Overall Hospital Quality Star Rating Frequently Asked Questions for Hospitals General Questions Q. What types of measures are used in the Star Rating calculation? A. CMS uses a subset of quality measures that are required as part of the Hospital Inpatient Quality Reporting (IQR) Program and Hospital Outpatient Quality Reporting (OQR) Program. The measures used fit into three main categories: 1. Process of Care measures are measures in which hospitals submit data to the CMS clinical data warehouse based on a set of specifications published on the Quality Net website. These measures are validated by the CMS Data and Abstraction Center (CDAC), a contractor tasked with re-abstracting data from medical records to assess inter-rater reliability. Measures that do not pass this validation are considered a mismatch. Hospital must achieve at least 75 percent matching score, or they fail validation and may not receive their entire annual payment update. 2. Claims based outcomes measures are calculated using Medicare part A hospital claims. The claims used for the calculation of the measures are the most final claims, which have already been reconciled and scrubbed for errors. This data is part of the Medicare Provider Analysis and Review or MEDPAR file. 3. Data on healthcare associated infections (HAIs) comes to CMS from the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN). These patient level data are submitted by participating hospitals to the CDC based on a set of specifications published on the CDC website. The HAI data relies on hospitals capturing the appropriate lab results and other clinical factors. CMS also validates this data through the CDAC. Q. Why is CMS planning to introduce the Overall Hospital Quality Star Rating to Hospital Compare? A. The Overall Hospital Quality Star Rating on Hospital Compare spotlights excellence in health care quality measures reported to CMS, and helps make quality information on Hospital Compare more accessible and actionable for consumers. CMS chose stars because consumers are familiar with the concept from other websites. These star rating programs are part of the Administration’s Open Data Initiative which aims to make government data freely available and useful while ensuring privacy, confidentiality, and security. The Hospital Compare Overall Hospital Quality Star Rating summarizes hospital quality data already reported on the Hospital Compare website. The Overall Hospital Quality Star Rating is intended to supplement, rather than replace, the information on the Hospital Compare website. At the facility level, the Overall Hospital Quality Star Rating provides a summary of a hospital’s performance on a broad range of measures displayed on Hospital Compare. Q. How can consumers use the Overall Hospital Quality Star Rating on Hospital Compare to choose a hospital? A. Hospitals with higher Overall Hospital Quality Star Rating (i.e., 4 - 5 stars) perform better on existing CMS quality measures compared to other facilities. Lower Overall Hospital Quality Star Rating (i.e., 1 - 2 stars) indicate lower overall quality compared to other facilities. A 3-star rating indicates that a hospital performs about the same as other hospitals. The Overall Hospital Quality Star Rating is one of many sources of information that consumers can use when choosing a hospital. Consumers can consult the Overall Hospital Quality Star Rating, along with other information on Hospital Compare, to learn about the quality of hospitals, compare facilities sideby-side, and ask quality-related questions when visiting a hospital or healthcare provider. Q. Does CMS plan to replace the measures currently displayed on Hospital Compare? A. No, the Overall Hospital Quality Star Rating will not replace measures currently displayed on Hospital Compare. Hospital Compare will continue to display the individual quality measure information used to calculate the overall rating. Data on individual measures will also be available for download. CMS will continue to update the measures reported on Hospital Compare based on rulemaking. The methodology for the Overall Hospital Quality Star Rating allows for future changes, like retirement of existing measures or addition of new measures through notice and comment rulemaking. Q. When did hospitals first see their Overall Hospital Quality Star Rating? A. Hospitals first had the opportunity to preview their Overall Hospital Quality Star Rating during the July 2015 “dry run” period where hospitals were given the chance to review reports and submit feedback through a 30-day public input period. In addition, hospitals were also able to view their updated Overall Hospital Quality Star Rating during the “preview” period, between May and June, 2016, using data consistent with what will be published during the July 2016 update to the website. Q. How will the information be useful to consumers if, for example, all hospitals in a given community receive 3 stars? A. While a majority of hospitals may receive a rating of 3-stars, the Overall Hospital Quality