HOSPITAL COMPARE PREVIEW REPORT HELP GUIDE PPS-EXEMPT CANCER HOSPITAL QUALITY REPORTING PROGRAM THE TARGET AUDIENCE FOR THIS PUBLICATION IS HOSPITALS PARTICIPATING IN THE PPS-EXEMPT CANCER HOSPITAL (PCH) QUALITY REPORTING PROGRAM. THE DOCUMENT SCOPE IS LIMITED TO INSTRUCTIONS FOR HOSPITALS ON HOW TO ACCESS AND INTERPRET THE DATA PROVIDED ON THE PREVIEW REPORT PRIOR TO THE PUBLICATION OF DATA ON HOSPITAL COMPARE. OCTOBER 2017 PREVIEW/DECEMBER 2017 HOSPITAL COMPARE RELEASE
HOSPITAL COMPARE PREVIEW REPORT HELP GUIDE: PPS-EXEMPT CANCER HOSPITAL QUALITY REPORTING PROGRAM TABLE OF CONTENTS Overview... 1 Hospital Compare... 1 PPS-Exempt Cancer Hospital Quality Reporting Program... 1 Preview Period... 2 Accessing Preview Reports... 3 Register as a QualityNet User... 3 Enroll for QualityNet Secure Portal Access... 4 Log into the QualityNet Secure Portal... 5 Run Preview Report... 8 PCH Preview Report Details... 11 Cancer-Specific Treatment Measures... 11 Oncology Care Measures... 12 External Beam Radiotherapy (EBRT) Measure... 13 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey Data... 14 State and National Average Rates... 17 Help Resources... 18 Cancer-Specific Treatment Measures, Oncology Care Measures and EBRT Measure... 18 HCAHPS Measures... 18
OVERVIEW Hospital Compare has information about the quality of care at more than 4,000 hospitals and facilities across the country. It uses information from providers that receive Medicare and Medicaid payments and participate in one or more of the various quality reporting programs. Along with some contextual information about Hospital Compare and QualityNet, this help guide focuses on accessing Preview Reports for the PPS-Exempt Cancer Hospital Quality Reporting Program. HOSPITAL COMPARE The Centers for Medicare & Medicaid Services (CMS) and the nation s hospitals worked collaboratively to create and publicly report hospital quality performance information on the Hospital Compare website, located at http://www.medicare.gov/hospitalcompare. Hospital Compare displays hospital performance data in a consistent, unified manner to ensure the availability of credible information about the care delivered in the nation s hospitals. Most of the participants are short-term acute care hospitals. These hospitals may receive a reduction to their annual payment update (APU) rate if they do not participate by submitting data. This requirement was initially established by Section 501(b) of the Medicare Modernization Act (MMA), which was extended and expanded by Section 5001(a) of the Deficit Reduction Act. PPS-exempt cancer hospitals (PCHs) are exempt and therefore do not receive reductions in APU; however, as participants in the quality reporting program, their data are subject to the same deadlines and procedures for any new releases of Hospital Compare. PPS-EXEMPT CANCER HOSPITAL QUALITY REPORTING PROGRAM The Social Security Amendments of 1983 exempted certain classified cancer hospitals from the Medicare inpatient prospective payment system (IPPS). These PPS-exempt cancer hospitals were also exempted from reporting on hospital inpatient quality measures. In 2010, the Affordable Care Act required the CMS to establish a specialized quality reporting program for the PPS-exempt cancer hospitals. The resulting PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program measures allow consumers to compare the quality of care given at the eleven PCHs currently participating in the program. Section 3005 of the Affordable Care Act added sections 1866(a)(1)(W) and (k) to the Act. Section 1866(k) of the Act establishes a quality reporting program for hospitals described in section 1886(d)(1)(B)(v) of the Act (referred to as PPS-Exempt Cancer Hospitals or PCHs ) that specifically applies to PCHs that meet the requirements under 42 CFR 412.23(f). Section 1866(k)(1) of the Act states that, for FY 2014 and each subsequent fiscal year, a PCH must submit data to the Secretary in accordance with section 1866(k)(2) of the Act with respect to such fiscal year. For additional background information, including previously finalized measures and other policies for the PCHQR Program, we refer readers to the following final rules: FY 2013 IPPS/Long-Term Care Hospital (LTCH) PPS Final Rule (77 FR 53555 53567); the FY 2014 IPPS/LTCH PPS Final Rule (78 FR 50837 50853); the FY 2015 IPPS/LTCH PPS Final Rule (79 FR 50277 50286); the FY 2016 IPPS/LTCH PPS Final Rule (80 FR 49713 49723), the FY 2017 IPPS/LTCH PPS Final Rule (81 FR 57182 57193), and the FY 2018 IPPS/LTCH (82 FR 38411 38425) Final Rule. PPS-Exempt Cancer Hospital Quality Reporting Program Page 1 of 18
