JCAHO and CMS QIO Liaisons
FROM: Pat Merryweather, IHA/AMR Vice President
SUBJECT: Performance Measurement Developments
Over the next few years, the demand for public accountability and performance measurements is expected to continue to increase. As consumers, employers, health plans, and patients and their families seek information to aid them in their health care decision-making processes; the need for process, outcome, and patient experience information is expected to increase dramatically.
Within the next few months, hospitals will begin to experience some additional changes with reporting of performance measurements with increased benefits of standardization and validation of information. However, these changes are not without effort and resource expenditure by providers and the more providers can plan ahead and anticipate changes, the greater likelihood they have of effectively and efficiently implementing these changes.
To better help you prepare for these upcoming changes, the information on the following items is meant to guide and assist you as you plan ahead for the upcoming changes:
National Performance Measurements
Upcoming February 2004 Release Centers for Medicare and Medicaid Services (CMS) Accepting Only Validation Process Medicare Patient ID Requirements Measurement Expansion CART for All Submitters SeminarsJoint Commission on Accreditation of Healthcare Organizations
Matching CMS Methodology
Expand Simultaneously with CMS
Adding Surgical Infection Prevention Measures and Implementation
- Pilot ICU
COMPdata Annual Meeting – “Patient and Consumer Driven Health Information Needs”
National Performance Measurements
On October 9th, the first reports from The National Voluntary Hospital Reporting Initiative became available to the public. Many providers, health plans, consumers, and purchasers have visited the web site to determine hospital participation and view results. The CMS web site information can be found at http://www.cms.gov/quality/hospital/
Much information on the National Performance Measurements and the information within this section will be supported by the Illinois Medicare QIO, Illinois Foundation for Quality Health Care (IFQHC); your Core Measurement vendor; and the American Hospital Association.
Upcoming February 2004 Release. The next release of public data for the National Voluntary Hospital Reporting Initiative will be in February 2004 and will include data for the 1st and 2nd Quarters of 2003. If your hospital is reporting data publicly starting with January 1, 2003, your hospital is urged to ‘clean up’ any missing variable measurement results or erroneous data by November 15th.
Hospitals that are using a vendor should check with their vendor as to how and if the vendor will accept and process updated data for 1st and 2nd Quarter 2003. Hospitals that are not releasing their data publicly for 1st and 2nd Quarters 2003 may opt not to update that information, as the purpose is to provide clean and comparable data to the public. Hospitals should check with their vendors as to how they will be handling this recent announcement and request by CMS. COMPdata will be sending out information in a separate memo to accommodate any providers that wish to make updates to their data.
CMS Accepting Only Accurate Data in Standard Format CMS will only be accepting data from vendors that are accurate and in the XML format. Starting with 2003 data, CMS will only accept data that meets their ‘hard or required’ edits. Up until now, vendors have been variable in their consistency and quality of data reporting. As CMS is committed to using the information for public reporting and consumer decision-making, the information needs to be consistently reported and have the same edits applied to the data. Vendors will be required to submit complete and accurate data based upon the CMS standard formats and edits.
Validation Process In order to ensure that providers are accurately abstracting information in a standardized manner from patient hospital files, CMS will be conducting validation studies on random patient records selected by CMS.
Basically, a provider will be notified of the approximate 5 patient cases that have been selected from the clinical information submitted. Hospitals will have a limited time frame to submit copies of the medical record and patient information to one of CMS’s data abstraction centers. When CMS receives the patient record, trained medical abstractors will re-abstract the patient information and compare the CMS abstraction results from the hospital patient record information to the clinical record submitted in the XML format to see how accurately they match.
Providers that meet the criteria established by CMS will be highlighted on the public web site as having accurately reported information. Providers that have less than the expected match will be either certified for six months or not at all and, if not certified, then requested to go through the process again. CMS has been using the thresholds in discussions of 90% match or greater for a year of certification; 80% to 90% match for six months of certification; less than 80% match will result in no certification and urging by CMS to the provider to try again.
Details on the validation process will be shared as the Validation Process is rolled out through the QnetExchange web site and IFQHC.
Medicare Patient ID Requirements CMS is expected to require the actual social security number or HIC Id Number on any clinical submissions in which Medicare is the primary or secondary payer (possibly beginning as early as January 1, 2004). CMS hopes in the future to create a linked record for all patient care services received by the Medicare beneficiary and be able to match the clinical cases to claims information.
Measurement Expansion CMS is expected to announce the expanded reporting of additional measurements for Acute Myocardial Infarction (AMI) and Pneumonia (PNE). Surgical Infection Prevention (SIP) measurements are also expected to be included in the requirements along with additional clinical areas of measurement. Some of these expanded reporting requirements for AMI and PNE are expected to occur in 2004 along with the addition of some other measurement areas; such as SIP.
CART For All Submitters A new release of the national CMS CART software is scheduled before the end of October. This newer version is being beta tested by IHA and is able to handle large volumes of data; process much easier; have all national edits built into it; and allow providers to quickly assess their performance through measurement reports.
