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cms Hospital Data Reporting & SubmissionHospital Data Reporting to the Centers for Medicare & Medicaid Services consists of two major data related activities: Reporting Hospital Quality Data for Annual Payment Update and Hospital Quality Alliance. 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. Acute Myocardial InfarctionHeart Attack Core Measures. Every year, about one million people suffer a heart attack (acute myocardial infarction or AMI). AMI is among the leading causes of hospital admission for Medicare beneficiaries, age 65 and older. Scientific evidence indicates that these process of care measures represent the best practices for the treatment of AMI. Heart FailureHeart Failure Core Measures. Heart failure is the most common hospital admission diagnosis in patients age 65 or older, accounting for more than 700,000 hospitalizations among Medicare beneficiaries every year. It is associated with severe functional impairments and high rates of mortality and morbidity. Substantial scientific evidence indicates that the following process of care measures represent the best-practices for the treatment of heart failure. PneumoniaPneumonia Core Measures. Community acquired pneumonia is a major contributor to illness and mortality in the United States, causing 4 million episodes of illness and nearly one million hospital admissions each year. Scientific evidence indicates that these process of care measures represent the best practices for the treatment of community-acquired pneumonia. Surgical Care Improvement Project (SCIP)Surgical Care Improvement Project Core Measures. Hospitals can reduce the risk of complications like wound infection or blood clots in surgery patients by giving the right treatments at the right time. For example, studies show a strong association of reduced incidence of post-operative infection with administration of antibiotics within the one hour prior to surgery. After the incision is closed, however, studies show that prolonged administration of prophylaxis with antibiotics may increase the risk of certain other infections at no additional benefit to the surgical patient. Scientific evidence shows that these process of care measures represent the best practices for preventing complications after certain surgeries (colon surgery, hip and knee arthroplasty, abdominal and vaginal hysterectomy, cardiac surgery (including coronary artery bypass grafts (CABG)) and vascular surgery). Hospital Inpatient Quality Measure Changes Beginning January 1, 2012Click on the following links to view fact sheets for hospital inpatient quality measure changes for January 1, 2012 discharges.
ResourcesInpatient Process Measures and HCAHPS Survey Dimensions Value-based purchasing measures graphs that provide hospital-specific performance, as well as national and state averages, December 2011. Hospital Communication Distribution List Stratis Health routinely emails important notices and reminders to hospitals related to quality data reporting and improvement. Print this form, indicate by topic who in your hospital should receive each type of information listed, and fax back to Stratis Health. Hospital Inpatient Quality Reporting Program: New Requirements for Submission of CLABSI data Hospitals participating in the Hospital Inpatient Quality Reporting Program that have an adult or pediatric ICU and/or NICU are required to submit data for the new measure, Central Line-Associated Bloodstream Infection (CLABSI). Data will be submitted to the Centers for Disease Control and Prevention National Healthcare Safety Network beginning with January 1, 2011, discharges. Submission of data is required to receive the Annual Payment Update for Fiscal Year 2013. 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 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.
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. Proposed Hospital Measures Centers for Medicare & Medicaid Services and Minnesota State hospital measures for 2012. Screen reader version 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.
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| This Web page was prepared by Stratis Health, the Quality Improvement Organization for Minnesota, under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-MN | |
