Frequently Asked Questions
How and why was this site developed?
The NC Hospital Quality Performance Report was developed by the North Carolina Quality Center, with guidance from a multi-stakeholder committee, with the goal of providing transparent information on hospital quality to the public and provider community.
The site was initially unveiled in 2007. At that time, the site pulled together measures of hospital quality which were available from Medicare's HospitalCompare website, allowing easy comparisons between hospitals and benchmark values. These measures were mostly process measures on select cohorts of patients, e.g. process measures for heart failure patients. The measures were selected by a team consisting of physicians, nurses, and executives representing hospitals, health systems, insurance, industry, the Carolinas Center for Medical Excellence (CCME), NC Medical Society, and NC Department of Health and Human Services. The group aimed to include measures that were actionable, standardized, well-defined, available, and would not add burden to hospital data collection efforts. Over time, the exact measures on the site have evolved, e.g. HCAHPS were added in 2009 and outpatient measures were added in 2011.
In recent years, several trends became apparent. First, hospitals were 'topped out' on many measures, with average scores as high as 97%. Second, the proliferation of quality measures made it necessary to identify a few areas where NC hospitals had meaningful opportunities to improve. Finally, reporting on this site was found to be most valuable when it aligns with areas where NCQC offers improvement resources.
In light of these developments, the NCQC Board decided in 2015 to re-orient this website to focus on areas where NC hospitals have most opportunity to improve and which align with NCQC's strategic goals. Therefore, for the 2016-2018 timeframe, this site will primarily report data on infections, readmissions, culture of safety, maternal/infant care, IHI's Triple Aim, and patient and family engagement. As a first step, in 2015, the NCQC team removed topped out CMS measures from the site and expanded reporting on CMS measures such as HCAHPS, readmission rates, and cost measures. In 2016, the site will be developed to add additional measures.
What is the purpose of this site?
This site has three goals. First, it aims to encourage hospitals and health systems to improve their quality measures. This is accomplished by providing transparent reporting, which allows easy comparisons to benchmarks and other hospitals and highlights high performers to support peer networking. Transparent reporting leverages the inherent professionalism and competitive spirit of hospital staff to encourage improvement. Second, the site demonstrates the commitment of NC hospitals and health systems to transparent quality reporting. Finally, the site provides information on state-level progress of quality performance to demonstrate the collective progress NC hospitals towards better care.
Why are some quality measures on this site, but not others?
Due to the extremely large number of quality measures available, NCQC focuses its reporting on a few areas where NC hospitals have most opportunity. For the 2016-2018 period, these areas include infections, readmissions, culture of safety, maternal/infant care, IHI's Triple Aim, and patient and family engagement. In addition, measures which are topped out are not displayed (for instance, AMI, HF, and PN process measures).
If you are seeking comprehensive information on all CMS measures, it can be found at https://www.medicare.gov/hospitalcompare/search.html or data.medicare.gov. In addition, the website www.whynotthebest.org compiles Medicare data into a graphical reporting format.
Why are you reporting measurement scores from previous years?
Hospital quality measurement has been evolving over the years to be more transparent. However, with the increase in transparency, comes the need for standardization of meaningful measures that can be used for accurate comparability of hospital performance. For both the hospital and the reporting organization, the process of collecting the data, validating the data, and preparing the data for public reporting is long and complicated, resulting in a lag between when the patient was seen and when the quality score can be reported.
In addition, in some cases, the patient volume is very small. For this reason, performance for the hospital may need to be tracked over many months or even several years to obtain a stable indicator of performance.
What is HCAHPS?
The Hospital Consumer Assessment of Healthcare Providers & Systems - HCAHPS (pronounced H-caps) is a national, standardized survey of patient's perception of their hospital experience. The survey includes roughly 30 questions which are used to report on various dimensions of the patient's experience in the hospital, such as adequacy of pain control, cleanliness, communication with doctors or nurses, etc.
Most acute care hospitals must conduct HCAHPS surveys, and perform well on these surveys, or else risk financial penalties. Specifically, IPPS hospitals must conduct the HCAHPS survey in order to be eligible for a full payment update. Non-IPPS hospitals, such as Critical Access Hospitals, may voluntarily participate in HCAHPS. In addition, Value-Based Purchasing, a pay-for-performance program, includes HCAHPS performance as part of the calculation for incentive payment.
More information about HCAHPS is available at http://www.hcahpsonline.org/home.aspx.
What are CMS readmissions measures?
Readmission measures show what happened after patients with certain conditions got hospital care. The rates of readmission focus on whether patients were hospitalized again within 30 days of being discharged from the hospital.
The hospital readmission rates are based on people with Original Medicare (traditional fee-for-service Medicare) who are 65 and older. These rates are calculated using Medicare enrollment and claims records, and a complex statistical procedure known as hierarchical logistic regression modeling. The readmission rates are risk-adjusted, meaning that the calculations take into account how sick patients were when they were first hospitalized. Risk-adjusting the readmission rates helps make comparisons accurate and meaningful, especially for hospitals that treat sicker patients.