Star Rating makes it easier for patients and families to identify those hospitals that perform better or worse than other hospitals. Consumers may also benefit from the knowledge that certain hospitals perform similarly. The Overall Hospital Quality Star Rating is one of many sources of information a consumer can use when selecting a hospital, including individual quality measures, input from providers, recommendations, and location. Q. How often will CMS update the Overall Hospital Quality Star Rating on Hospital Compare? A. CMS plans to update the Overall Hospital Quality Star Rating on a quarterly basis along with the website refresh, although a specific schedule for updates has not yet been determined. We welcome feedback and input on the frequency for Overall Hospital Quality Star Rating updates. Q. How does the Overall Hospital Quality Star Rating differ from the patient experience Star Rating that is already on Hospital Compare? A. The Overall Hospital Quality Star Rating is calculated using 64 existing quality measures across seven different measure groups and provides a comprehensive picture of hospital performance. The patient experience Star Rating (also known as the HCAHPS Summary Star Rating) is based only on HCAHPS Survey (patient survey) data. The HCAHPS Summary Star Rating Technical Notes are available on the HCAHPS survey website. Quality Measures Used in the Overall Hospital Quality Star Rating Q. How many individual measures are included in the calculation of the Overall Hospital Quality Star Rating? Which CMS programs do these measures come from? A. The Overall Hospital Quality Star Rating on Hospital Compare includes data from 64 existing measures adopted through notice and comment rulemaking. These measures are from the Hospital Inpatient Quality Reporting (IQR) Program and the Hospital Outpatient Quality Reporting (OQR) Program. CMS focuses on reporting measure data that have high impact and support national priorities for improved quality and efficiency of care for Medicare beneficiaries. Q. How did CMS choose the measures included in the Hospital Compare Overall Hospital Quality Star Rating? A. CMS developed the Overall Hospital Quality Star Rating to be inclusive of as many measures already published on Hospital Compare as possible to present the most comprehensive picture of hospital quality for patients and consumers. The methodology includes a systematic process for determining the eligibility of a measure. CMS uses the following criteria to exclude measures from the calculation: 1. Measures suspended, retired, or delayed in the programs and/or from public reporting on Hospital Compare 2. Measures with no more than 100 hospitals reporting performance publicly 3. Structural measures 4. Measures for which it is unclear whether a higher or lower score is better (nondirectional) 5. Measures no longer required for Hospital IQR Program or Hospital OQR Program 6. Duplicative measures (e.g., identical measures or a composite measure consisting of individual measures) CMS will continue to consider feedback when evaluating future measures along these criteria. Q. Why is PSI-90 and the Hospital-Wide Readmission (HWR) measure included in the Overall Hospital Quality Star Rating given recent concerns by some stakeholders? A. Both of these measures are NQF endorsed and MAP recommended, and we believe they are valid determinants of hospital quality. In developing the Overall Hospital Quality Star Rating, CMS set forth criteria for measure inclusion and exclusion based on recommendations from a Technical Expert Panel (TEP) and public input. The PSI-90 and HWR measures meet the criteria for inclusion, and therefore, will remain a part of the methodology. CMS will continue to analyze the data and determine in the future if changes need to be made to the measure selection criteria. Q. Will CMS add new measures to the Hospital Compare Overall Hospital Quality Star Rating? A. The measures included may change in the future as measures are added to, and removed from, relevant CMS quality programs through notice and comment rulemaking (e.g., the Hospital IQR and OQR Programs) and Hospital Compare. The Star Rating methodology was designed to allow for additions and removal of measures. When new measures are added to programs, CMS will evaluate whether they should be included in the Overall Hospital Quality Star Rating. Q. What are the reporting periods for the measures included in the Hospital Compare Overall Star Rating? A. As of the July release, the reporting periods for the measures included in the Overall Hospital Quality Star Rating are the same as for the individual measures reported on Hospital Compare. For a list of reporting periods for individual measures, see the Measures and data collection reporting periods table. Methodology of the Overall Hospital Quality Star Rating Q. Did CMS take stakeholders’ feedback into account when developing the methodology for the Overall Hospital Quality Star Rating? A. Responsiveness to stakeholder feedback was a guiding