Medical & Statistical Glossary

The Score represents the hospital's performance for a specific measure. For most complications and readmission measures, this score is a risk-standardized rate (RSR) or a ratio. It takes into account how sick the patients were when they were admitted, allowing for a fair comparison between hospitals that treat patients with varying levels of health complexities.

The National Average (or US Avg) represents the overall statistical average for a specific measure across all eligible hospitals in the United States. It serves as a benchmark. CMS uses this national rate to determine if a specific hospital is performing "Better", "Worse", or "No Different" than the rest of the country.

The State Average (such as AK Avg for Alaska, or TX Avg for Texas) represents the overall statistical average for a specific measure across all eligible hospitals within that specific state. This allows you to compare a hospital's performance against local standards, independent of the national benchmark.

The 95% Confidence Interval (CI) is a statistical range that indicates the reliability of the hospital's score. It means we can be 95% confident that the true score for the hospital falls between the lower and upper numbers of the interval. If the entire interval is below the National Average, the hospital is considered statistically "Better". If the entire interval is above, it is considered "Worse".

Cases (or Number of Patients/Denominator) refers to the total volume of eligible patients or procedures included in the calculation of the score during the reporting period. A higher number of cases generally leads to a narrower (more precise) Confidence Interval.

vs. National is CMS's official classification comparing a hospital's performance to the national rate. Based on the hospital's score and its 95% Confidence Interval, CMS assigns a performance category such as "Better than the National Rate", "No Different than the National Rate", or "Worse than the National Rate".

EDAC is a CMS measure that captures the number of days patients spend in acute care (such as returning to the emergency department, observation stays, or unplanned readmissions) within 30 days of being discharged for conditions like heart attack, heart failure, or pneumonia. A lower EDAC score indicates better care.

An unplanned readmission occurs when a patient is admitted to a hospital within 30 days of being discharged from an earlier hospital stay. High readmission rates can indicate inadequate care or poor coordination of care post-discharge.

The SIR is a summary measure used to compare the observed number of healthcare-associated infections (HAIs) in a facility to the predicted number of infections based on national baseline data. A SIR greater than 1.0 indicates that more HAIs were observed than predicted, while a SIR less than 1.0 indicates fewer HAIs were observed.

Observed Infections represents the actual, raw count of infections reported by the hospital during the reporting period.

Eligible Cases refers to the number of specific procedures or patients that met the criteria to be monitored for a potential infection.

Days / Procedures indicates the denominator used for calculating infection rates. It represents either the total number of days patients were at risk (e.g., central line days) or the total number of surgical procedures performed.

HAIs are infections that patients get while receiving treatment for medical or surgical conditions. CMS tracks several specific types:

A CLABSI occurs when germs (usually bacteria or viruses) enter the bloodstream through the central line. Monitoring it is crucial for patient safety in ICUs and other high-acuity wards.

A CAUTI is an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney, which is associated with the use of a urinary catheter.

An SSI is an infection that happens after surgery in the part of the body where the surgery took place. CMS specifically tracks SSIs for Colon procedures and Abdominal Hysterectomies.

MRSA is a type of bacteria that is resistant to several antibiotics. MRSA bacteremia means the staph bacteria is present in the patient's blood, which can be life-threatening.

C.diff is a bacterium that causes severe diarrhea and colitis (an inflammation of the colon). It frequently occurs after use of antibiotic medications.

The PSI-90 score provides an overview of hospital performance across multiple Patient Safety Indicators (PSIs). A lower score indicates better patient safety, meaning fewer potentially preventable adverse events such as pressure ulcers, falls, or post-operative sepsis occurred.

A Hospital-Acquired Condition is an undesirable situation or condition that affects a patient and that arose during a stay in a hospital or medical facility. The HAC Reduction Program penalizes hospitals that rank in the worst-performing quartile (the top 25%) with respect to HACs.

The Total Performance Score (TPS) is a composite score calculated under the Value-Based Purchasing (VBP) Program. It combines a hospital's performance on quality measures across various domains (clinical care, patient experience, safety, and efficiency). A higher TPS may result in positive payment adjustments from Medicare.

HRRP is a Medicare value-based purchasing program that reduces payments to hospitals with excess readmissions. The program evaluates readmissions for conditions such as heart attack, heart failure, and pneumonia.

Measures the rate of complications for elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA). Tracks major issues such as infections, deep vein thrombosis, and mechanical complications within 90 days of surgery.

PSI-4 tracks the rate of death among surgical inpatients with serious treatable complications (failure to rescue). It identifies hospital deaths that might have been prevented if the complication was caught and treated in time.

The 30-day, risk-standardized death rate for Medicare patients admitted to the hospital with an acute myocardial infarction (heart attack).

The 30-day death rate for patients who had Coronary Artery Bypass Graft (CABG) surgery, known as open-heart surgery.

The 30-day death rate for patients admitted with an acute exacerbation of Chronic Obstructive Pulmonary Disease.

The 30-day risk-standardized death rate for patients discharged following an admission for heart failure.

The 30-day risk-standardized death rate for patients treated in the hospital for pneumonia.

The 30-day death rate for patients tracking deaths following hospital admission for an acute ischemic stroke.

Tracks emergency department workflow efficiency. This includes average time spent in the ER before patients are sent home, or the median time from ER arrival to inpatient admission.

Measures the percentage of patients who left the Emergency Department without being seen by a medical professional (Against Medical Advice or Left Without Being Seen). A low figure indicates efficient emergency room triage and capacity.

Measures how well the hospital provides all elements of the recommended bundle of care for patients arriving with severe sepsis or septic shock. High percentages indicate better screening and faster treatment.

Measures the percentage of pregnant women having elective (non-medical) deliveries between 37 and 39 weeks. Lower rates are better, showing adherence to clinical guidelines protecting maternal/fetal health.

Analyzes the excess days a heart failure patient spends in acute care (hospital readmissions, observation beds, emergency room visits) during the 30 days after discharge.

Analyzes the excess days a pneumonia patient spends in acute care (hospital readmissions, observation beds, ER visits) during the 30 days after their initial hospital discharge.

Measures the percentage of hospital admissions for adults aged 65 and older who received optimal malnutrition care, including screening, assessment, and a documented care plan.

Evaluates the safe use of opioids in hospitals to ensure patients are prescribed opioids alongside proper education, tracking, and risk assessment to prevent addiction and overdose.

These are electronic Clinical Quality Measures (eCQMs) tracking specific preventable harms that happen during a hospital stay:
• HH_HYPER: Severe Hyperglycemia (dangerously high blood sugar)
• HH_HYPO: Severe Hypoglycemia (dangerously low blood sugar)
• HH_ORAE: Opioid-Related Adverse Events

Measures the percentage of healthcare personnel who receive the influenza (flu) vaccination. A higher rate helps protect both hospital staff and vulnerable patients from flu outbreaks.

Quality measures for outpatient procedures:
• OP-23: Head CT scan results reporting time (efficiency)
• OP-29: Appropriate follow-up interval for normal colonoscopy in average-risk patients
• OP-31: Cataract surgery with improvement in visual function