Hospital-Acquired Condition Reduction Program. Hospital-Specific Report User Guide Fiscal Year 2017

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1 Hospital-Acquired Condition Reduction Program Hospital-Specific Report User Guide Fiscal Year 2017

2 Contents Overview... 4 September 2016 Error Notice... 4 Background and Resources... 6 Updates for FY Measure Selection and Calculation... 7 Scoring Methodology... 8 Review and Corrections Process Public Reporting HSR File Contents and Descriptions Understanding Your Hospital s Performance on Domain 1, Domain 2, and Total HAC Score Understanding Your Hospital s Performance on AHRQ PSI 90 Composite Understanding Your Hospital s Discharge-Level Information for the AHRQ PSI Measures.. 22 Understanding Your Hospital's Performance on CDC CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI Measures Replication Instructions PSI 90 Composite Value PSI 90 Composite Measure Score and Domain 1 Score Domain 2 Score Total HAC Score Contacts and Additional Resources Appendix Tables Table A Point Assignment and Performance Deciles for Hospitals with PSI 90 Composite Measure Results... 9 Table B Point Assignment and Performance Deciles for Hospitals with CLABSI Measure Results Table C Point Assignment and Performance Deciles for Hospitals with CAUTI Measure Results Table D Point Assignment and Performance Deciles for Hospitals with SSI Measure Results 11 2

3 Table E Point Assignment and Performance Deciles for Hospitals with MRSA bacteremia Measure Results Table F Point Assignment and Performance Deciles for Hospitals with CDI Measure Results 12 Table G Contents of the Total HAC Score Results Worksheet Table H Contents of the Domain Scores Worksheet Table I Your Hospital's Performance on AHRQ PSI 90 Composite Worksheet Contents Table J Your Hospital's Discharge-Level Information for the AHRQ PSI Measures Worksheet Contents Table K Your Hospital's Performance on CDC CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI Measures Worksheet Contents Table L Medicare FFS National Rate Figures Figure 1 Overview of Scoring Methodology Figure 2 Scoring Methodology for Total HAC Score Figure 3 Distribution of Total HAC Scores Figure 4 AHRQ Replication Step Figure 5 AHRQ Replication Step Figure 6 AHRQ Replication Step Figure 7 AHRQ Replication Step Figure 8 AHRQ Replication Step Figure 9 Domain 1 Score Replication Figure 10 Domain 2 Score Replication (CLABSI, CAUTI, SSI) Figure 11 Domain 2 Score Replication (MRSA bacteremia, CDI, Domain 2 Score) Figure 12 Total HAC Score Replication

4 Overview This document accompanies the Hospital-Specific Report (HSR) for the Fiscal Year (FY) 2017 Hospital-Acquired Condition (HAC) Reduction Program. HSRs are available for download in a Microsoft Excel format at the QualityNet Secure Portal. The HSR includes the following information: Total HAC Score Domain 1 and Domain 2 scores Results for the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator (PSI) 90 Composite Discharge-level data used to calculate the PSI 90 Composite Results for the Centers for Disease Control and Prevention (CDC) Central Line- Associated Bloodstream Infection (CLABSI), Catheter-Associated Urinary Tract Infection (CAUTI), Surgical Site Infection (SSI) (Abdominal Hysterectomy and Colon Procedures), Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, and Clostridium difficile Infection (CDI) HSRs are read-only documents, which prevent users from unintentionally altering content. If you wish to make changes to the file, you may use the Save as option to create a new version under a different name. Note: The accompanying Microsoft Excel files contain discharge-level data that are protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Sharing protected patient-level data with other organizations, including the press, is a violation of HIPAA rules. ing protected health information poses a security issue, and each HIPAA-covered entity is responsible for ensuring compliance with the security standards. There are only two secure ways to send your patient-level data: (1) encrypting the data (using a minimum 128-bit encryption) and shipping them via a bonded courier with an established chain of custody (e.g., the United States Postal Service or FedEx) or (2) sending them via the government-approved, secure section of the QualityNet website ( Do not real HSR files, or their contents, because they contain personally identifiable information. When referring to specific worksheets in the HSRs, use the ID number provided in the first column of the worksheet. September 2016 CDI Recalculation Notice The Centers for Medicare & Medicaid Services (CMS) and the CDC found an error in the calculation of the risk-adjustment for 1st and 2nd quarter 2014 CDI measure data. CMS recalculated FY 2017 HAC Reduction Program CDI measure scores, Domain 2 scores, Total HAC Scores, the 75th percentile Total HAC Score, and worst-performing quartile designations, and created corrected HSRs for all subsection (d) hospitals eligible for the HAC Reduction Program. CDC also provided revised CDI infection measure standardized infection ratios (SIRs) included in the corrected HSRs. 4

5 The recalculation changed the 75 th percentile cut-off for Total HAC Scores from to Hospitals with a Total HAC Score greater than the 75 th percentile will be subject to a payment reduction. A new 30-day Review and Corrections period will begin on September 1, 2016, when the recalculated HSRs are made available to hospitals via QualityNet Secure Portal, and will end on September 30, The second Review and Corrections period will only focus on those data elements directly affected by the incorrect CDI data, namely CDI measure score, Domain 2 score, and Total HAC Score corrections. This Review and Corrections process does not allow hospitals to correct the following: reported number of HAIs, SIRs, or reported central-line days, urinary catheter days, surgical procedures performed, or patient days. Hospitals are not allowed to request corrections for the following scores, which were unaffected by the data recalculation: Domain 1 score and measure scores for PSI 90 Composite, CLABSI, CAUTI, SSI, and MRSA. Hospitals had an opportunity to review their Domain 1 scores, as well as CLABSI, CAUTI, SSI and MRSA bacteremia measure scores, during the initial Review and Corrections period. If hospitals identify any potential discrepancies in the calculation of their CDI measure score, Domain 2 score, or Total HAC Score, they can request a review of their scores by sending an to the QualityNet Help Desk at qnetsupport@hcqis.org. The subject line of the should be HACRP: Review and Corrections Request. Hospitals must include the following information: CMS Certification Number (CCN) Hospital Name Hospital Address Contact person s name, phone number and address Score(s) to be reviewed (include all that apply): o CDI measure score o Domain 2 score o Total HAC Score Reason(s) Describe the specific details for the reason of your review and request for correction of the item(s) identified above. Hospitals should not include personally identifiable information (PII) and protected health information (PHI) when ing the HAC Reduction Program Support Team. ing these data is a security violation. Following the Review and Corrections period, the measure scores, domain scores, and Total HAC Score will be publicly reported on Hospital Compare in December Information about the Total HAC Score calculations are available at Hospitals-Inpatient > HAC Reduction Program> Resources on QualityNet. 5

6 Background and Resources Section 3008 of the 2010 Patient Protection and Affordable Care Act (ACA) established the HAC Reduction Program to provide an incentive for hospitals to reduce HACs. Effective FY 2015 (October 1, 2014), the HAC Reduction Program requires the Secretary of the Department of Health and Human Services to adjust payments to applicable hospitals that rank in the worstperforming quartile of all subsection (d) hospitals with respect to risk-adjusted HAC quality measures. As stated in ACA Section 3008, these hospitals will have their payments reduced to 99 percent of what would otherwise be paid for such discharges. Updates for FY 2017 CMS made the following updates to the HAC Reduction Program for FY 2017: Added Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and Clostridium difficile Infection (CDI) measures to Domain 2. Changed Domain 1 weight from 25 to 15 percent. Domain 2 weight changed from 75 to 85 percent. Calculated the AHRQ PSIs using recalibrated version of the AHRQ PSI software. The recalibrated software is modified so that software parameters (risk-adjustment coefficients, signal variance, and PSI 90 composite weights) derive from the July 2012 June 2014 Medicare Fee-for-Service (FFS) claims data, rather than 2012 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SIDs) all-payer discharge data for patients 18 and older. Recalibration does not impact the individual PSI measure specifications, or which PSIs are included in the composite. Included Maryland hospitals in the calculation of the PSI 90 Composite, because Maryland hospitals were required to start reporting present on admission (POA) data, a field on an inpatient claim necessary for AHRQ PSI calculations, as of October 1, Calculated each of the measure scores for Domain 2 independently, without taking into account whether the hospital received a Domain 1 score or measure scores for other Domain 2 measures. Stopped calculating Domain 1 scores for hospitals that have a Medicare Accept Date during the final 12 months of the Domain 1 reporting period. 2 1 The recalibrated version of the AHRQ PSI software is not publicly available but is available upon request through the QualityNet Help Desk. 2 These new hospitals will not have a full 12 months of PSI 90 data during the reporting period 6

