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August 16, 2007
Reporting of Surgical Care Improvement Program (SCIP) Data for Hospital
Report Card Act
As noted in prior communications, the majority of all Illinois hospitals will
not need to modify their existing collection of SCIP data to meet the reporting
requirements of the infection portion of the Hospital Report Card Act for a
year. The only change for a year will be to meet the Illinois Department of
Public Health’s deadline and ensure your hospital information is being sent to
IHA.
Hospitals Currently Using COMPdata or Sending Patient Level SCIP Data for IHA
Comparative Performance Initiative
If your hospital is either using COMPdata or participating in IHA’s
Comparative Performance Initiative for SCIP measurements by submitting patient
level data to IHA, the only change you will experience is that you will be
required, like all hospitals, to submit your final, edited data by the end of
business on January 1, 2008.
Hospitals Currently Submitting SCIP Patient Level Data to Joint Commission or
the Centers for Medicare and Medicaid Services (CMS) and Hospital Quality
Alliance (HQA)
If your hospital is currently submitting SCIP patient level data to Joint
Commission or CMS and HQA, hospitals may have their CMS HQA and TJC vendors
submit their hospital SCIP data directly to IHA. As noted in prior
communications, hospitals or vendors unfamiliar with how to transmit clinical
SCIP data to IHA via Electronic File Transfer (EFT) may email IHA at
ubhelp@ihastaff.org or phone the IHA
data collection helpline at 630.276.5889, to obtain the EFT instruction manual
and instructions on how to obtain data submission access. Hospitals are
encouraged to communicate this information with their vendors soon so the
vendors can put in place the mechanisms to submit your edited and complete
hospital data by the IDPH deadlines.
Critical Access Hospitals Not Currently Submitting Data to Joint Commission
or CMS and HQA
IDPH has stated that according to the Hospital Report Card Act requirements,
that if any hospital has cases that fall into the SCIP measurement criteria,
they must report the cases to IDPH. Critical Access Hospitals (CAH) will be
required to report their SCIP data to IDPH starting with October 1, 2007 patient
discharges. While IDPH has stated they may not be able to display CAH data on a
quarterly basis, they will report at annual or aggregate statistical levels. IHA
will be working with CAH providers that are not currently reporting to Joint
Commission or CMS and HQA and who have had cases in the past, to bring them up
to date on data submission process.
IHA Ongoing Support Services
IHA is providing ongoing support and educational opportunities for all
hospital providers. To keep up on the latest updates on the Hospital Report
Card, please go to (click here). For questions on
the Hospital report card act, hospitals are asked to send nurse staff questions
to
nursestaffreporting@ihastaff.org and SCIP questions to
perfmeas@ihastaff.org.
Hospital Report Card Infection Reporting Requirements Reminder
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 using SCIP-Inf 1, SCIP-Inf 3, and
diagnoses codes reported.
October 1, 2007 inpatient discharges 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 inpatient discharges 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 with all corrections by
January 1, 2008. IDPH will not allow any data to be accepted, modified, or
corrected after 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.
Hospitals that are exempt from reporting SCIP measurements will be
required to submit an annual letter to IDPH identifying their reasons for
exemption. IHA will provide a model letter on the IHA Hospital Report Card Act
web site during the week of August 20 along with instructions on submission of
the letter.
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