Is your hospital ready for quality reporting next year? Yes, I said next year! I know it may sound a little early, but when it comes to successfully fulfilling regulatory reporting requirements, it’s never too soon to start preparing.
Quality reporting is no quick task. By starting now, your hospital can avoid last-minute scrambling and carefully take the time needed to review updated requirements, assess performance, make a game plan, decide which team member(s) will be responsible for overseeing each task and implement the proper technology.
Requirement changes in response to COVID-19 are reflected below. For details on all changes, read our quality reporting changes due to COVID-19.
To help you get ahead of the game, I’ve laid out the seven requirements your hospital will need to know to successfully complete one of the major regulatory programs in 2019: the Hospital Inpatient Quality Reporting (IQR) program. CMS finalized several changes to the program structure for next year in their 2019 IPPS final rule, including the removal of 39 measures between now and 2021. Be sure to check out the list of IQR measures being removed for 2018-2021 below. Keep in mind that a lot of these measures are removed from just the IQR program. You will still be evaluated on these measures in other programs such as the Hospital Acquired Condition program or the Hospital Value-Based Purchasing program.
1. Report Quarterly Data on These Three Chart-Abstracted Measures
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REQUIREMENT: (The following clinical process of care measures have been removed: ED-1: Median Time from ED Arrival to ED Departure for Admitted ED Patients, IMM-2: Influenza Immunization and VTE-6: Incidence of Potentially Preventable Venous Thromboembolism.) |
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SUBMISSION METHOD: |
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DEADLINE: Quarterly Submission Deadlines In response to COVID-19, Q4 data submission is optional. |
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| 1. ED-2: Admit Decision Time to ED Departure Time for Admitted Patients |
| 2. PC-01: Elective Delivery |
| 3. SEP-1: Early Management Bundle, Severe Sepsis/Septic Shock |
Hospitals with five or fewer discharges
Hospitals with five or fewer discharges (both Medicare and non-Medicare combined) per measure in a quarter are not required to submit patient-level data.
PC-01 measure submission
Hospitals are required to enter PC-01 measure data through the web-based tool on a quarterly basis. These data are manually entered. They cannot be transmitted via xml file. If you do not deliver babies at your organization, you must enter zeroes for the PC-01 measure each quarter or you can submit an IPPS Measure Exception Form.
Requirement Changes in Response to COVID-19:
- Q4 data submission is optional.
- If you do submit, CMS will use your entire year of data including Q4 to calculate your payment as applicable to each part of the program.
- If you don’t submit, CMS will use the data you submitted for Jan. 1 – Sept. 30 to calculate your performance and payment (where appropriate).
2. Submit Population and Sample Size Counts Quarterly to QualityNet
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REQUIREMENT: Hospitals must submit population and sampling numbers for all chart-abstracted measures. |
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SUBMISSION METHOD: |
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DEADLINE: Quarterly Submission Deadlines In response to COVID-19, Q4 submission of population and sample sizes is optional. |
Hospitals must submit aggregate population and sample size counts for each chart-abstracted measure. This requirement only applies to populations for the chart-abstracted measures. It must be completed quarterly through the QualityNet Secure Portal.
Hospitals with five or fewer discharges
If you have five or fewer discharges per measure (Medicare and non-Medicare combined) in a quarter you are not required to submit patient-level data for that measure for that quarter. However, you must submit the aggregate population and sample size counts even if the population is zero. Leaving a field blank does not fulfill the requirement.
3. Select Four Out of 15 eCQMs and Report One Quarter’s Worth of Data
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REQUIREMENT: Hospitals must report on at least four of the available 15 eCQMs. |
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SUBMISSION METHOD: |
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DEADLINE: |
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| 1. AMI-8a: Primary PCI Received Within 90 Minutes of Hospital Arrival |
| 2. CAC-3: Home Management Plan of Care Document Given to Patient/Caregiver |
| 3. ED-1: Median Time from ED Arrival to ED Departure for Admitted ED Patients |
| 4. ED-2: Admit Decision Time to ED Departure Time for Admitted Patients |
| 5. EHDI-1A: Hearing Screening Prior to Hospital Discharge |
| 6. PC-01: Elective Delivery |
| 7. PC-05: Exclusive Breast Milk Feeding |
| 8. STK-2: Discharged on Antithrombotic Therapy |
| 9. STK-3: Anticoagulation Therapy for Atrial Fibrillation/Flutter |
| 10. STK-5: Antithrombotic Therapy by the End of Hospital Day Two |
| 11. STK-6: Discharged on Statin Medication |
| 12. STK-8: Stroke Education |
| 13. STK-10: Assessed for Rehabilitation |
| 14. VTE-1: Venous Thromboembolism Prophylaxis |
| 15. VTE-2: Intensive Care Unit Venous Thromboembolism Prophylaxis |
Additional eCQM requirements
Unlike 2018, your EHR must be certified to the 2015 Edition of Certified EHR Technology (CEHRT) for reporting in 2019. You will no longer be able to use the 2014 Edition of CEHRT.
