CMS-10210 Inpatient Withholding Data form

Inpatient Hospital Compare

Request for Withholding Data from Public Reporting Form

October 2016

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 or emailing 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

Email:

[email protected]

This form must be received no later than close of business August 19, 2016.

Note: Forms received after the end of the preview period will not be considered for the October 2016 Hospital Compare release.

This request is in effect only for the July 21 through August 19, 2016 Preview Period for the measure(s) indicated on the following pages.

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:	(blank)
*CMS Certification Number (CCN):	(blank)
*Street Address:	(blank)
*City, State, ZIP Code:	(blank)
*Hospital Contact Name:	(blank)
*Hospital Contact Phone Number:	(blank)

Hospital/Health System CEO (or designee):

*Name:	(blank)
*Title:	(blank)
*Date:	(blank)

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).

1. Hospitals with an IQR NoP may suppress any measure on Table 1.

2. Hospitals with both an IQR and an Optional PR NoP may suppress any measure on Table 1.

3. Hospitals with only an Optional PR NoP may suppress any or all measures on Table 2.

Table 1: Hospitals with only an IQR NoP or both an IQR and an Optional PR NoP – May suppress the data for any or all of the measures listed.

Measure ID	Measure Name	Suppress
AMI-8a	Primary PCI Received Within 90 Minutes of Hospital Arrival
HF-2	Evaluation of LVS Function
STK-2	Discharged on Antithrombotic Therapy
STK-3	Anticoagulation Therapy for Atrial Fibrillation/Flutter
STK-5	Antithrombotic Therapy By End of Hospital Day 2
STK-10	Assessed for Rehabilitation
VTE-4	Venous Thromboembolism Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol or Nomogram
PN-6	Initial Antibiotic Selection for CAP in Immunocompetent Patient
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-9	Urinary Catheter Removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with Day of Surgery being Day Zero
SCIP-Card-2	Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who Received a Beta-Blocker During the Perioperative Period
SCIP-VTE-2	Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery

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

Measure ID	Measure Name	Suppress
AMI-7a	Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival	(blank)
AMI-8a	Primary PCI Received Within 90 Minutes of Hospital Arrival	(blank)
HF-2	Evaluation of LVS Function	(blank)
STK-1	Venous Thromboembolism (VTE) Prophylaxis	(blank)
STK-2	Discharged on Antithrombotic Therapy	(blank)
STK-3	Anticoagulation Therapy for Atrial Fibrillation/Flutter	(blank)
STK-4	Thrombolytic Therapy	(blank)
STK-5	Antithrombotic Therapy By End of Hospital Day 2	(blank)
STK-6	Discharged on Statin Medication	(blank)
STK-8	Stroke Education	(blank)
STK-10	Assessed for Rehabilitation	(blank)
VTE-1	Venous Thromboembolism Prophylaxis	(blank)
VTE-2	Intensive Care Unit Venous Thromboembolism Prophylaxis	(blank)
VTE-3	Venous Thromboembolism Patients with Anticoagulation Overlap Therapy	(blank)
VTE-4	Venous Thromboembolism Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol or Nomogram	(blank)
VTE-5	Venous Thromboembolism Warfarin Therapy Discharge Instructions	(blank)
VTE-6	Hospital Acquired Potentially-Preventable Venous Thromboembolism	(blank)
PN-6	Initial Antibiotic Selection for CAP in Immunocompetent Patient	(blank)
SCIP-Inf-1	Prophylactic Antibiotic Received Within 1 Hour Prior to Surgical Incision	(blank)
SCIP-Inf-2	Prophylactic Antibiotic Selection for Surgical Patients	(blank)
SCIP-Inf-3	Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time	(blank)
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	(blank)
SCIP-Card-2	Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who Received a Beta-Blocker During the Perioperative Period	(blank)
SCIP-VTE-2	Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery	(blank)
ED-1b	Median Time from ED Arrival to ED Departure for Admitted ED Patients	(blank)
ED-2b	Admit Decision Time to ED Departure Time for Admitted Patients	(blank)
IMM-2	Influenza Immunization	(blank)
PC-01	Elective Delivery	(blank)
STRUCTURAL_ CARDIAC	Participation in a Systematic Database for Cardiac Surgery	(blank)
STRUCTURAL_ SAFE_SURG	Safe Surgery Checklist Use	(blank)
STRUCTURAL_ NURSING	Participation in a Systematic Clinical Database Registry for Nursing Sensitive Care	(blank)
STRUCTURAL_ GEN_SURG	Participation in a Systematic Clinical Database Registry for General Surgery	(blank)
HCAHPS	Hospital Consumer Assessment of Healthcare Providers and Systems survey	(blank)
MORT-30-AMI	Acute Myocardial Infarction (AMI) 30-Day Mortality Rate	(blank)
MORT-30-CABG	30-Day Mortality Following Coronary Artery Bypass Graft (CABG) Surgery
MORT-30-COPD	Chronic Obstructive Pulmonary Disease (COPD) 30-Day Mortality Rate	(blank)
MORT-30-HF	Heart Failure (HF) 30-Day Mortality Rate	(blank)
MORT-30-PN	Pneumonia 30-Day Mortality Rate	(blank)
MORT-30-STK	Acute Ischemic Stroke 30-Day Mortality Rate	(blank)
READM-30-AMI	Acute Myocardial Infarction (AMI) 30-Day Readmission Rate	(blank)
READM-30-CABG	30-Day Readmission Following Coronary Artery Bypass Graft (CABG) Surgery
READM-30-COPD	Chronic Obstructive Pulmonary Disease (COPD) 30-Day Readmission Rate	(blank)
READM-30-HF	Heart Failure (HF) 30-Day Readmission Rate	(blank)
READM-30-PN	Pneumonia 30-Day Readmission Rate	(blank)
READM-30-STK	Acute Ischemic Stroke 30-Day Readmission Rate	(blank)
READM-30-HOSPWIDE	30-Day Hospital-Wide All-Cause Unplanned Readmission Rate	(blank)
READM-30-HIP-KNEE	30-Day Readmission Rate Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)	(blank)
COMP-HIP-KNEE	Complication Rate Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)	(blank)
PAYM-30-AMI	Risk-Standardized Payment Associated with a 30-Day Episode-of-Care for Acute Myocardial Infarction	(blank)
PAYM-30-HF	Risk-Standardized Payment Associated with a 30-Day Episode-of-Care for Heart Failure
PAYM-30-PN	Risk-Standardized Payment Associated with a 30-Day Episode-of-Care for Pneumonia
PSI-3	Pressure Ulcer Rate
PSI-4	Death among surgical inpatients with serious treatable complications	(blank)
PSI-6	Iatrogenic pneumothorax, adult	(blank)
PSI-7	Central Venous catheter-Related Bloodstream Infection Rate
PSI-8	Postoperative Hip fracture Rate
PSI-12	Perioperative Pulmonary Embolism (PE) or Deep Vein Thrombosis (DVT)	(blank)
PSI-13	Postoperative Sepsis Rate
PSI-14	Postoperative wound dehiscence	(blank)
PSI-15	Accidental puncture or laceration	(blank)
PSI-90	Complication/patient safety for selected indicators (composite)	(blank)
HAI-1	Central Line-Associated Bloodstream Infections (CLABSI) ICU and selected ward locations	(blank)
HAI-1a	Central Line-Associated Bloodstream Infections (CLABSI) ICU locations only
HAI-2	Catheter-Associated Urinary Tract Infections (CAUTI) ICU and selected ward locations	(blank)
HAI-2a	Catheter-Associated Urinary Tract Infections (CAUTI) ICU locations only
HAI-3	Surgical Site Infection for Colon surgery (SSI-Colon Surgery)	(blank)
HAI-4	Surgical Site Infection for Abdominal Hysterectomy (SSI-Abdominal Hysterectomy)	(blank)
HAI-5	MRSA Bacteremia	(blank)
HAI-6	Clostridium difficile (C. diff.)	(blank)
IMM-3	Healthcare Personnel Influenza (HCP) Vaccination	(blank)
EDV-1	Emergency Department Volume

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 21244-1650.

Expiration Date: xx-xx-xxxx

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