Hospital Data Reporting & Submission

CMS Hospital Data Reporting & Submission

Hospital Data Reporting to the Centers for Medicare & Medicaid Services consists of two major data related activities: Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) and Hospital Quality Alliance (HQA). It supports Minnesota hospitals by assessing data collection capabilities by providing education, resources, technical assistance and tools, and serving as a liaison in the validation appeal process.

Resources

CMS National Patient Safety Initiative for Surgical Care: Ongoing Opportunities for Improvement. Presented by Dale Bratzler, DO, MPH, President and CEO, Oklahoma Foundation for Medical Quality. (60-minute Webinar) Handout (23-page PDF, 45 slides)

Customized inter-rater reliability phone consultation service One-on-one assistance for hospital abstraction staff.

Data Collection (CART) The CMS Abstraction and Reporting Tool is used for the collection, retrospective analysis, and real-time reporting of quality improvement data by hospitals for acute myocardial infarction, heart failure, pneumonia, and the Surgical Care Improvement Project.

Data Submission Dates Important data submission deadlines for HCAHPS, HOP QDRP, Public Reporting, and Medical Record Validation.

Data Submission Reporting Hospitals participating in CMS quality improvement initiatives must submit specified data in the prescribed format to the QIO Clinical Warehouse, the national data repository for private health care data. Data must be submitted by CMS transmission deadlines.

Data Validation To verify the accuracy of information collected, each quarter a small sample of data that hospitals submit to the QIO Clinical Warehouse is validated, including all hospitals that have submitted abstracted data for six or more cases (discharges) during the previous quarter.

Guide to Assigning Program Management QualityNet Exchange Administrator Role Provides online self-serve functionality to select and maintain measure designation for each quarter and each clinical topic submitted to the QIO Clinical Warehouse. Allows self-reporting of sampling status and discharges.

Heart Failure Discharge Success Stories Success stories and strategies from hospitals that scored in the top 5 percent on the Heart Failure-1 Discharge Instructions measure.

Hospital HCAHPS A standardized survey instrument and data collection methodology for measuring patients' perspectives on hospital care. It also complements the data hospitals currently collect to support quality improvement.

Hospital Check-In e-newsletter. Stratis Health provides hospitals with news and updates on quality improvement and patient safety information in our monthly Hospital Check-In electronic newsletter. Hospital Check-In includes current quality and patient safety information, intervention tools, educational resources and trainings, and key Web links to assist hospitals in their quality improvement efforts. The newsletter also assists providers in understanding policies and programs initiated by the Centers for Medicare & Medicaid Services.

Hospital Inpatient Validation The Hospital Data Validation Case Selection Report, available from My QualityNet, includes patient identifiers for the five medical records selected for validation.

Hospital Quality Alliance The Hospital Quality Alliance (HQA) is a public-private collaboration that represents hospitals, health professionals, government agencies, quality experts, purchasers, and consumer groups. HQA provides easily understood information about hospital performance accessible to the public and to informing and encouraging efforts to improve quality.

HQA-RAQDAPU Data Release The September 2008 release of Hospital Compare updated existing quality of care data for providers participating in the Hospital

ICD-10-Clinical Modification/Procedure Coding System Fact Sheet Enhances accurate payment for services rendered and facilitates evaluation of medical processes and outcomes.

Medqic Patient Safety Update, July 2009 A comprehensive list of patient safety tools and resources posted to QualityNet/MedQIC. Resources are arranged by topic, including drug safety, MRSA, pressure ulcers, VTE, patient safety, and quality improvement.

Mortality Measures Publicly reporting risk-standardized, 30-day mortality measures for acute myocardial infarction, heart failure, and pneumonia.

Pneumonia Measure Set Change Change in composition of two pneumonia measures pursuant to the final Inpatient Prospective Payment System Rule (IPPS) published July 31, 2008.

Quality Alliance (HQA) and/or the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program.

