By Brian Hill, MSM, BSN October 27, 2017 Regulatory Updates: Hospital
I’m a planner. Anyone who knows me might laugh at the mildness of this statement. If I don’t have my bags packed a week in advance of any traveling I do, check my temperature.
So when it comes to planning ahead for my clients, I am always sure to have my ducks in a row. And speaking of planning, in my book, it’s never too early to begin thinking about next year. Specifically, how to prepare to meet the 2018 Inpatient Quality Reporting (IQR) program requirements.
While some hospitals have the IQR program down to a science, there are still many hospitals out there that scramble each year to figure out what the heck they need to do, by what date and who will be responsible for completing each of the requirements. It is especially important to do this now because of the onset of the newly required eCQMs.
One of simplest solutions to relieve some portion of this burden is to review the requirements in advance, assess the state of your hospital and lay out a plan that encompasses which team member(s) will be responsible for overseeing each task and what technology you already have in place or what you will require to complete the program.
To make it easier for you, I’ve laid out the eight requirements you must do in 2018 to successfully complete the IQR program.
1. Report quarterly data on these six chart-abstracted measures
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REQUIREMENT: Hospitals must report on all six chart-abstracted measures. |
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SUBMISSION METHOD: |
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DEADLINE Quarterly Submission Deadlines |
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| 1. ED-1: Median Time from ED Arrival to ED Departure for Admitted ED Patients |
| 2. ED-2: Admit Decision Time to ED Departure Time for Admitted Patients |
| 3. IMM-2: Influenza Immunization (The IMM-2 measure is collected for all four quarters; however, only discharges included in the first and fourth quarters will be included in the measure calculation. The IMM-2 measure is reported by flu season on the CMS Hospital Compare website.) |
| 4. PC-01: Elective Delivery |
| 5. SEP-1: Early Management Bundle, Severe Sepsis/Septic Shock |
| 6. VTE-6: Incidence of Potentially Preventable Venous Thromboembolism |
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
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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 |
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 Annual Submission Deadline of February 28, 2019 |
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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
Your EHR must be certified to either the 2014 or 2015 Edition of Certified EHR Technology (CEHRT) or a combination of both.
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 Meaningful Use (EHR Incentive) program.
If you choose to submit ED-1 and/or 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) |
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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. For the HCP measure, only data from October 1, 2017 – March 31, 2018 must be submitted by the annual submission deadline of May 15, 2018.
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 |
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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 Information for two structural measures
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REQUIREMENT: Hospitals must report two Structural measures. |
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SUBMISSION METHOD: |
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DEADLINE Annual Submission Deadline between April 1 – May 15, 2019 |
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| 1. Patient Safety Culture: Hospital Survey on Patient Safety Culture |
| 2. Safe Surgery Checklist: Safe Surgery Checklist Use |
Data can be entered through the QualityNet Secure Portal from April 1, 2019 – May 15, 2019.
7. 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, 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. You can attest anytime between April 1 – May 15, 2019. Hospitals may complete the DACA within the QualityNet Secure Portal.
8. Review your claims-Based Data
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REQUIREMENT: Hospitals are evaluated for their performance on 20 Claims-Based Outcome measures and 11 Claims-Based Payment measures. |
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SUBMISSION METHOD: |
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DEADLINE No submission deadline |
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| 1. MORT-30-AMI: Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Acute Myocardial Infarction (AMI) Hospitalization |
| 2. MORT-30- CABG: Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft (CABG) Surgery |
| 3. MORT-30-COPD: Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Chronic Obstructive Pulmonary Disease (COPD) Hospitalization |
| 4. MORT-30-HF: Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Heart Failure (HF) Hospitalization |
| 5. MORT-30-PN: Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Pneumonia Hospitalization |
| 6. MORT-30-STK: Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Acute Ischemic |
| 7. READM-30-AMI: Hospital 30-Day All-Cause Risk-Standardized Readmission Rate (RSRR) Following Acute Myocardial Infarction (AMI) Hospitalization |
| 8. READM-30-CABG: Hospital 30-Day, All-Cause, Unplanned, Risk-Standardized Readmission Rate (RSRR) Following Coronary Artery Bypass Graft (CABG) Surgery |
| 9. READM-30-COPD: Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) Following Chronic Obstructive Pulmonary Disease (COPD) Hospitalization |
| 10. READM-30-HF: Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) Following Heart Failure (HF) Hospitalization |
| 11. READM-30-HWR: Hospital-Wide All-Cause Unplanned Readmission (HWR) |
| 12. READM-30-PN: Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) Following Pneumonia Hospitalization |
| 13. READM-30-STK: 30-Day Risk Standardized Readmission Rate Following Stroke Hospitalization |
| 14. READM-30-THA/TKA: Hospital-Level 30-Day, All-Cause Risk-Standardized Readmission Rate (RSRR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) |
| 15. AMI Excess Days: Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction |
| 16. HF Excess Days: Excess Days in Acute Care after Hospitalization for Heart Failure |
| 17. PN Excess Days: Excess Days in Acute Care after Hospitalization for Pneumonia |
| 18. Hip/Knee Complications: Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) |
| 19. PSI 04: Death Rate Among Surgical Patients with Serious Treatable Complications |
| 20. PSI 90: Patient Safety and Adverse Events Composite |
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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 |
| 5. MSPB: Payment-Standardized Medicare Spending Per Beneficiary (MSPB) |
| 6. Cellulitis Payment: Cellulitis Clinical Episode-Based Payment |
| 7. GI Payment: Gastrointestinal Hemorrhage Clinical Episode-Based Payment |
| 8. Kidney/UTI Payment: Kidney/Urinary Tract Infection Clinical Episode-Based Payment |
| 9. AA Payment: Aortic Aneurysm Procedure Clinical Episode-Based Payment |
| 10. Chole and CDE Payment: Cholecystectomy and Common Duct Exploration Clinical Episode-Based Payment |
| 11. SFusion Payment: Spinal Fusion Clinical Episode-Based Payment |
Hospitals will receive a score for their performance on 20 Claims-Based Outcome measures and 11 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
There are two types of audits that CMS will perform next year. The chart-abstracted measure audits will continue as they have in the past. Starting in May of 2018, CMS will audit eCQMs from data submitted for the 2017 performance year. They will continue this eCQM audit with the 2018 performance data.
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.
CMS hasn’t officially released what the audit will look like in 2019, but here is what they plan to do for 2017.
If you are audited for your 2017 chart-abstracted submission, it contained data from Q3 2016, Q4 2016, Q1 2017 and Q2 2017. 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
2017 is the first year of data that eCQMs will be audited. 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. Up to 2% of your Medicare reimbursement funding is at risk. (Check out this infographic showing all at-risk Medicare funding.)
If you do not successfully complete each of these requirements, you risk losing up to 2% of your Medicare reimbursements in 2020. The same thing applies to your 2019 data. 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.
What to do now
Much of this burden often falls to Quality. And indeed the Quality department should review and become familiar with all of their data especially eCQM data since it’s so new. Get Quality and IT 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 2018 or 2019 eCQM data on Hospital Compare, but 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 2018.
ON-DEMAND WEBINAR: Data-driven Patient Care: Using eCQMs to drive performance improvement
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.
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