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§ 412.165 Performance scoring under the Hospital Value-Based Purchasing (VBP) Program.
(a) Points awarded based on hospital performance. (1) CMS will award points to hospitals for performance on each measure for which the hospital reports the applicable minimum number of cases during the applicable performance period. The applicable minimum number of cases are set forth as follows:
Table 1 to Paragraph (a)(1)—Minimum Case Number Requirements for Hospital VBP Program
| Measure short name | Minimum number of cases |
|---|---|
| Person and Community Engagement Domain | |
| HCAHPS | Hospitals must report a minimum number of 100 completed Hospital Consumer Assessment of Healthcare providers and Systems (HCAHPS) surveys. |
| Clinical Outcomes Domain | |
| MORT-30-AMI | Hospitals must report a minimum number of 25 cases. |
| MORT-30-HF | Hospitals must report a minimum number of 25 cases. |
| MORT-30-PN (updated cohort) | Hospitals must report a minimum number of 25 cases. |
| MORT-30-COPD | Hospitals must report a minimum number of 25 cases. |
| MORT-30-CABG | Hospitals must report a minimum number of 25 cases. |
| COMP-HIP-KNEE | Hospitals must report a minimum number of 25 cases. |
| Safety Domain | |
| CAUTI | Hospitals have a minimum of 1.000 predicted infections as calculated by the Centers for Disease Control and Prevention (CDC). |
| CLABSI | Hospitals have a minimum of 1.000 predicted infections as calculated by the CDC. |
| Colon and Abdominal Hysterectomy SSI | Hospitals have a minimum of 1.000 predicted infections as calculated by the CDC. |
| MRSA Bacteremia | Hospitals have a minimum of 1.000 predicted infections as calculated by the CDC. |
| CDI | Hospitals have a minimum of 1.000 predicted infections as calculated by the CDC. |
| SEP-1 | Hospitals must report a minimum number of 25 cases. |
| Efficiency and Cost Reduction Domain | |
| MSPB | Hospitals must report a minimum number of 25 cases. |