COMPdata announcements
January 6, 2004
June 17, 2004
M E M O R A N D U M
TO: COMPdata Quality Contacts
JCAHO and CMS QIO Liaisons
FROM: Pat Merryweather, Senior Vice President
SUBJECT: Status on Public Reporting of Hospital Performance
Important Deadline Dates and Hospital Review and Comment Periods
There are several developments regarding reporting of hospital performance that hospital providers should be aware of as some have impending deadlines for review or comment prior to information being made public.
The developments to be highlighted in this memo include:
ü JCAHO Updates
o NEW Quality Report
o Periodic Performance Review
o JCAHO Survey Fee Increase - floating an annual subscription fee approach
o Initial Results from 2004 New Hospital Survey
ü Medicare RHQDAPU
o Non-negotiable Deadlines
ü COMPdata Helpful Hints
o Medicare Record Validation Process
o Public Reporting
ü Medicare Public Listening (Hearing) Session - June 28th, Oak Brook
ü Medicare 8th Statement of Work Proposed Framework
o Cultural Change and Organizational Transformation
NEW Quality Report. On July 15, 2004, JCAHO will unveil to the public the NEW Quality Report highlighting hospital performance. There will be a series of public and media events hosted by JCAHO throughout the nation.
The new Quality Report includes specific information on hospital performance and compliance with the JCAHO survey standards; quality measurements; and patient safety goals. Additionally, hospitals that have received national awards or participate in JCAHO’s certification programs will have a notation on their report as their achievement or participation.
Preparing For Release. Hospitals should do the following immediately in preparation for the July 15th release:
1. Review the information on your hospital at the JCAHO extranet site that is accessible through your JCAHO assigned hospital id and password. Please note that you’re your hospital information will be available - no other hospital information will be available which is unlike the public reporting that will occur on July 15th when all accredited hospital information will be available to the public.
2. Notify immediately JCAHO in writing of any errors with your report. Ask JCAHO to provide an updated version of the Quality Report with any updates made to it to your organization prior to it being made public.
3. Review your performance measurement statistics from your vendor and that contained in the JCAHO report. If there are discrepancies, contact JCAHO immediately. Please note that the JCAHO statistics and that contained in the CMS web site for the National Voluntary Hospital Reporting Initiative will be different as the underlying methodologies and criteria for included and excluded cases differ between JCAHO and CMS. At a recent meeting of JCAHO and hospital state associations, JCAHO announced that they are hopeful that concurrent approaches can be reached starting with January 1, 2005 discharges. Remember, JCAHO receives aggregate statistics from different vendors while CMS receives the patient level data and processes all hospital data through the same software that allows for standardized measurement algorithms to be applied.
4. Prepare and submit written comments to JCAHO for inclusion with the Quality Report on your hospital if you want to demonstrate and report on activities your hospital has undertaken to improve performance in any areas you performed below expectations or the norm.
5. Share the new Quality Report with your Board and Staff. As this information will be publicly available on July 15th and you could experience inquiries from your patients and communities you serve; it is a good idea to acquaint everyone with the new report and your hospital’s performance.
IHA will continue to keep you updated on developments on the scheduled July 15th public release and media events.
Periodic Performance Review (PPR). At the meeting of JCAHO and State Hospital Associations in mid-May, JCAHO announced that the PPR should be viewed as an ongoing management tool that a hospital can use to stay current with the JCAHO standards. As JCAHO moves to unannounced surveys in 2006, hospitals should be using the PPR to be continuously ready to be surveyed and meet JCAHO standards at all times.
Several Illinois hospitals have completed their first PPR and several more are in various stages of completing their PPR. One of the most common questions asked by providers pertains to the percentage of providers selecting the various options. At a recent JCAHO Board of Commissioners meeting, the American Hospital Association reported in a memo to state hospital associations that of approximately 1,100 hospital organizations undertaking the PPR, 59% are doing the full PPR (preparing and submitting PPR results to JCAHO); 32% are choosing to do the PPR Option 1 (preparing PPR but not submitting to JCAHO); 8% are doing the PPR Option 2 and requesting a mid-site survey; and less than 1% are doing PPR Option 3 which is the on-site survey but written report or documentation is left at the survey site.
JCAHO Survey Fee Increase. At the May meeting with state hospital associations, JCAHO announced that they were advancing a plan to their Board of Commissioners to increase survey fees starting in 2005. JCAHO staff did not release any specific information but did communicate to attendees that they were possibly looking at an annual fee for accreditation as opposed to the survey fee.
Initial Results from 2004 Hospital Survey. At a recent JCAHO Board of Commissioners meeting, the American Hospital Association (AHA) reported in a memo to state hospital associations that “12% of organizations received full accreditation: 85% had accreditation pending as the hospitals were undertaking corrective actions; 2.2% of organizations received conditional accreditation; and 0.7% received preliminary denial.”