7 Stopped calculating Domain 2 scores for hospitals that meet either of the following criteria: 3 o Hospital s Medicare Accept Date is within the last 6 months of the Domain 2 reporting period o The hospital s Medicare Accept Date is between the 6 th and 9 th month prior to the end of the Domain 2 reporting period, and the Inpatient Quality Reporting (IQR) Notice of Participation is within the last quarter of the Domain 2 reporting period. Measure Selection and Calculation In the FY 2014 Inpatient Prospective Payment System (IPPS)/Long-Term Care Hospital Prospective Payment System (LTCH PPS) Final Rule, CMS adopted the AHRQ PSI 90 Composite and CDC CLABSI, CAUTI, SSI (Abdominal Hysterectomy and Colon Procedures), MRSA bacteremia, and CDI measures for the FY 2017 HAC Reduction Program. AHRQ PSI 90 Composite The AHRQ PSI 90 Composite includes the following eight PSIs: PSI 03 Pressure Ulcer Rate PSI 06 Iatrogenic Pneumothorax Rate PSI 07 Central Venous Catheter-Related Bloodstream Infection Rate PSI 08 Postoperative Hip Fracture Rate PSI 12 Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate PSI 13 Postoperative Sepsis Rate PSI 14 Postoperative Wound Dehiscence Rate PSI 15 Accidental Puncture or Laceration Rate The AHRQ PSI 90 Composite is a weighted average of the risk- and reliability-adjusted versions (or smoothed versions) of these eight PSIs. For the FY 2017 Program, CMS calculated the score using recalibrated version of the AHRQ PSI software. The recalibrated software is modified so the parameters (risk-adjustment coefficients, signal variance, smoothing target, and composite weights) are derived from the July 2012 June 2014 Medicare FFS population, rather than an all-payer 2012 HCUP population. Recalibration does not impact the individual PSI measure specifications, or which individual PSIs are included in the composite. When calculating the PSI 90 Composite, the Medicare FFS national rate is substituted for the hospital rate if the number of eligible discharges in the denominator for one of the eight PSI components is fewer than three. If the number of eligible discharges is fewer than three for all eight PSI components, the PSI 90 Composite is not calculated due to insufficient data; and CMS will not include the PSI 90 Composite in the hospital s HAC Reduction Program results. 3 These new hospitals are not required to submit NHSN data until after the Domain 2 reporting period has ended. The hospitals have a one-quarter reprieve after the notice of participation. 4 The recalibrated version of the AHRQ software is not publicly available but is available upon request through the QualityNet Help Desk. 7

8 The FY 2017 HAC Reduction Program measures differ from those calculated for the FY 2017 Hospital Value-Based Purchasing (Hospital VBP) Program. Although CMS uses the same PSI 90 Composite for these programs, your hospital s FY 2017 HAC Reduction Program results will likely differ from your hospital s FY 2017 Hospital VBP Program results due to differences in the applicable hospitals and performance periods (i.e., applicable years) used for these programs. CMS is using version of the AHRQ PSI software to calculate PSI 90 Composite results for the 2017 Hospital IQR Program and FY 2017 HAC Reduction Program. CMS used version 4.5a of the AHRQ PSI software to calculate the FY 2017 Hospital VBP Program results (vol. 79, FR 28365). CDC National Healthcare Safety Network (NHSN) CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI The FY 2014 IPPS/LTCH PPS Final Rule outlined the addition of the CDC NHSN MRSA bacteremia and CDI measures, starting in the FY 2017 HAC Reduction Program. The MRSA bacteremia and CDI measures are based on the hospitals observed number of healthcareassociated infections (HAIs) divided by the number of predicted HAIs. For the HAC Reduction Program, the CDC calculates SIRs for the CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI measures. SIRs are ratios of observed-to-predicted numbers of HAIs. The CLABSI and CAUTI measures are risk-adjusted at the hospital-level and patient care unit-level, the SSI measures are risk-adjusted at the procedure-level, and the MRSA bacteremia and CDI measures are risk-adjusted at the hospital-level. The CLABSI, CAUTI, and SSI measures use chart-abstracted surveillance data. The MRSA bacteremia and CDI measures use laboratory-identified surveillance data, which hospitals report to NHSN for infections occurring from January 1, 2014 through December 31, The CDC s calculations for the CLABSI and CAUTI measures only include patients in selected intensive care units (ICUs). CLABSI includes patients in adult, pediatric, or neonatal ICUs. CAUTI includes patients in adult or pediatric ICUs. The SSI measure includes data from abdominal hysterectomy and colon procedures. The MRSA bacteremia and CDI measures include data from all hospital inpatient units. The CDC will not calculate an SIR for CLABSI, CAUTI, SSI, MRSA bacteremia, or CDI if the predicted number of HAIs is less than one 5, because the hospital has insufficient data. The CDC will not calculate an SIR for MRSA bacteremia or CDI if the community-onset prevalence rates are within outlier bounds. Any such measures will not be included in the calculation of Domain 2 or Total HAC scores. Scoring Methodology In the FY 2014 IPPS/LTCH PPS Final Rule, CMS stated it will identify the worst-performing quartile of hospitals by calculating a Total HAC Score that is composed of two domains: patient safety (Domain 1) and HAIs (Domain 2). For the FY 2017 HAC Reduction Program, Domain 1 5 The predicted number of HAIs for the SSI measure is based on both abdominal hysterectomy and colon procedures combined. 8

9 will include the AHRQ PSI 90 Composite, and Domain 2 will include the CDC CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI measures. CMS determines whether a hospital should be subject to a payment reduction based on measure results and scoring. There are three major steps taken to determine a Total HAC Score. First, hospitals are classified based on their measure results. Each hospital is assigned a measure score between 1 and 10, which reflects a hospital s relative rank in 10 groups (or deciles). Then, the measure scores are used to calculate domain scores. For Domain 1, the points assigned for the PSI 90 Composite yield the Domain 1 score, because Domain 1 only contains the PSI 90 Composite. For Domain 2, the points assigned to the five measures are averaged. Third, Total HAC Scores are determined by the sum of weighted Domain 1 and Domain 2 scores. Domain 1 is weighted at 15 percent of the Total HAC Score. Domain 2 is weighted at 85 percent of the Total HAC Score. Higher scores indicate worse performance relative to other eligible hospitals. Hospitals with a Total HAC Score above the 75th percentile will be subject to payment reduction. Measure Score Calculation CMS calculates a measure result for each measure (PSI 90 Composite, CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI) for which a hospital has sufficient data. A performance decile 6 is assigned for each measure based on the measure result. A score between 1 and 10 is assigned for each measure based on the performance decile. Higher scores indicate worse performance. CMS assigns x points to hospitals with a measure result that falls within the x th performance decile. Points range from a minimum of 1 point assigned to hospitals in the first performance decile (best-performing hospitals) to a maximum of 10 points for the tenth performance decile (worstperforming hospitals). 7 CMS will not assign a measure score to hospitals labeled New, as defined in the updates for FY 2017 section in this document. Tables A-F show the points CMS assigned to hospitals for each performance decile based on measure results for PSI 90 Composite, CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI. Table A Point Assignment and Performance Deciles for Hospitals with PSI 90 Composite Measure Results Percentile* FY 2017 PSI 90 composite percentile thresholds** Performance decile Points assigned based on decile Minima p 10 th < r th < p 20 th < r th < p 30 th < r CMS divides hospitals into 10 groups based on the distribution of their measure results. Ideally, each decile would have approximately the same number of hospitals. 7 Hospitals will be assigned the minimum of one point for any measure for which they have a measure result of zero (vol. 79, FR ), regardless of the performance decile. For example, if 13 percent of hospitals have an SIR of 0 for the CAUTI measure, CMS will assign one point to each of these hospitals, even though, 10 of the 13 percent fall into the first decile, and the remaining 3 percent fall in the second decile. CMS will assign two points to the remaining 7 percent of hospitals in the second decile because their SIR is larger than 0, and each percentile range should represent 10 percent of hospitals. 9