principle for the initial development of the methodology, and will continue to be a priority for future refinements. CMS engaged closely with hospitals and other stakeholders throughout the development process. CMS held two opportunities for public input, two national stakeholder calls with over 4,000 participants, and technical expert panel (TEP) meetings. The TEP included several nominees from the Association of American Medical Colleges (AAMC), American Hospital Associations (AHA), and state hospital associations. In addition, CMS hosted a webinar for hospitals and other stakeholders to demonstrate the methodology. CMS maintained an open dialogue with hospitals, responding to individual questions during the July 2015 hospital “dry run” and both the April 2016 and July 2016 planned release dates. CMS is committed to improving outcomes and working with stakeholders to improve individual quality measures, while minimizing unintended consequences for all facilities, regardless of the characteristics of the patients they serve. Following the release of the Overall Hospital Quality Star Rating, CMS will continue to work with stakeholders and re-evaluate the methodology in order to inform modifications to promote improved alignment with the methodology development principles, and/or improve the statistical performance of the Overall Hospital Quality Star Rating. Q. How is the Hospital Compare Overall Hospital Quality Star Rating calculated? A. The Overall Hospital Quality Star Rating is calculated using a five-step process: 1. Measures are selected for inclusion based on a set of criteria. 2. Measures are assigned to groups. 3. Seven different latent variable models (discussed in detail below) are used to calculate measure group scores. 4. A hospital summary score is calculated using the weighted average of the group scores. 5. The hospital summary score is translated into a star rating using a clustering algorithm. The methodology report, posted on QualityNet, has more detailed information. Q. Is the dataset for the Hospital Compare Overall Hospital Quality Star Rating publicly available? A. In response to stakeholder feedback, CMS has determined we will be releasing the Statistical Analysis Software (SAS) Pack as soon as the website goes live. The SAS pack will include the statistical software code used in the calculation, the user guides and the national input file containing all of the data required to run the model. It is important to note that different versions of SAS, or even computer hardware, may generate minor differences in overall results. Q. How are the measures grouped? A. To calculate the Overall Hospital Quality Star Rating, the measures are categorized into seven mutually exclusive groups: 1. 2. 3. 4. 5. 6. 7. Outcomes – Mortality (7 measures) Outcomes – Safety of Care (8 measures) Outcomes – Readmissions (8 measures) Patient Experience (11 measures) Process – Effectiveness of Care (18 measures) Process – Timeliness of Care (7 measures) Efficiency – Outpatient Imaging Use (5 measures) These seven groups generally align with the categories on the Hospital Compare website, the CMS Hospital Value-Based Purchasing (VBP) Program, and other national quality initiatives. Listed below are the measures included in each group: Mortality (N=7) Measure MORT-30-AMI MORT-30-CABG MORT-30-COPD MORT-30-HF MORT-30-PN MORT-30-STK PSI-4-SURGCOMP Description Acute Myocardial Infarction (AMI) 30-Day Mortality Rate Coronary Artery Bypass Graft (CABG) 30-Day Mortality Rate Chronic Obstructive Pulmonary Disease (COPD) 30-Day Mortality Rate Heart Failure (HF) 30-Day Mortality Rate Pneumonia (PN) 30-Day Mortality Rate Acute Ischemic Stroke (STK) 30-Day Mortality Rate Death Among Surgical Patients with Serious Treatable Complications Safety of Care (N=8) Measure HAI-1 HAI-2 HAI-3 HAI-4 HAI-5 HAI-6 Description Central-Line Associated Bloodstream Infection (CLABSI) Catheter-Associated Urinary Tract Infection (CAUTI) Surgical Site Infection from colon surgery (SSI-colon) Surgical Site Infection from abdominal hysterectomy (SSI-abdominal hysterectomy) MRSA Bacteremia Clostridium Difficile (C.difficile) Measure COMP-HIP-KNEE PSI-90-Safety Description Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) Complication/Patient Safety for Selected Indicators (PSI) Readmission (N=8) Measure READM-30-AMI READM-30-CABG READM-30-COPD READM-30-HF READM-30-HipKnee READM-30-PN READM-30-STK READM-30-HOSPWIDE Description Acute Myocardial Infarction (AMI) 30-Day Readmission Rate Coronary Artery Bypass Graft (CABG) 30-Day Readmission Rate Chronic Obstructive Pulmonary Disease (COPD) 30-Day Readmission Rate Heart Failure (HF) 30-Day Readmission Rate Hospital-Level 30-Day All-Cause Risk- Standardized Readmission Rate (RSRR) Following Elective Total Hip Arthroplasty (THA)/ Total Knee Arthroplasty (TKA) Pneumonia (PN) 30-Day Readmission Rate Stroke (STK) 30-Day Readmission Rate HWR Hospital-Wide All-Cause Unplanned Readmission Patient Experience (N=11) Measure H-CLEAN-HSP H-COMP-1 H-COMP-2 H-COMP-3 H-COMP-4 H-COMP-5 