7 Hospital IQR Program Requirements for 2019

By Brian Hill. Posted Sep 28, 2018 in Academy, Quality Reporting, IQR Program

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.

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.

Measure-Removal-Guide-CTA



1. Report quarterly data on these three chart-abstracted measures

Circle_Icon_Requirements.png

REQUIREMENT: 
Hospitals must report on three chart-abstracted measures.

(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.)

Circle_Icon_SubmissionMethod.png

SUBMISSION METHOD:
QualityNet Secure Portal (Third party vendor authorization required.)

Circle_Icon_Deadline.png DEADLINE:
Quarterly Submission Deadlines

 


 Chart-Abstracted measures

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.

 

2. Submit Population and Sample Size Counts quarterly to QualityNet

Circle_Icon_Requirements.png REQUIREMENT: 
Hospitals must submit population and sampling numbers for all chart-abstracted measures.
Circle_Icon_SubmissionMethod.png

SUBMISSION METHOD:
QualityNet Secure Portal (Third party vendor authorization required.)

Circle_Icon_Deadline.png DEADLINE:
Quarterly Submission Deadlines


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

Circle_Icon_Requirements.png REQUIREMENT: 
Hospitals must report on at least four of the available 15 eCQMs.
Circle_Icon_SubmissionMethod.png

SUBMISSION METHOD:
QualityNet Secure Portal (Third party vendor authorization required.)

Circle_Icon_Deadline.png DEADLINE:
End of February, 2020
 


 Electronic Clinical Quality measures (eCQMs)

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

Circle_Icon_Requirements.png REQUIREMENT: 
Hospitals must report on six HAI measures.
Circle_Icon_SubmissionMethod.png

SUBMISSION METHOD:
National Healthcare Safety Network (NHSN) Portal

Circle_Icon_Deadline.png DEADLINE:
Quarterly Submission Deadlines (Exception: HCP measure)
 


 HAI measures

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. For the HCP measure, only data from October 2018–March 2019 must be submitted by the annual submission deadline of May, 2019.

 

5. Report quarterly data on the Patient Experience of Care Survey

Circle_Icon_Requirements.png REQUIREMENT: 
Hospitals must report Patient Experience of Care Survey measures data.
Circle_Icon_SubmissionMethod.png

SUBMISSION METHOD:
QualityNet Secure Portal

Circle_Icon_Deadline.png DEADLINE:
Quarterly Submission Deadlines
 


Patient Experience of Care Survey measures

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

Circle_Icon_Requirements.png REQUIREMENT: 
Hospitals must complete the Data Accuracy and Completeness Acknowledgment (DACA).
Circle_Icon_SubmissionMethod.png

SUBMISSION METHOD:
QualityNet Secure Portal

Circle_Icon_Deadline.png DEADLINE:
Annual Submission Deadline between between April and mid-May of 2020


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. You can attest anytime between April and mid-May of 2020. Hospitals may complete the DACA within the QualityNet Secure Portal.

 

7. Review your claims-Based Data

Circle_Icon_Requirements.png

REQUIREMENT: 
Hospitals are evaluated for their performance on 8 Claims-Based Outcome measures and 4 Claims-Based Payment measures.

(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.) 

Circle_Icon_SubmissionMethod.png

SUBMISSION METHOD:
No additional submission is required.

Circle_Icon_Deadline.png DEADLINE:
No submission deadline
 
 


 Claims-Based Outcome measures

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

 


 Claims-Based Payment measures

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.

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.

 

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 SeeHow 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.

Medisolv’s ENCOR Quality Reporting and Management software solution provides hospitals with the tools they need to meet all the CMS IQR reporting requirements. ENCOR is the only endorsed solution for quality reporting and management by the American Hospital Association.

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.

Learn about ENCOR >>


WEBINAR: 

Wednesday, October 24, 2018
1 p.m. ET | 12 p.m. CT | 10 a.m. PT

QUALITY REPORTING: 2018 AND BEYOND, IN PARTNERSHIP WITH NAHQ

Tying payments to performance across quality and cost dimensions requires robust measurement and reporting. Hospitals and providers, however, are demanding relief from regulatory burdens including quality reporting. What gives?

In response to both internal needs and external pressures, CMS continues to propose dramatic changes in its Quality Reporting programs. While this session will primarily focus on these hospital and ambulatory changes for quality reporting in 2018, future reporting trends and lessons applicable across the continuum of care will also be discussed. In addition, we’ll share some strategies that will help you to better manage multiple measure types for the major regulatory reporting programs.

Objectives

  • Review 2018 reporting requirements and discuss future trends in quality reporting. 
  • Gain insight into what quality reporting is likely to look like beyond 2018. 
  • Learn strategies to help you stay on top of the complex and changing reporting requirements year after year.


Speaker info:
Dr. Zahid Butt, MD, FACG
Medisolv, President & Chief Executive Officer

Register Now >>

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Brian Hill

Brian Hill

Director Of Quality Measures

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