10 Percentile* FY 2017 PSI 90 composite percentile thresholds** Performance decile Points assigned based on decile 30 th < p 40 th < r th < p 50 th < r th < p 60 th < r th < p 70 th < r th < p 80 th < r th < p 90 th < r th < p 100 th < r * In this column, p represents the percentile of a hospital s measure result. Table B Point Assignment and Performance Deciles for Hospitals with CLABSI Measure Results Percentile* FY 2017 CLABSI percentile thresholds** Performance decile Points assigned based on decile Minima p 10th r = th < p 20th r or 2*** 20th < p 30th < r th < p 40th 0.24 < r th < p 50th < r th < p 60th < r th < p 70th < r th < p 80th < r th < p 90th < r th < p 100th < r * In this column, p represents the percentile of a hospital s measure result. ** In this column, r represents a hospital s CLABSI measure result. *** Hospitals within this decile will receive one point if their measure result is zero, and two points for any measure result greater than zero. In FY 2017, percent (404 out of 2,282 hospitals with a CLABSI measure result) had a CLABSI measure result = 0. Table C Point Assignment and Performance Deciles for Hospitals with CAUTI Measure Results Percentile* FY 2017 CAUTI percentile thresholds** Performance decile Points assigned based on decile Minima p 10th r = th < p 20th r or 2*** 20th < p 30th < r th < p 40th < r th < p 50th < r th < p 60th < r

11 Percentile* FY 2017 CAUTI percentile thresholds** Performance decile Points assigned based on decile 60th < p 70th < r th < p 80th < r th < p 90th < r th < p 100th < r * In this column, p represents the percentile of a hospital s measure result. ** In this column, r represents a hospital s CAUTI measure result. *** Hospitals within this decile will receive one point if their measure result is zero, and two points for any measure result greater than zero. In FY 2017, percent (399 out of 2,567 hospitals with a CAUTI measure result) had a CAUTI measure result = 0. Table D Point Assignment and Performance Deciles for Hospitals with SSI Measure Results Percentile* FY 2017 SSI percentile thresholds** Performance decile Points assigned based on decile Minima p 10th r = th < p 20th r or 2*** 20th < p 30th < r th < p 40th 0.55 < r th < p 50th < r th < p 60th < r th < p 70th < r th < p 80th < r th < p 90th 1.42 < r th < p 100th < r * In this column, p represents the percentile of a hospital s measure result. ** In this column, r represents a hospital s SSI measure result. *** Hospitals within this decile will receive one point if their measure result is zero, and two points for any measure result greater than zero. In FY 2017, percent (271 out of 2,547 hospitals with a SSI measure result) had a SSI measure result = 0. Table E Point Assignment and Performance Deciles for Hospitals with MRSA bacteremia Measure Results Percentile* FY 2017 MRSA bacteremia percentile thresholds** Performance decile Points assigned based on decile Minima p 10th r = th < p 20th r or 2*** 20th < p 30th < r th < p 40th < r th < p 50th < r

12 Percentile* FY 2017 MRSA bacteremia percentile thresholds** Performance decile Points assigned based on decile 50th < p 60th < r th < p 70th < r th < p 80th < r th < p 90th < r th < p 100th < r * In this column, p represents the percentile of a hospital s measure result. ** In this column, r represents a hospital s MRSA bacteremia measure result. *** Hospitals within this decile will receive one point if their measure result is zero, and two points for any measure result greater than zero. In FY 2017, percent (355 out of 2,351 hospitals with a MRSA bacteremia measure result) had a MRSA bacteremia measure result = 0. Table F Point Assignment and Performance Deciles for Hospitals with CDI Measure Results*** Percentile* FY 2017 CDI percentile thresholds** Performance decile Points assigned based on decile Minima p 10th 0 < r th < p 20th < r th < p 30th < r th < p 40th < r th < p 50th < r th < p 60th < r th < p 70th < r th < p 80th < r th < p 90th < r th < p 100th < r * In this column, p represents the percentile of a hospital s measure result. ** In this column, r represents a hospital s CDI measure result. *** This table reflects the corrected CDI measure results There are four circumstances in which a hospital without a measure result for a Domain 2 measure would also not receive a measure score for that Domain 2 measure. When at least one of these circumstances occurs for all Domain 2 measures, the hospital does not receive a Domain 2 score: 1. Received a waiver for the measure (for CLABSI, CAUTI, and SSI only) 2. Had insufficient data for the measure 3. Classified as an outlier for the measure (for MRSA bacteremia and CDI only) 4. Classified as a Domain 2 new hospital 12

13 There is one circumstance in which a hospital without a measure result for a Domain 2 measure would receive a measure score. A measure score of 10 will be assigned for each Domain 2 measure when none of the following circumstances apply: 1. Received a waiver for the measure (for CLABSI, CAUTI, and SSI only), 2. Had insufficient data for the measure, 3. Classified as an outlier for the measure (for MRSA bacteremia and CDI only), or 4. Classified as a Domain 2 new hospital. See Figure 1 for a visual overview of the scoring methodology calculations for hospitals that are not new hospitals for Domain 1 or Domain 2. Domain Score Calculation CMS determines Domain 1 and Domain 2 scores based on the points assigned for each measure. Since Domain 1 has a single measure (PSI 90 Composite), a hospital s Domain 1 score equals the hospital s PSI 90 Composite measure score. Domain 2 consists of five measures (CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI). A Domain 2 score averages results for the Domain 2 measures. If your hospital has a measure score for all five Domain 2 measures, then your hospital s Domain 2 score equals the average of your hospital s (CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI) measure scores. If a hospital has one to four measure scores for Domain 2, then the hospitals Domain 2 score equals the average of the scores assigned for those measures. A hospital will not receive a domain score when none of the measures within the given domain have a measure score. Domain 1 and Domain 2 scores range from 1 to 10. Lower scores indicate better performance. See the Appendix for a list of scoring scenarios for each domain. See Figure 1 for a visual overview of the scoring methodology for domain score calculations. 13

14 Figure 1 Overview of Scoring Methodology a : The CDC will not calculate a SIR for MRSA bacteremia or CDI if the community-onset prevalence rates are within outlier bounds. b: A measure score will not be calculated if the hospital received a waiver for the measure. Hospitals may receive a waiver for CLABSI, CAUTI, and SSI by completing and submitting an HAI Exception Form. Hospital may receive a waiver for CLABSI and CAUTI through indicating having an active ICU in NHSN during the reporting period. c : CMS applies a weight of 15 percent for Domain 1 and 85 percent for Domain 2 to determine the Total HAC Score for hospitals that received both a Domain 1 score and a Domain 2 score. If a hospital has only one domain score, then CMS applies a weight of 100 percent to the domain for which the hospital has a score. Total HAC Score Calculation CMS applies a weight of 15 percent for Domain 1 and 85 percent for Domain 2 when calculating the Total HAC Score for hospitals that received both a Domain 1 score and a Domain 2 score. If a hospital has only one domain score, then CMS applies a weight of 100 percent to the domain for which the hospital has a score. Refer to Figure 2 for a visual overview of the scoring methodology for Total HAC Score calculations. 14