PREVIEW PERIOD Prior to the release of data on Hospital Compare, hospitals are given the opportunity to review data during a 30-day preview period. Reports can be accessed via the QualityNet Secure Portal, the only CMS-approved website for secure healthcare quality data exchange, at https://www.qualitynet.org. PPS-Exempt Cancer Hospital Quality Reporting Program Page 2 of 18
ACCESSING PREVIEW REPORTS There are four basic steps to access Preview Reports: 1. Register as a QualityNet User. 2. Enroll for QualityNet Secure Portal access and receive the PCH Preview Reports role. 3. Log in to the QualityNet Secure Portal. 4. Run Preview Reports. REGISTER AS A QUALITYNET USER To get the most up-to-date registration instructions go to the QualityNet Registration page. 1. Navigate to the QualityNet homepage at https://www.qualitynet.org/. The QualityNet homepage appears. 2. From the PPS-Exempt Cancer Hospitals drop-down menu, select the Registration option. The QualityNet homepage PPS-Exempt Cancer Hospital Quality Reporting Program Page 3 of 18
The QualityNet Registration screen appears. The QualityNet Registration: PCHQR Program Screen 3. Follow the link corresponding to the desired user role (either Security Administrator or Basic User) and follow the instructions to successfully register. ENROLL FOR QUALITYNET SECURE PORTAL ACCESS Detailed enrollment and login instructions can be found on the QualityNet homepage on the QualityNet Secure Portal Resources screen. To begin the enrollment and access process: 1. Navigate to the QualityNet homepage at https://www.qualitynet.org/. The QualityNet homepage appears. The QualityNet homepage 2. Under the Log in to QualityNet Secure Portal sidebar, on the right-hand side of the page, select the Portal Resources link. The Resources: QualityNet Secure Portal screen appears. PPS-Exempt Cancer Hospital Quality Reporting Program Page 4 of 18
The Resources: QualityNet Secure Portal screen 3. Select the resource material pertinent to your needs from the list of live links. NOTE: The PCH Preview Reports role must be assigned by the hospital s QualityNet Security Administrator (SA) to those with a User access level. This role is necessary in order to access the Preview Reports. LOG INTO THE QUALITYNET SECURE PORTAL Once the registration requirements are fulfilled, the QualityNet Help Desk has issued a User ID and Password, and your SA grants the PCH Preview Reports role, you are ready to access the Preview Reports. PPS-Exempt Cancer Hospital Quality Reporting Program Page 5 of 18
To access your institution s Preview Report: 1. Launch an Internet browser and go to https://www.qualitynet.org/. The QualityNet Home screen appears. The QualityNet Home Screen 2. Select the My QualityNet tab, the Log In button, or the Login link. All three lead to the same screen. PPS-Exempt Cancer Hospital Quality Reporting Program Page 6 of 18
The Choose Your QualityNet Destination screen appears. The Choose Your QualityNet Destination Screen 3. Select the PPS-Exempt Cancer Hospital Quality Reporting Program link. The Log In to QualityNet screen appears. The Log In to QualityNet Screen 4. Enter your User ID, Password, and the Symantec Validation & ID (VIP) Protection Software Security Code. (The installation of the Symantec Validation & ID (VIP) Protection Software is required.) 5. Select Submit and then I Accept on the Terms and Conditions window. NOTE: If you select I Decline on the Terms and Conditions window, the program will close. PPS-Exempt Cancer Hospital Quality Reporting Program Page 7 of 18
RUN PREVIEW REPORT Once you are enrolled and have the required access and role assignments, you can see your facility s reports. To access and run Preview Reports: 1. Navigate to QualityNet and log into the QualityNet Secure Portal. The QualityNet Secure Portal home screen appears. The QualityNet Secure Portal home screen 2. Select Run Reports from the My Reports drop-down. The Start tab appears. The Start tab 3. Select Run Reports from the I d Like To reports portlet. PPS-Exempt Cancer Hospital Quality Reporting Program Page 8 of 18
