Hospital Performance Measures

Information contained herein details progress made by Virginia hospitals and health systems in select quality and patient satisfaction elements of performance as directed by the VHHA Board of Directors. The individual data elements, whild publicly available from other sources, is provided here in one concise, easy-to-view format.

The VHHA quality and safety consensus measures selected were:

1) Healthcare-Associated Infections:

• Central Line-Associated Blood Stream Infections

2) Readmission 30-Day (All) for Acute Myocardial Infarction, Heart Failure and Pneumonia

3) Mortality 30-Day for Acute Myocardial Infarction, Heart Failure, and Pneumonia

4) Patient Satisfaction: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

Descriptive information about the measures selected and currently reported is provided below.

To review data on a Virginia hospital, click on the drop-down menu to choose a facility, then click View. You may view multiple hospitals by returning to this page and selecting each individually.

2012 2nd Quarter Quality Scorecard

Data Uploaded January 8 2013

About the measures selected

Healthcare-associated infections, or HAIs, are infections that people acquire while they are receiving treatment for another condition in a health care setting. HAIs can be acquired anywhere health care is delivered, including inpatient acute care hospitals, outpatient settings such as ambulatory surgical centers and end-stage renal disease centers, and long-term care facilities such as nursing homes and rehabilitation centers. HAIs may be caused by any infectious agent, including bacteria, fungi and viruses, as well as other less common types of pathogens.

Central Line-Associated Bloodstream Infection (CLABSI)

CLABSIs fall within a general category of primary bloodstream infections that are associated with the presence of a central line at the time or before the onset of the infection. The term primary bloodstream infection refers to those in which there is no obvious source. These are serious complications in that they typically cause a prolongation of hospital stay and increased cost and risk of mortality. The data in the report include CLABSIs that occur in the ICU setting.

Data Source: Virginia Department of Health

Data Timeframe: CLABSI data represent a rolling 12-month reporting

Readmission is defined as any admission to the same hospital occurring within 30 days after discharge from the initial visit. The data included here are risk adjusted, and include information on heart attack, heart failure and pneumonia patients. The presentation of the data on the VHHA scorecard is designed to mirror the presentation of the data on the CMS Hospital Compare web site, which incoporates a confidence interval to determine the color-coding scheme.

Data Source: The Centers for Medicare & Medicaid Services

Mortality is defined as death occurring within 30 days of a hospital admission. The data included here are risk adjusted, and include information on heart attack, heart failure and pneumonia patients.

Data Source: The Centers for Medicare & Medicaid Services

The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey is the first national, standardized, publicly reported survey of patients’ perspectives of their hospital experience. While many hospitals have collected information on patient satisfaction for their own internal use, until HCAHPS there was no national standard for collecting and publicly reporting information about patient experience of care that allowed valid comparisons to be made across hospitals locally, regionally and nationally. The two HCAHPS measures included on the scorecard are 1) Overall Value-Based Purchasing Pricing HCAHPS Score (combination of the eight measures used to calculate patient's experience of care domain score for value-based purchasing reimbursement by CMS; and 2) "How do patients rate the hospital overall?" (9 or 10)

Data Source: The Centers for Medicare & Medicaid Services