SUMMARY MINUTES
THURSDAY, APRIL 9, 2015
2–3 p.m. ET
· Welcome and Announcements Mary Ann Jones
IQR Project Director, HSAG
Quality Reporting Outreach and Education Support Contractor
· Upcoming Education Programs Karen VanBourgondien
Project Coordinator, HSAG
o April 2015
v April 8 eCQM: QRDA Cat-I eReporting Webinar for Eligible Hospitals
v April 15 OQR: QualityNet Reports: Digging Deeper into the Data
v April 16 IPF: Influenza Vaccination of Healthcare Personnel IMM-2 Measure
v April 21 VBP: 30-Day Mortality Measures and AHRQ PSI-90 Calculations
v April 23 PCH: Maximizing Your CDC Reporting and Data Experience
v April 27 IQR: Reports 101
o May 2015
v May 21 IPF: Proposed Rule
v May 6 ASC: Influenza Vaccine for Healthcare Personnel, to be presented by the CDC
v May 20 OQR: Quality Improvement with the Hospital OQR Program
v May 26 IQR: IPPS Proposed Rule as Related to IQR Requirements
v May 27 ASC: Understanding the Web-Based Measures
v May 28 PCH: FY 2016 Proposed Rule Changes
v May VBP: May webinar moved to June 3 resulting in two HVBP webinars in June
· APU Determination Process – FY 2016 Candace Jackson
Hospital VBP Team Lead, HSAG
o Phase I – Clinical Process of Care, Population and Sampling, and PC-01 (1Q–3Q2014); HAI Submissions (1Q–2Q2014)
v Facilities not meeting the IQR program requirements may receive a ¼ percentage point reduction in their FY 2016 APU.
v Of 3,250 participating facilities, 154 (4.8%) Failed to meet one or more of the requirements.
§ As of 4/9/2015, 90 reconsideration requests had been received.
Measure Failed / Number of Hospitals Failing / Percent of Hospitals FailingClinical Process of Care / 8 / 5.2%
Population & Sampling / 5 / 3.3%
PC-01 / 29 / 18.8%
HAI* / 89 / 57.8%
More than One Measure / 23 / 14.9%
*Indicates a large increase in the number of hospitals that did not meet HAI Submission requirements
v At-Risk letters were sent 3.15.2015
v Reconsideration Period ended 4.16.2015
o Phase II – Clinical Process of Care, Population & Sampling, and PC-01 (4Q2014); HAI Submissions (3Q–4Q2014); No Security Administrator; No HCAHPS Data Submission, Structural Measures, and/or DACA; No NoP; Did Not Pass Validation
v Will begin May 2015
o IQR Spec Manual for v.5.0 (10.1–6.30.2015 Discharges) was posted to QualityNet 4.1.2015
v Includes new Sepsis Bundle Measure (beginning with 4Q15 Discharges)
§ Training will be provided, beginning June –October 2015 re: the Sepsis Bundle Measure
· Hospital Value Based Purchasing Bethany Wheeler
Hospital VBP Team Lead, HSAG
o Updates to Hospital VBP for FY 2016–2017
v Changes from FY 2015–FY 2016
§ Change in reduction rate from 1.50% to 1.75%
v Clinical Process of Care Measure Changes
§ Clinical Process of Care Measures not adopted for FY 2016
□ Topped Out
w AMI-8a: Primary PCI Received within 90 Minutes of Hospital Arrival)
w SCIP-Inf-1: Prophylactic Antibiotic Received within One Hour Prior to Surgical Incision
□ No Longer Endorsed by NQF
w PN-3b: Blood Cultures Performed in the ED Prior to an Initial Antibiotic Received in Hospital
w HF-1: Discharge Instructions
□ Classification Changes
w The SCIP- Inf-4: Cardiac Surgery Patient with Controlled 6 a.m. Postoperative Serum Glucose
§ Clinical Process of Care Additions
□ IMM-2 Measure
§ Final Eight FY 2016 Clinical Process of Care Measures include:
□ AMI-7a
□ PN-6
□ SCIP-Inf-2
□ SCIP-Inf-3
□ SCIP-Inf-9
□ SCIP-Card-2
□ SCIP-VTE-2
□ IMM-2
§ Clinical Process of Care Domain Weight Decrease
□ From 20% in FY 2015 to 10% in FY 2016
w Started at 70% in FY 2013
v Patient Experience of Care
§ No changes in dimensions or scoring
§ Weight decreased from 30% in FY 2015 to 25% in FY 2016
v Outcome Domain
§ Added two new measures for FY 2016 to the five added in FY 2015
□ CAUTI – NEW for FY 2016
□ SSI – NEW for FY 2016
□ 30-Day Mortality Measure for AMI
□ 30-Day Mortality Measure for Heart Failure
□ 30-Day Mortality Measure for Pneumonia
□ AHRQ PSI-90 Composite
w Calculated by utilization of AHRQ QI software version 4.4 in FY 2015 and FY 2016
