Hospital Public Reporting
Hospital Quality Alliance (HQA) and the Reporting Hospital Quality Data
for Annual Payment Update (RHQDAPU) 1st Quarter 2008 discharge data is
due into the clinical warehouse by 12:00 a.m. eastern standard time on
August 15, 2008.
Local and national benchmarks for Quarter 3 2007 are now available.
If you would like a copy contact Marcy Cameron, Project Assistant,
at mcameron@coqio.sdps.org
or 303.695.3300, ex. 3040.
The consumer website called Hospital Compare,
www.hospitalcompare.hhs.gov,
was unveiled
on April 1, 2005. This resource provides instant,
objective, easy-to-use and free information about the quality of
hospital care in Colorado and nationwide. Under the Hospital Quality
Initiative, hospitals voluntarily submit quality of care information so
that consumers can compare care and make better-informed decisions.
Hospital Compare was created by the Centers for Medicare & Medicaid
Services (CMS) and the Hospital Quality Alliance, a public-private
collaboration.
Quality Measures
The 24 quality measures, which are based on established guidelines,
have gone through years of extensive testing for validity and
reliability by CMS and the Medicare quality improvement organizations (QIOs),
the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO), and researchers. The National Quality Forum (NQF), a voluntary
standard-setting consensus-building organization representing providers,
consumers, purchasers, and researchers, has endorsed these measures.
Heart Attack Process of Care Measures
For more information about Heart Attack,
click here. |
Brief Explanation |
| Percent of Heart Attack Patients Given ACE
Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) |
ACE (angiotensin converting enzyme) inhibitors
and ARBs (angiotensin receptor blockers) are medicines used to
treat heart attacks, heart failure, or a decreased function of
the heart. |
| Percent of Heart Attack Patients Given Aspirin
at Arrival |
Aspirin can help keep blood clots from forming
and dissolve blood clots that can cause heart attacks. |
| Percent of Heart Attack Patients Given Aspirin
at Discharge |
Taking aspirin may help prevent further heart
attacks. |
| Percent of Heart Attack Patients Given Beta
Blocker at Arrival |
Beta blockers are a type of medicine used to
lower blood pressure, treat chest pain (angina) and heart
failure, and to help prevent a heart attack. |
| Percent of Heart Attack Patients Given Beta
Blocker at Discharge |
Beta blockers are a type of medicine used to
lower blood pressure, treat chest pain (angina) and heart
failure, and to help prevent a heart attack. |
| Percent of Heart Attack Patients Given
Fibrinolytic Medication Within 30 Minutes Of Arrival |
Blood clots can cause heart attacks. Doctors may
give this medicine, or perform a procedure to open the blockage,
and in some cases, may do both. |
| Percent of Heart Attack Patients Given PCI
Within 90 Minutes Of Arrival |
The procedures called Percutaneous Coronary
Interventions (PCI) are among those that are the most effective
for opening blocked blood vessels that cause heart attacks.
Doctors may perform PCI, or give medicine to open the blockage,
and in some cases, may do both. |
| Percent of Heart Attack Patients Given Smoking
Cessation Advice/Counseling |
Smoking is linked to heart attacks. Quitting may
help prevent another heart attack. |
Heart Failure Process of Care Measures
For more information about Heart Failure,
click here. |
Brief Explanation |
| Percent of Heart Failure Patients Given ACE
Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) |
ACE (angiotensin converting enzyme) inhibitors
and ARBs (angiotensin receptor blockers) are medicines used to
treat heart attacks, heart failure, or a decreased function of
the heart. |
| Percent of Heart Failure Patients Given an
Evaluation of Left Ventricular Systolic (LVS) Function |
An evaluation of the LVS function checks how the
left chamber of the heart is pumping. |
| Percent of Heart Failure Patients Given
Discharge Instructions |
The staff at the hospital should provide you
with information to help you manage your heart failure symptoms
when you are discharged. |
| Percent of Heart Failure Patients Given Smoking
Cessation Advice/Counseling |
Smoking is linked to heart failure. Quitting may
help improve your condition. |
Pneumonia Process of Care Measures
For more information about Pneumonia,
click here. |
Brief Explanation |
| Percent of Pneumonia Patients Assessed and Given
Influenza Vaccination |
An influenza shot can help prevent influenza in
the future, even for patients who have been hospitalized for
pneumonia. |
| Percent of Pneumonia Patients Assessed and Given
Pneumococcal Vaccination |
