Performance Measures:

CMS Hospital Inpatient Quality Reporting Program (IQR)Update

As of November 2012

CMS Inpatient Prospective Payment System (IPPS) Payment Rates* Wage index, files, and reform Outlier payments Disproportionate Share (DSH) Direct Graduate Medical Education (DGME) Indirect Medical Education (IME) New Medical Services and New Technologies Three Day Payment Window Hospital Value Based Purchasing Program Readmissions Reduction Program Hospital Acquired Conditions Inpatient Quality Reporting (IQR) Program *Inpatient only procedures are covered under the Outpatient Prospective Payment System (OPPS)

Inpatient Quality Reporting (IQR)Program

• Developed out of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 • Deficit Reduction Act (DRA) of 2005 gave new requirements – Inpatient Prospective Payment System (IPPS) pays hospitals an incentive for reporting measures which is referred as the Annual Payment Update (APU)  Intent is to encourage hospitals to submit accurate, complete, and timely data reflecting the hospitals ability to adopt evidence based, outcomes driven health care delivery practices

IQR Connected to Reimbursement

Submit IQR Reporting Measures Data Passes Validation Review Hospital Receives Full CMS Payment Update (Market Basket)

Information to Cover

• Changes to Inpatient CMS Measures • Future CMS Measures • Previous Measures Approved for 2013 • Alignment with National Quality Strategy **Updates in RED **

Information to Cover

• Changes to Inpatient CMS Measures • Future CMS Measures • Previous Measures Approved for 2013 • Alignment with National Quality Strategy

CMS Measures: Inpatient - Old

• Surgical Care Improvement Project (SCIP) (abstracted) – Surgical patients with recommended VTE prophylaxis ordered (removed from IQR FY15 because no longer recommended for endorsement) • Hospital Acquired Conditions (claims data) (removed due to duplication of HAC reporting) - Air embolism (removed from IQR FY15) – Blood incompatibility (removed from IQR FY15) – Catheter associated urinary tract infection (removed from IQR FY15) – Falls and trauma (removed from IQR FY15) – Foreign object retained after/during surgery (removed from IQR FY15) – Manifestations of poor glycemic control (removed from IQR FY15) – Pressure ulcers stage III and IV (removed from IQR FY15) – Vascular catheter associated infections (removed from IQR FY15)

Note: FY15 is for CY 2013 data collection

CMS Measures: Inpatient - Old

• Association of Healthcare Quality and Research (AHRQ)Indicators

(claims data) – Abdominal aortic aneurysm (AAA) repair mortality rate (with or without volume) (removed from IQR FY15)* – Hip fracture mortality rate (removed from IQR FY15)* – Mortality for selected medical conditions (removed from IQR FY15)* – Iatrogenic pneumothorax (removed from IQR FY 15)** – Postoperative wound dehiscence (removed from IQR FY15)** – Accidental puncture or laceration (removed from IQR FY15)** – Post operative respiratory failure (removed from IQR FY15)*** – Post operative pulmonary embolism/deep vein thrombosis (removed from IQR FY15)**

*Removed to reduce redundancy and overlap with other measures, ** removed because included in the PSI composite that remains in IQR, ***removed due to better analysis by NHSN data later

CMS Measures: Inpatient -

New

• Patient’s Experience of Care (HCAHPS)

* – 3 item care transition set (Added to IQR FY 15)    Staff took my/family/caregiver preferences into account in deciding on my health care needs when I left When I left the hospital, I had an understanding of things I was responsible for managing my health When I left the hospital, I clearly understood the purpose for taking each of medications – About you items (Added to IQR FY 15)   Were you admitted to the hospital through the ER?

How would you rate your overall mental or emotional health?

*Added in July 2012 by our organization

CMS Measures: Inpatient -

New

• Claims Based Readmission Measures

– 30 day risk standardized readmission following total hip/knee arthroplasty (Added to IQR FY 15) – Hospital wide all cause unplanned readmission (Added to IQR FY 15) • Claims Based Complication Measure – Hospital level risk standardized complication rate following elective primary total hip arthroplasty (Added to IQR FY 15) • Chart Abstracted Measure – Elective delivery prior to 39 completed weeks of gestation (Added to IQR FY 15)

Note: FY15 is for CY 2013 data collection

CMS Measures: Inpatient -

New

• Safe Surgery Checklist

(Added to IQR FY16) – Hospital inpatient department indicates whether or not it uses a safe surgery checklist for procedures during three timeframes (1) time prior to administration of anesthesia (2) time prior to skin incision and (3) time of closure of incision and prior to patient leaving the operating room

Note: FY16 is for CY 2014 data collection

Information to Cover

• Changes to Inpatient CMS Measures • Future CMS Measures • Previous Measures Approved Next Year • Alignment with National Quality Strategy

CMS Measures: Inpatient -

New

• Future Measures

– Tobacco cessation (No Date Set)  Screening, treatment provided, treatment management at discharge, assessment of status after discharge – Alcohol cessation (No Date Set)  Screening, brief intervention provided, disorder treatment provided/offered at discharge, assessment of status after discharge – Central line associated bloodstream infections of non-ICU patients (No Date Set) – Catheter associated urinary tract infections of non-ICU patients (No Date Set)

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• Changes to Inpatient CMS Measures • Future CMS Measures • Previous Measures Approved for 2013 • Alignment with National Quality Strategy

Previous Measures Approved: Inpatient 2013

• • Healthcare Associated Infections (IP/NHSN data)    Methicillin Resistant Staphylococcus Aureus (MRSA) bacteremia (Added to IQR FY 15) C. Difficile standardized infection ratio (Added to IQR FY 15) Influenza vaccination coverage among health care personnel (Added to IQR FY 15) Stroke Measures         (Added to IQR FY 15) VTE prophylaxis Antithrombotic therapy for ischemic stroke Anticoagulation therapy for A-fib/flutter Thrombolytic therapy for acute ischemic stroke Antithrombotic therapy by the end of hospital day 2 Discharged on statin Stroke education Assessed for rehab

Note: FY15 is for CY 2013 data collection

Previous Measures Approved: Inpatient 2013

• Venous Thromboembolism(VTE) (Added to IQR FY 15)       VTE prophylaxis ICU VTE prophylaxis VTE patients with anticoagulation overlap therapy VTE patients receiving unfractionated Heparin with dosages/platelet count monitoring by protocol VTE discharge instructions Incidence of potentially preventable VTE

Note: FY15 is for CY 2013 data collection

Previous Measures Approved in IQR for Outpatient 2013

• Outpatient – Safe surgery checklist use (Attestation in July 2013 for Jan-Dec 2012) – Hospital outpatient volume data on selected outpatient surgical procedures (Report volume of cases in Jul 2013 for Jan-Dec 2012) – Cardiac rehabilitation patient referral from an outpatient setting (DEFERED until 2014)

Information to Cover

• Changes to Inpatient CMS Measures • Future CMS Measures • Previous Measures Approved for 2013 • Alignment with National Quality Strategy

Selection of Future Measures

• Align with National Quality Strategy – Clinical quality – Care coordination – Patient safety – Patient/caregiver experience of care – Population/community health – Efficiency

Questions

For more information regarding the CMS FY 15 and FY 16 IQR Program measures visit https://www.cms.gov/Medicare/Medicare Fee-for-Service Payment/AcuteInpatientPPS/FY-2013-IPPS Final-Rule-Home-Page.html