According to AHA, standard areas that continue to be problematic include IM.3.10 - abbreviations, symbols, acronyms are standardized (33% non-compliance); IM.6.50 - verbal orders including read back (10% non-compliance); PC.8.10 - patient is assessed and treated when pain is identified (12% non-compliance); and medication management standards: MM.2.20 - medications are safely and appropriately stored (13% non-compliance) ; MM.3.20 - medication orders are written clearly and transcribed correctly (13% non-compliance); and MM.4.10 - all prescriptions are reviewed for appropriateness (11% non-compliance).
MEDICARE RHQDAPU
Non-negotiable Deadlines. In order for hospitals under the Medicare DRG based Prospective Payment System to review the full Medicare market basket increase for the entire Federal Fiscal Year 2005 (FFY 2005), hospitals must meet the following deadlines for submission of all applicable data for the Reporting of Hospital Quality Data for Annual Payment Update (RHQDAPU) program.
Hospitals that fail to meet a deadline will not be granted an extension as Medicare is operating under some very tight deadlines to meet the time frames for establishing the FFY 2005 payments for every hospital. These deadlines are as follows:
- June 1, 2004 - Complete QNET Exchange forms and have an id and password for each hospital
- July 1, 2004 - Either directly or through your vendor, have 1st Quarter 2004 discharge data on each of the ten performance measurements accepted at the CMS QIO warehouse. If your hospital does not provide a service covered under the ten measurements, just report on the measurements on which you have cases. Please remember this includes ALL patients, not just Medicare patients.
- August 1, 2004 - Either directly or through your vendor, have 1st Quarter 2004 FINAL discharge data on each of the ten performance measurements accepted at the CMS QIO warehouse for all of your hospital patients. Please remember, this data for 1st Quarter 2004 will be made publicly available - hospitals requesting participating in RHQDAPU have agreed to their performance measurement results to be made publicly available on the www. Medicare.gov web site. Public access to this information is expected to be available any time from November 2004 through January 2005 after hospital review of their own information.
- August 1, 2004 - Complete the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) Notice of Participation form. IHA urges all hospitals to do this sooner - do not wait until the last minute! The form is available at the following QnetExchange web site: http://www.qnetexchange.org/public/hdc/docs/ms/rhqdapu_notice.doc
COMPdata Helpful Hints. As we are the Illinois hospital advocate and representative, and a vendor, we are in a unique position to identify areas in which hospitals are placing themselves at risk to not receive the full payment update. Medicare officials have clearly communicated their expectations to QIOs and vendors and fully expect that providers meet all deadlines and submit complete and accurate data on all of their patients.
Helpful hints:
- DO NOT WAIT for a deadline to approach. Medicare is expecting that hospitals submit accurate data on all the ten measurements for 1st Quarter 2004 inpatient discharges for all patients at a hospital. If any errors are found and reported back to a hospital by Medicare, the hospital is expected to fix and re-submit that patient case.
- Ensure that the Medicare identification numbers or social security number is reported for Medicare patients. Medicare will be matching your clinical results against the administrative billing data for Medicare patients to link for future usage AND to identify any hospitals with under-reported data.
- Report complete and accurate data on all patients. Once the data submission to CMS is ended on August 1, 2004, hospitals will be required to submit medical records on CMS randomly selected patient cases to verify the reporting of patient clinical information through the “CMS Validation Process.”
- Review Your Hospital Results on QnetExchange shortly after your hospital or your hospital vendor submits data to the QIO warehouse. If you have data that has errors in it, you will be required by CMS to re-submit that patient case by August 1, 2004. In a recent meeting with QIOs and vendors, CMS announced that they are expecting 100% of all the patient data for the ten measurements - and that any patient cases that are rejected due to errors be re-submitted by August 1, 2004 otherwise the hospital is at risk for not receiving the FFY 2005 market basket increase.
Medicare Record Validation Process. In order to ensure the accuracy of the reported data and provide consumers with confidence in the information they will be using, Medicare is conducting a quarterly validation process for each hospital reporting data to the CMS warehouse for RHQDAPU or the National Voluntary Hospital Reporting Initiative. Currently, CMS is conducting record reviews for 4th Quarter 2003. Hospitals participating in the voluntary hospital reporting initiative for 4th Quarter 2003 have already been notified by CMS and should check their private, secure location on the www.qnetexchange.org web site for a list of the patient records required to be submitted to CMS for validation. This process will be similar to that to be conducted for the 1st Quarter 2004 discharges for RHQDAPU.
Public Reporting. Again, please keep in mind, that your hospital measurement results for 1st Quarter 2004 if you are participating in RHQDAPU will be made public. This is an opportune time to make sure that the patient level data is accurately reported and that hospitals review the feedback reports on the www.qnetexchange.org web site.