QualityNet Exchange A national CMS knowledge forum and searchable online resource center for health care and quality improvement professionals, QualityNet supports providers of health care services to Medicare beneficiaries in finding, using, and sharing quality improvement resources.

Recorded Abstracting for Accuracy conference call To educate hospital data abstractors about data abstraction changes for April 1, 2009 through September 30, 2009 discharges.

Reporting Hospital Quality Data for Annual Payment Update The RHQDAPU initiative is intended to equip consumers with quality of care information to make more informed decisions about their health care (available on Hospital Compare), while encouraging hospitals and clinicians to improve the quality of inpatient care provided to all patients.

RHQDAPU Measures for FY2010 Inpatient hospital quality measures for acute myocardial infarction, heart failure, and pneumonia.

Specifications Manual for National Hospital Quality Measures The manual has been updated. Use version 2.6b for the data collection period April 1, 2009, to September 30, 2009.

Structural Measures Release Notes, July 2009 A new application for hospitals and vendors, Structural Measures v1.0, is located within the secure area of QualityNet (My QualityNet > My Tasks > Manage Measures >Hospital Inpatient >Structural Measures).

Release Notes detail the content of this release.  

Updated Joint Commission Universal Protocol, effective January 1, 2009.

• 2009 FAQs about Universal Protocol
• Ambulatory Health Care

• Critical Access Hospital
• Disease Specific Care
• Hospital

• Office-Based Surgery

Public Reporting Sites

Tools consumers can use to help make health care decisions.

CMS' Hospital Compare Information and survey results on how well hospitals care for patients with certain medical conditions or surgical procedures.

JCAHO Quality Check Includes Joint Commission-accredited health care organizations and organizations not accredited or certified by The Joint Commission.

Minnesota Hospital Quality Report Hospital information on quality of care and patient experiences.

Contacts

Abstraction
Robyn Carlson, data quality specialist
952-853-8587

Data and Public Reporting

Mary Lou Haider, vice president, Contract Management and Internal Quality
952-853-8536

General Hospital Information
Mary Montury, program coordinator
952-853-8541

Minnesota Health Care Reform - Quality Measures for Hospitals

Minnesota Statewide Quality Reporting and Measurement Rule Adopted December 28, 2009

The Minnesota Department of Health has adopted a permanent rule establishing the Minnesota Statewide Quality Reporting and Measurement System. This rule compels physician clinics and hospitals to submit data on a set of quality measures to be publicly reported and establishes a broader standardized set of quality measures for health care providers across the state. The notice of adoption of this rule was published in the December 28, 2009 edition of the State Register, and is effective as of that date.  Email support@govdelivery.com with questions.

Background

In 2008, the Minnesota Legislature passed a comprehensive health reform law, which requires the Commissioner of Health to establish a standardized set of quality measures for health care providers across the state and publicly report a subset of the standardized set of measures. The Minnesota Department of Health had several goals in developing the standard measure set and public reporting system, including fostering a uniform approach to quality measurement, increasing the availability of health care quality information for consumers and health care providers, and improving the quality of health care delivery.

Stratis Health has played an active role in the development of quality measures for hospitals. It is crucial for hospitals to be prepared for this new world of measurement. Larger hospitals already reporting these measures will have little, if any, change in abstraction and reporting requirements. For Critical Access Hospitals not presently abstracting and reporting the Centers for Medicare & Medicaid Services core measures, it is imperative to become educated on the proposed rule and plan for implementation.

Resources

Ambulatory measures

Proposed quality measures

Requirements for physician clinics

Stratis Health and Minnesota Hospital Association Patient Safety and Quality Meetings 2010. Current quality and patient safety issues, common barriers and success stories, patient safety needs assessment, and updates from the Minnesota Alliance for Patient Safety, Stratis Health, and the Minnesota Hospital Association. Presented by Stratis Health Program Managers, Annette Kritzler and Janelle Shearer. Agenda (1-pg PDF) Data Transmission Process (1-pg PDF) Measures Grid (8-pg PDF)

Contact Annette Kritzler, Stratis Health, at 952-853-8590.