15 Figure 2 Scoring Methodology for Total HAC Score* *This figure displays 4 of the 64 possible combinations of presence ( ) or absence (x) of calculated measure scores for the PSI 90 Composite, CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI measures. Identification of Worst Performers As summarized above, CMS calculates the Total HAC Score by multiplying the Domain 1 score by the Domain 1 weight, and the Domain 2 score by the Domain 2 weight. Hospitals that do not receive a Domain 1 score or a Domain 2 score will not receive a Total HAC Score. Higher Total HAC Scores indicate worse performance on patient safety events and HAIs. Hospitals with a Total HAC Score greater than the 75th percentile (i.e., worst-performing 15

16 quartile) will be subject to a payment reduction (see Figure 3) 8. Hospitals that are not in the worst-performing quartile will not be subject to a payment reduction. Figure 3 Distribution of Total HAC Scores* *This graphic does not reflect the actual distribution of Total HAC Scores for the FY 2017 HAC Reduction Program. Review and Corrections Process CMS gives hospitals 30 days to review their data to ensure Total HAC Scores were calculated correctly. CMS will notify hospitals of the exact dates of the Review and Corrections period, and post these date on QualityNet once finalized. CMS provides hospitals with their HSRs via QualityNet Secure Portal accounts 9 at the beginning of the Review and Corrections period. 8 Maryland hospitals have a waiver for the FY 2017 HAC Reduction Program. Maryland hospitals will receive an HSR with their PSI 90 Composite measure results, Domain 1 score, CLABSI, CAUTI, SSI, MRSA and CDI measure results, Domain 2 score, and Total HAC Score but will not be subject to a payment reduction. Maryland hospitals Total HAC Scores are not included in the distribution to determine the top quartile of scores. 9 Hospitals that do not have a QualityNet secure portal account will not be able to receive their HSRs. If your hospital did not receive an HSR or does not have a QualityNet secure portal account, please contact qnetsupport@hcqis.org 16

17 Hospitals have the opportunity to review and correct the following information prior to public reporting: Measure result for the PSI 90 Composite Measure scores for the PSI 90 Composite, CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI measures Domain 1 and Domain 2 scores Total HAC Score Please note, however, the Review and Corrections process does not allow hospitals to submit additional corrections related to the underlying claims data for the PSI 90 Composite, or add new claims to the data extract used to calculate the results. Under the Hospital IQR Program, hospitals had an opportunity to submit, review, and correct the chart-abstracted information used to calculate the CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI measures. Hospitals were given the opportunity to review and correct the CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI data for the FY 2017 HAC Reduction Program. This Review and Corrections process does not allow hospitals to correct (1) the reported number of HAIs, (2) CLABSI, CAUTI, SSI, MRSA bacteremia, or CDI SIRs, or (3) reported central-line days, urinary catheter days, surgical procedures performed, or patient days. If you have concerns or questions about your hospital s calculations, please qnetsupport@hcqis.org no later than 11:59 pm PT on the final day of the Review and Corrections period with the subject line: HACRP Review and Corrections Inquiry. Public Reporting In December 2016, CMS plans to make the following HAC Reduction Program information publicly available for each hospital on Hospital Compare at hospitalcompare/search.html PSI 90 Composite, CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI measure scores Domain 1 and Domain 2 scores Total HAC Score 17

18 HSR File Contents and Descriptions This section contains descriptions of the tables included in the HAC Reduction Program HSR. The HSR workbook contains Domain 1 and Domain 2 scores; Total HAC Score; performance on PSI 90 Composite; PSI 90 Composite discharge-level data; and performance on the CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI measures. Understanding Your Hospital s Performance on Domain 1, Domain 2, and Total HAC Score Table 1 in the HSR contains information on interpreting performance results for Domain 1 score, Domain 2 score, and Total HAC Score, as well as the weight and contribution of each domain score under the Total HAC Score. Table G provides a description of the data included in Table 1 of your HSR. Table G Contents of the Total HAC Score Results Worksheet Column Variable name Description Column A Domain 1 Score The Domain 1 score equals the points assigned to your hospital based on the decile in which your hospital s AHRQ PSI 90 Composite value falls. Refer to Table A in Section 1 and the Appendix for more information on how CMS assigns points for the PSI 90 Composite. Column B Weight of Domain 1 Score for Your Hospital Column C Domain 1 Contribution to Total HAC Score Weight assigned to your hospital s Domain 1 score in order to determine the contribution of the Domain 1 score to your hospital s Total HAC Score. CMS applies a weight of 0.15 to Domain 1 and 0.85 to Domain 2 for hospitals that have both a Domain 1 and Domain 2 score. If your hospital has only one domain score, CMS applies a weight of 1.00 to the domain for which your hospital has a score. Refer to the Appendix for a list of the scoring scenarios for Domain 1. Domain 1 Contribution to Total HAC Score is calculated by multiplying your hospital s Domain 1 Score (Column A) by the Weight of Domain 1 Score for Your Hospital (Column B). This value is used to determine a portion of your hospital s Total HAC Score. Column D Domain 2 Score If your hospital has a measure score for all five Domain 2 measures, then your hospital s Domain 2 score equals the average of the points assigned for each Domain 2 measure (CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI). If your hospital has measure scores for between one and four measures for Domain 2, then your hospital s Domain 2 score equals the average of the scores assigned for those measures. If your hospital has no measure scores, then your hospital will not receive a Domain 2 score. Refer to Tables B-F in Section I and the Appendix for more information on how CMS assigns points to the CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI measures and calculates the Domain 2 score. Column E Weight of Domain 2 Score for Your Hospital Weight assigned to your hospital s Domain 2 score in order to determine the contribution of the Domain 2 score to your hospital s Total HAC Score. CMS applies a weight of 0.85 to Domain 2 for hospitals that have both a Domain 1 and Domain 2 score. If your hospital has only one domain score, then CMS applies a weight of 1.00 to the domain for which your hospital has a score. Refer to the Appendix for more information on scoring scenarios from Domain 2 based on a hospital s individual reporting circumstance. 18

19 Column Variable name Description Column F Domain 2 Contribution to Total HAC Score Column G Column H Column I Your Hospital's Total HAC Score Payment Reduction Threshold (75th Percentile) Subject to Payment Reduction (Yes/No) Domain 2 Contribution to Total HAC Score is calculated by multiplying your hospital s Domain 2 Score (Column D) by the Weight of Domain 2 Score for Your Hospital (Column E). This value determines a portion of your hospital s Total HAC Score. Your hospital s Total HAC Score is the sum of your hospital s Domain 1 Contribution to Total HAC Score (Column C) and Domain 2 Contribution to Total HAC Score (Column F). Higher Total HAC Scores indicate worse performance on patient safety events and HAIs. The Payment Reduction Threshold is the value of the 75th percentile among eligible hospitals Total HAC Scores. The location of your hospital s Total HAC Score with respect to the Payment Reduction Threshold determines if your hospital will be subject to a payment reduction. Maryland hospitals are not included in the distribution to determine the Payment Reduction Threshold (75th percentile), since they are waived from the payment penalties for the HAC Reduction Program for FY If your hospital s Total HAC Score (Column G) is greater than the Payment Reduction Threshold (Column H), then your hospital will be subject to a payment reduction. Table 2 in the HSR contains your hospital s measure results, performance decile, and assigned points based on the performance decile (i.e., measure score) for each measure in Domain 1 (PSI 90 Composite) and Domain 2 (CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI). This table also contains your Domain 1 and Domain 2 scores. Table H provides a description of the data included in Table 2 of your HSR. Table H Contents of the Domain Scores Worksheet Column Variable name Description Column A Domain The two domains that make up the FY 2017 HAC Reduction Program and the measures that are included in each domain. Column B Measure Result Your hospital s measure results for PSI 90 Composite, CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI measures. Column C Performance Decile The Performance Decile is the decile that your hospital falls in based on your hospital s PSI 90 Composite, CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI measure results relative to other hospitals. Refer to Tables A-F above for more information on how CMS determines the performance decile for the PSI 90 Composite, CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI measures. Column D Points Assigned Based on Decile (Measure Score) Your hospital is assigned a number of points for each measure based on its Performance Decile for the given measure. Refer to Tables A-F above for more information on how CMS assigns points for the PSI 90 Composite, CLABSI, CAUTI, and SSI, MRSA bacteremia, and CDI measures. 19

