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April 18, 2007
Hospital Report Card Act - Final Rules Published
On March 28, the final rules covering the Hospital Report Card Act became
effective and were published in the April 13, 2007 Illinois Register. These
rules cover the nurse staff information and infection process and outcome
measurements to be reported to the Illinois Department of Public Health and the
public.
The new rules can be found at either the State of Illinois Illinois Register
site or by clicking here. These rules are
included in the Administrative Code of Illinois under Title 77 – Public Health,
Part 255. As you will recall, under the Hospital Report Card Act under Public
Act 93-563, hospitals are already required to follow the Whistleblower
Protections (Section 35) and Staffing Levels upon request (Section 15). This
Public Act is available by
clicking here.
Nurse Staffing Reporting Requirements
In addition to existing requirements for providing nurse staffing
information to consumers upon request, the new rules do have some additional
requirements:
Effective March 28, 2007 – Hospitals should notify the public of the right
to access nurse staffing information, including posting on their web site and
disseminating patient education materials on how to obtain nurse staffing
information.
In order to ensure you are compliant with existing and recently released
rules and turnaround timelines on patient or consumer requests, hospitals
are encouraged to review Section 255.150 of the Administrative Code for
Public Health.
- July 1-September 30, 2007 -- Hospitals will be educated by Illinois
Department of Public Health on reporting requirements for nurse staffing.
- October 1-December 31, 2007 -- Hospitals will participate in a pilot
submission of data using a standardized submission approach.
- January 1-March 31, 2008 -- First set of nurse staffing information to be
gathered by hospitals and submitted by April 20 with any updates by July 1
2008.
- July 2- September 30, 2008 -- First set of comparative nurse staffing
information to be released to public.
Please note that all hospitals are required to submit nurse staffing
information. When the actual results are released to the public, there are
requirements to adjust and offer comparisons by types of hospitals and service
areas and units.
Infection Reporting Requirements.
Infection reporting requirements have various phase in dates beginning with
July 1, 2007 and extending to July 1, 2008.
Starting with July 1, 2007 for PPS inpatient hospital discharges and
October 1, 2007 for non-PPS inpatient hospital discharges according to CMS
Hospital Quality Alliance reporting guidelines:
SCIP-Inf 1 – Prophylactic antibiotic received within one hour prior to
surgical incision
SCIP- Inf 2 – Prophylactic antibiotic selection for surgical patients
SCIP- Inf 3 – Prophylactic antibiotics discontinued within 24 hours
after surgery end time
Surgical outcome measures by reporting postoperative wound infection
diagnosed during index hospitalization
October 1, 2007 for both PPS and non-PPS hospitals according to CMS
Hospital Quality Alliance reporting guidelines:
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
July 1, 2008 for both PPS and non-PPS hospitals:
Central vascular catheter-related bloodstream infection rates in
designated critical care units
Patients diagnosed with postoperative ventilator-associated pneumonia
(VAP) during index hospitalization as set forth in SCIP
PPS hospitals will be required to report the first quarter of data
covering third quarter 2007 patient discharges by October 31, 2007 and to make
all corrections by January 1, 2008. It is anticipated that this first set of
quarterly information could be reported publicly during 1st quarter
2008 pending there is sufficient number of cases that make the reported
information meaningful to consumers.
Please be aware of the following when you are reviewing the infection
reporting SCIP requirements:
Sampling can be used in reporting as long as hospital follows CMS Hospital
Quality Alliance rules on sampling and the volume meets the criteria
established by CMS for sampling
Hospitals may find that they do not provide the surgical services under
SCIP and therefore are not required to report the SCIP measurements. Surgical
services currently covered under SCIP include: CABG, Hip Arthroplasty, Knee
Arthroplasty, Colon Surgery, Hysterectomy, Vascular Surgery, and other Cardiac
Surgery procedures
Patients included in reporting are those 18 years and older and for
patients in specialty pediatric hospitals, age requirements are extended to
include those patients who, due to condition, care and treatment requirements,
continue to be considered pediatric.
To the extent possible, the rules include nationally adopted measurements
currently reported by hospitals to CMS to reduce the reporting burden on
hospitals.
Training and Support
IHA is working closely with the Illinois Department of Public Health and
will be helping to coordinate education, training, and support on both the
infection and nurse staffing information reporting requirements. Within a couple
of weeks, IHA will have more details on the Webinars, conference calls,
educational meetings and material, and a combined effort and process to quickly
address and respond to questions or issues by hospitals on reporting
requirements.
Helpful Hints To Get Started
Review rules to ensure hospital is compliant with existing provisions such
as whistleblower, nurse staffing, orientation and training
Review rules to understand how your hospital may best comply with the
nurse staffing information reporting requirements. While there will be
standardized methods that hospitals will need to utilize in defining and
reporting information, it is helpful to understand what your current practice
is for definitional and collection purposes.
Review rules on infection reporting to understand the reporting
requirements and time frames for reporting this information.
As the rules are now in place, initiate discussions with hospital and
executive management on reporting requirements and any information already
gathered or provided. Update your hospital board on new rules and your
hospital plans for reporting this information.
For hospital infections, continue or initiate multi-disciplinary
discussions on methods and approaches for reducing hospital infections as the
Hospital Report Card Act includes public reporting of process and outcome
measurements. As many efforts in reducing infections involve expenditure of
resources, incorporate the infection control and prevention specialists,
quality improvement staff, chief financial officer or their staff, nursing
executives, chief medical officer, health information technology staff, and
other clinical and executive staff in your discussions. Many hospitals are
undertaking organizational assessments on return on investment approaches in
reducing hospital infections and have found these investments to result in
improved outcomes of care for patients and a financial return on this type of
quality improvement investment.
Assess if there are any gaps in consistency of information within
administrative billing, internal infection control data and results, and
current SCIP reporting. CMS has already started to link some of the billing
and Hospital Quality Alliance information together and is identifying
variations in reported information. Hospitals should strive to reach
consistency within their organization on internal and externally reported
information.
IHA will continue to keep you updated on developments and to provide
hospitals with resources and support for not only reporting of information under
the Hospital Report Card Act rules, but also on strategies and opportunities for
quality improvement.
Staff Contact: Pat Merryweather:
(630) 276-5590
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