The Run Reports tab appears. The Run Reports tab 4. Select PCHQR from the Report Program drop-down. The Run Reports tab prompts the selection of a Report Category. The Run Reports tab 5. Select Public Reporting Preview Reports from the list in the Report Category drop-down. The Report Name is populated with the selection. The Run Reports tab 6. Select View Reports and the selected report will display under Report Name. 7. Select Public Reporting Preview Reports under Report Name. PPS-Exempt Cancer Hospital Quality Reporting Program Page 9 of 18
8. Select Run Reports. 9. To see the Preview Report, select the Search Reports tab. The requested report and the report status will display. A green check mark will display in the Status column when the report is complete. Once complete, the report can be viewed or downloaded. PPS-Exempt Cancer Hospital Quality Reporting Program Page 10 of 18
PCH PREVIEW REPORT DETAILS The Preview Report displays your hospital CMS Certification Number (CCN) and name above the hospital characteristics information. Hospital characteristics include your hospital s address, city, state, ZIP Code, phone number, county, type of facility, type of ownership, and emergency service provided status. Type of ownership and emergency service provided are not publicly reported. If the hospital characteristics displayed are incorrect, your hospital should contact your state Certification and Survey Provider Enhanced Reporting (CASPER) agency coordinator to correct the information. The state CASPER contact list is available from the Hospital Compare home page by selecting the Resources button located between the About the Data and Help buttons, directly above the Find a Hospital selection area. Once the screen refreshes, select the CASPER/ASPEN (Automated Survey Processing Environment) contacts link from the navigation pane on the left-hand side. The direct link is http://www.medicare.gov/hospitalcompare/resources/casper.aspx. If your hospital s state CASPER agency is unable to make the needed change, your hospital should contact its CMS regional office. The Measure IDs (e.g., PCH-1) and the National Quality Forum (NQF) numbers, that are displayed on Hospital Compare, have been provided to assist in measure identification. However, neither will display on the preview report. The measure descriptions are modified for reporting purposes. CANCER-SPECIFIC TREATMENT MEASURES The Cancer-specific Treatment Measures section of the Preview Report includes the following measures: PCH-1 (NQF# 0223) Adjuvant Chemotherapy Colon Cancer PCH-2 (NQF# 0559) Combination Chemotherapy Breast Cancer PCH-3 (NQF# 0220) Adjuvant Hormone Therapy The Preview Report displays an aggregate of four rolling quarters of data. (A new quarter of data is added and the oldest quarter is removed.) PPS-Exempt Cancer Hospital Quality Reporting Program Page 11 of 18
Cancer-Specific Treatment Measures Details Each measure displays: Measure Set: Cancer Specific Measure Measure Numerator Denominator Reporting Period Cancer-Specific Treatment Measures Footnotes Number Description Application 1 5 7 The number of cases/ patients is too few to report. Results are not available for this reporting period. No cases met the criteria for this measure. Applied to any measure where either the numerator or denominator is greater than zero and less than eleven (Data will not display on Hospital Compare) Applied when a hospital either elected not to submit data or the hospital had no data to submit for a particular measure, or when a hospital elected to suppress a measure Applied when a hospital treated patients for a particular topic, but no patients met the criteria for inclusion in the measure calculation ONCOLOGY CARE MEASURES The Oncology Care Measures (OCM) section of the preview report includes the following measures: PCH-14 (NQF #0382) Radiation Dose Limits to Normal Tissues PCH-15 (NQF #0383) Plan of Care for Pain Medical Oncology and Radiation Oncology PCH-16 (NQF #0384) Medical and Radiation Pain Intensity Quantified PCH-17 (NQF #0390) Adjuvant Hormonal Therapy for High or Very High Risk Prostate Cancer Patients PCH-18 (NQF #0389) Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients PPS-Exempt Cancer Hospital Quality Reporting Program Page 12 of 18
