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The national rankings for hospitals are calculated using publicly reported data downloaded from the Centers for Medicare & Medicaid Services (CMS) Hospital Compare website (www.hospitalcompare.hhs.gov - last accessed 4/17/20151). The Hospital Compare data set contains hospital-specific quality data for over 4,500 hospitals nationwide. The quality data include clinical process of care, patient outcomes and patient experience of care measures. The national rankings are based on hospitals' performance on the clinical process of care measures and a national survey of patients' experience of care. Hospitals are ranked separately on the process of care and patient experience of care measures. These ranks are then combined into an overall, composite performance ranking, with the process of care measures contributing 70% and the patient experience of care measures 30% to the composite ranking. We also rate hospitals separately based on their performance on readmission and mortality measures.
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Process of Care Measures
The process of care measures show how often hospitals give recommended treatments that are known to get the best results for patients. Information about these treatments is taken from patients' records. Hospitals voluntarily report their data, and some hospitals may not provide data for some measures. For each measure the denominator is the number of eligible cases, and the numerator is the number of eligible cases where the recommended care was provided. CMS does not report data for a measure when the number of eligible cases is less than 11.
For the process of care measures ranks are determined by first calculating the overall performance rate for each hospital by summing the numerators and denominators over all topics for all measures in the measure set and reported for the facility. We rank hospital performance on this overall rate and then convert the ranks to percentiles.
Hospitals' performance on the quality measures has improved dramatically over time, with the result that for a number of measures the great majority of hospitals are achieving perfect or near perfect performance. Including these 'topped out' measures in the set of measures used to rank hospitals has the effect of obscuring the real performance differences between hospitals, and results in a situation where very small differences in overall performance on the quality measures produce large differences in hospitals' ranks. Therefore, we exclude topped out measures, which we define as measures for which 50% or more of the hospitals have a performance rate of 100%, from our measure set.
Our hospital rankings are based on the set of 20 remaining process of care measures, representing one hospital-wide prevention measure and process of care measures for five clinical topic areas: heart attack; heart failure; stroke; blood clot prevention and treatment; and surgical care2. Hospitals are ranked only if they have three or more process of care measures reported.
Patient Experience of Care Measures
The patient experience of care measures are based on the results of a national, standardized survey of patients' perspectives of hospital care known as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). The survey asks a random sample of discharged patients 25 questions about their recent hospital stay. For each participating hospital results on 11 measures (seven summary measures, two individual survey items and two global ratings) are publically reported on the Hospital Compare website3,4.
For the patient experience of care measures hospitals are ranked based on the percentage of survey respondents who give the most favorable response (the 'top-box' score) for each measure; for example the percentage of patients who report that their nurses always communicated well with them, or the percentage of patients who reported that they would definitely recommend the hospital to family or friends. The top-box scores for the eleven measures are averaged for each hospital to get a patient experience of care performance score. The hospitals are then ranked on this score and the ranks are converted to percentiles.
Mortality and Readmission Measures
The Hospital Compare data set also contains hospital-specific 30-day risk-standardized mortality and readmission measures for hospitalized patients. These measures are produced from Medicare claims and enrollment data using statistical techniques that adjust for patient-specific characteristics and differences between hospitals in patient populations (risk adjustment). To ensure accuracy, the mortality and readmission measures are based on three years of data and CMS does not report data for a measure when the number of eligible cases is less than 25. For mortality, hospitals are categorized based on their risk-adjusted, all-cause 30-day mortality rates for patients hospitalized for heart attack, heart failure, and pneumonia. All-cause mortality is defined as death from any cause within 30 days of discharge, regardless of whether the patient dies while still in the hospital or after discharge. For readmissions hospitals are categorized based on their risk-adjusted, 30-day unplanned readmissions for all discharged patients (hospital-wide readmissions)
The star ratings for mortality are based on hospitals' performance for each of the three conditions. The ratings are calculated by assigning hospitals a score for each condition, based on which quartile they fall in. Hospitals in the first quartile have the lowest risk-standardized rates and are assigned a score of 3; hospitals in the second quartile are assigned a score of 2; hospitals in the third quartile are assigned a score of 1; and hospitals in the fourth quartile, which have the highest risk-standardized rates, are assigned a score of 0. These ratings are averaged over the three conditions and the average scores are rounded to the nearest 0.5 and converted to stars. The star ratings for readmissions are based on hospitals' performance on the hospital-wide readmission measure. Hospitals are given a score, based on which quartile they fall in. Hospitals in the first quartile have the lowest rates and are assigned a score of 3; those in the second quartile are assigned a score of 2; those in the third quartile are assigned a score of 1; and hospitals in the fourth quartile, which have the highest rates, are assigned a score of 0. These scores are then converted to stars.
1 This currently includes data from the time period 7/1/2013 to 6/30/2014 for the process of care and patient experience of care measures and 7/1/2010 to 6/30/2013 for the 30-day mortality and readmissions measures. To obtain a copy of the database, go to: Hospital Compare and click on "Download Database".
2 These Quality Measures are:
Heart Attack (Acute Myocardial Infarction or AMI)
- Fibrinolytic medication within 30 minutes of arrival
- PCI within 90 minutes of arrival
- Statin prescribed at discharge
- Fibrinolytic medication within 30 minutes of arrival for outpatients
- Aspirin at arrival for outpatients
- Discharge instructions
- ACE Inhibitor for Left Ventricular Systolic Dysfunction
- Influenza Immunization
Surgical Infection Prevention
- Preventative antibiotic one hour before incision for outpatients having Surgery
- Appropriate preventative antibiotic for outpatients having surgery
- VTE prophylaxis
- Thrombolytic therapy
- Discharged on statin medication)
- Stroke education
Blood Clot (Venous Thromboembolism or VTE) Prevention and Treatment
- VTE prophylaxis
- VTE prophylaxis for ICU patients
- VTE patients with anticoagulation overlap therapy
- VTE patients receiving IV blood thinner who were appropriately monitored
- VTE patients discharged on a blood thinner who received written instructions on that medicine
- Patients who did not receive preventive treatment for VTE and who acquired a blood clot in the hospital - Note: This process measure differs from all others in that a lower score indicates better performance; therefore this measure is 'flipped' so that the numerator is the number of patients who did not acquire a blood clot and a higher score indicates better performance.
3 The HCAHPS Measures and the response levels reported by CMS are (most favorable responses are in bold):
- How often did nurses communicate well with patients? (Sometimes or Never; Usually; Always)
- How often did doctors communicate well with patients? (Sometimes or Never; Usually; Always)
- How often did patients receive help quickly from hospital staff? (Sometimes or Never; Usually; Always)
- How often was the patient's pain well controlled (Sometimes or Never; Usually; Always)
- How often did staff explain about medicines before giving them to patients? (Sometimes or Never; Usually; Always)
- Were patients given information about what to do during their recovery at home (No; Yes)
- Patients understood their care when they left the hospital (Strongly Disagree or Disagree; Agree; Strongly Agree)
- How often were the patients' rooms and bathrooms kept clean? (Sometimes or Never; Usually; Always)
- How often was the area around the patient's rooms kept quiet at night? (Sometimes or Never; Usually; Always)
- How do patients rate the hospital overall? [on a scale of 1-10: 6 or lower (low); 7 or 8 (medium); 9 or 10 (high)
- Would patients recommend the hospital to friends or family? (No, Probably; Definitely)
4 For more details on hospital participation, the Quality Measures, and HCAHPS go to: Hospital Compare