All data must be submitted using the QRDA (Quality Reporting Document Architecture) Category 1 file format. File submission must include one QRDA 1 file per patient, per quarter that contains all episodes of care and the measures associated with the patient file.
Hospitals must use the most recent version of the eCQM specifications.
Hospitals must use a combination of factors to successfully complete their eCQM requirements. If you have at least five cases in the Initial Patient Population and have no zeros in your denominators for the measures you are submitting, you have successfully met the requirements for submission. If, however, you do not have at least five cases in the Initial Patient Population field, you must submit a Case Threshold Exemption. If your measure has zero in the denominator you must submit a Zero Denominator Declaration.
Other considerations for eCQM submission
By submitting your eCQMs to the IQR program, you will also successfully meet your CQM requirement for the Promoting Interoperability (Meaningful Use) program.
If you choose to submit ED-2 and/or PC-01 as an eCQM you still must submit the chart-abstracted data as well.
4. Report Quarterly Data on These Six HAI Measures
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REQUIREMENT: Hospitals must report on six HAI measures. |
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SUBMISSION METHOD: |
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DEADLINE: Quarterly Submission Deadlines (Exception: HCP measure) In response to COVID-19, Q4 data submission is optional. Additionally, the HCP measure is not required for the 2019-2020 reporting period. |
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| 1. CAUTI: NHSN Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure |
| 2. CDI: NHSN Facility-Wide Inpatient Hospital-Onset Clostridium Difficile Infection (CDI) Outcome Measure |
| 3. CLABSI: NHSN Central Line-Associated Bloodstream Infection (CLABSI) Outcome Measure |
| 4. Colon & Abdominal Hysterectomy SSI: American College of Surgeons – Centers for Disease Control and Prevention (ACS- CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure |
| 5. HCP: Influenza Vaccination Coverage Among Healthcare Personnel |
| 6. MRSA Bacteremia: NHSN Facility-Wide Inpatient Hospital-Onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure |
Healthcare Personnel Influenza Vaccination Measure Requirements
All HAI measures, with the exception of the HCP measure, are submitted quarterly to the CDC through the NHSN Portal. Submission is no longer required due to the COVID-19 crisis.
5. Report Quarterly Data on the Patient Experience of Care Survey
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REQUIREMENT: Hospitals must report Patient Experience of Care Survey measures data. |
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SUBMISSION METHOD: |
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DEADLINE: Quarterly Submission Deadlines In response to COVID-19, Q4 data submission is optional. |
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| 1. HCAHPS: Hospital Consumer Assessment of Healthcare Providers and Systems |
| 2. CTM-3: 3-Item Care Transition Measure |
Other considerations for the HCAHPS Survey
Hospitals with six or more HCAHPS-eligible discharges in a month must submit the total number of HCAHPS-eligible cases for the month as part of the quarterly survey data submission.
Hospitals with five or fewer HCAHPS-eligible discharges in a month are not required to submit the HCAHPS survey for that month.
If you have no HCAHPS-eligible discharges in a month, you must submit a zero for that month as a part of the quarterly data submission.
6. On an Annual Basis, Complete the DACA
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REQUIREMENT: Hospitals must complete the Data Accuracy and Completeness Acknowledgment (DACA). |
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SUBMISSION METHOD: |
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DEADLINE: Annual submission deadline between April 1 - May 15, 2020. Due to COVID-19, hospitals do not need to submit the DACA for 2019. |
The Data Accuracy and Completeness Acknowledgment (DACA) is a requirement for hospitals participating in the IQR program. The DACA is a method of electronically attesting that the data they submitted to the program is accurate and complete to the best of their knowledge. Due to COVID-19, hospitals do not need to submit the DACA for 2019.
