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Specifications Manual for National Hospital Inpatient Quality Measures v5.5a Update Candace Jackson, ADN Project Lead, Hospital Inpatient Quality Reporting (IQR) Program Hospital Inpatient Value, Incentives, and Quality Reporting (VIQR) Outreach and Education Support Contractor (SC) November 15, 2018
Purpose This presentation will provide information regarding version (v)5.5a of the Specifications Manual for National Hospital Inpatient Quality Measures, including the following: Measures collected by CMS and/or The Joint Commission Population and Sampling Measure-specific data element updates General abstraction and data element guidelines 7
Objectives By the end of the presentation, participants will be able to: Determine which measures are collected by CMS and/or The Joint Commission for January 1, 2019 through June 30, 2019 discharges. Identify data element changes. Better understand and interpret the general abstraction guidelines and data elements. 8
Acronyms and Abbreviations APN advanced practice nurse mmol millimole CCN CMS Certification Number PA physician assistant CMS Centers for Medicare & Medicaid Services PC Perinatal Care ED emergency department PPS prospective payment system EOC Episode of Care Q&A questions-and-answers FY Fiscal Year SC support contract ICU intensive care unit SEP Sepsis IMM Immunization SUB Substance Use IPPS inpatient prospective payment system TOB Tobacco Treatment IQR Inpatient Quality Reporting UB Uniform Bill L Liter v Version LTCH Long-Term Care Hospital VIQR Value, Incentives, and Quality Reporting VTE Venous Thromboembolism 11/15/2018 Back 9
Specifications Manual v5.5a Addendum Effective for January 1, 2019 through June 30, 2019 discharges Posted to QualityNet at this direct link: https://www.qualitynet.org/dcs/contentser ver?c=page&pagename=qnetpublic%2fp age%2fqnettier2&cid=1141662756099 10
Measurement Information: Severe Sepsis and Septic Shock (SEP-1) Will continue to be collected by CMS only No changes related to the Fiscal Year (FY) 2019 Inpatient Prospective Payment System (IPPS)/Long-Term Care Hospital Prospective Payment System (LTCH PPS) Final Rule 11
Measurement Information: Venous Thromboembolism (VTE-6) Removed from the Hospital IQR Program Will continue to be collected by The Joint Commission only 12
Measurement Information: Emergency Department (ED) ED-1 o Removed from the Hospital IQR Program o Will continue to be collected by The Joint Commission only ED-2 o Will continue to be collected by both CMS and The Joint Commission o For CMS, hospitals that do not have an ED can submit an IPPS Measure Exception Form Located on QualityNet: https://www.qualitynet.org/dcs/contentserver?c=page&pagename=qnetpub lic%2fpage%2fqnettier2&cid=1138115987129 Hospitals that do not have an ED must submit ED files prior to each quarterly submission deadline unless they submit this form. 13
Measurement Information: Immunization (IMM-2) Removed from the Hospital IQR Program Will continue to be collected by The Joint Commission only 14
Measurement Information: Substance Use (SUB) Removed SUB-1 The Joint Commission only will continue to collect SUB-2, SUB-2a, SUB-3, and SUB-3a 15
Measurement Information: Tobacco Treatment (TOB) Removed TOB-1 The Joint Commission only will continue to collect TOB-2, TOB-2a, TOB-3, and TOB-3a 16
V5.5a Measures Summary Measure ID Collected by CMS Collected by The Joint Commission SEP-1 Yes No VTE-6 No Yes ED-1 No Yes ED-2 Yes Yes IMM-2 No Yes SUB-2 No Yes SUB-2a No Yes SUB-3 No Yes SUB-3a No Yes TOB-2 No Yes TOB-2a No Yes TOB-3 No Yes TOB-3a No Yes 17
Population and Sampling For CMS, hospitals will continue to submit aggregate Medicare and Non-Medicare Population and Sampling counts for the following: o Sepsis o Global Hospitals are still required to submit the Global Population and Sampling counts even if they do not have an ED and have submitted an IPPS Measure Exception Form. Global Population and Sampling continues to include ED, IMM, TOB, and SUB. o For CMS, only the ED measure set (ED-2) is required and will be allowed to be submitted to the CMS Clinical Warehouse. 18
Data Transmission: Allowable Measure Set Combinations Submission of multiple files for different measure sets for a single episode of care is allowable for the following measure set combinations: CMS Clinical Warehouse only: o ED and SEP for patients age 18 and older The Joint Commission s Data Warehouse only o ED, IMM, TOB, SUB, and VTE - Other VTE Only sub-population for patients age 18 and older 19
Structural Measures Removed the Hospital Survey on Patient Safety Culture and Safe Surgery Checklist Use structural measures with the 2018 reporting period. Removed the Inpatient Structural Measure section from the specifications manual. 20
