NC Hospital Quality Performance Report

This report is developed by the
NC Quality Center.

Additional support comes from the
North Carolina Hospital Association

and The Carolinas Center for Medical Excellence.

FAQ | Measures | Future | NC Hospitals

Frequently Asked Questions

What's new on this site as of April 2008?

New surgical care measures and a new hospital "Highlights" section.

New Measures

Two new individual measures related to surgical care have been added to the website. The measures are regarding treatment to prevent blood clots (Venous Thromboembolism or VTE) for certain types of surgeries.

The first measure (VTE1) tells how often surgery patients' doctors ordered treatment to prevent blood clots from forming in the veins after certain surgeries. The second measure (VTE2) tells how often surgery patients received treatment to prevent blood clots within 24 hours before or after certain surgeries.

Now that the surgical care condition on this website includes five individual measures, we've calculate a new SCIP-5 optimal care score based on the five measures. This measure has not yet been added to the regional comparison graphs, but can be found in the report tables. The methodology for the optimal care score is described below.

Hospital "Highlights"

The website has a new section to highlight hospitals that we label as "High Reliable" as measured by the condition-specific optimal care score across time. For example, if a hospital's heart failure optimal care score is at or above 90% across the four 6-month time periods on this site then they meet the High Reliable criteria for heart failure care. This means that the hospital's compliance to the evidence-based recommended treatments for their patients are consistent and exceptional.

Criteria for High Reliable Hospital

Heart Attack: Optimal care score is 95% or higher for four 6-month time periods.
Heart Failure: Optimal care score is 90% or higher for four 6-month time periods.
Pneumonia: Optimal care score is 90% or higher for four 6-month time periods.
Surg. Inf. Prevention: Optimal care score is 90% or higher for four 6-month time periods.

Another new distinction in the new highlight section is a hospital deemed "Most Improved" per condition. These are the 12 hospitals that have seen the most improvement in their optimal care scores over time. More specifically, these are the top 3 hospitals per condition with the largest absolute value increase in optimal care score from 6-month baseline (10/05-3/06) to the last 6-month time period (4/07-9/07) without any substantial dips (10 percentage pts or more) in performance over 18 months.

Determining Most Improved Hospitals

Four time periods for April 2008 release were used:

1. October 1, 2005 - March 31, 2006 (baseline)
2. April 1, 2006 - September 30, 2006
3. October 1, 2006 - March 31, 2006
4. April 1, 2007 - September 30, 2007 (last 6 months available)

Steps taken to determine top 3 Most Improved hospitals per condition:

1. Exclude hospitals with <= 10 patients during 4th time period.
2. Determine the absolute difference in the O.C. score between 10/05-3/06 (baseline) and last 6 months (4/07-9/07).
3. Exclude hospitals where time 4 score <= (time 3 score - 10 percentage points). (Only small dip allowed.)
4. Exclude hospitals where time 3 score <= (time 2 score - 10 percentage points). (Only small dip allowed.)
5. Exclude hospitals where time 2 score <= (time 1 score - 10 percentage points). (Only small dip allowed.)
6. Per condition, list rank the remaining hospitals by descending absolute difference from baseline (calculated in step 2) and select the top 3 hospitals to be highlighted.

How is the "Optimal Care" score calculated?

The optimal care measure uses the "all or none" methodology to determine if a patient received all of the recommended treatment for which they were eligible. For each condition on this site (heart attack, heart failure, pneumonia, surgery), performance is determined at the patient level and then summarized per hospital.

A hospital optimal care percentage score is calculated with this formula (per condition):

The steps to the methodology are:

1. Per discharged patient, determine if he/she met the eligibility to be categorized as a patient with a primarily diagnosis of heart attack, heart failure, pneumonia, or admitted for surgery.

2. Determine which measures per condition a patient has been deemed eligible for from a patient's medical chart.

3. Did the patient receive the recommended care for all eligible measures? If yes, patient receives a 1. If no, patient receives a 0.

4. Per hospital, sum the numbers from step 3 (above.) This is the sum of the numerators.

5. Per hospital, sum the total number of patients that had at least one eligible measure. This is the sum of the denominators and is a count of unique patients.

EXAMPLE: Let's say a heart failure patient who was a smoker was eligible to receive all 4 of the heart failure measures. If the patient received 3 of the 4 they would have a rate of 0/1 = 0%. (Not a rate of 3/4 = 75%.) The numerator is either a 1 or a 0 and each patient has a denominator of 1. A hospital's rate per condition = the sum of the patient numerators divided by the total number of patients.

What is a PCI-capable Hospital?

A PCI-capable hospital is a hospital that performs percutaneous coronary interventions (i.e., angioplasty, stenting) for patients suffering from a heart attack. To be grouped with PCI-capable hospitals on this website, the hospital performed these interventions on 10 or more patients during the last 6-month time period. This subgroup of NC hospitals is used to develop a separate mean score and 90th percentile score for the heart attack optimal care measure for only those hospitals that were performing PCI.

The subgroup was created so that hospitals with patients eligible for the measure titled "PCI Within 90 Minutes of Arrival" could be compared to each other in one graph. In addition, in the report tables, a hospital is highlighted in green if they meet or exceed the 90th percentile optimal care score of all hospitals (100% score) OR they meet or exceed the 90th percentile optimal care score of PCI hospitals (98%).

Why are some hospitals missing from the regional bar graph or trend graph?