Source: https://www.medicare.gov/hospitalcompare/About/RCD.html. Accessed 12/8/2015
What is the Medicare Spend per Beneficiary measure?
The Medicare Spending Per Beneficiary (MSPB or “Medicare hospital spending per patient”) measure shows whether Medicare spends more, less, or about the same on an episode of care for a Medicare patient treated in a specific inpatient hospital compared to how much Medicare spends on an episode of care across all inpatient hospitals nationally. This measure includes all Medicare Part A and Part B payments made for services provided to a patient during an episode of care, which includes the 3 days prior to the hospital stay, the inpatient hospital stay, and the 30 days after discharge from the hospital.
The payments included in this measure are price-standardized and risk-adjusted. Price standardization removes sources of variation that are due to geographic payment differences such as wage index and geographic practice cost differences, as well as indirect medical education (IME) or disproportionate share hospital (DSH) payments. Risk adjustment accounts for variation due to patient health status.
This result is a ratio calculated by dividing the amount Medicare spent per patient for an episode of care initiated at this hospital by the median (or middle) amount Medicare spent per episode of care nationally. A lower ratio means that Medicare spent less per patient.
A ratio equal to the national average means that Medicare spends ABOUT THE SAME per patient for an episode of care initiated at this hospital as it does per episode of care across all inpatient hospitals nationally.
A ratio that is more than the national average means that Medicare spends MORE per patient for an episode of care initiated at this hospital than it does per episode of care across all inpatient hospitals nationally.
A ratio that is less than the national average means that Medicare spends LESS per patient for an episode of care initiated at this hospital than it does per episode of care across all inpatient hospitals nationally.
Source: https://www.medicare.gov/hospitalcompare/search.html. Accessed 12/8/2015
What is the source of the data on this site?
The source for all data on this site is https://data.medicare.gov.
Why are some hospitals missing from the regional bar graph?
The reports on this site include measurement information on the roughly 110 non-federal, general acute-care hospitals in North Carolina. Hospitals that primarily serve children, psychiatric, or rehabilitation patients are not included in this site.
In addition, all hospitals are not required to report on all measures. For instance, some critical access hospitals may choose not conduct HCAHPS surveys. In other cases, a hospital may report a measure, but have too few patients for reliable information to be displayed.
How are quality measures developed?
Extensive work is done nationally to select and develop quality measures. The National Quality Forum (NQF) is responsible for evaluating quality measures. They work closely with other entities, such as CMS, to identify a collection of quality measures which are shared between all hospitals and capture what is important to patients. Once a quality measure has been developed, it can be used for public reporting, quality improvement, and pay-for-performance.
What are the average, top 10%, and top 25% scores?
Throughout this site, the average score refers to the mean score for NC hospitals reported on this site for the time period. This average is unweighted by patient volume. For example, the score for the hospital with 20 patients has as much "weight" in calculating the average as the hospital with 200 patients.
The top 10% scores are the 90th percentile score for all the hospitals reported on this site for the time
Throughout this site, the state average refers to the mean score for NC hospitals reported on this site for the time period. For HCAHPS measures, the average is unweighted by patient volume. For example, the score for the hospital with 20 completed surveys has as much "weight" in calculating the state average as the hospital with 200 completed surveys. The state average for the Medicare Spending per Beneficiary (MSPB) measure is also unweighted.
For readmissions measures, the state average is weighted by patient volume. This means that a hospital with 2,000 patients will contribute more “weight” to the state average than a hospital with 200 patients.
The top 10% represents the 90th percentile score for all hospitals reported on this site for the time period..
The top 25% represents the 75th percentile score for all hospitals reported on this site for the time period.
What is being done to improve performance?
Many organizations work to improve the quality of hospital care. Quality improvement initiatives are performed in hospitals to continuously improve evidence-based processes of care and to improve the health outcomes of all patients.
The data on this site is monitored by the North Carolina Quality Center and used to develop initiatives to assist NC hospitals. A list of initiatives led by the North Carolina Quality Center is available at www.ncqualitycenter.org.
How can consumers and patients use this information?
This information helps patients, family, and friends compare the quality and safety of care in North Carolina hospitals. Scientific evidence shows that high quality care leads to fewer repeat hospitalizations, hospital-acquired infections and medical errors, thereby reducing costs.
This site is a resource to inform consumers about hospital quality care and to help North Carolinians make good decisions about health care. Consumers should view this information as a starting point for educating themselves about hospital quality, for talking to their doctors about choosing a hospital for medical care, and for asking questions while receiving care in the hospital. Consumers may want to review the quality measure information when considering a hospital visit for a scheduled procedure.
How can healthcare providers use this data?
This information is used by the medical community to heighten their awareness of the opportunity that exists to improve the care that they currently deliver. The public reporting of this data also provides an incentive for hospitals to continue to improve the care they provide.
How can I get more information?
Staff at the North Carolina Quality Center are happy to receive questions or comments about this site. Please reach out by email at firstname.lastname@example.org.