Timely & effective care measures
The measures of timely and effective care, also known as process of care measures, show how often or how quickly hospitals provide care that research shows gets the best results for patients with certain conditions. Hospital Compare reports measures in these categories:
- Sepsis care
- Cataract surgery outcome
- Colonoscopy follow-up
- Heart attack care
- Emergency department care
- Preventive care (includes influenza vaccination measures)
- Cancer care
- Pregnancy and delivery care
- Use of medical imaging
Where the information comes from
Most of the measures included under timely and effective care come from the data that hospitals get from the medical records of their eligible patients. The data submission process includes auditing procedures and edit checks that allow hospitals to check if the data they are submitting are consistent with what the Center for Medicare & Medicaid Services (CMS) has specified. CMS later validates some of the submitted data to ensure that it is accurate. Visit QualityNet- Opens in a new window Exit Disclaimer - Opens in a new window for more information on the data validation process.Healthcare worker vaccination data comes from the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN)- Opens in a new window. Hospitals submit data to the NHSN based on employee health records and self-reported vaccination records.
The use of medical imaging measures are calculated using data from claims that hospitals and physicians submit for Medicare beneficiaries enrolled in Original Medicare.
Data are available for Veterans Health Administration (VHA) hospitals for some heart attack care, emergency department care, preventive care, and blood clot prevention measures. View the complete list of timely and effective care measures reported on Hospital Compare for VHA hospitals- Opens in a new window.
VHA collects this information through the VA’s External Peer Review Process (EPRP) or directly from electronic medical records. Validation of VHA data is performed within the EPRP process, by VHA staff, and by The Joint Commission- Opens in a new window.
Department of Defense (DoD) data is collected from military hospitals. Clinical quality measures are reviewed and monitored through special clinical studies, Joint Commission facility reviews, and Health Plan performance oversight.
Who the measures apply to
Most of the measures of timely and effective care apply to any adult patients treated at hospitals participating in the Hospital Inpatient Quality Reporting (IQR) Program - Opens in a new window and Outpatient Quality Reporting (OQR) Program. - Opens in a new window These include people with Medicare, Medicare managed care patients, and non-Medicare patients. Hospitals with a large number of discharges may provide data from a sample of eligible Medicare and non-Medicare patients, based on CMS sampling rules. For VHA and Department of Defense (DoD) hospitals, the measures apply to eligible adult patients treated at VHA or DoD hospitals in accordance with The Joint Commission guidelines.
The healthcare worker influenza vaccination measure tracks the number of healthcare workers who got the flu vaccine each flu season. This measure applies to all facility employees, licensed independent practitioners, adult students/trainees and adult volunteers, and includes those employees who work in a hospital outpatient department.
The use of medical imaging measures apply only to Medicare beneficiaries enrolled in Original Medicare who were treated as outpatients in hospital outpatient departments participating in the OQR Program. These measures don’t include Medicare managed care patients, non-Medicare patients, or patients who were admitted to the hospital as inpatients.
CMS doesn't perform tests of statistical significance in reporting hospital data on the measures of timely and effective care on Hospital Compare. However, the information provided on the site allows confidence intervals to be calculated for each reported measure, based on sample size. The smaller the sample size, the greater the difference in rates must be in order for that difference to be statistically meaningful. Large differences between individual hospitals’ rates may be significant, but small differences between hospitals are usually not significant.