Hospitals will be provided the opportunity to preview their hospital data before it goes public through their private location on the Qnet Exchange web site. As this will be the first wide-reaching release of information by Medicare on hospital quality performance, hospitals in major metro areas should expect public inquiries. Hospitals in non-major metro areas should also prepare for inquiries, as CMS will send media announcements to every media publication and source.
At the recent QIO and vendor conference call hosted by CMS, CMS did mention that they are seriously considering lowering the threshold on the criteria for publication of results based upon case volumes. Currently, CMS and JCAHO will not release information on a given measurement if the measurement has 25 or less cases in the denominator for the given time period. As the ’25 case volume’ threshold has resulted in many hospitals not having their information displayed to the public, CMS is revisiting this criteria in hopes that they can allow for more hospital data to be displayed while not jeopardizing any reliability or statistical guidelines.
To view any of the detailed resources and reports above, please go to the following IHA web site location for additional information at http://www.ihatoday.org/public/quality and then select the “Ten Measurement Starter Set.” If you would like to share your hospital’s success story on any of the upcoming measurements, please contact Tim Philipp, Director of Quality Improvement, at IHA at tphilipp.ihastaff.org
MEDICARE PUBLIC LISTENING SESSION - JUNE 28, 2004
The Centers for Medicare and Medicaid Services (CMS) is holding the last of five public “listening sessions” in Oak Brook, Illinois on Monday, June 28th from 1:00 p.m. to 5:00 p.m. at the Oak Brook Marriott Hotel (1401 W. 22nd Street). The purpose of the hearing according to CMS is “to solicit input from health care consumers, payers, plans, providers, and purchasers regarding its (CMS) ongoing initiative to provide hospital-specific information on clinical quality.”
The agenda for the June 28th meeting is:
1:oo - 1:30 Introductory Remarks by CMS
1:30 - 2:30 Panel Discussion
2:30 - 3:00 Reactions from the Audience
3:00 - 3:15 Break
3:15 - 4:15 Concurrent Break-Out Sessions - including one for small and rural hospital measurement issues
4:15 - 5:00 Final comments and summary
Registration for this meeting is strongly encouraged. Please register in advance for this meeting at http://www.ipro.org under “Upcoming Events for Providers.”
In April, IHA staff attended the first of these five “listening sessions” in Boston in conjunction with the National Quality Forum. The panelists include a wide range of government, consumer, employer group, health plan, physician, and hospital representatives. There were some lively debates and discussions and an enriching sharing of perspectives on current and future public reported hospital measurements. Due to the large volume of non-registrants for this meeting, there was significant overflow to the outside of the room and many registrants could not be accommodated. While it is difficult to gauge the participation in Chicago, hospitals are encouraged to register early.
MEDICARE 8th STATEMENT OF WORK - PROPOSED FRAMEWORK
CMS has released a proposed framework for the 8th Statement of Work for the Medicare Quality Improvement Organizations and in turn, the hospitals and other providers. The proposed vision of the 8th Statement of Work Program will be very familiar to many of you :
“ The Program seeks to realize the following vision: “The right care for every person every time.” The “right” care corresponds to the goals expounded by the Institute of Medicine in its Crossing the Quality Chasm report: care that is safe, effective, patient-centered, timely, efficient, and equitable.” To view the proposed framework, please go to the following web site at: http://www.cms.hhs.gov/qio/2s.pdf
Cultural Change and Organizational Transformation. In order to keep pace with the rapidly evolving evidence-based practices and the increasing number of performance measurements, CMS is expecting hospitals to embrace a culture of quality and organizational transformation. In earlier documents, CMS estimated that at the present rate of hospital change, it would take 20 years to achieve 95% of compliance with the “Ten Measurement Starter Set.” Most people in an outside of health care view this as unacceptable.
As a result, CMS is setting forth their proposed 8th Statement of Work Objective to be:
“In the 8th SOW, the Program seeks to assist providers in adopting and implementing systems, redesigning processes, and achieving culture so as to accelerate the rate of improvement and broaden its impact.”
There will be many opportunities to discuss the 8th Statement of Work and its details, as they become available over the next several months. The start up period for Illinois hospitals begins August 1, 2005; but it is not too early to start thinking about the changes that need to occur within an organization to support a culture of quality. Clearly, executives need to be at the forefront of the cultural change and organizational transformation, but it will take everyone within their organization to embrace and actively engage themselves in creating a culture that supports quality for the health and well-being of the patients and communities the hospitals serve.
COMPdata will continue to work closely with you and to advocate on your behalf as we all work together to improve the quality of care to the patients and communities we serve. If you have additional questions, please e-mail me at pmerryweather@ihastaff.org
Thank you.
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