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FAQs

1. Who or what is CMS?

Centers for Medicare and Medicaid Services. It is the national administering agency for the Medicare program. It also works with states to administer each state’s Medicaid program. CMS also insures many of the most complicated patients. If a hospital preforms well with their CMS patients, it is a good indication they will do well with less complicated patients.

2. Who is the CDC?

Center for Disease Control and Prevention. It is a national organization under the Department of Health and Human Services and is headquartered in Atlanta Georgia. Why isn’t it called the CDCP? We wonder the same thing.

3. What is the Patient Summary score?

It is an aggregate score of the patient survey results, referred to as HCAHPS or hospital consumer assessment of healthcare providers and systems. It affects the reimbursement of a facility by CMS.

4. What is a Central Line Associated Bloodstream Infection?

According to the CDC, a central line is like an IV, but instead of being put in a peripheral location like the hand or arm, these are long-term access points for the administration of medicine and fluids and/or the collection of blood. Because these access points can be in place for weeks or months, they can be prone to infection. Strict medical procedures are in place for keeping the area clean and maintained.

5. What is a Catheter Associated Urinary Tract Infection?

According to the CDC, this is any infection of the urinary system when a catheter is in place. It is the most common type of healthcare-related infection as reported by the National Healthcare Safety Network.

6. What is an "SSI"?

SSI is an abbreviation for Surgical Site Infection. This means at the site of surgery a patient exhibits an infection after the surgery is done. It is possible for incisions to become infected if the surgical site is not cared for properly before and after surgery.

7. What is MRSA Bacteremia?

It stands for Methicillin-resistant Staphylococcus aureus. It is a type of bacterial infection that is resistant to antibiotics.

8. What is Clostridium Difficile (C. Diff)?

C.Diff is a bacterium that causes severe diarrhea. According to the CDC, 1 in 11 people that get Clostridium Difficile, who are over the age of 65 will die within a month.

9. What is discharge information?

When a patient is transitioning from a hospital stay to home care, these are the advice, prescriptions, directions, instructions, and expectations for the patient and caregivers to take over care and recovery. What happens after a procedure can be as important than the procedure itself. Top performing hospitals educate and empower their patients and caregivers with knowledge and a path forward to recovery.

10. What is the difference between a heart attack and heart failure?

According to the CDC, a heart attack is what happens when part of the heart muscle doesn’t get enough blood flow. It is also known as a Myocardial Infarction (MI). Heart failure is when the heart cannot pump enough blood to the rest of the body. Both are types of heart disease, but have unique symptoms and different treatments.

11. What is CABG surgery?

CABG is an abbreviation for Coronary Artery Bypass Grafting. According to the NIH it is one of the more common heart related surgeries. It is commonly referred to as a heart bypass or just bypass surgery.

12. What is COPD?

COPD is an abbreviation for Chronic Obstructive Pulmonary Disease. COPD refers to a group of diseases that cause airflow blockage and breathing-related problems. It is frequently one of the top 5 reasons for death in a patient of the United States.

13. What is iatrogenic pneumothorax?

According to the NIH, this refers to a buildup of gas in the space between the lung and the outer lining of the lung and is frequently caused from trauma, or even from a procedure. It can be asymptomatic, a minor discomfort, or even life-threatening.

14. What does perioperative mean when discussing surgery?

Perioperative refers to the phase before surgery (preoperative), the phase during surgery (intraoperative) and the phase after surgery (postoperative).

15. What is a hemorrhage?

It is the loss, often acute (significant), of blood from a blood vessel. It can be either internal (bleeding inside the body), or external (bleeding outside the body) and from any cause.

16. What is a hematoma?

It is a pocket or collection of blood, from an internal hemorrhage.

17. What is a pulmonary embolism?

The blocking of the arteries going to the lungs or one of the branches of the lungs by a blood clot or other undissolved object.

18. What is a deep vein thrombosis (DVT)?

According to the CDC, this is when a blood clot has formed in one of the deep veins far from the heart. These most commonly occur in the legs, often in the lower legs.

19. What is sepsis?

Sepsis is an overreaction from the immune system that can cause significant damage to the tissues, organs, and even death. It is not the disease itself, but the body’s reaction to the disease.

20. What is wound dehiscence?

According to the NIH, this is when a wound separates before completely healing, thus reopening. It can be caused by infection, internal pressures, adverse elements to the clotting process, or a host of other factors.

21. What is the abdominopelvic area?

This is the area of the body roughly from the bottom of the sternum to the pelvic synthesis (the pelvic bone just above the genitals).

22. Do you have information on pediatric services and Labor and Delivery (L&D)?

Not at this time. CMS is tracking patients usually over the age of 65. This is helpful when looking at the scores we have posted because these are often the most challenging medical situations. Unfortunately, this also means CMS is not checking services specifically for pediatrics and labor and delivery. As we find credible data sources, we will make the information available. To stay in the know, sign up for our email updates, and follow us on Facebook, Twitter or Instagram.