Web-Based Measure No changes to the PC-01, Elective Delivery, web-based measure. For CMS, hospitals will continue to submit the aggregate initial patient population and sample size, sampling frequency, numerator, denominator, and exclusion counts. Data is submitted on a quarterly basis through the QualityNet Secure Portal web-based data collection tool. Hospitals that do not deliver babies may opt out of reporting PC-01 measure data by submitting an IPPS Measure Exception Form. o Hospitals that do not deliver babies must enter a zero (0) for each of the PC-01 data entry fields prior to each quarterly submission deadline unless they submit this form. 21
Data Elements: Crystalloid Fluid Administration Date and Time Suggested data collection questions: o Date: What was the earliest date on which crystalloid fluids were initiated within the specified time frame? o Time: What was the earliest time at which crystalloid fluids were initiated within the specified time frame? 22
Data Elements: Crystalloid Fluid Administration Date and Time Notes for Abstraction Added bullet: o The specified time frame for abstraction of crystalloid fluids is within 6 hours prior through 3 hours after either of the following trigger events. If both are present the specified time frame is determined by the earliest trigger. Initial Hypotension Date and Time Septic Shock Presentation Date and Time Deleted bullet and examples: o In some cases, the crystalloid fluid will be infusing prior to the time of presentation of Initial Hypotension, an Initial Lactate Level Result >=4 mmol/l, or physician/apn/pa Documentation of Septic Shock; if so, use the date the unit of fluid was started or hung. 23
General Abstraction Guidelines: Episode of Care (EOC) EOC is defined as the health care services given during a certain period of time, usually during the hospital stay (e.g., from the day of arrival or admission to the day of discharge). The medical record should be abstracted as it was billed. In the event that there are multiple ED visits within the medical record, for the same EOC, it is recommended that the ED visit resulting in the admission to observation or inpatient status be utilized for the purposes of abstraction. If a patient is transferred from an acute care hospital to another acute care hospital, which is within the same healthcare system and share the same CMS Certification Number (CCN), this should be abstracted as one episode of care. 24
General Abstraction Guidelines: Medical Record Documentation Late entries or addendums to the medical record can be used, for abstraction purposes, as long as they have been added within 30 days of discharge, unless otherwise specified in the specific data element. Data element information ascertainable from previous testing or previous history and determined to be part of the current medical record may be used in abstraction. o As electronic data are available at all times during the hospitalization, it is acceptable to use this data for abstraction purposes. 25
EOC and Medical Record Documentation Example #1 Patient presents to the ED on 10/1/2018 at 9:00 a.m. and is discharged home at 1:00 p.m. The patient returns to the ED on 10/2/2018 at 10:00 a.m. and is admitted as inpatient at 2:00 p.m. Patient is discharged on 10/5/2018. Both ED visits are included in the inpatient bill. The EOC would be from 10/1/2018 through 10/5/2018. If abstracting ED, the Arrival Date and Arrival Time would be 10/2/2018 at 10:00 a.m. Admission Date would be 10/2/2018. Discharge Date would be 10/5/2018. Would be able to use any applicable documentation from the 10/1/2018 ED visit. 26
EOC and Medical Record Documentation Example #2 Patient was admitted as an inpatient on 10/1/2018 and discharged on 10/4/2018. Patient was readmitted as an inpatient on 10/5/2018 and discharged on 10/8/2018. Both admissions were billed as one EOC. Abstract as one EOC. Admission Date would be 10/1/2018. Discharge Date would be 10/8/2018. 27
EOC and Medical Record Documentation Example #3 Patient was admitted as an inpatient on 10/1/2018 and discharged on 10/4/2018; account number 1234. Patient was readmitted as an inpatient on 10/5/2018 and discharged on 10/8/2018; account number 5678. Both admissions were billed as one EOC. Abstract as one EOC, from 10/1/2018 through 10/8/2018, even though each EOC has a different account number. For purposes of abstraction, the number used by the hospital to identify the patient s stay is the Patient Identifier. This could be the medical record number, account number, or any unique identifiable number as determined by the hospital. 28
