Hospital Quality Initiative Public Reporting Data Refresh for Hospitals

The Centers for Medicare & Medicaid Services (CMS) Compare tool on Medicare.gov website provides consumers with information on over 100 quality measures for over 4,000 hospitals nationwide, including Veterans Administration (VA) medical centers and Department of Defense (DoD) military hospitals.

With the Provider Data Catalog, users can explore and download hospital data, as well as data on ambulatory surgical centers, inpatient psychiatric facilities, and some cancer hospitals. Publicly displaying quality information encourages hospitals and other health care facilities to make continued improvements in care.

CMS updates the data on the Compare tool on Medicare.gov and the Provider Data Catalog websites quarterly, though not all data are updated each quarter.

Data Updates

On October 30, 2024, CMS updated data for hospitals on the public reporting websites.

CMS updated data for the following measures, measure groups, quality reporting programs and payment programs:

• Complications & death
• Healthcare associated infections (HAI)
• Maternal health
• Timely and effective care
• Ambulatory Surgical Center Quality Reporting (ASCQR)
• Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey (includes data on Medicare-certified hospitals, VA medical centers, and Department of Defense [DoD] hospitals)
• Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) Survey for ambulatory surgical centers and hospital outpatient departments.
• Inpatient Psychiatric Facility Quality Reporting (IPFQR)
• Prospective Payment System -Exempt Cancer Hospital (PCH) Quality Reporting Program

CMS added the following new ASCQR Web-Based measures for October 2024 public reporting:

• ASC-1 (Number of patients who experience a burn prior to discharge from the ASC)
• ASC-2 (Number of patients who experience a fall within the ASC)
• ASC-3 (Number of patients who experience a wrong site, side, patient, procedure, or implant)
• ASC-4 (Percentage of ASC patients who are transferred or admitted to a hospital upon discharge from the ASC)

CMS added the following new IQR Electronic Clinical Quality and Health Equity measures for October 2024 public reporting:

• HH-01 (Proportion of patients who are at risk and who had a low blood glucose test result (less than 40 mg/dL) and no subsequent confirmatory blood glucose within 5 minutes and in the normal range (greater than 80 mg/dL))
• HH-02 (Number of hospital days with a severe hyperglycemic event among the total qualifying hospital days for at risk inpatient encounters)
• ePC-02 (The rate of nulliparous women with a term, singleton baby in a vertex position delivered by C-section birth)
• ePC-07a (Rate of any serious complications for mothers during delivery (per 10,000 deliveries))
• ePC-07b (Rate of serious complications (excluding blood transfusions) for mothers during delivery (per 10,000 deliveries))

CMS added the following IQR Structural Measure for October 2024 public reporting:

• HCHE (The number of domains (0-5) that the hospital can affirm they used to assess hospital commitment to health equity using a suite of equity-focused organizational competencies aimed at achieving health equity.)

CMS added the following OQR Electronic Clinical Quality Measure for October 2024 public reporting:

• OP-40 (Percentage of ED patients with a diagnosis of STEMI who received timely delivery of guideline-based reperfusion therapies appropriate for the care setting and delivered in the absence of contraindications)

In addition to measures refreshing, CMS has updated the following measure descriptions per the FY 2024 IPPS/LTCH PPS final rule:

• IPFQR-HCP COVID-19 (Percentage of healthcare personnel who are up to date with COVID-19 vaccinations)
• HCP COVID-19 (Percentage of healthcare personnel who are up to date with COVID-19 vaccinations)
• PCH-38 (Percentage of healthcare personnel who are up to date with COVID-19 vaccinations)

In addition to measures refreshing, CMS has updated the following measure title per the FY 2024 IPPS/LTCH PPS final rule:

• PSI 08 (In-hospital fall - associated fracture rate)

CMS has not retired any measures for October 2024 public reporting.

More Information and Compare Websites

For more information on the Compare tool, please visit: https://www.medicare.gov/care-compare/

For more information on the Provider Data Catalog, please visit: https://data.cms.gov/provider-data/topics/hospitals

For general questions regarding Hospital Public Reporting go to the QualityNet Question and Answer Tool. Under Program please select: Hospital Care Compare Site Support and choose your specific Topic. This will get your inquiry directly to the Hospital Care Compare Site inbox.

For questions regarding Overall Hospital Quality Star Ratings go to the QualityNet Question and Answer Tool. Under Program please select: Overall Hospital Star Ratings and choose your specific Topic. This will get your inquiry directly to the Overall Star Ratings inbox.