Oncology Care Measures Details The Preview Report displays an aggregate of four quarters of data. The OCM data are updated annually. Each measure displays: Measure Set: Oncology Care Measures Measure Your Hospital Performance Aggregate Rate for All Four Quarters o PCH-14, PCH-17, and PCH-18 display as a percent of patients (denominator). o PCH-15 and PCH-16 display as a percent of patient encounters. Reporting Period Oncology Care Measure Footnotes Number Description Application 1 The number of cases/patients is too few to report 2 Data submitted were based on a sample of cases/patients 5 Results are not available for this reporting period 7 No cases met the criteria for this measure Applied to any measure rate where the denominators are greater than zero and less than eleven. (Data will not display on Hospital Compare.) Applied when data submitted were sampled for the reporting time period. Applied when a hospital either elected not to submit data, had no data to submit for a particular measure, or elected to suppress a measure. Applied when a hospital treated patients for a particular topic, but no patients met the criteria for inclusion in the measure calculation. EXTERNAL BEAM RADIOTHERAPY (EBRT) MEASURE The EBRT measure section of the Preview Report contains the following measure: PCH-25 (NQF #1822) External Beam Radiotherapy for Bone Metastases Data displays as a percent of patients (denominator) PPS-Exempt Cancer Hospital Quality Reporting Program Page 13 of 18
The Preview Report displays an aggregate of four quarters of data. The EBRT measure data are updated annually. Each measure displays: Measure Set: EBRT Measure Your Hospital Performance Aggregate Rate for All Four Quarters. Reporting Period EBRT Measure Footnotes Number Description Application 1 The number of cases/patients is too few to report 2 Data submitted were based on a sample of cases/patients 5 Results are not available for this reporting period 7 No cases met the criteria for this measure Applied to any measure rate where the denominators are greater than zero and less than eleven. (Data will not display on Hospital Compare.) Applied when data submitted were sampled for the reporting time period. Applied when a hospital either elected not to submit data, had no data to submit for a particular measure, or elected to suppress a measure. Applied when a hospital treated patients for a particular topic, but no patients met the criteria for inclusion in the measure calculation. HOSPITAL CONSUMER ASSESSMENT OF HEALTHCARE PROVIDERS AND SYSTEMS (HCAHPS) SURVEY DATA The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) (PCH-29) (NQF# 0166)Survey Data section of the report contains survey results from four quarters of data, which display as aggregate results. Each hospital s aggregate results are compared to state and national averages. Also, the Preview Report contains each hospital s number of completed surveys and survey response rate for the reporting period. HCAHPS Star Ratings HCAHPS Star Ratings are based on the quarters of survey data in the Preview Report. Hospitals will receive an HCAHPS Star Rating (1, 2, 3, 4, or 5 stars) for each of the 11 HCAHPS measures, plus the HCAHPS Summary Star Rating, which is a single summary of all the HCAHPS Star Ratings. The Preview Report also contains the linear mean scores that are used in the calculation of the HCAHPS Star Ratings. For additional information on HCAHPS Star Ratings and linear mean scores, please see the HCAHPS Star Ratings section on the official HCAHPS website, http://www.hcahpsonline.org. PPS-Exempt Cancer Hospital Quality Reporting Program Page 14 of 18