If a hospital is currently not using CART, they can opt to use the software to verify their submitted data by a vendor and to directly submit measurement information to CMS. Please note that CART is also being promoted to vendors as vendors can run their data through the CART XML Case Checker to ensure that they have the proper edits in place prior to submitting data to the QnetExchange.
Seminars As we know there are so many changes and updates occurring quickly, COMPdata is working with state Quality Improvement Organizations and will be conducting collaborative seminars in each state. Announcements regarding locations, times, and registration will be forwarded shortly. One of these seminars is already scheduled for November 17th in Illinois and will be held in conjunction with the COMPdata meeting on November 18th and 19th.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
For hospitals that are accredited by JCAHO, there will be a number of changes that will be made to their reporting requirements so they are aligned with the National Quality Initiative and CMS specifications.
Matching CMS Methodology Starting with July 1, 2004 patient discharges, JCAHO will align their existing measurement methodologies with the CMS measurement methodology. Currently the methodologies are not in sync and providers are dealing with different results depending upon which methodology or system is being utilized.
Remember, JCAHO collects statistical results from vendor submissions on behalf of the hospitals and therefore, JCAHO needs to audit and validate the algorithms and results of all of its vendors. The auditing and validation process of vendors is expected to occur in early 2004 to ensure all vendors are ready and prepared for the July 1, 2004 start up date.
Expand Simultaneously with CMS JCAHO is working to expand the measurement sets for their Core Measurement program so that they coincide with the CMS measurements. As CMS and JCAHO jointly expand, they have promised to work collaboratively and together to ensure the data being collected are the same and the information can be consistently compared and utilized across systems.
Adding Surgical Infection Prevention Measures and Implementation Time Frame
Pilot ICU
In 2004, JCAHO has stated to vendors and state associations that they will add in Surgical Infection Prevention measurements. It is anticipated that this new measurement set will be added in on July 1, 2004 or shortly thereafter.
Currently, JCAHO is accepting voluntary hospitals to pilot the Intensive Care Unit measurement set. If a hospital is interested in participating in the ICU pilot, please visit the JCAHO web site at http://www.jcaho.org/pms/core+measures/candidate+core+measure+sets.htm
COMPdata Annual Meeting – “Patient and Consumer Driven Health Information Needs”
In order to provide hospitals with a perspective and a sense of upcoming events that will effect hospital public reporting, COMPdata has assembled some of the most noteworthy leading experts that are shaping the consumer and patient information initiatives. The COMPdata Annual Meeting from the afternoon of November 17th through noon on November 19th will also provide attendees with practical tools and knowledge for them to use in their own hospital setting. For additional information on the COMPdata Annual Meeting and to view a Registration Form, please see the following portion of the COMPdata web site. http://www.ihatoday.org/compdata/annmtg.pdf Please note that there is a maximum attendance limit for this valuable meeting. So please register as soon as possible.
On Tuesday, November 18th, Dr. Arnold Milstein, who has been a leader in moving health information demands into reporting initiatives throughout the country will address the COMPdata audience as the keynote speaker. Arnie Milstein, M.D., M.P.H., has led initiatives in New York, Leapfrog, Pacific Business Group on Health, JCAHO, and now with the Consumer-Purchaser Disclosure Project. The JCAHO ICU pilot is one that Dr. Milstein has been involved in from the beginning in response to the hospital industry objections to the Leapfrog intensivist requirements.
Michael Parkinson, M.D., M.P.H. is a leading expert in consumer driven information needs and is working closely to identify the information needs of consumers and employers in offering various health plan approaches.
Jamie Orlikoff, President of Orlikoff and Associates, is one of the healthcare industry’s leading futurists. Jamie will help providers to better understand the environmental reasons behind the increasing information and accountability needs of health plans and employers. Armed with the futurist perspective, providers are better able to anticipate how they might structure and respond to the increasing information demands that will continue to be placed upon them.
A representative of the Agency for Healthcare Research and Quality will highlight some of the recently published studies focused on hospital quality of care. The AHRQ representative will also focus on the over 100 measurements on quality, patient safety, and utilization that used hospital administrative (UB) data in the study. Upcoming studies utilizing the quality, patient safety, and utilization data will rank order state overall performance. The AHRQ representative will also discuss the pilots that are being conducted using the “Patient Experience Survey” that will become a standardized tool for all providers to assess patient satisfaction and report that info to CMS and the public.
On Monday afternoon, November 17th, IHA and IFQHC will host a workshop on all of the new National Quality Initiative changes mentioned in this memo. Additionally, a demonstration of the new CART features will be provided for all attendees as it will become increasingly beneficial for providers and their vendors to take advantage of the new CART features and functions.
On Wednesday morning, November 19th, Robert Lloyd, Ph.D. of Advocate Healthcare and a national speaker and author, will conduct a workshop on understanding and interpreting the national measurements, statistics, control charts, and how best to share results and information with hospital executives, clinicians, and eventually the general public.
IHA will continue to keep you informed of all of these developments so you might plan and design your electronic medical records, information systems, and clinical response teams to meet the increasing demands and requirements on hospital providers