CMS: Centers for Medicare and Medicaid Services

The U.S. Department of Health and Human Services operates a database of quality measures in hospitals. The quality measures are collected by each hospital through a detailed review of patients’ medical records, according to common definitions, and some may be audited by CMS. Some measures are also collected by surveying patients. 

“Welcome to Hospital Compare. In this tool you will find information on how well hospitals care for patients with certain medical conditions or surgical procedures, and results from a survey of patients about the quality of care they received during a recent hospital stay. This information will help you compare the quality of care hospitals provide. Talk to your doctor about this information to help you, your family and your friends make your best hospital care decisions. Hospital Compare was created through the efforts of the Centers for Medicare & Medicaid Services (CMS), the Department of Health and Human Services, and other members of the Hospital Quality Alliance: Improving Care Through Information (HQA). The information on this website comes from hospitals that have agreed to submit quality information for Hospital Compare to make public.”

Source: www.hospitalcompare.hhs.gov.

Below are our CMS measures

Heart Attack Care

• Beta blockers prescribed at discharge for heart attack patients 
• Death from any cause within 30 days of hospitalization for heart attack 
• Heart attack: aspirin at arrival 
• Heart Attack: Aspirin Prescribed at Discharge 
• Counseling to stop smoking for heart attack patients 
• Heart attack: medications ACEI or ARB for LVSD 
• Statins prescribed at discharge for heart attack patients
• 30-day rate of readmission for heart attack 
• Time taken to receive angioplasty (PCI) during a heart attack 

Heart Failure Care

• Death from any cause within 30 days of hospitalization for heart failure 
• Counseling to stop smoking for heart failure patients 
• Heart failure discharge instructions 
• Evaluation of left ventricular systolic function for heart failure 
• Heart failure medications: ACEI or ARB for LVSD 
• 30-day rate of readmission for heart failure

Pneumonia Care

• Death from any cause within 30 days of hospitalization for pneumonia
• Pneumonia Vaccine 
• Pneumonia: Counseling to stop smoking 
• Pneumonia: Flu Vaccine 
• Pneumonia: Selection of Appropriate Antibiotics 
• Pneumonia: Antibiotics given in a timely manner 
• Pneumonia: Timely Test for Type of Infection 
• 30-day rate of readmission for pneumonia 

General Surgical Care

• Inpatient surgical care: appropriate antibiotic before surgery
• Inpatient surgical care: timely antibiotic before surgery
• Inpatient surgical care: antibiotic stopped timely after surgery
• Inpatient surgical care: appropriate method of hair removal before surgery
• Inpatient surgical care: beta-blockers given to surgical patients currently on beta-blocker therapy
• Inpatient surgical care: management of blood sugar after heart surgery
• Inpatient surgical care: normal body temperature after surgery
• Inpatient surgical care: treatment to prevent blood clots
• Inpatient surgical care: treatment to prevent blood clots after surgery
• Inpatient surgical care: urinary catheter removed within 48 hours after surgery
• Outpatient surgical care: appropriate antibiotic before surgery
• Outpatient surgical care: timely antibiotic before surgery 
• Cardiac imaging tests before low-risk outpatient surgery

 Outpatient Radiology Practices

• Combination or double CT scans of the abdomen
• Combination or double CT scans of the chest
• Follow up mammogram or ultrasound
• MRI for low back pain 
• Cardiac imaging tests before low-risk outpatient surgery
• Brain CT scan with sinus CT scan

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measures

• Patient satisfaction and willingness to recommend hospital
• Patient satisfaction with cleanliness of room
• Patient satisfaction with doctor communication
• Patient satisfaction with hospital overall
• Patient satisfaction with information about medication
• Patient satisfaction with information for recovery at home
• Patient satisfaction with nurse communication
• Patient satisfaction with pain control
• Patient satisfaction with quiet environment
• Patient satisfaction with timely help