H-COMP-6 H-HSP-RARTING H-QUIET-HSP H-RECMND H-COMP-7 Description Cleanliness of Hospital Environment (Q8) Nurse Communication (Q1, Q2, Q3) Doctor Communication (Q5, Q6, Q7) Responsiveness of Hospital Staff (Q4, Q11) Pain management (Q13, Q14) Communication About Medicines (Q16, Q17) Discharge Information (Q19, Q20) Overall Rating of Hospital (Q21) Quietness of Hospital Environment (Q9) Willingness to Recommend Hospital (Q22) HCAHPS 3 Item Care Transition Measure (CTM-3) Effectiveness of Care (N=18) Measure CAC-3 IMM-2 IMM-3/OP-27 OP-4 OP-22 OP-23 Description Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver Influenza Immunization Healthcare Personnel Influenza Vaccination Aspirin at Arrival ED-Patient Left Without Being Seen ED-Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke who Received Head CT or MRI Scan Interpretation Within 45 Minutes of Arrival Measure OP-29 OP-30 PC-01 STK-1 STK-4 STK-6 STK-8 VTE-1 VTE-2 VTE-3 VTE-5 VTE-6 Description Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use Elective Delivery Prior to 39 Completed Weeks Gestation: Percentage of Babies Electively Delivered Prior to 39 Completed Weeks Gestation Venous Thromboembolism (VTE) Prophylaxis Thrombolytic Therapy Discharged on Statin Medication Stroke Education Venous Thromboembolism Prophylaxis Intensive Care Unit Venous Thromboembolism Prophylaxis Venous Thromboembolism Patients with Anticoagulation Overlap Therapy Venous Thromboembolism Warfarin Therapy Discharge Instructions Hospital Acquired Potentially-Preventable Venous Thromboembolism Timeliness of Care (N=7) Measure ED-1b ED-2b OP-3 OP-5 OP-18b/ED-3 OP-20 OP-21 Description Median Time from ED Arrival to ED Departure for Admitted ED Patients Admit Decision Time to ED Departure Time for Admitted Patients Median Time to Transfer to Another Facility for Acute Coronary Intervention Median Time to ECG Median Time from ED Arrival to ED Departure for Discharged ED Patients Door to Diagnostic Evaluation by a Qualified Medical Professional ED-Median Time to Pain Management for Long Bone Fracture Efficient Use of Medical Imaging (N=5) Measure OP-8 OP-10 OP-11 OP-13 OP-14 Description MRI Lumbar Spine for Low Back Pain Abdomen CT Use of Contrast Material Thorax CT Use of Contrast Material Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac Low-Risk Surgery Simultaneous Use of Brain Computed Tomography (CT) and Sinus CT Q. Are the measures weighted? If so, how are they weighted and why? A. Yes. For each hospital, each group score is weighted to calculate a summary score. The weights are as follows: Measure Group Mortality Safety Readmission Patient Experience Effectiveness of Care Timeliness of Care Efficient Use of Medical Imaging Weight of Measure Group Used in Calculation 22% 22% 22% 22% 4% 4% 4% The following criteria were applied to determine how each measure group is weighted: • • • • Measure importance, including prioritizing outcome measures over process measures Consistency with other CMS programs, such as the Hospital Value-Based Purchasing Program Alignment with CMS priorities, as outlined in the CMS Quality Strategy Stakeholder input, including the prioritization of measure groups by the Technical Expert Panel (TEP), public input periods, the hospital dry run, and additional sources of patient and consumer feedback. Q. Is any single measure given relatively more weight in the calculation of the Overall Hospital Quality Star Rating? A. Yes, some measures are given more weight in the group score calculation. Group scores are calculated using latent variable models (LVM). The LVM accounts for the correlation between measures for a single hospital. Latent variable modeling is a commonly used method for developing composite measures. 1 CMS chose this approach based on statistical literature regarding healthcare quality measure aggregation and the previous use of LVM in other disciplines, such as psychology and education. The LVM assigns a “loading” to each measure in the group. Measures that are more consistent with each other, as well as measures with large denominators, have a higher “loading” and greater influence on the group score than measures with lower loadings. The loadings for an individual measure are re-estimated each time the Overall Hospital Quality Star Rating are updated; and can dynamically change as the distribution of hospitals’ performance on the measure, and its correlation with other measures, evolve over time. The use of data-driven loadings also allows the star ratings to evolve over time without requiring more subjective assignments of weights to individual measures each quarter. 