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Hospital Reporting Requirements

Measurement specifications

Stratis Health supports the national Inpatient Quality Program, Outpatient Quality Program , and Medicare Beneficiary Quality Improvement Project. The 2013 Summary is a compilation of those programs. 2013 Hospital Measure Summary (7-page PDF)
2014 Hospital Measure Summary (7-page PDF) 2015 Hospital Measure Summary (9-page PDF) 2016 Hospital Measure Summary (9-page PDF) 2017 Hospital Measure Summary (11-page PDF)

Rural Emergency Department Transfer Communication Resources. These resources help rural hospitals implement the emergency department (ED) transfer communication measure, which is included in the Medicare Beneficiary Quality Improvement Project (MBQIP).

Inpatient specification manual. Developed by the Centers for Medicare & Medicaid Services and Joint Commission to provide a uniform set of national hospital quality measures to be implemented in the hospital inpatient setting to promote high quality care for patients receiving services in hospital inpatient settings.

Outpatient specifications manual. Developed by the Centers for Medicare & Medicaid Services (CMS) to provide a uniform set of quality measures to be implemented in hospital outpatient settings to promote high quality care for patients receiving services in hospital outpatient settings.

AHRQ quality indicators. Agency for Healthcare Research and Quality (AHRQ) measures of health care quality that make use of readily available hospital inpatient administrative data.

Healthcare Associated Infection (HAI). Operational Guidance for Acute Care Hospitals to Report on required CMS Measures for the purpose of fulfilling CMS’s Hospital Inpatient Quality Reporting (IQR) Requirements.

The National Healthcare Safety Network (NHSN) Manual Patient Safety Component Manual. Includes protocol for submitting: Device-Associated Module -Central Line-Associated Bloodstream Infection (CLABSI) Event, Catheter-Associated Urinary Tract Infection (CAUTI) Event, Procedure-Associated Module- Surgical Site Infection (SSI) Event, and Antimicrobial Use and Resistance Module- Multidrug-Resistant Organism and Clostridium difficile Infection (MDRO/CDI). (335-page PDF)

The NHSN Manual Healthcare Personnel Safety Component Protocol. For submitting Healthcare Personnel Influenza Vaccination Summary data. (72-page PDF)

Hip/Knee complication. 2013 Measures Update and Specifications: Elective Primary Total Hip Arthroplasty (THA) And/Or Total Knee Arthroplasty (TKA) Risk-Standardized Complication Measure. (51-page PDF)

Medicare spending per beneficiary (MSPB) measures overview. As part of the hospital value-based purchasing program, the MSPB measure assesses Medicare Part A and Part B payments for services provided during a spending-per-beneficiary episode that spans from three days prior to an inpatient hospital.

Mortality measures overview. Publicly reporting risk-standardized, 30-day mortality measures for AMI, HF, and PN. The Centers for Medicare & Medicaid Services 30-day mortality measures assess a broad set of healthcare activities that affect patients' well-being.

Readmission measures overview. Publicly reporting risk-standardized, 30-day readmission measures for AMI, HF, PN, HWR, and THA/TKA. The CMS 30-day readmission measures assess a broad set of healthcare activities that affect patients’ well-being.

Perinatal measure. Patients with elective vaginal deliveries or elective cesarean sections at >= 37 and < 39 weeks of gestation completed.

PSI composite measure. Patient safety for selected indicators. (1-page PDF)

Vermont Oxford Network Database. Manual of operations part 2: data definitions and data forms for infants born in 2013 release 17.0. (97-page PDF)

Rules

Hospital Inpatient PPS (IPPS). FY 2013 IPPS final rule and files related to the final rule, including correction notices, tables, and additional data and analysis.

Hospital Outpatient PPS (OPPS). This final rule revises the Medicare OPPS and Medicare ambulatory surgical center (ASC) payment system for CY 2013.

Statewide Quality Reporting and Measurement System (SQRMS). Health Care Quality Measures Final Adopted Rule, November 13, 2012, and appendices.

Reporting of Healthcare Associated Infections for Minnesota Acute Care Hospitals October 2012. Reporting changes that align state and federal reporting so that measures are meaningful to the consumer and hospital, provide value in quality reporting; and reduce the data collection burden when possible. (1-page PDF)

Reporting Change for Healthcare Associated Infections for Minnesota Critical Access Hospitals August 2013. Reporting changes that align state and federal reporting so that measures are meaningful to the consumer and hospital, provide value in quality reporting; and reduce the data collection burden when possible. (1-page PDF)

CMS timeline. This timeline denotes the process for recommending and approving quality measures designated by the Centers for Medicare and Medicaid Services. (1-page Word doc)

State timeline. This timeline denotes the process for recommending and approving quality measures for the Minnesota Statewide Quality Reporting and Measurement System (SQRMS). (1-page Word doc)

Contacts

Contact Stratis Health for assistance with your quality improvement and patient safety needs. If your hospital has projects it would like to work on, contact us to discuss how we can work together to support new initiatives.

Abstraction, General Hospital Information

Robyn Carlson, quality reporting specialist

952-853-8587

National Helpdesk Contact

7:00 a.m. - 7:00 p.m., CST, Monday - Friday

866-288-8912, Fax 888-329-7377, email