Hospital Data Collection and P4R The Right Care for Every ... · PDF fileHospital Data...

Hospital Data Collection and P4R The Right Care for Every Patient, Every Time

Mary Cox, RN,C., BAHospital Reporting Program QIOSC

April 22, 2007

ObjectivesLearn about Hospital Data Collection and the Specifications Manual for National Hospital Quality MeasuresUnderstand the data abstraction, submission and validation processesUnderstand the significance of Hospital Compare and RHQDAPUUnderstand the connection between the reported quality measures and the hospitals' goal of providing the right care for every patient, every time

Together, Our Goal is to Improve the Quality of CareHospital Reporting

QIOsHRPQIOSC

Vendors

Accessing the Specifications Manual

www.qualitynet.org

Accessing the Specifications Manual

Specifications Manual Versions

Specifications Manual SectionsAcknowledgement DocumentIntroductionTable of ContentsUsing the ManualSection 1 – Data DictionarySection 2 - Measurement InformationSection 3 – Missing and Invalid Data Section 4 – Population and Sampling SpecificationsSection 5 – Data Quality

Specifications Manual SectionsSection 6 – Risk AdjustmentSection 7 –Steps to Calculate Rates Section 8 – National Hospital Quality Measure Verification ProcessSection 9 - National Hospital Quality Measure Data TransmissionSection 10 – CMS Risk-Adjusted 30-Day Mortality Measures Appendices

Provider Provider –– Vendor RelationshipVendor RelationshipHospitals are responsible to ensure valid data is submitted into the QIO Clinical WarehouseCMS encourages providers to work very closely with their vendorsCMS provides support to both providers and vendors to ensure the data is accurate and timely [vendor/QIO call, WebEx presentations, etc.]

Submission/Reporting Schedule

Hospital Data ValidationLocked warehouse (universe): Validation, APU, Hospital Public ReportingOpen warehouse (universe): Many reports, real timeAll data accepted into the QIO Clinical Warehouse is subject to validation5 cases per quarterValidation less than 80% can appeal

Case Selection ReportIdentifies cases selected for validation sampleMedical Records Request date: date CDAC mails request to providerRecord received: indicates only that a record with this patient’s face sheet was received at the CDAC

Case Selection Report

Clinical Data Abstraction CenterClinical Data Abstraction CenterOne validation quarter, CDAC receives thousands of recordsFace Sheet: green, one for each record requested, project abbreviation number has a V at the end of the numberCDAC will deem status of "Invalid Record Selection" if any of the following on the submitted medical record do not match what was requested:

– Admission Date– Discharge Date– Birthdate

Hospital Compare vs. RHQDAPU

Different data purposes– Hospital Compare – data used to provide the most

accurate data for public reporting (data display)Preview Reports quarterlyHospital Compare updated quarterly

– RHQDAPU – data used to determine payment (DRA)

Hospital CompareHospital Compare was developed as a result of an collaborative integration of HQA

– American Hospital Association– Federation of American Hospitals– American Association of Medical Colleges

American Hospital AssociationFederation of American HospitalsAmerican Association of Medical Colleges

All data accepted into the locked QIO Clinical Warehouse may be used for Public Reporting purposesAPU data is currently posted on Hospital Compare

Hospital Quality Alliance Preview Report

Hospital data for HQA on Hospital Comparehttp://www.hospitalcompare.hhs.gov/hospital/home2.asp

Reporting Hospital Quality Data for Annual Payment Update

History– Section 501(b) of the MMA requires that PPS hospitals submit

a set of 10 quality measures for each of the FY’s 2005-2007 to receive full Medicare market basket update

Final List– In the initial year of the Act, FY 2005, over 99% of PPS

hospitals received the full market basket update– For FY 2006 approximately 96% of the eligible hospitals

passed all requirements and received the full update– For FY 2007 approximately 97% of the eligible hospitals

passed all requirements and will receive the full update

RHQDAPU - Past Requirements

FY 2005 Requirement:– Complete RHQDAPU Notice of Participation form– Register with QNet Exchange– Identify an QNet Exchange Administrator– Successfully submit at least one record into the

SDPS Clinical Warehouse by the designated deadline

RHQDAPU - Past Requirements

FY 2006 Requirements:– Complete RHQDAPU Notice of Participation form– Register with QNet Exchange– Identify an QNet Exchange Administrator– Submit 10 measures where applicable, each quarter– Meet 80 percent reliability based on 3Q 04

validation results

RHQDAPU - Past Requirements FY 2007 Requirements:

– Sign and submit the FY 2007 Pledge of Participation form to QIO by specified timeframe indicating you will collect and submit data into the CDW on the expanded measure set (21 measures) beginning with 3rd Qtr. 2006

– Register with QNet Exchange– Identify QNet Exchange Administrator– Submit 10 measures where applicable, each quarter– Meet validation requirements based on CI of 80 percent

for first three quarters of CY 2005– Submit complete data in accordance with the joint

CMS/JCAHO sampling requirements located on theQualityNet Website

RHQDAPU - Future RequirementsRefer to IPPS rule on www.cms.hhs.gov

– Regulation No. CMS-1488-F; Title: Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2007 Rates; Display Date: 08/01/2006; Year: 2007

– Publication Date: 08/18/2006Refer to OPPS rule on www.cms.hhs.gov

– Regulation No.CMS-1506-P, Title: Proposed Changes to the Hospital Outpatient PPS and CY 2007 Rates; Year: 2007

Proposed IPPS rule for FY2008 will be posted for 60 day comment period in the spring 2007Final IPPS rule for FY2008 will be posted late summer 2007

RHQDAPU ~ Accessing Reports

APU/RHQDAPU Provider Participation Report

The Quality Connection

Feedback reports available to identify Quality Measure outcomes– Heart Failure (Facility Only)– Heart Failure (Facility, State and National)– Measure Status Summary Report– Measure Status by Case Report– Data Submission Detail Report

Utilize report information to identify areas of focus for quality improvement

Heart Failure (Facility Only)

Heart Failure (Facility, State and National)

Measure Status Summary Report

Measure Status by Case Report

Data Submission Detail Report

Contact Information

Mary Cox, RN,C., BADirector, HRP QIOSC– E-mail mcox@iaqio.sdps.org– Phone 515-273-8853

This material was prepared by the Iowa Foundation for Medical Care, the Medicare Quality Improvement Organization for Iowa, under contract for 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.

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