1 Shwartz M, Ren J, Pekoz EA, Wang X, Cohen AB, Restuccia JD. Estimating a composite measure of hospital quality from the Hospital Compare database: differences when using a Bayesian hierarchical latent variable model versus denominator-based weights. Medical Care 2008;46:778-85. By studying outlying hospitals, CMS concluded that it is unlikely that any one measure precludes a hospital of a given type from performing well. For example, a hospital that has poor performance on a single safety of care measure, such as PSI-90, may still receive a high safety of care group score and a high rating if it performs well on other safety of care measures. Q. What is “loading” in the current methodology? Please provide a concrete example. A. Loading is the influence of an individual measure on the group score. Measures that are more consistent, or more correlated, with other measures within the group have a greater influence on a hospital’s group score. A loading reflects the degree of the measure’s influence on the group score relative to the other measures in the same group. A measure’s loading is the same across all hospitals. Measures with higher loadings are more strongly associated with the group score and the other measures within that group. All measures included in the Overall Hospital Quality Star Rating have an effect on the group score; however, measures with higher loadings have a greater association (or impact) on the group score than measures with substantially lower loadings. The degree a given measure contributes to a hospital’s group score is dependent upon the following: • • • • A hospital’s measure score; A hospital’s measure denominator (case count); National performance on the measure; and The value of the loading relative to the loadings of other measures in the group. For example, if a hospital performs well on a measure with a large denominator (indicating greater precision of the measure score estimate), broad distribution of national performance, and high loading, this measure will contribute more to the group score than a measure for which any of these characteristics are reversed. In other words, if a measure has the same loading value but a narrow distribution of national performance, this measure will contribute less to the hospital’s group score. The loadings alone cannot evaluate the measure’s relationship to the group score, and therefore cannot alone determine a hospital’s star rating. Q. Does the methodology adjust for differences in patient populations between academic vs. non-academic settings? A. The Overall Hospital Quality Star Rating incorporates risk adjustment at the individual measure-level where appropriate. Many hospital outcome measures are currently risk-adjusted to account for differences in patient case-mix, or health risk, between hospitals. For example, for patients transferred from a smaller hospital to an academic medical center, the condition-specific mortality measures hold the transferring facility accountable, not the receiving facility. Q. Does the Overall Hospital Quality Star Rating only use Medicare fee-for-service (FFS) data or do they utilize data from all payers, including, Medicare Advantage, dual eligible, and other categories? A. The claims-based measures, which include the mortality, readmission, complications, PSI-90, and imaging efficiency measures, are calculated using Medicare FFS hospital claims data only. The process of care, healthcare-associated infection (HAI), and HCAHPS Survey measures include data from all payers. Q. What is the k-means clustering approach and why was it used? A. CMS considered several approaches for classifying hospitals into each of the five star categories. The TEP and public input helped to determine that the k-means clustering would allow the Overall Hospital Quality Star Rating to meet a variety of classification goals. K-means clustering intuitively groups hospitals together that have similar hospital summary scores. Kmeans clustering is preferred to other approaches, such as the quintile approach, which may draw arbitrary distinctions between otherwise similarly scoring hospitals that happen to fall on each side of a cutoff point. K-means clustering allows for the size of each group to be unequal and for a non-normal distribution of the Overall Hospital Quality Star Rating. For example, in the most recent reporting period, there are more three star hospitals because many hospitals perform near the national average overall and across many of the measures that they report. Q. What is Winsorization? Why is it used in the methodology? A. Winsorization is a strategy commonly used to set extreme outliers to a specified percentile of the data. Winsorization is used in the methodology to reduce the effect of outliers at two different stages of the calculation: 1) we Winsorize individual measures scores; 2) we Winsorize hospital summary scores prior to k-means clustering. The decision to Winsorize hospital summary scores was made following the second public input period and is responsive to patients’ and consumers’ preference for a broader distribution of Overall Hospital Quality Star Rating. Hospital Eligibility Q. Will every hospital have an Overall Hospital Quality Star Rating on Hospital Compare? A. In order to receive an Overall Hospital Quality Star Rating, a hospital must have sufficient data to report measure results. Hospitals must meet a minimum measure threshold of three measures, in a minimum measure