Materials for all MAP Workgroup meetings are available on the NQF Public SharePoint Page as well as the project web pages.
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1 Agenda Measure Applications Partnership Hospital Workgroup In-Person Meeting December 16, :00 am 5:00 pm ET December 17, :00 am 3:00 pm ET Participant Instructions: Materials for all MAP Workgroup meetings are available on the NQF Public SharePoint Page as well as the project web pages. Streaming Audio Online Direct your web browser to: Under Enter a Meeting type in the meeting number: o Day 1: ; and o Day 2: In the Display Name field, type in your first and last names and click Enter Meeting. Teleconference Dial (888) for workgroup members or (877) for public participants. If you need technical assistance, you may press *0 to alert an operator or send an to nqf@commpartners.com. Meeting Objectives: Review and provide input on measures under consideration for use in federal programs Finalize input to the MAP Coordinating Committee on measures for use in federal programs; and Identify gaps in measures for federal hospital quality programs. Day 1: December 16, :30 am Breakfast 9:00 am Welcome, Introductions, Disclosures of Interest, and Review of Meeting Objectives Cristie Upshaw Travis, MAP Hospital Workgroup Co-Chair Ronald Walters, MAP Hospital Workgroup Co-Chair Ann Hammersmith, General Counsel, NQF 9:15 am CMS Opening Remarks Pierre Yong, CMS 9:30 am Overview of Pre-Rulemaking Approach Erin O Rourke, Senior Project Manager, NQF Zehra Shahab, Project Manager, NQF Approach to decision-making
2 PAGE 2 Instructions for Voting Process 9:45 am Overview of the Hospital Inpatient Quality Reporting (HIQR) Program 9:50 am Opportunity for Public Comment on Measures Under Consideration for HIQR 10:00 am Pre-Rulemaking Input on Hospital Inpatient Quality Reporting Measure Set Consent Calendar 1 Leslie Schultz (Lead Discussant) Andrea Benin (Lead Discussant) 1. Adult Local Current Smoking Prevalence (MUC ) 2. American College of Surgeons-Centers for Disease Control and Prevention (ACS- CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (MUC15-534) 3. INR Monitoring for Individuals on Warfarin after Hospital Discharge (MUC ) 4. IQI-22: Vaginal Birth After Cesarean (VBAC) Delivery Rate, Uncomplicated (MUC ) 5. National Healthcare Safety Network (NHSN) Antimicrobial Use Measure (MUC15-531) 10:30 am Pre-Rulemaking Input on Hospital Inpatient Quality Reporting Measure Set Consent Calendar 2 Nancy Foster (Lead Discussant) Kelly Trautner (Lead Discussant) 1. Aortic Aneurysm Procedure Clinical Episode-Based Payment Measure (MUC15-835) 2. Cholecystectomy and Common Duct Exploration Clinical Episode-Based Payment Measure (MUC15-836) 3. Hospital-level, risk-standardized 30-day episode-of-care payment measure for pneumonia (MUC15-378) 4. Spinal Fusion Clinical Episode-Based Payment Measure (MUC15-837) 5. Transurethral Resection of the Prostate (TURP) for Benign Prostatic Hyperplasia Clinical Episode-Based Payment Measure (MUC15-838) 11:00 am Pre-Rulemaking Input on Hospital Inpatient Quality Reporting Measure Set Consent Calendar 3 Gregory Alexander (Lead Discussant) Heather Lewis (Lead Discussant) 1. Excess Days in Acute Care after Hospitalization for Pneumonia (MUC15-391) 2. Hospital 30-Day Mortality Following Acute Ischemic Stroke Hospitalization Measure (MUC15-294) 3. Hybrid 30-Day Risk-Standardized Acute Ischemic Stroke Mortality Measure with Claims and Clinical Electronic Health Record (EHR) Risk Adjustment Variables (MUC ) 4. Hybrid 30-Day Risk-Standardized Acute Ischemic Stroke Mortality Measure with Electronic Health Record (EHR)-Extracted Risk Adjustment Variables (MUC )
3 PAGE 3 11:30 am Break 5. Patient Safety for Selected Indicators /AHRQ Patient Safety Indicator Composite (MUC15-604) 11:40 am CMS Measure Concepts Presentation Tara Lemons, CMS 11:50 am Overview of the Hospital Value-Based Purchasing (HVBP) Program 11:55 am Opportunity for Public Comment on Measures Under Consideration for HVBP 12:05 pm Pre-Rulemaking Input on Hospital Value-Based Purchasing Program Measure Set 1 David Engler (Lead Discussant) Martin Hatlie (Lead Discussant) 1. Hospital-level, risk-standardized 30-day episode-of-care payment measure for pneumonia (MUC15-378) 2. Hospital-level, risk-standardized payment associated with a 30-day episode-of-care for Acute Myocardial Infarction (AMI) (MUC15-369) 3. Hospital-level, risk-standardized payment associated with a 30-day episode-of-care for heart failure (HF) (MUC15-322) 4. Hospital-level, risk-standardized payment associated with an episode of care for primary elective total hip and/or total knee arthroplasty (THA/TKA) (MUC15-295) 12:25 pm Pre-Rulemaking Input on Hospital Value-Based Purchasing Program Measure Set 2 Cristie Travis (Lead Discussant) Michael Phelan (Lead Discussant) 1. Cellulitis Clinical Episode-Based Payment Measure (MUC ) 2. Gastrointestinal Intestinal (GI) Hemorrhage Clinical Episode-Based Payment Measure (MUC ) 3. Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure (MUC ) 12:45 pm Pre-Rulemaking Input on Hospital Value-Based Purchasing Program Measure Set 3 LaDawna Howard (Lead Discussant) Jeff Jacobs (Lead Discussant) 1. ACS-CDC Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (MUC15-534) 2. Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft (CABG) Surgery (MUC15-395)