7. Review your Claims-Based Data
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REQUIREMENT: (The following measures have been removed: PSI 90, READM-30-AMI, READM-30-COPD, READM-30-CABG, READM-30-HF, READM-30-PN, READM-30-STK, READM-30-THA/TKA, MORT-30-AMI, MORT-30-HF, Medicare Spending Per Beneficiary (MSPB), Cellulitis Payment, GI Payment, Kidney/UTI, Payment, AA Payment, Chole and CDE Payment, SFusion Payment, Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Chronic Obstructive Pulmonary Disease (COPD) Hospitalization and Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Pneumonia Hospitalization.) |
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SUBMISSION METHOD: |
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DEADLINE: No submission deadline. In response to COVID-19, Q4 data will not be used for performance and payment. |
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| 1. MORT-30- CABG: Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft (CABG) Surgery |
| 2. MORT-30-STK: Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Acute Ischemic |
| 3. READM-30-HWR: Hospital-Wide All-Cause Unplanned Readmission (HWR) |
| 4. AMI Excess Days: Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction |
| 5. HF Excess Days: Excess Days in Acute Care after Hospitalization for Heart Failure |
| 6. PN Excess Days: Excess Days in Acute Care after Hospitalization for Pneumonia |
| 7. Hip/Knee Complications: Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) |
| 8. PSI 04: Death Rate Among Surgical Patients with Serious Treatable Complications |
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| 1. AMI Payment: Hospital-Level, Risk-Standardized Payment Associated with a 30-Day Episode-of- Care for Acute Myocardial Infarction (AMI) |
| 2. HF Payment: Hospital-Level, Risk-Standardized Payment Associated with a 30-Day Episode-of- Care for Heart Failure (HF) |
| 3. PN Payment: Hospital-Level, Risk-Standardized Payment Associated with a 30-Day Episode-of- Care for Pneumonia |
| 4. THA/TKA Payment: Hospital-Level, Risk-Standardized Payment Associated with an Episode-of-Care for Primary Elective Total Hip Arthroplasty and/or Total Knee Arthroplasty |
Hospitals will receive a score for their performance on 8 Claims-Based Outcome measures and 4 Claims-Based Payment Measures. No additional data submission is required to calculate the claims measure rates. CMS uses enrollment data, as well as Part A and Part B claims data, to calculate the measure rates.
You will receive a Hospital-Specific Reports (HSRs) from CMS for these Claims-Based measures in the QualityNet Secure Portal. These reports contain discharge-level data, hospital-specific results and state and national results for comparison.
Validation/Audits
CMS will continue conducting audits for both chart-abstracted measures and eCQMs next year.
Chart-abstracted audits
CMS performs random and targeted provider audits of hospitals participating in the IQR program. To successfully pass the audit, hospitals must receive a 75% score or better.
If you are audited for your 2018 chart-abstracted submission, it contained data from Q3 2017, Q4 2017, Q1 2018 and Q2 2018. CMS will validate up to eight cases for clinical process of care measures (STK, ED, IMM, VTE or SEP) and up to 10 candidate HAI cases (up to four candidate HAI per template and up to two candidate SSI cases) per quarter per hospital.
Hospitals are also required to submit either:
MRSA & CDI Validation Templates OR CLABSI & CAUTI Validation Templates
Each quarter the CDAC will send hospitals a request to submit a patient medical record for each case and candidate case that CMS selected to be audited.
* Note:
• Q3 & Q4 abstracted measure audits do not need to be submitted.
• Q4 HAI audits do not need to be submitted.
eCQM audits
CMS will select 200 hospitals to audit via random sample. Eight cases (individual patient-level reports) will be selected from the QRDA 1 files that were submitted. The hospital must then submit at least 75% of sample eCQM medical records within 30 days of the request. The eCQM data submitted must contain sufficient patient-level information including arrival date and time, inpatient admission date and discharge data from the inpatient episode of care.
Hospitals who were selected for chart-abstracted audits or hospitals granted an extraordinary circumstances exception will be excluded from the eCQM audit.
*Note:
• Any 2019 eCQM audit requests do not need to be submitted.
Consequences for Inaction
A word of caution to you. If you don’t successfully complete all elements of the IQR program in 2019, you could lose 2% of your Medicare reimbursement in 2021. Hospitals are facing a significant decrease in funding over time if they don’t fully participate.
Also See: How much could you lose from these Quality Reporting Programs? [Infographic]
What to do now
Much of this burden often falls to Quality. And while the Quality department should review and become familiar with all of their data, both Quality and IT will benefit from working together to start creating a plan for next year. Look at the list of requirements above and decide on the resources you have (tech and human) to complete the program. Figure out what you will need to be successful and incorporate that into your planning sessions.
A Word About ECQMs
Unlike the other measure results of the IQR program, CMS has decided NOT to publish the 2019 eCQM data on Hospital Compare. However, if we look at the history of quality reporting, it will only be a matter of time until results will be posted there. So, it’s prep time.
If you have not already implemented eCQMs in your hospital, there’s no time to lose. It takes time to properly implement. Not to mention how long it can take to educate and improve compliance with workflow changes.
If you have implemented the eCQMs already, we suggest that you review your results and identify any gaps in performance. Then create a plan for addressing these gaps before or during 2019.
eCQMS 101: Getting Started with Electronic Clinical Quality Measures
Getting ECQM Help
We’ve heard a few statements over the course of the year that go something like this, “I’d rather take the penalty then put forward the expense for getting all of these programs up and running.” We hear you.
Medisolv has worked with many hospitals from the very beginning of their quality improvement process. We’ve felt their frustration and understand their concerns. But we can assure you that we can get you through this process and provide long-term support as the regulations and requirements change.
Not making a plan is still a plan, but not a sustainable one. Yearly penalty assessments will become steeper and accumulate.
In addition to the software, our solution provides your hospital with expert clinical consultants that will guide your hospital through implementation, validation and submission. Unlike other companies, we do the heavy lifting for you when it comes to submission.
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