20 Column Variable name Description Column E Domain Score Your hospital s Domain 1 score is equivalent to the points assigned to the PSI 90 Composite (Column D). If your hospital has a measure score for all five Domain 2 measures, then your hospital s Domain 2 score equals the average of your hospital s (CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI) measure scores. If a hospital has between one and four measure scores for Domain 2, then the hospitals Domain 2 score equals the average of the scores assigned for those measures. Finally, your hospital will not receive a domain score when it does not have measure scores for any of the measures within the given domain. Domain 1 and Domain 2 scores range from 1 to 10, with lower scores indicating better performance. Understanding Your Hospital s Performance on AHRQ PSI 90 Composite Table 3 in the HSR provides information on interpreting performance results for the PSI 90 Composite and the eight PSI component measures that make up the PSI 90 Composite. Table 3 also summarizes your hospital s number of eligible discharges, number of outcomes, observed rates, expected rates, risk-adjusted rates, and smoothed rates for each of the eight component PSIs. This table also provides the Medicare FFS national results for the PSI 90 Composite and risk-adjusted rates for each of the eight component PSIs. In addition, the table contains each PSI component measure s weight in the PSI 90 Composite along with the reliability weight. The information in this table enables your hospital to replicate its PSI 90 Composite value, based on discharges between July 1, 2013 and June 30, Table I provides a description of the data included in the corresponding Table 3 in your HSR. Table I Your Hospital's Performance on AHRQ PSI 90 Composite Worksheet Contents Row* Variable name Description Row 1 Composite Value The AHRQ PSI 90 Composite value is a weighted average of eight component PSIs. This value will be used to determine your measure score and Domain 1 score. Row 2 Row 3 Row 4 Total Number of Eligible Discharges (Denominator) at Your Hospital Number of Outcomes (Numerator) Observed Rate per 1,000 Eligible Discharges Number of discharges from your hospital that meet the inclusion criteria for the given PSI component. This variable is applicable to the eight individual PSI components included in the PSI 90 Composite but not presented for the PSI 90 Composite as a whole. Actual number of outcomes of interest that occurred at your hospital between July 1, 2013 and June 30, This variable is applicable to the eight individual PSI components included in the PSI 90 Composite but not presented for the PSI 90 Composite as a whole. Actual number of outcomes identified at your hospital (numerator, Row 3) divided by the number of eligible discharges for that component measure at your hospital (denominator, Row 2), multiplied by 1,000 for PSIs. This is also known as the raw rate. This variable is applicable to the eight individual PSI components included in the PSI 90 Composite but not presented for the PSI 90 Composite as a whole. 20

21 Row* Variable name Description Row 5 Row 6 Row 7 Row 8 Row 9 Row 10 Expected Rate per 1,000 Eligible Discharges Risk-Adjusted Rate per 1,000 Eligible Discharges Smoothed Rate per 1,000 Eligible Discharges National Composite Value National Risk- Adjusted Rate per 1,000 Eligible Discharges Measure s Weight in Composite Estimate of your hospital s expected performance if your hospital performed the same as the reference population given your hospital s actual case-mix (e.g., age, gender, diagnosis-related group, and comorbidity categories). This variable is applicable to the eight individual PSI components included in the PSI 90 Composite but not presented for the PSI 90 Composite as a whole. Estimate of your hospital s performance if your hospital had an average patient case-mix, given your hospital s actual performance. Average case-mix is defined using the Medicare FFS reference population. If your hospital had a healthier case-mix of patients than the case-mix in the Medicare FFS reference population, then the risk-adjusted rate is higher than the observed rate. If your hospital has a less healthy patient case-mix than the case-mix in the Medicare FFS reference population, then the risk-adjusted rate is lower than the observed rate. This variable is applicable to the eight individual PSI components included in the PSI 90 Composite but not presented for the PSI 90 Composite as a whole. Estimate of your hospital s expected performance with a large population of patients. This rate is a weighted average of the Medicare FFS national riskadjusted rate in the Medicare FFS population and your hospital s risk-adjusted rate. The weight used to construct the average is an estimate of the reliability of your hospital s risk-adjusted rate. This variable is applicable to the eight individual PSI components included in the PSI 90 Composite but not presented for the PSI 90 Composite as a whole. However, CMS uses the smoothed rates for each PSI component indicator to calculate the PSI 90 Composite. Calculated by averaging the PSI 90 Composite values across all subsection (d) and Maryland hospitals in the country, weighted by the number of Medicare FFS discharges at each hospital. Calculated by averaging the risk-adjusted rate across all subsection (d) and Maryland hospitals in the country, weighted by the number of Medicare FFS discharges at each hospital. Weights that were used to construct the PSI 90 Composite from the eight individual PSI components using recalibrated version of the AHRQ PSI software. The same weights are applied for all hospitals. AHRQ recommends these weights for use with recalibrated version of the AHRQ PSI software. QualityNet contains a description of the Medicare FFS reference population, which was used to calculate the component weights. Row 11 Reliability Weight Weights that are used to construct the smoothed rate for each individual PSI component. Reliability weights are calculated for each hospital based on the calculated reliability of the hospital. A reliability weight ranges from 0 to 1, representing the ratio of between-hospital variance to total variance. A larger reliability weight places a greater emphasis on the hospital s data when calculating the smoothed rate. *Refers to the row number in the first column of the Excel worksheet. 10 The recalibrated version of the AHRQ PSI software is not publicly available but is available upon request through the QualityNet Help Desk. 21