EOC and Medical Record Documentation Example #4 Patient is admitted to the psychiatric unit on 9/25/2018. On 9/30/2018, the patient develops a fever and is admitted to the inpatient medical unit with VTE. The case is included in the VTE initial patient population and is abstracted for VTE-6. Psychiatric and medical unit stays billed as one entire EOC under acute CMS Certification Number (CCN). Abstract as one entire EOC. o Admission Date: 9/25/2018 o Arrival Date: 9/25/2018 Psychiatric unit stay billed under inpatient psychiatric facility CCN and medical unit stay billed under acute CCN. Only abstract the medical unit stay. o Admission Date: 9/30/2018 o Arrival Date: 9/30/2018 29
EOC and Medical Record Documentation Example #5 Patient is admitted to acute inpatient with sepsis on 9/21/2018. On 9/28/2018, the patient status is changed to hospice. The patient is discharged on 10/2/2018. Acute inpatient and hospice billed as one entire EOC under the acute CCN. Abstract as one entire EOC. o Admission Date: 9/21/2018 o Discharge Date: 10/2/2018 Acute inpatient billed under the acute CCN and hospice stay billed to hospice agency. Only abstract the acute inpatient stay. o Admission Date: 9/21/2018 o Discharge Date: 9/28/2018 30
Admission Date Admission date is the date that the patient was admitted to acute inpatient care. If there are multiple inpatient orders, use the order that most accurately reflects the date that the patient was admitted. The physician order is the priority source. If there is not a physician order in the medical record, use the Face Sheet or UB-04 to determine the admission date. o For purposes of abstraction, what constitutes a physician order is not defined. For patients who are admitted to Observation status and subsequently admitted to acute inpatient care, abstract the date that the determination was made to admit to acute inpatient care and the order was written. Do not abstract the date that the patient was admitted to Observation. 31
Admission Date Examples Patient presented to the ED on 10/1/2018 at 6:58 p.m. Inpatient admission order was electronically signed and held by the physician on 10/1/2018 at 11:49 p.m. The order was released on 10/2/2018 at 12:04 a.m. o Admission Date: 10/1/2018 Patient presented to the ED on 9/27/2018. The ED progress notes reflect that the decision to admit to the ICU was made at 6:15 p.m. on 9/27/2018. The Admit as Inpatient order was not written until 9/28/2018. o Admission Date: 9/28/2018 32
Admission Date Examples Preoperative orders, with an order to admit to inpatient, are dated 9/17/2018. The patient presents to the hospital for surgery on 10/5/2018. Postoperative orders, with an order to admit to acute inpatient, are written on 10/5/2018. o Admission Date: 10/5/2018 The patient was admitted to observation status on 10/2/2018. On 10/3/2018 the physician writes an order to admit to acute inpatient effective 10/2/2018. o Admission Date: 10/3/2018 33
Specification Manual Questions Hospital Inpatient Q&As: https://cms-ip.custhelp.com/ General abstraction guideline/element questions: Hospital IQR Program ED-2, SEP-1, PC-01 guideline/element questions: Hospital Inpatient Measures and Data Element Abstraction 34
Specifications Manual for National Hospital Inpatient Quality Measures v5.5a Update Questions 11/15/2018 35
Specifications Manual for National Hospital Inpatient Quality Measures v5.5a Update Thank You 11/15/2018 36
Disclaimer This presentation was current at the time of publication and/or upload onto the Quality Reporting Center and QualityNet websites. Medicare policy changes frequently. Any links to Medicare online source documents are for reference use only. In the case that Medicare policy, requirements, or guidance related to this presentation change following the date of posting, this presentation will not necessarily reflect those changes; given that it will remain as an archived copy, it will not be updated. This presentation was prepared as a service to the public and is not intended to grant rights or impose obligations. Any references or links to statutes, regulations, and/or other policy materials included in the presentation are provided as summary information. No material contained therein is intended to take the place of either written laws or regulations. In the event of any conflict between the information provided by the presentation and any information included in any Medicare rules and/or regulations, the rules and regulations shall govern. The specific statutes, regulations, and other interpretive materials should be reviewed independently for a full and accurate statement of their contents. 37