4 PAGE 4 1:00 pm Lunch 3. Patient Safety for Selected Indicators /AHRQ Patient Safety Indicator Composite (MUC15-604) 2:00 pm Overview of the Hospital Acquired Condition Reduction Program (HACRP) 2:05 pm Opportunity for Public Comment on Measures Under Consideration for HACRP 2:15 pm Pre-Rulemaking Input on Hospital Acquired Condition Reduction Program Consent Calendar Mitchell Levy (Lead Discussant) Brock Slabach (Lead Discussant) 1. American College of Surgeons-Centers for Disease Control and Prevention (ACS- CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (MUC15-534) 2. Patient Safety and Adverse Events Composite (MUC15-604) 3:15 pm Overview of the PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program 3:20 pm Opportunity for Public Comment on Measures Under Consideration for PCHQR 3:30 pm Pre-Rulemaking Input on PPS-Exempt Cancer Hospital Quality Reporting Program Ron Walters (Lead Discussant) Shelley Fuld Nasso (Lead Discussant) Wei Ying (Lead Discussant) 1. Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy (MUC15-951) 2. American College of Surgeons-Centers for Disease Control and Prevention (ACS- CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (MUC15-534) 3. National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure (MUC15-533) 4. National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (MUC15-532) 5. Oncology: Radiation Dose Limits to Normal Tissues (MUC15-946) 4:40 pm Opportunity for Public Comment 4:55 pm Summary of Day Erin O Rourke, Senior Project Manager
5 PAGE 5 5:00 pm Adjourn Day 2: December 17, :30 am Breakfast 9:00 am Welcome and Review of Day 1 Cristie Upshaw Travis, MAP Hospital Workgroup Co-Chair Ronald Walters, MAP Hospital Workgroup Co-Chair Melissa Mariñelarena, Senior Director, NQF 9:15 am Overview of the End-Stage Renal Disease Quality Improvement Program (ESRD-QIP) 9:20 am Opportunity for Public Comment on Measures Under Consideration for ESRD-QIP 9:30 am Pre-Rulemaking Input on End-Stage Renal Disease Quality Improvement Program Allen Nissenson (Lead Discussant) Elizabeth Evans (Lead Discussant) Sean Morrison (Lead Discussant) 10:45 am Break 1. Avoidance of Utilization of High Ultrafiltration Rate ( 13 ml/kg/hour) (MUC15-758) 2. ESRD Vaccination: Full-Season Influenza Vaccination (MUC15-761) 3. Measurement of Phosphorus Concentration (MUC ) 4. Proportion of Patients with Hypercalcemia (NQF #1454) (MUC ) 5. Standardized Hospitalization Ratio Modified (MUC15-693) 6. Standardized Mortality Ratio Modified (MUC15-575) 7. Standardized Readmission Ratio (SRR) for dialysis facilities (MUC ) 11:00 am Overview of the Hospital Outpatient Quality Reporting Program (HOQR) 11:05 am Opportunity for Public Comment on Measures Under Consideration for HOQR 11:15 am Pre-Rulemaking Input on Hospital Outpatient Quality Reporting Program Consent Calendar Helen Haskell (Lead Discussant) Shekhar Mehta (Lead Discussant) 12:00 pm Lunch 1. Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy (MUC15-951) 2. Risk-standardized hospital visits within 7 days after hospital outpatient surgery (MUC15-982) 1:00 pm Overview of the Ambulatory Surgery Center Quality Reporting (ASCQR) Program
6 PAGE 6 1:05 pm Opportunity for Public Comment on Measures Under Consideration for ASCQR 1:15 pm Pre-Rulemaking Input on Ambulatory Surgical Center Quality Reporting Program Donna Slosburg (Lead Discussant) Karen Roth (Lead Discussant) 1. Toxic Anterior Segment Syndrome (TASS) Outcome (MUC ) 1:50 pm Overview of the Inpatient Psychiatric Facilities Quality Reporting (IPFQR) Program 1:55 pm Opportunity for Public Comment on Measures Under Consideration for IPFQR 2:05 pm Pre-Rulemaking Input on Inpatient Psychiatric Facilities Quality Reporting Program Jack Fowler (Lead Discussant) Ann Marie Sullivan (Lead Discussant) Dolores Mitchell (Lead Discussant) 1. Substance Use Core Measure Set (SUB)-3 Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge and SUB-3a Alcohol & Other Drug Use Disorder Treatment at Discharge (MUC ) 2. Thirty-day all-cause unplanned readmission following psychiatric hospitalization in an Inpatient Psychiatric Facility (IPF) (MUC ) 2:40 pm Opportunity for Public Comment 2:55 pm Wrap Up and Next Steps Christine Cassel, President and CEO, NQF Zehra Shahab, Project Manager 3:00 pm Adjourn
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