Illinois Hospital Association

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February 7, 2008

Quality Improvement and Public Reporting Update

TO:	Chief Executive Officers
	Chief Medical Officers
	Chief Nursing Officers
	Directors of Quality
	COMPdata Contacts

In response to many inquiries received, there are several updates below on quality improvement and public reporting that will help guide your hospital in meeting and understanding reporting requirements and new initiatives.

Administrative Data Reporting Requirements for 1^st Quarter, 2008 Discharges and Outpatient Cases
As a quick reminder, all inpatient discharges and outpatient cases for 1^st Quarter, 2008, must be submitted to IHA in the new format – either HIPAA 837 4010A1 or the IHA Expanded Format. This same format is required by the Illinois Department of Public Health (IDPH) for the same time period. As the Illinois Hospital Association serves as the data collection agent for IDPH, hospitals need to submit data only once to IHA and IHA forwards the data on to IDPH at the end of the quarterly submission data.

Deadline Approaching for Testing of New Format. According to IDPH rules, hospitals have until the end of February to submit a successful test to IHA using the new format. As of today, 47% of hospitals have electronically tested the new formats successfully; however, 53% of hospitals have not.

At the end of February, IHA must supply IDPH with a listing of hospitals that have successfully tested the new format. If you are unsure as to your hospital’s status with this requirement, please contact by the COMPdata Helpline by telephone at 630-276-5889 or by e-mail at ubhelp@ihastaff.org. IHA will be personally contacting every hospital that has not yet submitted a successful test to IHA so we can ensure all of our hospitals are compliant with the testing deadline.

Any hospital that submits data for the 1^st Quarter 2008 in the old format will have their data rejected. According to state reporting requirements, data can only be submitted in new format due to all of the new data reporting requirements.

New Data Elements To Be Reported. The 1^st Quarter of 2008 data will include new information to be reported on each patient case under state rules include, but are not limited to the following:

Up to and including 25 diagnoses codes and 25 procedure codes

Race and ethnicity using federal OMB standards (similar requirements for CMS HQA and Joint Commission Core Measurements)

Present on Admission Code for all inpatient diagnoses codes – identifying whether a condition occurred prior to hospital admission, during hospital stay, not clinically determined, unknown, or not required (i.e., Pregnancy, tumors, etc.)

Birthweight of newborns in grams

E-Codes (external cause of injury codes – including poisoning, falls, etc.)

And several more HIPAA elements

Hospital Report Card Act Reminder – SCIP and Nurse Staff Information
SCIP. Surgical Care Improvement Program reporting is required for all Illinois hospitals starting with 4^th Quarter, 2007 inpatient discharges. For 3^rd Quarter, 2007 inpatient discharges, only inpatient PPS providers were required to report SCIP. Starting with 4^th Quarter 2007 discharges, all providers, including Critical Access Hospitals are required to report data. As in the past, the information to be sent to IHA, and in turn IHA forwards to IDPH, is the case level data for each SCIP case.

Please keep in mind that in addition to SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3 reporting requirements, 4^th Quarter 2007 has additional reporting requirements, including:

SCIP Inf – 3b, 3c - Cardiac surgery patients with prophylactic antibiotics discontinued within 48 hours after surgery
SCIP-Inf-4 - Cardiac surgery patients with controlled 6 a.m. postoperative serum Glucose

Hospital reporting deadline for 4^th Quarter 2007 SCIP case level data is March 31, 2008 for all Illinois hospitals. After March 31, 2008, IDPH will not allow any new cases to be added or any modifications to cases submitted prior to the March 31, 2008 deadline.

Vacancy Rate. Just a quick reminder that the nurse staff vacancy rate as of January 1, 2008 is required to be reported by April 1, 2008.

QIO 9^th Statement of Work (SOW)
Starting August 1, 2008, the Medicare Quality Improvement Organizations (QIOs) will begin a new statement of work that will extend through July 31, 2011. This new statement of work has many new initiatives from the current 8^th Statement of Work and also puts in place assessment tools to determine each QIOs performance in carrying out the activities. For the first time, QIOs that are not achieving targeted goals mid-stream during the contract will have the non-performing activities transferred and carried out by another QIO. Also, starting with the 10^th SOW in 2011, all QIOs will need to go through a competitive bidding process as only a few were required to be competitively bid for the 9^th SOW.

