Facility Quality Reporting (IPFQR)

Measure Hospital Score National Average State Average
No Data are available for this hospital.