22 Understanding Your Hospital s Discharge-Level Information for the AHRQ PSI Measures Table 4 in the HSR includes information about discharges that meet criteria for one or more of the PSI component measures in the PSI 90 Composite. This worksheet contains data for all Medicare FFS patients aged 18 years or older who had the outcome of interest from July 1, 2013 through June 30, 2015, complete POA data, and a POA flag of N or U associated with the outcome of interest. An N indicates that the diagnosis was not present at the time of inpatient admission, while a U indicates that the documentation was insufficient to determine whether a condition was present at the time of admission. The PSI 90 Composite does not have dischargelevel data because it is calculated from the individual PSI component measures. Table J provides a description of the data included in Table 4 of your HSR. External cause of injury codes (E codes) were not used to calculate the PSIs for the FY 2017 HAC Reduction Program, although they are included in discharge-level data. If your hospital submitted a claim with more than 25 diagnoses or procedures, the 26 th and subsequent diagnoses and procedures are not included in the AHRQ calculation or accompanying discharge-level data file. CMS only uses the first 25 diagnosis codes and 25 procedure codes to calculate PSI rates. Do not the contents of Table 4 of your HSR because it contains Personally Identifiable Information (PII) and Protected Health Information (PHI). ing this data is a security violation. If you have questions, please contact the QualityNet Help Desk at qnetsupport@hcqis.org, and they will provide directions for transmitting data. When referring to the contents of Table 4 in the HSR, use the ID Number. Table J Your Hospital's Discharge-Level Information for the AHRQ PSI Measures Worksheet Contents Column Variable name Description Column A ID Number Unique identifier for each discharge included in the worksheet. Column B Measure Identifies for which PSI measure discharge-level data are provided. Column C HICNO 6-12 digit Medicare health insurance claim account number. Note: This is not the same as the Social Security number (SSN). Column D Medical Record Number Your hospital s Medical Record Number associated with each discharge. Column E Beneficiary DOB Patient date of birth (DOB) (MM/DD/YYYY) Column F Admission Date Patient admission date (MM/DD/YYYY) Column G Discharge Date Patient discharge date (MM/DD/YYYY) Column H Columns: I BE (Every Other Column) PSI Trigger Diagnoses or Procedures DX1-DX25 Indicates which diagnoses or procedures were counted as a PSI outcome (e.g., for PSI 03) and included in the numerator. If one stay record has multiple diagnoses or procedure codes for the same PSI, all of these codes will be flagged in this variable, but at the hospital level, the discharge is only counted once for the PSI measure. If a hospital stay qualified for two separate PSI measures, they are repeated in this file in each measure section. ICD-9 code for diagnoses 1-25 respectively 22

23 Column Variable name Description Columns: J BF (Every Other Column) Columns BG- CE POA1-POA25 PR1-PR25 Present on Admission flag for diagnoses 1-25 respectively (i.e., Y (Yes), N (No), U (Unknown), W (Clinically undetermined), 1 (Unreported/Exempt)) ICD-9 Code for Procedure(s) 1-25 respectively Understanding Your Hospital's Performance on CDC CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI Measures Table 5 in the HSR includes information on interpreting performance results for the CDC CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI measures. Table 5 summarizes your hospital s reported number of HAIs. Table K provides a description of the data included in Table 5 of your HSR. Table K Your Hospital's Performance on CDC CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI Measures Worksheet Contents Row* Variable name Description Row 1 Reported Number of HAIs For CLABSI and CAUTI: the sum of your hospital's reported number of HAIs across all applicable intensive care unit (ICU) locations within your hospital from January 1, 2014 through December 31, For SSI: the sum of your hospital s reported number of HAIs across abdominal hysterectomy and colon procedures performed within your hospital from January 1, 2014 through December 31, For MRSA bacteremia and CDI: the data are collected based on surveillance at the facility-wide level from January 1, 2014 through December 31, Row 2 Predicted Number of HAIs For CLABSI and CAUTI: the CDC calculates the number of predicted HAIs for each patient care location by multiplying each ICU location s reported central-line or urinary catheter days by the ICU location's NHSN-specific infection rate and dividing by 1,000. NHSN-specific infection rates are generated from a standard population during a baseline period of 2006 through 2008 for CLABSI and a baseline period of 2009 for CAUTI. They are adjusted for several risk factors that have been found to be significantly associated with differences in infection incidence. Your hospital's predicted number of HAIs equals the sum of the predicted number of HAIs across each applicable ICU location within your hospital. For SSI: the predicted number of HAIs following abdominal hysterectomy and colon procedures performed within your hospital is derived from a logistic regression model based on data from a baseline period of 2006 through For MRSA bacteremia and CDI: the CDC calculates the number of predicted HAIs based on patient days from a model using a baseline time period of 2010 to

24 Row* Variable name Description Row 3 Reported Central-line or Urinary Catheter Days; Surgical Procedures Performed; MRSA bacteremia Patient Days; CDI Patient Days For CLABSI and CAUTI: the total number of central-line days (for CLABSI) or urinary catheter days (for CAUTI) reported for all applicable ICU locations. For SSI: the total number of abdominal hysterectomy and colon procedures performed within your hospital from January 1, 2014 through December 31, For MRSA bacteremia and CDI: the total number of patient days based on data collected during surveillance at the facility-wide level. Row 4 SIR The CDC calculates SIRs by dividing a hospital's Reported Number of HAIs (Row 1) by a hospital's Predicted Number of HAIs (Row 2). A hospital must have greater than or equal to one predicted HAI in order to have sufficient data. A SIR will not be calculated for hospitals with less than one predicted HAI. For MRSA bacteremia, the CDC will not calculate a SIR for the measure if the MRSA bacteremia community-onset prevalence rate for the hospital for all quarters during the performance period is above For CDI, the CDC will not calculate a SIR for the measure if the CDI community-onset prevalence rate for the hospital for all quarters during the performance period is above Row 5 National SIR The national SIR is calculated by summing all reported HAIs among subsection (d) hospitals, including Maryland hospitals for the January 1, 2014 through December 31, 2014-time period and dividing by the sum of all predicted HAIs for those hospitals during the same time period. * Refers to the row number included in the first column of the Excel worksheet. 24

25 Replication Instructions This section provides instructions for replicating the PSI 90 Composite measure calculation results using the component PSI results, Domain 1 score, Domain 2 score, and Total HAC Score. The calculation steps utilize results calculated for the FY 2017 HAC Reduction Program, including the payment reduction threshold, national PSI 90 Composite value, Medicare FFS national risk-adjusted PSI rates, national SIRs based on subsection (d) hospitals, and PSI component weights in the PSI 90 Composite. Other hospital-specific values in the calculation steps are based on mock data. This section does not include instructions on replicating the CDC CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI measure results because, under the Hospital IQR Program, hospitals have the opportunity to review and correct their chart-abstracted CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI data for the full 4½ months following the last discharge date in a calendar quarter. PSI 90 Composite Value For the FY 2017 HAC Reduction Program, CMS calculated the AHRQ measures using version of the AHRQ PSI software. Note that your hospital s FY 2017 HAC Reduction Program results will likely differ from your hospital s FY 2017 Hospital Value-Based Purchasing (VBP) Program performance period results for PSI 90, CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI due to differences in the applicable hospitals, performance periods, and for the PSI 90 Composite, the version of the AHRQ PSI software used across the programs. Step-by-step instructions are provided on how to replicate your hospital s PSI 90 Composite value, using the example found in the mock HSR 12. Each step is followed by an image of the process in Excel. An Excel file combining the steps (and showing formulas) is also available upon request by contacting the QualityNet Help Desk at qnetsupport@hcqis.org with the following subject line: Request for HAC Reduction Program Replication Example. Note: For each individual PSI for which your hospital has fewer than three eligible discharges, skip to Step 5a and refer to footnote 13. Step 1: Identify Discharges Associated with Each PSI Start on the tab titled Table 4. AHRQ PSI Discharges in your HSR. For each individual PSI (03, 06, 07, 08, 12, 13, 14, and 15), limit your replication calculations to rows where Measure (Column B) in Table 4 equals the individual PSI that you are trying to replicate. In Figure 4, the discharges highlighted in Rows are the number of outcomes for PSI 12 (also shown in Table 3, Row 8 of the HSR). 11 The recalibrated version of the AHRQ PSI software is not publicly available but is available upon request through the QualityNet Help Desk. 12 Instructions on how to replicate CMS s results for the AHRQ PSIs can be found on the QualityNet website ( > Hospitals-Inpatient>Claims-Based Measures>AHRQ Indicators>Resources. 25

