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March 22, 2007 Developments on Quality Improvement Initiatives and Public AccountabilityThere are a number of key developments that have recently occurred that IHA wanted to make sure our member hospitals were aware of as well as some upcoming educational opportunities that will be beneficial to your hospital. Hospital Report Card Act Implementation. As noted in the second posting of rules, PPS inpatient hospitals will be required to begin implementation of infection reporting starting July 1, 2007 for the three Surgical Care Improvement Program measurements (currently required for Medicare Annual Market Basket Increase). Non-PPS hospitals would begin reporting October 1, 2007. Other measurement reporting begins at different dates but will also be based upon availability of nationally accepted and adopted measurements. As noted in prior communications, nursing staff information would start out with the first quarter devoted to education of reporting standardized data on nursing staff followed by a quarter of pilot submissions of data. That is, third quarter 2007 would be devoted to education on nursing staff reporting requirements followed by fourth quarter 2007 pilot submissions of data. The first quarter of actual reporting of nursing staff data would occur starting with first quarter 2008 nursing staff information. Educational Opportunities. IHA will be conducting several telephone conference calls during April and May to acquaint everyone with the reporting requirements. Additionally, the Hospital Report Card Act reporting requirements will be discussed in detail at the May 23 and 24 Illinois Quality Leadership Conference. In July and August, IHA will provide in-person educational programs throughout Illinois to ensure that everyone has an opportunity to fully understand the reporting requirements and address hospital questions. Consumer Guide The proposed rules have been published for the first notice period and are available on the IDPH web site (click here). IHA will be submitting comments to IDPH on these rules prior to the comment closing period of April 23, 2007. If you have comments that you would like IHA to advance to IDPH, please send your comments to Pat Merryweather (pmerryweather@ihastaff.org). Please note that this is the first posting of rules and the public has until April 23 to comment. After April 23, IDPH will review all comments received and consider suggestions and comments and then submit the second set of rules to JCAR. JCAR will then confer with IDPH and issue a second notice on the proposed rules followed by a final rule. Consumer Guide Rules Content In addition to the expanded reporting formats for inpatient and outpatient surgical data, IDPH will begin collecting observation care and emergency department data starting January 1, 2009. The majority of IHA member hospitals are already submitting this data to IHA and are utilizing the information to better understand community health needs and delivery system issues. IHA’s COMPdata has been providing in-person training and educational Webinars on the expanded reporting requirements since fall 2006 and has many more educational programs planned to assist member hospitals in transitioning to the new formats. Please visit IHA’s COMPdata web site (click here) to find out about upcoming training and to register for these free educational programs and Webinars. Please note that all of the new formats and supporting educational material are available on each COMPdata Hospital Data Coordinator account - they have been available since January 2007. Consumer Guide - The Consumer Guide will be available electronically and in hard copy format and will focus on services and procedures with the highest volume and variations in charges, lengths of stay, and quality of care. The Consumer Guide will also include information from the Hospital Report Card Act. As noted in the Consumer Guide Act, the information will be risk adjusted and hospitals will have the opportunity to review their information prior to it going public. Additionally, as part of the Consumer Guide Act, a subset of the hospital reported data will be publicly available with masking done of elements done to protect patient confidentiality and privacy of patients. There will also be a research oriented data set available for research purposes only; such as for disease trends and analysis, etc. These sets of data were available in the past in the same types of formats, but now there are additional safeguards and agreements that will be in place for the protection of patient confidentiality and privacy under federal HIPAA rules and regulations. Educational Opportunities- IHA will be providing countless opportunities throughout the upcoming years on data reporting through COMPdata and ongoing education and communication on public reports for the Consumer Guide. IHA will continue to keep you updated and will be providing additional information on the status of the rules, implementation dates, reporting requirements, and educational Webinars and programs. Federal Initiative on Value Based Purchasing Educational Opportunities April 12: Quality Encounter at Evanston Hospital The program content is geared toward hospital executives, board members, chief medical officers, chief information officers, directors of quality, and clinical staff leaders. As with all Quality Encounter programs of IHA, this program is offered at no charge. May 9-11: National Quality Forum Spring Meeting in Chicago Please remember that the National Quality Forum is a private, not-for-profit membership organization created to develop and implement a national strategy for healthcare quality measurement and reporting. Members include national and state government organizations and associations, hospital providers, consumers, employers, health plans, and other interested parties on healthcare quality measurement and reporting. IHA is an active member of NQF given all of the public reporting initiatives occurring at national, state, and local levels. May 11: Kickoff of Patient Safety Center of Northwestern University hosted
at Northwestern Memorial Hospital There is no charge for this meeting and registration is not required. The meeting is open to the public, and appropriate for all physicians, clinicians, management, and staff who are interested in quality of care and patient safety. For additional information on the meeting and meeting logistics, contact Allan Doeksen, Project Coordinator for the Center for Patient Safety, at patientsafety@northwestern.edu. May 23-24: Illinois Quality Leadership Conference The conference will include a day long focus on the IHI 5 Million Lives
Campaign with special guest speakers from the Institute for Healthcare
Improvement (IHI), including a special videotaped message for Illinois providers
from Dr. Don Berwick, M.D., M.P.P., F.R.C.P.; President
and Chief Executive Officer of IHI. | |
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