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2. Mortality Measures. First Outcome MeasureIntroduced by CMS in December 2006RHQDAPU program requirement for full APU FY 2008 for PPS hospitals.NO DATA SUBMISSION is required on the part of hospitals.. 3. Mortality Measures. Risk Adjusted Algorithm Developed by statistician
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1. MORTALITY MEASURE
2. 2 Mortality Measures
First Outcome Measure
Introduced by CMS in December 2006
RHQDAPU program requirement for full APU FY 2008 for PPS hospitals.
NO DATA SUBMISSION is required on the part of hospitals.
3. 3 Mortality Measures
Risk Adjusted Algorithm
Developed by statisticians over two years
Accepted by the NQF
AMI and HF only
Provides range of expected mortality with demographic and medical condition considerations.
4. 4 Mortality Measures Dry Run Reports provided Dec 2006
Calendar year 2003 data
All PPS hospitals
CAHs with data available also received a report with hospital specific data.
CAHs with no data had a mock report available to them.
Reports sent to
Quality Net administrator(s) at each hospital
Q-Net Exchange Inbox
5. 5 Mortality Measures Purpose of the Dry Run
Familiarity with format and contents
NOT publicly reported
Question and Comment period
Ended Jan 15
650 comments received
Response forthcoming
6. 6 Mortality Measures Whats next?
April 2007
AMI & HF mortality reports
July 1, 2005 through June 30, 2006
Q-Net Administrators In box
RHQDAPU & HQA hospitals
30 day preview period (aligned with measures)
PN Mortality Measure pending
7. 7 Mortality Measures Whats next?
June 2007
Mortality Measure posted to Hospital Compare
As Expected / Better than / Worse than
Data Suppression
PPS forfeits full APU
HQA-only hospitals (section 1886d) may suppress
CAHs may suppress
8. HCAHPS Hospital Consumer Assessment of
Healthcare Providers and Systems
9. 9 HCAHPS
Purpose
To provide a nationally standardized method for reporting patients perspectives on care
10. 10 HCAHPS
RHQDAPU program requirement for full APU FY 2008 for PPS hospitals
Voluntary for others
Publicly Reported on Hospital Compare
11. 11 HCAHPS Topics:
Communication with doctors
Communication with nurses
Responsiveness of Hospital Staff
Cleanliness and Quietness
Pain management
Communications about medications
Discharge information
12. 12 HCAHPS Collection:
Integrate HCAHPS into an existing patient survey
or
Implement HCAHPS as a separate survey
Mail, Telephone, a combination of the two or use of an automated response system.
Random sample
Non-psych
> 18 years
Overnight stay
Monthly
13. 13 HCAHPS Submission:
Use an approved vendor
or
Collect and submit your own HCAHPS data
Submit data to CMS quarterly
300 complete surveys per year (minimum 100 surveys per year for smaller hospitals)
14. 14 HCAHPS Participation requirements:
Select an approved vendor
List of approved vendors on quality net
15. 15 HCAHPS Participation requirements:
Hospital authorizes vendor
Hospital Q-Net Administrator assigns HCAHPS Vendor Authorization role
Access the HCAHPS Vendor Authorization in Q-Net Exchange
Hospital user selects the survey vendor.
16. 16 HCAHPS Participation requirements:
Attend HCAHPS training
Mandatory for any party planning to administer the survey Hospital or Vendor
Participate in both the Introduction to HCAHPS Training and HCAHPS Update Training; two day (4 hour) sessions
Iowa Foundation for Medical Care (IFMC)
https://ifmcevents.webex.com/ifmcevents/mywebex/default.php?Rnd3986=0.6574112525546858
At a minimum, the organization's Project Manager must attend training as a representative of the organization.
17. 17 HCAHPS Participation requirements:
Review the HCAHPS Quality Assurance Guidelines
http://www.hcahpsonline.org/files/QAGuidelines.pdf
Quality Assurance Plan (QAP)
Participate and cooperate in all oversight activities conducted by the HCAHPS Project Team
See the above guidelines
Submit to hcahps@azqio.sdps.org
Due Jan 16, 2007 for those in first Dry Run (Q2 06)
Due date pending for those participating in second Dry Run March 2007.
18. 18 HCAHPS Participation requirements:
Participate in the HCAHPS Dry Run prior to HCAHPS Data Collection and Public Reporting.
March 2007
Submit a formal pledge
Summer 2007; details pending
Attest to the accuracy of the organization's data collection, following guidelines set forth in the HCAHPS Quality Assurance Guidelines
19. 19 HCAHPS TIMELINE:
Feb 2006
Initial HCAHPS training sessions offered
April through June 2006
First Dry Run
October 1, 2006
Voluntary hospitals begin ongoing data collection
20. 20 HCAHPS TIMELINE:
Jan 31, 2007
Voluntary participants begin uploading data for Q3 06
Jan and Feb 2007
HCAHPS Initial Training offered online by the IFMC
March 2007
Second Dry Run
21. 21 HCAHPS TIMELINE:
April 11, 2007
Data submission deadline for Q4 06 results for voluntary participants.
May 2007
Update Training Webinar
July 1, 2007
New hospitals begin ongoing collection of data
22. 22 HCAHPS TIMELINE:
July 13, 2007
Data submission deadline for Q1 07 results (Publicly Reported)
Data submission deadline for March 2007 Dry Run results (NOT Publicly Reported)
Summer 2007
All participants sign a pledge of participation
23. 23 HCAHPS