group threshold of three groups (with at least one outcomes group) for a total of at least 9 measures. If a hospital has missing values for three or more measures in a measure group and lacks sufficient measures in three or more groups, an Overall Hospital Quality Star Rating cannot be calculated. This does not necessarily mean that a hospital did not report data or that a hospital provides poor quality care. The facility could be new and/or small, or have an insufficient number of cases. Q. How would the Overall Hospital Quality Star Rating be calculated for a small hospital with few measures on Hospital Compare? A. To receive an Overall Hospital Quality Star Rating, a hospital must have sufficient data to calculate measure results. If the hospital meets the minimum requirements, then the Overall Hospital Quality Star Rating will be reported using the same methodology as hospitals with many measures. If the hospital does not meet the minimum requirement in at least three groups (with at least one outcomes group), then the hospital does not receive an Overall Hospital Quality Star Rating. Overall Hospital Quality Star Rating Results Q. How does each star category indicate quality of care? A. Hospitals with a higher Overall Hospital Quality Star Rating (i.e., 4 - 5 stars) perform better on CMS quality measures compared to other facilities. A lower Overall Hospital Quality Star Rating (i.e., 1 - 2 stars) indicates poorer performance compared to other facilities. Three stars indicate a hospital performs about the same as other hospitals. Q. If hospitals are not satisfied with their Overall Hospital Quality Star Rating, how can hospitals improve? A. The scoring methodology supports excellence in quality across all seven measure groups (i.e., Outcome – Mortality; Outcome – Safety of Care; Outcomes – Readmission; Patient Experience; Process – Effectiveness of Care; Process – Timeliness of Care; and Efficiency – Imaging Use). A hospital can improve its star rating by improving quality across all reported measures, particularly outcome measures and patient experience measures which receive higher weighting. Improvement in a few specific measures or a lower weighted measure group is unlikely to substantially change a rating. It is important to note that the Overall Hospital Quality Star Rating is based on relative performance, and hospitals that improve to a greater degree than other hospitals are likely to achieve higher Overall Hospital Quality Star Rating. Q. Could hospitals improve their Overall Hospital Quality Star Rating by selecting the measures for CMS to report? A. No, the Hospital Compare Overall Hospital Quality Star Rating is based on reported measures across seven categories that meet the inclusion criteria. The Overall Hospital Quality Star Rating does not alter or modify any quality reporting requirements or payment incentives, and hospitals may not select specific measures for the Overall Hospital Quality Star Rating. Q. Is it possible for hospitals to submit more timely reporting data to improve its Overall Hospital Quality Star Rating before the quarterly update? A. No, the data used to generate the Overall Hospital Quality Star Rating must be from the same reporting data as the data on Hospital Compare and the data from other hospitals used to generate the national average. Overall Hospital Quality Star Rating and Payment Programs Q. Will CMS reduce hospital payments based on the Overall Hospital Quality Star Rating on Hospital Compare? A. No, CMS will not use the Overall Hospital Quality Star Rating on Hospital Compare to determine payment; however, the measures included in the star rating are also used in other CMS programs such as IQR and OQR. The overall rating is only intended to summarize existing measures. Other Q. How can I correct suspected errors or appeal my rating? A. Please submit a request, including the CMS Certification Number (CCN) via the Inpatient Questions and Answers tool at https://cms-ip.custhelp.com or the Outpatient Questions and Answers tool at https://cms-ocsq.custhelp.com. Q. How can the general public use the confidence intervals to help make informed choices about hospitals using the Overall Hospital Quality Star Rating? A. CMS is exploring opportunities, both within the display and the support materials, to present relevant concepts, like the confidence intervals, to patients and consumers in a fashion that does not increase confusion, but conveys the information within the Overall Hospital Quality Star Rating. Q. Why is there a nine-month time lag for the HCAHPS Survey data? A. The nine-month lag is a result of the behind-the-scenes submission timeline and processing that occurs prior to public reporting of the data. For example, hospitals have up to four and a half months after the close of the calendar quarter to finalize and submit their data to CMS. Q. Where can I submit questions about the Hospital Compare Overall Hospital Quality Star Rating? A. Questions about the methodology can be submitted to: cmsstarratings@lantanagroup.com.