26 Figure 4 AHRQ Replication Step 1 Step 2: Calculate the Observed Rate per 1,000 Eligible Discharges Click on the tab titled Table 3: AHRQ PSI Performance in your HSR. 2a. Divide the number of outcomes found in Step 1 (Table 3, Row 8 of the HSR) by the total number of eligible discharges at your hospital (Table 3, Row 7 of the HSR) highlighted in Figure 5. 2b. Multiply the value calculated in Step 2a by 1,000. For example, after dividing cell G8 by G7 in Step 2a, multiply the result by 1,000. This is the Observed Rate per 1,000 Eligible Discharges that, when rounded to four decimal places, should match the number in Table 3, Row 9 in your HSR. 2c. Repeat Steps 2a 2b for all individual PSI columns (Table 3, Columns C Column J of the HSR). 26

27 Figure 5 AHRQ Replication Step 2 Step 3: Calculate the Risk-Adjusted Rate per 1,000 Eligible Discharges 3a. Divide the unrounded observed rate (from Step 2b) by the expected rate (Table 3, Row 10 of the HSR) highlighted in Figure 6. 3b. Multiply the value calculated in Step 3a by the respective measure s Medicare FFS national rate, which can be found in Table L below. Table L Medicare FFS National Rate PSI Medicare FFS Reference Population PSI PSI PSI PSI PSI PSI PSI PSI c. Multiply the value calculated in Step 3b by 1,000 and round to four decimal places to get the Risk-Adjusted Rate per 1,000 Eligible Discharges in Table 3, Row 11 of the HSR. 3d. Repeat Steps 3a 3c for all individual PSI columns (Table 3, Column C Column J of the HSR). 27

28 Figure 6 AHRQ Replication Step 3 Step 4: Calculate the Smoothed Rate per 1,000 Eligible Discharges 4a. Multiply the unrounded risk-adjusted rate (calculated in Step 3c) by each measure s respective reliability weight (Table 3, Row 16 of the HSR) highlighted in Figure 7. 4b. Multiply the Medicare FFS national risk-adjusted rate (Table 3, Row 14 of the HSR) highlighted in Figure 7 by the value of one minus the reliability weight (Table 3, Row 16 of the HSR) highlighted in Figure 7. 4c. Add the value calculated in Step 4a to the value calculated in Step 4b. This sum, when rounded to four decimal places, should match your hospital s smoothed rate (Table 3, Row 12 of the HSR) highlighted in Figure 7 4d. Repeat Steps 4a 4c for all individual PSI columns (Table 3, Column C Column J of the HSR). 28

29 Figure 7 AHRQ Replication Step 4 Step 5: Calculate the PSI 90 Composite 5a. Start with the unrounded smoothed rate calculated in Step 4c and divide by 1,000 for each PSI measure. 13 5b. Divide the quantity in Step 5a by the corresponding Medicare FFS national rate shown in Table L above. 5c. Multiply the quantity in Step 5b by the corresponding composite weight (Table 3, cell G15 of the HSR) highlighted in Figure 8. 5d. Repeat Steps 5a 5c for each individual PSI component. 5e. Sum the results of all PSI components from Step 5d and round to four decimal places. This should match the PSI 90 Composite value (Table 3, cell B6 of the HSR) highlighted in Figure If any of the component PSI measures have fewer than three eligible discharges, then the National risk-adjusted rate (Table 3, Row 14 of the HSR) is used for calculating that component PSI when calculating the PSI 90 Composite. 14 PSI 90 Composite calculations you complete in Step 5e may be different from the PSI 90 Composite Value in Table 2 of the HSR out to the fourth decimal due to differences in rounding between Excel and SAS. When CMS calculates the PSI 90 Composite for the HAC Reduction Program, it uses the statistical software SAS, and the value in cell B7 of your HSR is based on this SAS calculation. The value that you calculate in step 5e is using Excel. 29

30 Figure 8 AHRQ Replication Step 5 PSI 90 Composite Measure Score and Domain 1 Score Start on the tab titled Table 2. Domain Scores in your HSR. D1.1 First, determine your hospital s PSI 90 Composite value from the Measure Results column (Table 2, cell B7 of the HSR) highlighted in Figure 9. D1.2 Next, determine the performance decile in which your hospital s PSI 90 Composite value falls from the Performance Decile column (Table 2, cell C7 of the HSR) highlighted in Figure 9. D1.3 Then, refer to Table A to validate your performance decile and to determine the number of points associated with your hospital s performance decile; this is your hospital s PSI 90 Composite measure score. The points assigned to the PSI 90 Composite should match the Points Assigned Based on the Decile column (Table 2, cell D7 of the HSR) highlighted in Figure 9. The PSI 90 Composite measure score from this step is also your Domain 1 score (Table 2, cell E7 of the HSR) highlighted in Figure 9. 30

31 If your hospital has insufficient data ( INS in Table 2, Row 7 of the HSR) for the PSI 90 Composite or is a new hospital for Domain 1 ( NEW in Table 2, Row 7 of the HSR), then your hospital will not receive a PSI 90 Composite value, PSI 90 Composite measure score, or Domain 1 score, and your hospital s Total HAC Score will be based exclusively on your hospital s Domain 2 score (if present). Figure 9 Domain 1 Score Replication Domain 2 Score Start on the tab titled Table 2. Domain Scores in your HSR. If your hospital has a CLABSI SIR in cell B9 of Table 2, follow steps D2.1 through D2.3, otherwise skip to step D2.4. D2.1 First, determine your hospital s CLABSI SIR from the Measure Result column (Table 2, cell B9 of the HSR) highlighted in Figure 10. D2.2 Next, refer to Table B to determine the performance decile in which your hospital s CLABSI SIR falls. This should match your hospital s CLABSI Performance Decile column (Table 2, cell C9 of the HSR) highlighted in Figure 10. D2.3 Then refer to Table B to determine the number of points associated with your hospital s CLABSI performance decile. This should match your hospital s CLABSI Measure Score column (Table 2, cell D9 of the HSR) highlighted in Figure 10. If your hospital does not have a CLABSI SIR in cell B9 of Table 2, follow steps D2.4 and D

32 D2.4 If cell B9 of Table 2 of your HSR contains an INS (i.e., insufficient data to calculate the CLABSI SIR), NF (i.e., did not indicate an active ICU for at least one quarter, and did not indicate any active ICUs for any other quarter), WV (i.e., submitted HAI Exception Form for CLABSI), or NEW (i.e., hospital was not required to submit data to NHSN for the Hospital IQR Program prior to the end of the Domain 2 performance period [December 31, 2015]), then CLABSI will not factor into your hospital s Domain 2 score because a CLABSI measure result was not calculated for your hospital. D2.5 If cell B9 of Table 2 of your HSR contains a MAX (i.e., maximum 10 points for nonsubmission of CLABSI data), then 10 points will be your hospital s measure score for CLABSI because your hospital did not submit data for CLABSI, did not receive a waiver for CLABSI, indicated having an active ICU location in NHSN for at least one quarter during the reporting period, and was not considered a NEW hospital for Domain 2. Start on the tab titled Table 2. Measure Scores in your HSR. If your hospital received a CAUTI SIR in cell B10 of Table 2, follow steps D2.6 through D2.8, otherwise skip to step D2.9. D2.6 First, determine your hospital s CAUTI SIR from the Measure Result column (Table 2, cell B10 of the HSR) highlighted in Figure 10. D2.7 Next, refer to Table C to determine the performance decile in which your hospital s CAUTI SIR falls. This should match your hospital s CAUTI Performance Decile column (Table 2, cell C10 of the HSR) highlighted in Figure 10. D2.8 Then refer to Table C to determine the number of points associated with your hospital s CAUTI performance decile. This should match your hospital s CAUTI Measure Score column (Table 2, cell D10 of the HSR) highlighted in Figure 10. If your hospital does not have a CAUTI SIR in cell B10 of Table 2, follow steps D2.9 and D2.10. D2.9 If cell B10 of Table 2 of your HSR contains an INS (i.e., insufficient data for CAUTI), NF (i.e., did not indicate an active ICU for at least one quarter, and did not indicate any active ICUs for any other quarter), WV (i.e., submitted HAI Exception Form for CAUTI), or NEW (i.e., hospital was not required to submit data to NHSN for the Hospital IQR Program prior to the end of the Domain 2 performance period [December 31, 2015]), then CAUTI will not factor into your hospital s Domain 2 score because a CAUTI measure result was not calculated for your hospital. D2.10 If cell B10 of Table 2 of your HSR contains a MAX (i.e., maximum 10 points for nonsubmission of CAUTI data), then 10 points will be your hospital s measure score for CAUTI because your hospital did not submit data for CAUTI, did not receive a waiver for CAUTI, indicated having an active ICU location in NHSN for at least one quarter during the reporting period, and was not considered a NEW hospital for Domain 2. Start on the tab titled Table 2. Measure Scores in your HSR. If your hospital received an SSI SIR in cell B11 of Table 2, follow steps D2.11 through D2.13, otherwise skip to step D2.14. D2.11 First, determine your hospital s SSI SIR from the Measure Result column (Table 2, cell B11 of the HSR) highlighted in Figure 10. D2.12 Next, refer to Table D to determine the performance decile in which your hospital s SSI SIR falls. This should match your hospital s SSI Performance Decile column (Table 2, cell C11 of the HSR) highlighted in Figure

