HOSPITAL INPATIENT VIQR/OUTPATIENT QR OUTREACH AND EDUCATION SUPPORT CONTRACTOR/QIN-QIO MEETING SUMMARY MINUTES
THURSDAY, MARCH 12, 2015
2:00 p.m. to 3:00 p.m. ET
· Welcome AND roll call
o Elaine Krantzberg, Outpatient Project Director, welcomed participants and acknowledged all attendees.
· upcoming education programs
o Deb Price, Education Coordinator, reviewed the webinar schedule as detailed in the agenda. She encouraged QIN-QIOs to attend these in order to assist with their D1 efforts. Continuing education credits are available for attendees.
o The OQR webinars are held at 10:00 and 2:00 ET on the selected presentation day; the IQR and ASCQR webinars are held at 2:00 ET only.
o Registration materials and reminders for every webinar are sent via each program’s respective ListServe. QIN-QIOs may register for ListServes on QualityNet.
· IQR: HOSPITALS WITH HCAHPS IMPROVEMENT STORIES
o Bethany Wheeler, HVBP Project Lead, highlighted the upcoming webinars focusing on the HVBP Program, noting the March 25 HAI Improvement Series presentation, the April webinar from the Reports and Analytics contractor on the 30-day mortality measures and AHRQ PSI-90 calculations, and Acumen’s presentation on the MSPB measures that will occur in either May or early June. Webinars planned for the summer concern how to improve HCAHPS scores and scoring for the FY 2016 Percentage Payment Summary Reports.
o Bethany asked participants to email her with any suggestions for future educational programs or to submit examples of hospitals that have successfully implemented a process or program to improve their HCAHPS rates at .
Question: Are there any suggestions or examples of improvement for the Medicare spending per beneficiary topic?
Answer: A series on that topic was held earlier, and the recorded webinar is available at the archived events section of qualityreportingcenter.com.
Question: Will the QIN-QIOs have access to the FY 2017 VBP reports?
Answer: That report was not on the list from the memo, so they are not accessible at this time. If the QIN-QIOs believe that they should have access, please email Bethany at the address above, and she will forward your concerns to CMS.
· ASCQR Program
o Renee Parks, Project Lead, presented an overview of the ASCQR Program, referencing the two handouts attached to the agenda. She recommended accessing the ASCQR Program Guide for New Facilities, available on qualityreportingcenter.com, for a detailed guide to the program and its requirements. The Specifications Manual is also an excellent resource.
o The first five measures represent rare events: patient burns; falls; procedures performed on the wrong site, side, or patient, wrong procedures performed, or wrong implants inserted; hospital transfer or admission from the ASC; and prophylactic IV antibiotic timing. For ASC-5, facilities should report high numbers, but the numbers should be low for ASC-1, -2, -3, and -4. These are claims-based, reported on the facilities’ CMS 1500 forms, and indicated by the appropriate G code as delineated in the attached handout or on page 7 of the ASCQR Program Guide for New Facilities. QIN-QIOs can see facility-level data for these measures on the Provider Participation Reports on QualityNet.
o The next two measures are similar to Outpatient measures – Safe Surgery Checklist Use and ASC Facility Volume Data on Selected Surgical Procedures – and are web-based. Data for these measures are also available on the Provider Participation Report. ASC-8, the influenza vaccination measure, is reported to the NHSN.
o Two new measures for this year are duplicated in the OQR Program as well: the endoscopy/polyp surveillance measures. They are web-based, as is the voluntary cataracts measure. The facility seven-day hospital visit rate after colonoscopy is reported via claims as a dry run for this year.
o State and national data for the ASCQR Program from 2013 are available on qualityreportingcenter.com within the April 23, 2014, webinar titled, “What Have We Learned? 2013 Data Analysis from the Ambulatory Surgical Center Quality Reporting (ASCQR) Program.” Slides 42 and 43 contain measure rates by specialty and claim size that may be helpful for benchmarking purposes. The national cumulative measure rates for CY 2013 and CY 2014 are:
Measure / CY 2013 / CY 2014ASC-1 / .247 / .378
ASC-2 / .156 / .094
ASC-3 / .039 / .028
ASC-4 / .537 / .465
ASC-5 / 96.2% / 96.0%
o ASCs that call QIN-QIOs with issues regarding enrollment in the NHSN should be directed to contact the CDC at . They do not operate a call center. ASCs may call the Outpatient Support Contractor at 866.800.8756, but we can only help in a limited way.
Question: Do we have access to the Provider Participation Report for ASCs?
Answer: It appears that some do, but some do not. We will check into that situation. Public reporting for ASC data will not begin until later this year. We did supply to the QIN-QIO NCC a list of the ASCs by state, NPI, and CCN, along with contact information and phone numbers, so those should be accessible to you soon. Keep in mind that the ASC community operates much more like a physician’s office than a hospital; some do not post their emails.
· using hospital compare data for analysis
o Jifeng Ma, Senior Statistician, directed attendees to the location of the Hospital Compare data at www.data.medicare.gov. The data are available in a Microsoft Access version or CSV format. The Microsoft Access database format may be easier to import into SAS for analysis. Provider- level data can be compared to state or national data to identify low performing providers in certain measures. For example, hospitals with measure performance lower than the national or state median by one measure, two measures, or three measures can be identified in order to prioritize the hospital list for implementing interventions.
o The benefits of using these data are that they are updated every quarter, are easy to obtain, and contain many measures, though, as Renee stated, the ASC data are not yet available. The data include measures for IQR, OQR, HCAHPS, VBP, MSPB, HAI, readmission, PSI, etc.
o The drawbacks of using these data are that the time frames may be problematic, e.g., CY 2013 OQR data are available from Q4 2012 to Q3 2013 or from Q2 2013 to Q1 2014. In addition, provider data with denominators of less than 10 are suppressed. Please note that the state and national summaries are based upon the raw data, whereas the provider data excludes data with denominators of less than 10, making comparisons more difficult.
· oqr program update
o Elaine stated that CMS is working intently on a solution to the data access difficulties that some QIN-QIOs are experiencing.
Question: Should we refer questions from providers about validation to the Validation Contractor?
Answer: Yes, that is the right place to start.
Question: Where should ASCs with questions about the calculation for ASC-12 be directed?
Answer: The Specifications Manual would be the best resource. A different contractor is conducting the dry run and will be sending individual reports to ASCs. Once these are received, the contractor will present a webinar to review the results and dialog with the facilities. We highly recommend that you register with the ListServe to receive notification of when that webinar will be held.
· Call for topics
o Elaine asked that participants email her with any suggestions for topics for future calls at .
· questions and answers
Question: When will registration for the VBP webinar become available?
Answer: Registration information will be posted on qualityreportingcenter.com closer to the presentation date of March 25.
· The next National QIN-QIO Call is scheduled for Thursday, April 9, 2015, at 2:00 PM ET.
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