CMS-10360 HC Formative Testing Handout 3_

Safety/Preventing Injuries

Surgical Care – Prevention of Infections and Complications
Outpatients having surgery who got an antibiotic at the right time - within one hour before surgery
(higher numbers are better)
Outpatients having surgery who got the right kind of antibiotic (higher numbers are better)
Surgery patients who were taking heart drugs called beta blockers before coming to the hospital, who
were kept on the beta blockers during the period just before and after their surgery
Surgery patients who were given an antibiotic at the right time (within one hour before surgery) to
help prevent infection
Surgery patients who were given the right kind of antibiotic to help prevent infection
Surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after
surgery)
Heart surgery patients whose blood sugar (blood glucose) is kept under good control in the days right
after surgery
Surgery patients needing hair removed from the surgical area before surgery, who had hair removed
using a safer method (electric clippers or hair removal cream – not a razor)
Surgery patients whose urinary catheters were removed on the first or second day after surgery.
Surgery patients whose doctors ordered treatments to prevent blood clots after certain types of
surgeries
Patients who got treatment at the right time (within 24 hours before or after their surgery) to help
prevent blood clots after certain types of surgery

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Safety/Preventing Injuries (continued)
Rates of Serious Complications and Death
Serious Complications [including:]
Pressure sores (bed sores)
Infections from a large venous catheter
Broken hip from a fall after surgery
Bloodstream infection after surgery
Collapsed lung due to medical treatment
Serious blood clots after surgery
A wound that splits open after surgery
Accidental cuts and tears from medical treatment
Other Complications and Deaths
Death from serious treatable complications after surgery
Breathing failure after surgery

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Safety/Preventing Injuries (continued)
Hospital-Acquired Conditions
Objects accidentally left in the body after surgery
Air bubble in the blood stream
Mismatched blood types
Severe pressure sores
Falls and injuries
Vascular catheter-associated infection
Catheter-associated urinary tract infection
Signs of uncontrolled blood sugar

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Effectiveness

Heart Attack Care
Average number of minutes before outpatients with chest pain or possible heart attack who needed
specialized care were transferred to another hospital
(a lower number of minutes is better)
Average number of minutes before outpatients with chest pain or possible heart attack got an ECG
(a lower number of minutes is better)
Outpatients with chest pain or possible heart attack who got drugs to break up blood clots within 30
minutes of arrival
(higher numbers are better)
Outpatients with chest pain or possible heart attack who got aspirin within 24 hours of arrival
(higher numbers are better)
Heart attack patients given aspirin at arrival
Heart attack patients given aspirin at discharge
Heart attack patients given ACE inhibitor or ARB for left ventricular systolic dysfunction (LVSD)
Heart attack patients given smoking cessation advice/counseling
Heart attack patients given beta blocker at discharge
Heart attack patients given fibrinolytic medication within 30 minutes of arrival
Heart attack patients given PCI within 90 minutes of arrival
Deaths after admission for heart attack (inpatient)
Death rate for heart attack patients (30-day)
Rate of readmission for heart attack patients (30-day)

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Effectiveness (continued)

Pneumonia Care
Pneumonia patients assessed and given pneumococcal vaccination
Pneumonia patients whose initial emergency room blood culture was performed prior to the
administration of the first hospital dose of antibiotics
Pneumonia patients given smoking cessation advice/counseling
Pneumonia patients given initial antibiotic(s) within 6 hours after arrival
Pneumonia patients given the most appropriate initial antibiotic(s)
Pneumonia patients assessed and given influenza vaccination
Deaths after admission for pneumonia (inpatient)
Death rate for pneumonia patients (30-day)
Rate of readmission for pneumonia patients

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Effectiveness (continued)

Heart Failure Care
Heart failure patients given discharge instructions
Heart failure patients given an evaluation of left ventricular systolic (LVS) function
Heart failure patients given ACE inhibitor or ARB for left ventricular systolic dysfunction (LVSD)
Heart failure patients given smoking cessation advice/counseling
Deaths after admission for congestive heart failure (inpatient)
Death rate for heart failure patients (30-day)
Rate of readmission for heart failure patients

Children’s Asthma Care
Children who received reliever medication while hospitalized for asthma
Children who received systemic corticosteroid medication (oral and iv medication that reduces
inflammation and controls symptoms) while hospitalized for asthma
Children and their caregivers who received a home management plan of care document while
hospitalized for asthma

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Effectiveness (continued)
Deaths from Certain Conditions [including:]
Deaths after admission for broken hip
Deaths after admission for heart attack
Deaths after admission for congestive heart failure
Deaths after admission for a stroke
Deaths after admission for bleeding in the digestive system
Deaths after admission for pneumonia

Other Deaths
Death after surgery to repair a weakness in the abdominal aorta

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Patient-Centeredness

Survey of Patients’ Hospital Experiences
Patients who reported that their nurses "Always" communicated well.
Patients who reported that their doctors "Always" communicated well.
Patients who reported that they "Always" received help as soon as they wanted.
Patients who reported that their pain was "Always" well controlled.
Patients who reported that staff "Always" explained about medicines before giving it to them.
Patients who reported that their room and bathroom were "Always" clean.
Patients who reported that the area around their room was "Always" quiet at night.
Patients at each hospital who reported that YES, they were given information about what to do during
their recovery at home.
Patients who gave their hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest).
Patients who reported YES, they would definitely recommend the hospital.

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Surgical Care
Outpatients having surgery who got an antibiotic at the right time - within one hour before surgery
(higher numbers are better)
Surgery patients who were given an antibiotic at the right time (within one hour before surgery) to
help prevent infection
Surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after
surgery)
Patients who got treatment at the right time (within 24 hours before or after their surgery) to help
prevent blood clots after certain types of surgery

Timeliness

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Heart Attack Care
Average number of minutes before outpatients with chest pain or possible heart attack who needed
specialized care were transferred to another hospital
(a lower number of minutes is better)
Average number of minutes before outpatients with chest pain or possible heart attack got an ECG
(a lower number of minutes is better)
Outpatients with chest pain or possible heart attack who got drugs to break up blood clots within 30
minutes of arrival
(higher numbers are better)
Outpatients with chest pain or possible heart attack who got aspirin within 24 hours of arrival
(higher numbers are better)
Heart attack patients given aspirin at arrival
Heart attack patients given fibrinolytic medication within 30 minutes of arrival
Heart attack patients given PCI within 90 minutes of arrival

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Timeliness (continued)

Pneumonia Care
Pneumonia patients whose initial emergency room blood culture was performed prior to the
administration of the first hospital dose of antibiotics
Pneumonia patients given initial antibiotic(s) within 6 hours after arrival

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Efficiency/Resource Use
Use of Medical Imaging
Outpatients with low back pain who had an MRI without trying recommended treatments first, such as
physical therapy.
(If a number is high, it may mean the facility is doing too many unnecessary MRIs for low back pain.)
Outpatients who had a follow-up mammogram or ultrasound within 45 days after a screening
mammogram.
(A number that is much lower than 8% may mean there’s not enough follow-up. A number much
higher than 14% may mean there’s too much unnecessary follow-up.)
Outpatient CT scans of the chest that were “combination” (double) scans.
(The range for this measure is 0 to 1. A number very close to 1 may mean that too many patients are
being given a double scan when a single scan is all they need.)
Outpatient CT scans of the abdomen that were “combination” (double) scans.
(The range for this measure is 0 to 1. A number very close to 1 may mean that too many patients are
being given a double scan when a single scan is all they need.)

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