CMS-10210 Inpatient Withholding Data form

Inpatient Hospital Compare
Request for Withholding Data from Public Reporting Form
July 2015
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 IQR Program have the
option to withhold data from public reporting on Hospital Compare by completing this form and faxing the
completed form to the Hospital Inpatient Value, Incentives, and Quality Reporting (VIQR) Outreach and
Education Support Contractor (SC).
Secure fax:
1.877.789.4443
This form must be received no later than close of business May 2, 2015.
Note: Forms received after the end of the preview period will not be considered for the July 2015 Hospital
Compare release.
This request is in effect only for the April 3 through May 2, 2015 Preview Period for the measure(s)
indicated on the following pages. This completed form also gives the IQRSC 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 measure(s) indicated on the following pages.
Required fields on the first page are marked with an asterisk (*).
Hospital/Health System Specifics:
*Hospital Name:

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*CMS Certification Number
(CCN):

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*Street Address:

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*City, State, ZIP Code:

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*Hospital Contact Name:

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*Hospital Contact Phone
Number:

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Hospital/Health System CEO (or designee):
*Name:

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*Title:

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*Date:

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April 2015 Preview/July 2015 Hospital Compare Release

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Inpatient Hospital Compare
Request for Withholding Data from Public Reporting Form
July 2015
Instructions for completing the withholding form:
1.
Determine your hospital’s Notice of Participation (NoP) status: IQR, Optional Public Reporting (PR),
or both.
2.Utilize the table appropriate to your hospital’s NoP(s).
• Hospitals with an IQR NoP may suppress any measure on Table 1.
• Hospitals with both an IQR and Optional PR NoP may suppress any measure on Table 1
• Hospitals with only an Optional PR NoP may suppress any or all measures on Table 2.
Table 1: Hospitals with either IQR NoP only or both IQR and Optional PR NoP – May
suppress the data for the measures listed.
Measure ID
AMI-2

Measure Name
Aspirin Prescribed at Discharge

AMI-10

Statin Prescribed at Discharge

HF-1

Discharge Instructions

HF-3

ACEI or ARB for LVSD

SCIP-Inf-10

Surgery Patients with Perioperative Temperature Management

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Table 2: Hospitals with only an Optional PR NOP – May suppress any or all of the measures
listed.
Measure ID
AMI-2

Measure Name
Suppress
Aspirin 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
Venous Thromboembolism (VTE) Prophylaxis
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Thrombolytic Therapy
Antithrombotic Therapy By End of Hospital Day 2
Discharged on Statin Medication
Stroke Education
Assessed for Rehabilitation
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis
Venous Thromboembolism Patients with Anticoagulation Overlap
Therapy
Venous Thromboembolism Patients Receiving Unfractionated
Heparin with Dosages/Platelet Count Monitoring by Protocol or
Nomogram
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AMI-7a
AMI-8a
AMI-10
HF-1
HF-2
HF-3
STK-1
STK-2
STK-3
STK-4
STK-5
STK-6
STK-8
STK-10
VTE-1
VTE-2

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VTE-3

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VTE-4

April 2015 Preview/July 2015 Hospital Compare Release

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Inpatient Hospital Compare
Request for Withholding Data from Public Reporting Form
July 2015
Measure ID

Measure Name
Suppress
Venous Thromboembolism Warfarin Therapy Discharge
Instructions
Hospital Acquired Potentially-Preventable Venous
Thromboembolism
Initial Antibiotic Selection for CAP in Immunocompetent Patient
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
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
Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who
Received a Beta-Blocker During the Perioperative Period
Surgery Patients Who Received Appropriate Venous
Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery
to 24 Hours After Surgery
Median Time from ED Arrival to ED Departure for Admitted ED
Patients
Admit Decision Time to ED Departure Time for Admitted Patients
Influenza Immunization
Elective Delivery
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VTE-5

