CMS-10210 Request for Withholding Data from Public Reporting

Inpatient Hospital Compare

Request for Withholding Data From Public Reporting

Month YYYY

Hospitals voluntarily submitting data as part of Hospital Inpatient Quality Reporting may elect to have data withheld from public reporting 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 Month, D, YYYY.

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 January 2012 Hospital Compare release.

This request is in effect for the Month, D, YYYY through Month, D, YYYY preview period for the measure(s) indicated on the following pages. The data will be released on Hospital Compare for subsequent releases unless the hospital submits a withdrawal form, submits a new pledge form with a revised discharge quarter start date or submits this form indicating the measures the hospital would like to withhold from public reporting for the period.

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 HQA Contact Name:

Hospital HQA Contact Phone Number:

Hospital/Health System CEO (or designee):

Name (please print):

Title:

Date:

Instructions for completing the withholding form:

1. Determine hospital notice of participation or pledge status.

2. Use the table appropriate for your hospital’s pledge status.

• Hospital IQR Program Notice of Participation

  • Hospitals may not suppress any measures listed in Table 1

  • Hospitals may suppress measures listed in Table 2.

• Voluntary Pledge

  • Hospitals may suppress any or all measures listed in Table 1

  • Hospitals may suppress any or all measures listed in Table 2

Table 1 APU Required Measures
Measure ID	Measure Name	Check to Suppress ()
AMI-1	Aspirin at Arrival
AMI-2	Aspirin Prescribed at Discharge
AMI-3	ACEI or ARB for LVSD
AMI-4	Adult Smoking Cessation Advice/Counseling
AMI-5	Beta-Blocker Prescribed at Discharge
AMI-7a	Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
AMI-8a	Primary PCI Received Within 90 Minutes of Hospital Arrival
AMI-10	Statin Prescribed at Discharge
HF-1	Discharge Instructions
HF-2	Evaluation of LVS Function
HF-3	ACEI or ARB for LVSD
HF-4	Adult Smoking Cessation Advice/Counseling
PN-2	Pneumococcal Vaccination
PN-3b	Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital
PN-4	Adult Smoking Cessation Advice/Counseling
PN-5c	Initial Antibiotic Received Within 6 Hours of Hospital Arrival
PN-6	Initial Antibiotic Selection for CAP in Immunocompetent Patient
PN-7	Influenza Vaccination
SCIP-Inf-1	Prophylactic Antibiotic Received Within 1 Hour Prior to Surgical Incision
SCIP-Inf-2	Prophylactic Antibiotic Selection for Surgical Patients
SCIP-Inf-3	Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time
SCIP-Inf-4	Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Blood Glucose
SCIP-Inf-6	Surgery Patients with Appropriate Hair Removal
SCIP-Inf-9	Urinary Catheter Removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with Day of Surgery being Day Zero
SCIP-Inf-10	Surgery Patients with Perioperative Temperature Management
Table 1 APU Required Measures (continued)
Measure ID	Measure Name	Check to Suppress ()
SCIP-Card-2	Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who Received a Beta-Blocker During the Perioperative Period
SCIP-VTE-1	Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered
SCIP-VTE-2	Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery
MORT-30-AMI	Acute Myocardial Infarction (AMI) 30-Day Mortality Rate
MORT-30-HF	Heart Failure (HF) 30-Day Mortality Rate
MORT-30-PN	Pneumonia (PN) 30-Day Mortality Rate
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
HCAHPS	Hospital Consumer Assessment of Healthcare Providers and Systems survey
STRUCTURAL_ CARDIAC	Participation in a Systematic Database for Cardiac Surgery
STRUCTURAL_ STROKE	Participation in a Systematic Clinical Database Registry for Stroke Care
STRUCTURAL_ NURSING	Participation in a Systematic Clinical Database Registry for Nursing Sensitive Care
PSI-4	Death among Surgical Inpatients with Serious Treatable Complications
PSI-6	Iatrogenic Pneumothorax
PSI-11	Postoperative Respiratory Failure
PSI-12	Postoperative Pulmonary Embolism or Deep Vein Thrombosis
PSI-14	Postoperative Wound Dehiscence
PSI-15	Accidental Puncture or Laceration
PSI-90	Complications/Patient Safety for Selected Indicators (Composite Score)
IQI-11	Abdominal Aortic Aneurysm (AAA) Repair Mortality
IQI-19	Hip Fracture Mortality
IQI-91	Mortality for Selected Conditions (Composite Score)
CLABSI	Central Line-Associated Bloodstream Infections

Table 2 Voluntary Measures

Measure ID	Measure Name	Check to Suppress ()
ED-1	Median Time from ED Arrival to ED Departure for Admitted ED Patients
ED-2	Admit Decision Time to ED Departure Time for Admitted Patients

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