10210 Inpatient Hospital Compare

Inpatient Hospital Compare
Request for Withholding Data From Public Reporting
April 2012
Hospitals participating in the Hospital Inpatient Quality Reporting (IQR) Program agree to have
data publicly reported on Hospital Compare.
Hospitals not participating in the Hospital Inpatient Quality Reporting (IQR) Program have an
option to withhold data from public reporting on Hospital Compare by completing this form and
mailing or faxing the completed form to the hospital’s Quality Improvement Organization (QIO)
contact.
This form must be received by the QIO no later than QIO close of business April 10, 2012.
Note: When faxing this request, notify the QIO. Withholding forms received by the QIO after the
end of the preview period will not be considered for the April 2012 Hospital Compare release.
This request is in effect only for the March 12, 2012 through April 10, 2012 preview period for
the measure(s) indicated on the following pages. This completed form also gives the QIO and the
Centers for Medicare & Medicaid Services (CMS) the authority to notify the American Hospital
Association (AHA), the Federation of American Hospitals (FAH) and the Association of American
Medical Colleges (AAMC) of this information.
My hospital has reviewed its preview report. For this preview period, we wish to withhold from
public reporting the data submitted for the measures indicated on the following pages.
Hospital Name:
CMS Certification Number (CCN):
Street Address:
City, State, ZIP Code:
Hospital Contact Name:
Hospital Contact Phone Number:
Hospital/Health System CEO (or designee):
Name (please print):
Title:
Date:

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Inpatient Hospital Compare
Request for Withholding Data From Public Reporting
April 2012
Instructions for completing the form:
1.

Determine Hospital’s IQR Program Notice of Participation status (active/not active).

2.

Use the table appropriate for your hospital.
•

Hospitals with only an active Hospital IQR Program Notice of Participation may not
suppress any measures listed in Table 1.

•

Hospitals without an active Hospital IQR Program Notice of Participation may
suppress any or all measures listed in Table 1. Hospitals must be appropriately
pledged to suppress data.

Table 1
Measure ID

Measure Name

AMI-1
AMI-2
AMI-3
AMI-4
AMI-5
AMI-7a
AMI-8a
AMI-10
HF-1
HF-2
HF-3
HF-4
PN-2

Aspirin at Arrival
Aspirin Prescribed at Discharge
ACEI or ARB for LVSD
Adult Smoking Cessation Advice/Counseling
Beta-Blocker Prescribed at Discharge
Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
Primary PCI Received Within 90 Minutes of Hospital Arrival
Statin Prescribed at Discharge
Discharge Instructions
Evaluation of LVS Function
ACEI or ARB for LVSD
Adult Smoking Cessation Advice/Counseling
Pneumococcal Vaccination
Blood Cultures Performed in the Emergency Department Prior to Initial
Antibiotic Received in Hospital
Adult Smoking Cessation Advice/Counseling
Initial Antibiotic Received Within 6 Hours of Hospital Arrival
Initial Antibiotic Selection for CAP in Immunocompetent Patient
Influenza Vaccination
Prophylactic Antibiotic Received Within 1 Hour Prior to Surgical
Incision
Prophylactic Antibiotic Selection for Surgical Patients
Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery
End Time
Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Blood
Glucose
Surgery Patients with Appropriate Hair Removal
Urinary Catheter Removed on Postoperative Day 1 (POD 1) or
Postoperative Day 2 (POD 2) with Day of Surgery being Day Zero
Surgery Patients with Perioperative Temperature Management

PN-3b
PN-4
PN-5c
PN-6
PN-7
SCIP-Inf-1
SCIP-Inf-2
SCIP-Inf-3
SCIP-Inf-4
SCIP-Inf-6
SCIP-Inf-9
SCIP-Inf-10

Check to
Suppress ()

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Inpatient Hospital Compare
Request for Withholding Data From Public Reporting
April 2012
Table 1 (continued)
Measure ID

Measure Name

Check to
Suppress ()

Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who
Received a Beta-Blocker During the Perioperative Period
Surgery Patients with Recommended Venous Thromboembolism
SCIP-VTE-1
Prophylaxis Ordered
Surgery Patients Who Received Appropriate Venous
SCIP-VTE-2
Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24
Hours After Surgery
Acute Myocardial Infarction (AMI) 30-Day Mortality Rate
MORT-30-AMI
Heart Failure (HF) 30-Day Mortality Rate
MORT-30-HF
Pneumonia (PN) 30-Day Mortality Rate
MORT-30-PN
READM-30-AMI Acute Myocardial Infarction (AMI) 30-Day Readmission Rate
READM-30-HF
Heart Failure (HF) 30-Day Readmission Rate
READM-30-PN Pneumonia (PN) 30-Day Readmission Rate
Hospital Consumer Assessment of Healthcare Providers and Systems
HCAHPS
survey
STRUCTURAL_ Participation in a Systematic Database for Cardiac Surgery
CARDIAC
STRUCTURAL_ Participation in a Systematic Clinical Database Registry for Stroke
STROKE
Care
STRUCTURAL_ Participation in a Systematic Clinical Database Registry for Nursing
NURSING
Sensitive Care
Death among Surgical Inpatients with Serious Treatable Complications
PSI-4
Iatrogenic Pneumothorax
PSI-6
Postoperative Respiratory Failure
PSI-11
Postoperative Pulmonary Embolism or Deep Vein Thrombosis
PSI-12
Postoperative Wound Dehiscence
PSI-14
Accidental Puncture or Laceration
PSI-15
Complications/Patient Safety for Selected Indicators (Composite
PSI-90
Score)
Abdominal Aortic Aneurysm (AAA) Repair Mortality
IQI-11
Hip Fracture Mortality
IQI-19
Mortality for Selected Conditions (Composite Score)
IQI-91
Central Line-Associated Bloodstream Infections
CLABSI
SCIP-Card-2

This material was prepared by IFMC, Hospital Inpatient Quality Reporting Program Support Contractor, under contract with the
Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services.
10SoW-IA-HIQRP-01/12-091
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