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VTE-6
PN-6

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SCIP-Inf-1
SCIP-Inf-2

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SCIP-Inf-3

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SCIP-Inf-9
SCIP-Inf-10

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SCIP-Card-2

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SCIP-VTE-2

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ED-1b
ED-2b
IMM-2
PC-01
STRUCTURAL_
CARDIAC
STRUCTURAL_
STROKE
STRUCTURAL_
NURSING
STRUCTURAL_
GEN_SURG

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Participation in a Systematic Database for Cardiac Surgery

Participation in a Systematic Clinical Database Registry for Stroke
Care
Participation in a Systematic Clinical Database Registry for
Nursing Sensitive Care
Participation in a Systematic Clinical Database Registry for
General Surgery
Hospital Consumer Assessment of Healthcare Providers and
HCAHPS
Systems survey
MORT-30-AMI
Acute Myocardial Infarction (AMI) 30-Day Mortality Rate
30-Day Mortality Following Coronary Artery Bypass Graft (CABG)
MORT-30-CABG
Surgery
Chronic Obstructive Pulmonary Disease (COPD) 30-Day Mortality
MORT-30-COPD
Rate
MORT-30-HF
Heart Failure (HF) 30-Day Mortality Rate
MORT-30-PN
Pneumonia 30-Day Mortality Rate
MORT-30-STK
Acute Ischemic Stroke 30-Day Mortality Rate
READM-30-AMI
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate
30-Day Readmission Following Coronary Artery Bypass Graft
READM-30-CABG
(CABG) Surgery

April 2015 Preview/July 2015 Hospital Compare Release

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Inpatient Hospital Compare
Request for Withholding Data from Public Reporting Form
July 2015
Measure ID

Measure Name
Chronic Obstructive Pulmonary Disease (COPD) 30-Day
READM-30-COPD
Readmission Rate
READM-30-HF
Heart Failure (HF) 30-Day Readmission Rate
READM-30-PN
Pneumonia 30-Day Readmission Rate
READM-30-STK
Acute Ischemic Stroke 30-Day Readmission Rate
HOSPITAL-WIDE
30-Day Hospital-Wide All-Cause Unplanned Readmission Rate
READMISSION
HIP/KNEE
30-Day Readmission Rate Following Elective Primary Total Hip
READMISSION
Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)
HIP/KNEE
Complication Rate Following Elective Primary Total Hip
COMPLICATIONS Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)
Risk-Standardized Payment Associated with a 30-Day EpisodeAMI PAYMENT
of-Care for Acute Myocardial Infarction
Risk-Standardized Payment Associated with a 30-Day EpisodeHF PAYMENT
of-Care for Heart Failure
Risk-Standardized Payment Associated with a 30-Day EpisodePN PAYMENT
of-Care for Pneumonia
Death among surgical inpatients with serious treatable
PSI-4
complications
PSI-6
Iatrogenic pneumothorax, adult
Post-Operative Pulmonary Embolism (PE) or Deep Vein
PSI-12
Thrombosis (DVT)
PSI-14
Postoperative wound dehiscence
PSI-15
Accidental puncture or laceration
PSI-90
Complication/patient safety for selected indicators (composite)
HAI-1
Central Line-Associated Bloodstream Infections (CLABSI)
HAI-2
Catheter-Associated Urinary Tract Infections (CAUTI)
HAI-3
Surgical Site Infection for Colon surgery (SSI-Colon Surgery)
Surgical Site Infection for Abdominal Hysterectomy (SSIHAI-4
Abdominal Hysterectomy)
HAI-5
MRSA Bacteremia
Clostridium difficile (C. diff.)
HAI-6
IMM-3
Healthcare Personnel Influenza (HCP) Vaccination
EDV-1
Emergency Department Volume

Suppress
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PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0938-1022.The time required to complete this information collection
is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed,
and complete and review the information collection. If you have comments concerning the accuracy of the time estimates(s) or suggestions for
improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, MD 212441650.
This material was prepared by the Inpatient Value, Incentives, and Quality Reporting Outreach and Education Support Contractor, under contract
with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. HHSM-500-201313007I, FL-IQR-Ch8-03272015-01

April 2015 Preview/July 2015 Hospital Compare Release

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