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Hospital Public Reporting & [insert your name] an Overview. Arizona’s Hospital Public Reporting Pilot and the National Voluntary Hospital Reporting Initiative. Public Reporting is Not New. At least 36 Web sites provide hospital information — some sites charge the viewer

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Hospital public reporting insert your name an overview

Hospital Public Reporting &[insert your name]an Overview

Arizona’s Hospital Public Reporting Pilot

and the

National Voluntary Hospital Reporting Initiative

Public reporting is not new
Public Reporting is Not New

  • At least 36 Web sites provide hospital information—some sites charge the viewer

  • Several states mandate public reporting, to a greater or lesser extent

  • CMS began public reporting with a three state pilot

What is new
What is New?

  • Public reporting sponsored by government and other prestigious stakeholders

    • Centers for Medicare & Medicaid Services (CMS)

    • American Hospital Association (AHA)

    • Federation of American Hospitals (FAH)

    • JCAHO

    • National Quality Forum (NQF)

    • AARP

    • AFL-CIO

Three state pilot
Three State Pilot

  • Began November 2002

  • Involves 325 hospitals from Arizona, Maryland, and New York

  • Maryland and, to a lesser extent, New York have mandated public reporting in place

Arizona s uniqueness
Arizona’s Uniqueness

  • Unlike other non-mandated states, Arizona has a high proportion of hospitals participating (47 hospitals—70%)

  • Hospitals actively participate in monthly meetings, provide feedback, offer suggestions, and support one another

The national voluntary hospital reporting initiative nvhri
The National Voluntary Hospital Reporting Initiative(NVHRI)

  • Program began December 2002

  • Supported by the AHA, AAMC, and CMS

  • Data reports are the same for NVHRI and the three state pilot

Why now
Why Now?

This is CMS’s answer:

  • Stimulate QI activities

  • Provide patients with information to assist them in making health care decisions

  • “Hospitals should be leaders in sharing information with the public they serve”

    April 2003, Recruitment Letter signed by CMS, AHA and AAMC

First step
First Step

  • Data publicly posted 10/9/2003

  • Posted to the CMS Web site for health care professionals (

  • 47 hospitals from Arizona are represented

  • 415 hospitals, nationally, have data posted

Of 69 AZ Hospitals

Hospital Participation

Of 4,143 U.S. Hospitals

47 (70%) volunteered

27 (40%)submitted data for Oct. 9

1,238 (30%) volunteered

415 (10%) submitted data for Oct. 9

Interpretation is complex
Interpretation is Complex

  • Data is fragmentary

  • Data validation is minimal

  • Data is difficult to compare

    • First posting is JCAHO hospitals only

    • Limited indicators

Data is fragmentary
Data is Fragmentary

  • 47 Arizona hospitals participate

  • Low participation by non-mandated states

    • New Mexico, 7 hospitals submitted data (18%)

    • Alabama, 2 hospitals submitted data (16%)

    • Minnesota, 9 hospitals submitted data (10%)

    • California, 74 hospitals submitted data (20%)

States that mandate reporting
States that Mandate Reporting

  • Connecticut, 31 out of 32 reported (97%)

  • Maryland, 48 out of 49 reported (98%)

  • Rhode Island, 11 out of 11 reported (100%)

    Yet, Arizona—without mandating reporting—

    has 70% of hospitals participating

Arizona is the only state where most hospitalshave freely volunteeredand where, as a result, there is little selection bias

Selection bias
Selection Bias

Why are such a limited number of some states’ hospitals participating?

  • Possible reasons for lower participation . . .

    • Participation involves commitment to public reporting

    • Hospitals are not yet comfortable with publicly reporting data

    • Data results are not satisfactory to the hospitals

Arizona participation
Arizona Participation

  • Arizona hospitals want to be involved

  • All Arizona hospitals collected and reported data for all indicators and all projects during the 6th Scope of Work

  • All but one Arizona hospital is participating in the 7th Scope of Work

Validation is minimal
Validation is Minimal

  • The process for validating data is being implemented, but was not in place for the first posting of data

  • In the future, Arizona hospitals will have records randomly chosen for validation

  • Data will be considered valid at 80% accuracy

Data is difficult to compare
Data is Difficult to Compare

  • First step was limited to JCAHO hospitals only

  • Hospitals with small sample sizes were not included

  • Hospitals were given the opportunity to not publish results during the first release of data


  • [insert hospital name] has been actively participating since [insert date here]

  • Participation has included

    • Providing opinion on the Web site design

    • Advising the national program about recruitment and retention

    • Posting data

Quality indicators
Quality Indicators

  • Three clinical conditions

    • Heart Attack (AMI)

    • Heart Failure (HF)

    • Pneumonia

  • Ten clinical indicators

  • Quality indicators1

    Heart Attack

    Aspirin on arrival

    Aspirin at discharge

    ACE-I for LVSD

    Beta blocker on arrival

    Beta blocker at discharge

    Heart Failure

    LVEF assessment

    ACE-I for LVSD


    Oxygen assessment

    Pneumonia immunization

    Antibiotic administered within 4 hours of admission

    Quality Indicators

    The future of public reporting
    The Future of Public Reporting

    • Data is scheduled to be posted quarterly

    • National mandated reporting by all hospitals in 2005

    • Additional indicators

      • Coronary Artery Bypass Graft Surgery

      • Hip and Knee Replacement

      • Patient Satisfaction

  • Financial incentives may be tied to results

  • Financial incentives from the premier hospital quality incentive demonstration project
    Financial Incentivesfrom the Premier Hospital Quality Incentive Demonstration Project

    • Top Performers

      • Top 50% are recognized on the Web site

      • Top 10% rewarded with 2% bonus

      • Top 20%–10% rewarded with 1% bonus

    Financial incentives from the premier hospital quality incentive demonstration project1
    Financial Incentivesfrom the Premier Hospital Quality Incentive Demonstration Project

    • Poor Performers

      • Lowest 10%, lose 2% if no improvement in 3 years

      • Next lowest, 20%–10%, lose 1% if no improvement in 3 years

    Final thoughts
    Final Thoughts

    • Participation is an opportunity to prepare for mandatory reporting

    • This experience will prepare us for financial incentives

    • Arizona hospitals are working together for mutual benefit