Under the 9^th SOW, QIOs will be charged with 4 main areas of responsibility:

Protecting Beneficiaries – including quality of care, beneficiary appeals; and reviewing EMTALA cases

Patient Safety – SCIP, MRSA and other MDROs, and a focused approach on hospitals with the largest gaps in current performance

Prevention (Not all in the traditional public health sense of prevention) – focused on the adherence to care guidelines for diabetes patients; adult immunization; early detection of kidney disease; colorectal and mammography screening; and identifying and addressing disparities in care

Patient Pathways (Care Transition) – ensuring that patients have discharge instructions; medication reconciliation; and patient care plans on passed on appropriately to providers and care givers involved in the patient’s care

There are also several pilot initiatives that the individual QIOs will bid on focused in improvements in transitional care and health information technology.

Targeted Hospitals and Nursing Homes. At the same time that CMS released the Request for Proposal (RFP) in a press conference on Tuesday, February 5, CMS also released a listing of 924 hospitals and several thousand nursing homes ‘targeted for improvement.’

CMS listed 40 Illinois Hospitals targeted for quality improvement for the SCIP program as identified in the list for needing improvement for SCIP 1 and SCIP 3. When IHA and other state hospital associations questioned CMS on the methodology employed to create the list of hospitals, CMS replied that the list did not just include factors such as SCIP 1 or SCIP 3, but other factors which they would not describe. A public document produced by CMS states that the list was based upon SCIP 1 and SCIP 3 and hospital acquired pressure ulcers. However, there is no way to know if pressure ulcers were acquired during the hospital stay as that becomes a reporting requirement on Medicare claims using Present on Admission codes starting April 1, 2008. IHA is urging hospitals and others not to read anything into this list of providers that CMS listed as many performed quite well on SCIP 1 and SCIP 3 and above state and national averages; some of the providers do not even provide the SCIP surgical procedures; and others had annual cases of less than 5 per year.

As for several hundred Illinois nursing homes listed, CMS described them as targeted for improvement based upon their performance on pressure ulcers and restraint usage. Again, providers and others are asked to be cautious about reading anything into this listing.

IHA will be providing a more complete overview of the 9^th Statement of Work in a subsequent memo next week, but wanted to make sure you understood some of the basics of the 9^th SOW and the lists of providers that appeared with the CMS press release.

CMS Methodology Issues on Mortality, HCAHPS, and Targeted SCIP List
IHA has been contacted by just about every hospital in Illinois on the issue of Medicare not disclosing the methodology and co-efficients used in the HQA mortality measurements; HCAHPS (patient satisfaction) Patient Mix Adjustment; and the list of providers in the recent 9^th SOW press release. IHA is working with the American Hospital Association and other state hospital associations in requesting that this information be released. CMS has stated they would release the HCAHPS Patient Mix Adjustment methodology and co-efficients some time after the public release of the hospital HCAHPS survey results.

IHA is fully aware of the need for transparency on methodologies and will continue to request that the information be shared with hospital providers. As the recent CMS Value Based Purchasing paper to Congress suggests that the Hospital Quality Alliance measurements on mortality and HCAHPS will figure into a hospital’s performance, and in turn their annual market basket increase or decrease, it is important that hospitals understand the scoring mechanisms and are able to validate CMS results.

As a quick reminder, CMS is closing the HCAHPS preview by hospitals on February 15. After February 15, the results will not be available to hospitals until the public release in March. Hospitals that have not reviewed their reports after the February 1 update are urged to do so before February 15.

Training and Educational Opportunities
IHA is continuing to conduct educational and training sessions on reporting requirements for the Hospital Report Card Act and Consumer Guide. For additional information or to sign up, please click here and click on the area most appropriate. There also are educational material available on the IHA web site at http://www.ihatoday.org/issues/quality/statereq.html and also on COMPdata at http://www.compdatainfo.com/ and then click on Training. Deadlines for reporting requirements are also available on-line at http://www.ihatoday.org/issues/quality/statereq.html and scrolling down to Public Reporting Schedule for State and National.

Ongoing IHI educational series for improvement and targeted interventions are available at http://www.ihatoday.org/issues/quality/improvement.html.

IHA will continue to keep you updated on developments to ensure you are aware of reporting requirements and also on some of the unresolved issues on methodological concerns. If you have questions, please contact Pat Merryweather at pmerryweather@ihastaff.org.