A pneumonia (pneumococcal) shot can help prevent
pneumonia in the future, even for patients who have been
hospitalized for pneumonia. |
| Percent of Pneumonia Patients Given Initial
Antibiotic(s) within 6 Hours After Arrival |
Timely use of antibiotics can improve the
treatment of pneumonia caused by bacteria. |
| Percent of Pneumonia Patients Given Oxygenation
Assessment |
Having enough oxygen in your blood is important
to your health. |
| Percent of Pneumonia Patients Given Smoking
Cessation Advice/Counseling |
Smoking is linked to pneumonia. Quitting may
help prevent you from getting pneumonia again. |
| Percent of Pneumonia Patients Given the Most
Appropriate Initial Antibiotic(s) |
Antibiotics are medicines that treat infection,
and each one is different. Hospitals should choose the
antibiotics that best treat the infection type for each
pneumonia patient. |
| Percent of Pneumonia Patients Whose Initial
Emergency Room Blood Culture Was Performed Prior To The
Administration Of The First Hospital Dose Of Antibiotics |
A blood culture tells what kind of medicine will
work best to treat your pneumonia. |
Surgical Care Improvement/Surgical Infection
Prevention Process of Care Measures
For more information about Surgical Care Improvement/Surgical
Infection Prevention,
click here. |
Brief Explanation |
| Percent of Surgery Patients Who Received
Preventative Antibiotic(s) One Hour Before Incision |
Getting an antibiotic within one hour before
surgery reduces the risk of wound infections. Hospitals should
check to make sure surgery patients get antibiotics at the right
time. |
| Percent of Surgery Patients Who Received the
Appropriate Preventative Antibiotic(s) for Their Surgery |
Certain antibiotics are recommended to help
prevent wound infection for particular types of surgery. |
| Percent of Surgery Patients Who Received
Treatment To Prevent Blood Clots Within 24 Hours Before or After
Selected Surgeries to Prevent Blood Clots |
This measure tells how often surgery patients
received treatment to prevent blood clots within 24 hours before
or after certain surgeries |
| Percent of Surgery Patients Whose Doctors
Ordered Treatments to Prevent Blood Clots (Venous
Thromboembolism) For Certain Types of Surgeries |
This measure tells how often surgery patients'
doctors ordered treatment to prevent blood clots from forming in
the veins after certain surgeries |
| Percent of Surgery Patients Whose Preventative
Antibiotic(s) are Stopped Within 24 hours After Surgery |
It is important for hospitals to stop giving
preventative antibiotics within 24 hours after surgery to avoid
side effects and other problems associated with antibiotic use.
For certain surgeries, however, antibiotics may be needed for a
longer time. |
Heart Attack Process of Care Measures
For more information about Heart Attack,
click here. |
Brief Explanation |
Benefits of Participation
Hospitals benefit from publicly reporting quality of care
information in several ways. Participation helps hospitals to
highlight their successes and to identify and focus on areas for
improvement in quality of care, as well as using national and local
benchmarks to assess performance. Hospitals also have the
opportunity to give consumers important information about quality of
care to help them compare and make informed decisions. In addition
to these benefits, hospitals receive technical assistance and
hands-on training in submitting data and improving quality from
quality improvement organizations (QIOs).
Which Hospitals Should Participate?
Most hospitals are subject to the RHQDAPU Initiative. They are
designated as 'subsection d hospitals' and are defined in the Social
Security Act under Section 1886(d)(1)(B).
Data is now available on Hospital Compare at
www.medicare.gov
or
www.hospitalcompare.hhs.gov (links opens new windows).
Hospital Quality Alliance (HQA)
The American Hospital Association (AHA), the Federation of American
Hospitals (FAH), and the Association of American Medical Colleges (AAMC)
have launched a national voluntary initiative to collect and report
hospital quality performance information. This effort is intended to
make critical information about hospital performance accessible to
the public and to inform and invigorate efforts to improve quality.
Voluntary reporting is an essential first step to realize this goal.
This project builds upon previous CMS and QIO strategies to identify
illnesses and/or clinical conditions that affect Medicare
beneficiaries in order to: promote the best medical practices
associated with the targeted clinical disorders; prevent or reduce
further instances of these selected clinical disorders; and prevent
related complications.