This site graphically displays hospital performance on four optimal care measures for heart attack, heart failure, pneumonia, and surgical infection prevention.

There are two reasons why a hospital may not have an optimal care score for graphing. The first reason is patient volume that is too low (< 10 patients) to adequately compare or trend a hospital's performance. For example, during the six-month time period, if a hospital cared for less than 10 patients that had a heart attack, they do not have enough volume to be shown on this site's heart attack graphs. The second reason that a hospital does not have an optimal care score is incomplete data for a time-period. Both of these "Too Few" reasons are indicated with a "TF" in the report tables' column for the optimal care score.

A list of hospitals, per condition, that are excluded from this site's bar and trend graphs can be found in this downloadable spreadsheet: g0_sep07.xls

The report tables on this site include measurement information on 103 non-federal, general acute-care hospitals in North Carolina. However, six percent of NC's acute care hospitals have yet to join the NC Hospital Quality Performance Report site. Lastly, hospitals that primarily serve children, psychiatric, or rehabilitation patients are not included in this site.

How are the individual measures developed?

The information posted on this site comes from the quality data submitted by hospitals to the Quality Improvement Organization (QIO) Clinical Data Warehouse (part of the Centers for Medicare & Medicaid Services (CMS)) for all inpatient discharges. Except where noted, all rates are derived from data reflecting two quarters (six months) of experience, which is updated on a rolling basis.

Each of the measures tell you the proportion of cases where a hospital provided the recommended process of care. Only patients meeting the inclusion criteria for a measure are included in the calculation of the rate for a measure. A rate of 88% means that the hospital provided the recommended process of care 88% of the time. For example, the rates for aspirin at discharge for individuals who have had an acute myocardial infarction -- a heart attack -- tell you the percentage of patients who received an aspirin when they are discharged from the hospital. The ultimate goal for each measure is 100%. Hospitals with effective quality improvement programs are continually working toward this goal.

From CMS' QualityNet site, specification manuals are available that provide the detailed information on the specifications and the methodology used to calculate each measure's score. These manuals represent the result of efforts by the CMS and the Joint Commission to achieve identity among common national hospital performance measures and to share a single set of common documentation.

What is the source of this data?

The Carolinas Center for Medical Excellence provides to the NC Quality Center quarterly hospital level data from the CMS/QIO data warehouse. The data include numerators and denominators from the most recent 3 months for each measure per hospital for all hospitals that have signed a consent form to share their data with the NC Quality Center.

The hospital scores from the individual quality measures displayed on this site (excluding the optimal care score) have been publicly reported by U.S. Dept. of Health and Human Services, through their online resource called Hospital Compare.

These measures are part of a national program called the Hospital Quality Alliance (HQA). HQA is a national public-private collaboration to encourage hospitals to voluntarily collect and report hospital quality performance information. Hospitals across the country have been providing information through the HQA initiative since October 2003.

A list of when each measure became part of the HQA program can be found here: HQA MeasuresQ32007.pdf

The hospital quality measures in this report come from information collected on patients (all adults including Medicare beneficiaries) who were discharged from North Carolina's general acute-care hospitals. In order to collect the necessary information for these process measures, hospitals review patients' medical charts and document whether each treatment was completed as recommended. The information is sent to the Centers for Medicare & Medicaid Services and the Joint Commission.

What are the Average and Top 10% Scores?

On the top of each condition table there are two rows that display state-level scores. The first line says "Average for NC Hospitals". This is the mean score for the N.C. hospitals that currently participate in the NC Hospital Quality Performance Report. 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 second line says "Top 10% of NC Hospitals". The values shown are the 90th percentile score for all the hospitals participating in the NC Hospital Quality Performance Report.

The optimal care averages and 90th percentiles were developed using only the scores from hospitals with 10 or more patients per condition.

What is being done to improve performance?

Hospital-level and statewide performance on the process measures displayed on this site is monitored by the NC Center for Hospital Quality and Patient Safety. To improve surgical care improvement, which includes reducing the risk of post-surgical infection, the Quality Center and the Carolinas Center for Medical Excellence are leading the N.C. Surgical Care Improvement Project collaborative with the help of statewide partners. The goal is to reduce surgical complications and to improve performance on the following processes of care:

1. Prophylactic antibiotic received within one hour prior to surgical incision
2. Prophylactic antibiotic selection for surgical patients
3. Prophylactic antibiotics discontinued within 24 hours after surgery end time
4. Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose
5. Surgery patients with appropriate hair removal
6. Colorectal surgery patients with immediate postoperative normothermia
7. Surgery patients with recommended venous thromboembolism prophylaxis ordered
8. Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery

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. The quality measures reported on this site are well accepted nationally as steps that should be taken in the care of the conditions. 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.

In this report, each quality measure includes only patients whose history and condition indicate the treatment is appropriate. Talk to your doctor if you have questions about your treatment.

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 their use of recommended best treatments.

How can I get more information about this site?

Additional questions or comments about this site should be directed to info@nchospitalquality.org.

Who was involved in this project?

The North Carolina Center for Hospital Quality and Patient Safety ("NC Quality Center") initiated the NC Performance Reporting Committee to determine which clinical measures should be included on this site. The Committee is a multi-disciplinary 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 principles set by the group were to include measures that were actionable, standardized, well-defined, available, and would not add burden to hospital data collection efforts. In December 2007, the Workgroup's recommendations for new measures and a new "highlights" section for this site were approved by the NC Quality Center's Board and endorsed by the NCHA Policy Development Committee.