Ø V4.5a will be used for FY 2017
□ CLABSI
§ Domain Weight Increase
□ From 30% in FY 2015 to 40% in FY 2016
v Efficiency Domain
§ Domain Weight Increase
□ From 20% in FY 2015 to 25% in FY 2016
v Total Performance Scores (TPS)
§ Unchanged for FY 2016
□ Hospitals will receive a TPS if they receive at least two domain scores
v Changes from FY 2016–FY 2017
§ Change in reduction rate from 1.75% to 2.00%
§ Realignment of measures and domains based on the National Quality Strategy (NQS)
□ Four Domains were adopted
w Clinical Care
w Patient and Caregiver Centered Experience of Care/Care Coordination
w Safety
w Efficiency and Cost Reduction
□ Clinical Domain separated into two sub-domains
w Process sub-domain includes:
Ø AMI-7a
Ø IMM-2
Ø PC-01
Ø Process sub-domain weighted at 5% of the TPS
w Outcomes sub-domain includes:
Ø 30-Day Mortality Measure AMI
Ø 30-Day Mortality Measure Heart Failure
Ø 30-Day Mortality Measure Pneumonia
w Outcomes sub-domain weighted at 25% of the TPS
□ Patient- and Caregiver-Centered Experience of Care/Care Coordination Domain
w Same dimensions as the Patient Experience of Care Domain in past years
w Weighted at 25% of the TPS
□ Safety Domain includes:
w AHRQ PSI-90
w CLABSI
w CAUTI
w SSI
w MRSA – New for FY 2017
w C.diff – New for FY 2017
w Weighted at 20% of the TPS
□ Efficiency and Cost Reduction Domain
w Contains the MSPB Measure
w Weighted at 25% of the TPS
v Total Performance Score – Minimum Domain Change
§ From two of the four domains to three of the four domains in order to receive a TPS
§ Meeting the minimums in just one of the two Clinical Care sub-domains is sufficient for meeting the domain requirement for inclusion
□ If less than the minimum domains are scored, the unused domain’s weight will be proportionately reweighted to the remaining domains
o List of Data Sources
v Report 542 (VBP Summary Report) Uploaded in January
v Table 16B on CMS.gov IPPS Rule Pages
v Hospital Compare Data Pages
v Hospital Compare Downloadable Databases
v Hospital Compare Payment Pages
v FY 2017 Baseline Measures Reports – PDF Bundles coming soon
o Overview of Upcoming Educational Opportunities
v April 21 by the Reports and Analytics Contractor
§ How to calculate the 30-Day Mortality Measures and the AHRQ PSI-90 Composite
§ How to Read HSRs
§ How to Submit a Review and Corrections request
v June 3 by Acumen
§ How to calculate the MSPB measure
§ How to submit a review and correction request
§ How to read the MSPB HSR
v Late June by HSAG HCAHPS Contractor and Bill Lehrman
§ The methodology and calculation of the HCAHPS rates
§ Two process improvement stories from hospitals
v July by Bethany Wheeler, HSAG
§ Overview of the FY 2016 Hospital VBP Program
§ How to read a Percentage Payment Summary Report
o For additional information regarding changes in the Hospital VBP program, please reference QualityNet>Hospital Value-Based Purchasing>Webinars/Calls and access the webinar documents for February 17, 2015, as well as the webinar documents for April 29, 2014.
o Bethany requested the QINs to send the name of a hospital that successfully implemented HCAHPS procedures that improved their rates. Please send your suggestions to .
· Outpatient Quality Reporting Update Elaine Krantzberg
OQR Project Director, HSAG
o Submission Deadlines
v Clinical Data – May 1, 2015
v IMM Data to NHSN – May 15, 2015
o An Outpatient Needs Assessment is in development
o Data Update
v CMS is working on a solution to getting you access to the data and reports you need
· Questions and Closing Mary Ann Jones
IQR Project Director, HSAG
Quality Reporting Outreach and Education Support Contractor
· The next call is scheduled for Thursday, May 14, 2015, at 2 p.m. ET.
This material was prepared by the Inpatient Value, Incentives, and Quality Reporting Outreach and Education Support Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. HHSM-500-2013-13007I, FL-IQR-Ch8-04142015-05
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