Objectives of the HQA
- Refine and standardize hospital data transmission and performance
measures
- Provide useful and valid clinical information to the public
- Provide hospitals with a sense of predictability about public
reporting expectations
- Stimulate improvement in hospital quality of care
HQA Measures
- AMI
o Aspirin at arrival o Aspirin at discharge o Beta-blocker at arrival o Beta-blocker at discharge o ACE
or ARB for LVSD
o Percutaneous coronary intervention within 90 minutes of arrival o
Fibrinolytic therapy received within 30 minutes of arrival o
Adult smoking cessation advice/counseling
- HF
o Left ventricular function assessment o ACE or ARB for LVSD o Discharge instructions o
Adult smoking cessation advice/counseling
- PN
o Initial antibiotics received within 4 hrs of
hospital arrival o Pneumococcal vaccination o Oxygenation assessment
o Blood culture before antibiotic o Adult smoking cessation
advice/counseling o Influenza Vaccination
o
Initial antibiotic selection for CAP in immunocompetent patient
- Surgical Complication Improvement
o Timing of prophylaxis antibiotic o Selection of antibiotic o Duration of prophylaxis
o Recommended venous thromboembolism prophylaxis
o Appropriate venous thromboembolism prophylaxis within 24 hours
prior to surgery to 24 hours after surgery
o Immediate postoperative normothermia
Comparison of CMS, JCAHO, and HQA Measures
CMS Timeline Visit
QualityNet or
AHA for more information on Hospital Public Reporting.
Hospital Patient Perspective on
Care Survey (HCAHPS)
The intent of the HCAHPS initiative is to provide a standardized
survey instrument and data collection methodology for measuring
patients' perspectives on hospital care. While many hospitals currently
collect information on patients' satisfaction with care, there is no
national standard for collecting or publicly reporting this information
that would enable valid comparisons to be made across all hospitals. In
order to make "apples to apples" comparisons to support consumer choice,
it is necessary to introduce a standard measurement approach. HCAHPS can
be viewed as a core set of questions that can be combined with a
broader, customized set of hospital-specific items. HCAHPS is meant to
complement the data hospitals currently collect to support improvements
in internal customer services and quality related activities.
To learn more about HCAHPS, please visit the following website:
http://www.hcahpsonline.org/
For information and technical assistance, contact the Arizona QIO:
hcahps@azqio.sdps.org or 1-888-884-4007.
Reporting Hospital Quality Data
for Annual Payment Update (RHQDAPU)
The Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU)
initiative was initially developed as a result of the Medicare
Prescription Drug, Improvement and Modernization Act (MMA) of 2003.
Section 5001(a) of Pub. 109-171 of the Deficit Reduction Act (DRA) of
2005 set out new requirements for the RQHDAPU program, which build on
the ongoing voluntary Hospital Quality Initiative.
That initiative is intended to equip consumers with quality of care
information to make more informed decisions about their health care,
while encouraging hospitals and clinicians to improve the quality of
inpatient care provided to all patients. The hospital quality of care
information gathered through the initiative is available to consumers on
the Hospital Compare website.
The RHQDAPU initiative requires "sub-section (d)" hospitals to submit
data for specific quality measures for health conditions common among
people with Medicare, and which typically result in hospitalization. For
fiscal year 2008, CMS requires that hospitals submit data regarding 27
quality measures. The data collected encompasses the following
conditions: acute myocardial infarction, heart failure, pneumonia,
surgical care improvement, 30-day mortality rates for acute myocardial
infarction and heart failure patients, and the patients? experience of
care through the HCAHPS patient survey.
Hospitals that do not participate in the RHQDAPU initiative will receive
a reduction of 2.0 percent in their Medicare Annual Payment Update for
fiscal year 2009. To avoid the reduction in their Annual Payment Update,
hospitals must meet specific requirements outlined in the
RHQDAPU participation steps (Reference Checklist) for FY 2009, PDF.
Visit QualityNet for additional RHQDAPU Information
(link opens a new window).
Questions?
For information on Hospital Public Reporting contact:
Michelle Mills, Project Director, at 303.847-1727,
mmills@coqio.sdps.org
or
Marcy Cameron, Project Assistant, at
mcameron@coqio.sdps.org
or 303.695-3300, ex.3040.
The Colorado Foundation for Medical Care (CFMC), the Medicare quality improvement organization for Colorado, prepared this material under
contract with the Centers for Medicare & Medicaid Services (CMS), an
agency of the U.S. Department of Health and Human Services. The contents
do not necessarily reflect CMS Policy.
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