The HCAHPS Survey Results have four sections: HCAHPS Survey Completion, Response Rate, and Summary Star Rating HCAHPS Star Ratings and HCAHPS Linear Mean Scores HCAHPS Composites and Individual Items HCAHPS Global Items The HCAHPS Survey Completion, Response Rate, and Summary Star Rating section includes: Number of Completed Surveys Survey Response Rate HCAHPS Summary Star Rating The HCAHPS Composites and Individual Items section includes: HCAHPS Composites o Composite 1 Communication with Nurses (Q1, Q2, Q3) o Composite 2 Communication with Doctors (Q5, Q6, Q7) o Composite 3 Responsiveness of Hospital Staff (Q4, Q11) o Composite 4 Pain Management (Q13, Q14) o Composite 5 Communication about Medicines (Q16, Q17) Hospital Environment Items o Cleanliness of Hospital Environment (Q8) o Quietness of Hospital Environment (Q9) Discharge Information Composite 6 Discharge Information (Q19, Q20) Care Transition Composite7 Care Transition (Q23, Q24, Q25) The HCAHPS Global Items section includes: Overall Rating of Hospital (Q21) Willingness to Recommend this Hospital (Q22) HCAHPS Star Rating Hospitals must have at least 100 completed surveys in order to receive HCAHPS Star Ratings. HCAHPS Star Ratings are provided for each of the seven composite measures, two environment items, and two global items. Whole stars (1, 2, 3, 4, or 5) are assigned to each of the 11 HCAHPS measures, plus the HCAHPS Summary Star Rating. PPS-Exempt Cancer Hospital Quality Reporting Program Page 15 of 18
HCAHPS Linear Mean Scores are provided for each of the seven composite measures, two environment items, and two global items and are available in the downloadable database on Hospital Compare. HCAHPS Measures Footnotes Number Description Application 1 The number of cases/patients Applied when a hospital has zero cases, or five or is too few to report fewer eligible HCAHPS patient discharges. HCAHPS scores based on fewer than 25 completed surveys will display on the preview report. Data will not display on Hospital Compare. 3 Results are based on a shorter Applied when CMS has opted to display HCAHPS time period than required 4 Data suppressed by CMS for one or more quarters 5 Results are not available for this reporting period 6 Fewer than 100 patients completed the HCAHPS survey. (Use these scores with caution, as the number of surveys may be too low to reliably assess hospital performance.) 10 Very few patients were eligible for the HCAHPS survey. The scores shown reflect fewer than 50 completed surveys. (Use these scores with caution, as the number of surveys may be too low to reliably assess hospital performance.) results on fewer than the required months of survey data. Reserved for CMS use. Applied in the following situations: When a hospital did not participate in HCAHPS during the period covered by the preview report When a hospital participated in HCAHPS but only for a portion of the period covered by the preview report OR When a hospital has HCAHPS results but chooses to suppress public reporting, HCAHPS results will display on its Preview Report, but will be suppressed on Hospital Compare. Applied when the number of completed HCAHPS surveys is 50 99. Applied when the number of completed HCAHPS surveys is fewer than 50. PPS-Exempt Cancer Hospital Quality Reporting Program Page 16 of 18
Number Description Application 11 There were discrepancies in Applied when there have been deviations from the data collection process HCAHPS data collection protocols. 15 The number of cases/patients is too few to report a Star Rating State and National Average Rates Applied when CMS has determined there are too few cases or patients to report a Star Rating. State and national un-weighted average rates for each HCAHPS measure are calculated based on all data available in the HCAHPS Data Warehouse. State and national averages are not reported for the HCAHPS Star Ratings. PPS-Exempt Cancer Hospital Quality Reporting Program Page 17 of 18
HELP RESOURCES For more information regarding specific measure calculations, please refer to the following resources. CANCER-SPECIFIC TREATMENT MEASURES, ONCOLOGY CARE MEASURES AND EBRT MEASURE Contact the Hospital Inpatient Value, Incentives, and Quality Reporting Support Contractor through the Inpatient Questions and Answers tool at: https://cms-ip.custhelp.com/, or by calling, toll-free, (844) 472-4477 or (866) 800-8765 weekdays from 8 a.m. to 8 p.m. ET HCAHPS MEASURES Contact the HCAHPS Project Team by email at hcahps@hcqis.org. PPS-Exempt Cancer Hospital Quality Reporting Program Page 18 of 18