33 D2.13 Then refer to Table D to determine the number of points associated with your hospital s SSI performance decile. This should match your hospital s SSI Measure Score column (Table 2, cell D11 of the HSR) highlighted in Figure 10. If your hospital does not have a SSI SIR in cell B11 of Table 2, follow steps D2.14 and D2.15. D2.14 If cell D11 of Table 2 of your HSR contains an INS (i.e., insufficient data for SSI), WV (i.e., submitted HAI Exception Form for SSI), or NEW (i.e., hospital was not required to submit data to NHSN for the Hospital IQR Program prior to the end of the Domain 2 performance period [December 31, 2015]), then SSI will not factor into your hospital s Domain 2 score because an SSI measure result was not calculated for your hospital. D2.15 If cell D11 of Table 2 of your HSR contains a MAX (i.e., maximum 10 points for nonsubmission of SSI data), then 10 points will be your hospital s measure score for SSI because your hospital did not submit data for SSI, did not receive a waiver for SSI, and was not considered a NEW hospital for Domain 2. Figure 10 Domain 2 Score Replication (CLABSI, CAUTI, SSI) 33

34 Start on the tab titled Table 2. Measure Scores in your HSR. If your hospital received a MRSA bacteremia SIR in cell B12 of Table 2, follow steps D2.16 through D2.18, otherwise skip to step D2.19. D2.16 First, determine your hospital s MRSA bacteremia SIR from the Measure Result column (Table 2 cell B12 of the HSR) highlighted in Figure 11. D2.17 Next, refer to Table E to determine the performance decile in which your hospital s MRSA bacteremia SIR falls. This should match your hospital s MRSA bacteremia Performance Decile column (Table 2, cell C12 of the HSR) highlighted in Figure 11. D2.18 Then refer to Table E to determine the number of points associated with your hospital s MRSA bacteremia performance decile. This should match your hospital s MRSA bacteremia Measure Score column (Table 2, cell D12 of the HSR) highlighted in Figure 11. If your hospital does not have a MRSA bacteremia SIR in cell B12 of Table 2, follow steps D2.19 and D2.20. D2.19 If cell D12 of Table 2 of your HSR contains an INS (i.e., insufficient data for MRSA bacteremia) NEW (i.e., hospital was not required to submit data to NHSN for the hospital IQR Program prior to the end of the Domain 2 performance period [December 31, 2015]), or Outlier (i.e., the CDC will not calculate a SIR for the measure if the MRSA bacteremia community-onset prevalence rate for the hospital for all quarters during the performance period is above 0.88), then MRSA bacteremia will not factor into your hospital s Domain 2 score because a MRSA bacteremia measure result was not calculated for your hospital. D2.20 If cell D12 of Table 2 of your HSR contains a MAX (i.e., maximum 10 points for nonsubmission of MRSA bacteremia data), then 10 points will be your hospital s measure score for MRSA bacteremia because your hospital did not submit data for MRSA bacteremia and was not considered a NEW hospital for Domain 2. Start on the tab titled Table 2. Measure Scores in your HSR. If your hospital received a CDI SIR in cell B13 of Table 2, follow steps D2.21 through D2.23, otherwise skip to step D2.24. D2.21 First, determine your hospital s CDI SIR from the Measure Result column (Table 2 cell B13 of the HSR) highlighted in Figure 11. D2.22 Next, refer to Table F to determine the performance decile in which your hospital s CDI SIR falls. This should match your hospital s CDI Performance Decile column (Table 2, cell C13 of the HSR) highlighted in Figure 11. D2.23 Then refer to Table F to determine the number of points associated with your hospital s CDI performance decile. This should match your hospital s CDI Measure Score (Table 2, cell D13 of the HSR) highlighted in Figure 11. If your hospital does not have a CDI SIR in cell B13 of Table 2, follow steps D2.24 and D2.25. D2.24 If cell D13 of Table 2 of your HSR contains an INS (i.e., insufficient data for CDI) NEW (i.e., hospital was not required to submit data to NHSN for the Hospital IQR Program prior to the end of the Domain 2 performance period [December 31, 2015]), or Outlier (i.e., the CDC will not calculate a SIR for the measure if the CDI community- 34

35 onset prevalence rate for the hospital for all quarters during the performance period is above 1.78) then CDI will not factor into your hospital s Domain 2 score because a CDI measure result was not calculated for your hospital. D2.25 If cell D13 of Table 2 of your HSR contains a MAX (i.e., maximum 10 points for nonsubmission of CDI data), then 10 points will be your hospital s measure score for CDI because your hospital did not submit data for CDI and was not considered a NEW hospital for Domain 2. D2.26 If your hospital was assigned points for CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI, then add together your hospital s measure score for CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI and divide by five. This is your hospital s Domain 2 score. Otherwise, if your hospital received a measure score for more than one of the Domain 2 measures, then add together your hospital s measure scores for those measures and divide by the number of Domain 2 measures that have a score. This is your hospital s Domain 2 score. If your hospital received a measure score for only one of the Domain 2 measures, then your hospital s Domain 2 score equals the score for that measure. If your hospital did not receive a measure score for any Domain 2 measure, then your hospital will not receive a Domain 2 score, and your hospital s Total HAC Score will be based exclusively on your hospital s Domain 1 score (if present). The Domain 2 score you calculate should match the Domain Score column (Table 2, cell E8 of the HSR) highlighted in Figure 11. Figure 11 Domain 2 Score Replication (MRSA bacteremia, CDI, Domain 2 Score) 35

36 Total HAC Score Start on the tab titled Table 1. Total HAC Score in your HSR. THS.1 Multiply your hospital s Domain 1 score (result from Step D1.3 above) by the weight of the Domain 1 score for your hospital (Table 1, cell B7 of the HSR) highlighted in Figure 12. Refer to the Appendix for a list of scoring scenarios for each domain. THS.2 Multiply your hospital s Domain 2 score (result from Step D2.26 above) by the weight of the Domain 2 score for your hospital (Table 1, cell E7 of the HSR) highlighted in Figure 12. Refer to the Appendix for a list of scoring scenarios for each domain. THS.3 Sum the results from steps THS.1 and THS.2. This sum should match your hospital s Total HAC Score (Table 1, cell G7 of the HSR) highlighted in Figure 12. If this value is greater than the payment threshold (75 th percentile), , and you are not a Maryland hospital, then your hospital will be subject to a payment reduction. Figure 12 Total HAC Score Replication 36

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