23. What is the CMS Medicare PSI 90?

It is a composite average of all of the Adverse Condition scores measured by CMS. It is understood in healthcare as a kind of overall risk score.

24. What does Nurse Communication star score mean?

It is actually four scores involving patient interactions with nurses. Those questions cover general communication, if the patient felt respected, did the nurse(s) listen, and if they explained things in a way the patient could understand. For each of these, the patient can choose between “always”, “usually”, “sometimes” or “never.”

25. What does Doctor Communication star score mean?

It is actually four scores involving interactions with doctors. Those questions cover general communication, if the patient felt respected, did the doctor(s) listen, and if they explained things in a way the patient could understand. For each of these the patient can choose between “always”, “usually”, “sometimes” or “never.”

26. What does Staff Responsiveness star score mean?

It is a summary of three questions. The scores are related to if patients received help as soon as they wanted, received responses from the call button as soon as they wanted, and received help for the bathroom as soon as they wanted. For each of these, the patient can choose between “always”, “usually”, “sometimes” or “never.”

27. What does Communication About Medicines star score mean?

It is a summary of three questions. The scores are related to if medicines were explained before giving them, if it was explained what the medications were for, and if side effects of the medications were explained. For each of these the patient can choose between “always”, “usually”, “sometimes” or “never.”

28. What does Discharge Information star score mean?

It is a summary of three questions. The scores are related to information about what to do during their recovery at home, discuss if the patient would need help after discharge, and if patients received written information about possible symptoms on their discharge. For each of these the patients can choose between “Yes” or “No.”

29. What does Care Transition star score mean?

It is a summary of four questions. The scores are related to if the patients understood their care when they left the hospital, the staff took the patient's preference into account when determining the patients healthcare needs, patients understood their responsibilities in managing their health, and patients understood the purpose of their medication when leaving the hospital. For each of these the patient can choose between “Strongly Agree”, “Agree”, “Disagree”, or “Strongly Disagree.”

30. What does Cleanliness star score mean?

It is the summary of one question. The score is for reporting their room and bathroom were clean. For the question the patient could choose “Always”, “Usually”, “Sometimes”, or “Never.”

31. What does Quietness star score mean?

It is the summary of one question. The score is for reporting the area around their room was quiet at night. For the question the patient could choose “Always”, “Usually”, “Sometimes”, or “Never.”

32. What does Overall Hospital rating mean?

It is the summary of one question. The score is for reporting patients overall rating from 0-10. Patient ratings are grouped by 0-6, 7-8, and 9-10.

33. What does Recommended Hospital rating mean?

It is the summary of one question. The score is for reporting if patients would recommend the hospital. Patients could choose between “No”, “Yes (probably)”, and “Yes (definitely).”

34. What are the national averages for?

The national averages show an aggregate look at healthcare across the nation. The advantage is in some measurements it gives a benchmark to compare the hospital with. Context is everything. Unfortunately it is not structured in a way that is easily drilled down to the facility level.

35. How is the Overall CMS score calculated?

According to the CMS, the score is compiled based on the following: Mortality 22%, Safety 22%, Readmission 22%, Patient Experience 22% and Timely & Effective Care 12%. Some hospitals will be lacking in service line related scores. For example, an orthopedic surgical hospital will not be seeing labor and delivery, cancer or heart attack patients. As a result, they will not have those scores, so the remaining scores are weighted heavier to come to the full 100% summary.

36. How are the Overall CMS rankings distributed across the United States?

According to CMS, as of April 2021: ⭐ star 204 hospitals or 6.06%| ⭐⭐ star 690 hospitals or 20.57%| ⭐⭐⭐ star 1,018 hospitals or 30.34%| ⭐⭐⭐⭐ star 988 hospitals or 29.45%| ⭐⭐⭐⭐⭐ star 455 hospitals or 13.56%|

37. What do the Infection scores mean and how are they calculated?

The easy explanation is the value 1.000 is the national average. Less than 1.000 is better than the national average, the smaller the better. More than 1.000 is worse than the national average, the greater the number the worse. | Easy answer ends here| For the complicated answer go to the National Healthcare Safety Network (NHSN) and look for SIR (standard infection ratio) reporting. https://www.cdc.gov/nhsn/ps-analysis-resources/keys-to-success.html

38. What is an HAI?

An HAI is a Healthcare Associated Infection. In short it is an infection a patient did not have prior to seeking healthcare treatment that was acquired in the process of receiving treatment. HAIs are the events reported on the Infections table.

39. Why are the scores "Not Available" for some hospitals?

There are a couple of reasons. First if it is a Children's Hospital, a VA Hospital or a Psychiatric Hospital they don't see the right type of patients for most scores. Another reason is it might be a Specialty Hospital that is devoted to a single medical service like Cardiology or Orthopedics. These Hospitals will have some data, but not complete scores and may not have the Overall CMS scores. We also see Hospitals not open during the evaluation period.

40. What is the National Institute of Health (NIH)?

The National Institutes of Health (NIH) is a part of the U.S. Department of Health and Human Services and is the nation's medical research agency. It is made up of 27 different components called Institutes and Centers.

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