The data presented on this website comes from hospitals that volunteered to
submit their data for public reporting. The clinical measures reported here
focus on heart attack, heart failure, pneumonia, asthma (children only) and the surgical care improvement project. Each rate calculation is based on the
hospital's relevant discharges. Detailed information concerning measure
specifications and calculation of the rates is available at www.QualityNet.org.
This site displays data provided by
acute care "general"- Opens in a new window
hospitals (including acute care - VA Medical Centers- Opens in a new window),
children's- Opens in a new window
hospitals, and "critical access"- Opens in a new window
hospitals, which are small, generally geographically remote rural hospitals.
Beginning with discharges in 2004, eligible acute care hospitals could elect to
report quality data in order to receive the incentive payment established by
Section 501(b) of the Medicare Prescription Drug, Improvement and Modernization
Act of 2003 (MMA). To obtain increased payment, the provision required eligible
hospitals to report on an initial set of 10 quality performance measures (the
"starter set") and to agree to have their data publicly displayed.
Initially, almost all hospitals eligible for the payment incentive provided data
for the 10 "starter set" measures, reflecting care delivered during 2004. Under
Section 5001(a) of the Deficit Reduction Act of 2005, the set of measures
included in the incentive was expanded, the magnitude of the incentive was
increased, and the time-limit for the provision removed. More information about
these provisions is available at
Reporting Hospital Quality Data for Annual Payment Update.- Opens in a new window
The majority of these acute care hospitals are voluntarily providing data on measures that have been identified by CMS and other stakeholders. The measure set currently consists of 36 measures:
- the ten "starter set" measures first published in October 2003
- seven new measures first published in April 2005
- three new measures first published in September 2005
- one measure first published in December 2006
- one measure first published in June 2007
- two measures first published in December 2007
- two measures first published in August 2008
- two measures first published in December 2008
- one measure first published in September 2009
- one measure first published in December 2009
- seven measures first published in June 2010
- one measure first published in December 2010
For a full listing of the measures see
measures list- Opens in a new window.
Critical access hospitals, which also provide acute care, also participate in the HQA. The critical access hospitals do
not receive any financial incentive to report since they are not eligible for the incentive payment established by Section
501(b) of the MMA or 5001(a) of the DRA. These hospitals may elect to submit data for any or all of the measures in the
measure set, and may elect to report data but not have it displayed on the website. While critical access hospitals play
an important role in care in rural areas, measure design may affect the number of eligible cases reported by these hospitals.
The data collection approach was primarily retrospective. Data sources for required data elements included administrative
data and medical record documents. Some hospitals may prefer to gather data concurrently by identifying patients in the
population of interest. This approach provides opportunities for improvement at the point of care/service. However,
complete documentation includes the principal and other ICD-9-CM diagnosis and procedure codes, which require retrospective data entry.