Day 1 |
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8:30 am |
Breakfast |
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9:00 am |
Welcome, Introductions, Disclosures of Interest, and
Review of Meeting Objectives |
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Cristie Upshaw Travis, MAP Hospital Workgroup Co-Chair Ronald Walters,
MAP Hospital Workgroup Co-Chair Melissa Mariñelarena, Senior Director, NQF
Ann Hammersmith, General Counsel, NQF
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9:15 am |
CMS Opening Remarks |
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Pierre Yong, Director, Quality Measurement and Value-Based Incentives
Group, CMS
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9:45 am |
NQF Strategic Plan |
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Helen Burstin, Chief Scientific Officer, NQF
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10:00 am |
Overview of Pre-Rulemaking Approach |
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Melissa Mariñelarena, Senior Director, NQF Kate McQueston, Project
Manager, NQF
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10:15 am |
Overview of the End-Stage Renal Disease Quality
Incentive Program (ESRD QIP) Program |
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10:25 am |
Opportunity for Public Comment on Measures Under
Consideration for End-Stage Renal Disease Quality Incentive Program (ESRD
QIP) |
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10:35 am |
Pre-Rulemaking Input Measure Sets on End-Stage Renal Disease Quality
Incentive Program (ESRD QIP)—Consent Calendar 1 |
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Allen Nissenson, Kidney Care Partners Elizabeth Evans, Individual
Subject Matter Expert |
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Programs under consideration:
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- Hemodialysis Vascular Access: Long-term Catheter Rate (MUC
ID: MUC16-309)
- Description: Percentage of adult hemodialysis
patient-months using a catheter continuously for three months or
longer for vascular access.
- Preliminary analysis summary
- Contribution to program measure set:This measure is
intended to replace the existing vascular access type measure in the
ESRD QIP. The measure is currently under review by the Renal
Standing Committee. The Standing Committee and CSAC recommended the
measure for endorsement
- Impact on quality of care for patients:This measure
provides dialysis patients with information about the long-term use
of catheters for vascular access.
- Preliminary analysis result: Support for Rulemaking
- Notes:
- Hemodialysis Vascular Access: Standardized Fistula Rate (MUC
ID: MUC16-308)
- Description: Adjusted percentage of adult hemodialysis
patient-months using an autogenous arteriovenous fistula (AVF) as the
sole means of vascular access.
- Preliminary analysis summary
- Contribution to program measure set:This measure is
intended to replace the existing vascular access type measure in the
ESRD QIP. The measure is currently under review by the Renal
Standing Committee. The Standing Committee and CSAC recommended the
measure for endorsement.
- Impact on quality of care for patients:This measure
provides dialysis patients with information about the use of
autogenous arteriovenous fistula (AVF) as the sole means of vascular
access.
- Preliminary analysis result: Support for Rulemaking
- Notes:
- Standardized Transfusion Ratio for Dialysis Facilities (MUC
ID: MUC16-305)
- Description: The risk adjusted facility level transfusion
ratio “STrR” is specified for all adult dialysis patients. It is a
ratio of the number of eligible red blood cell transfusion events
observed in patients dialyzing at a facility, to the number of
eligible transfusion events that would be expected under a national
norm, after accounting for the patient characteristics within each
facility. Eligible transfusions are those that do not have any claims
pertaining to the comorbidities identified for exclusion, in the one
year look back period prior to each observation window.
- Preliminary analysis summary
- Contribution to program measure set:This measure has
undergone substantial changes but details of the changes to the
measure are not provided. The measure is currently under review by
the Renal Standing Committee. The Standing Committee and CSAC
recommended the measure for endorsement.
- Impact on quality of care for patients:This measure
encourages dialysis facilities to avoid blood transfusions when
managing patients with anemia.
- Preliminary analysis result: Support for Rulemaking
- Notes:
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11:15 am |
Break |
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11:30 am |
Overview of the PPS-Exempt Cancer Hospital Quality
Reporting (PCHQR) Program |
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11:40 am |
Opportunity for Public Comment on Measures Under
Consideration for PCHQR |
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11:50 am |
Pre-Rulemaking Input for Prospective Payment System (PPS)-Exempt
Cancer Hospital Quality Reporting (PCHQR)—Consent Calendar 2 |
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R. Sean Morrison, Individual Subject Matter Expert Sarah Nolan,
Service Employees International Union Heather Lewis, Geisinger Health
System |
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Programs under consideration: Prospective Payment System-Exempt Cancer
Hospital Quality Reporting Program
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- PRO utilization in in non-metastatic prostate cancer patients
(MUC ID: MUC16-393)
- Description: Use of a validated patient-reported outcome
(PRO) instrument to measure functional status in adult, non-metastatic
prostate cancer patients during the 12-month measurement period.
- Preliminary analysis summary
- Contribution to program measure set:It is unclear if the
value of this measure to patients/consumers outweighs the burden of
implementation. There is limited information regarding how the
measure can be operationalized and the measure is not fully
specified and tested.
- Impact on quality of care for patients:This measure would
encourage facilities measure functional status in adult patients
with non-metastatic prostate cancer using a validated survey
instrument.
- Preliminary analysis result: Do Not Support for
Rulemaking
- Notes:
- Proportion of patients who died from cancer admitted to hospice
for less than 3 days (MUC ID: MUC16-274)
- Description: Proportion of patients who died from cancer
admitted to hospice for less than 3 days
- Preliminary analysis summary
- Contribution to program measure set:The measure is not
specified and tested at the facility level in the hospital setting.
The Palliative Care and End-of-Life Standing Committee, CSAC and the
NQF Executive Committee recommended the measure for endorsement at
the group/clinician level in the ambulatory care setting. The
measure should be specified, tested and NQF endorsed at the facility
level in the hospital setting for the PPS-Exempt Cancer Hospital
Quality Reporting Program.
- Impact on quality of care for patients:This measure
provides the proportion of patients who died from cancer and were
admitted to hospice for less than 3 days.
- Preliminary analysis result: Refine and Resubmit
- Notes:
- Proportion of patients who died from cancer admitted to the ICU
in the last 30 days of life (MUC ID: MUC16-273)
- Description: Proportion of patients who died from cancer
admitted to the ICU in the last 30 days of life
- Preliminary analysis summary
- Contribution to program measure set:The measure has not
been specified and tested at the facility level in the hospital
setting. The Palliative Care and End-of-Life Standing Committee,
CSAC and the NQF Executive Committee recommended the measure for
endorsement at the group/clinician level in the ambulatory care
setting. The measure should be specified, tested and NQF endorsed at
the facility level in the hospital setting for the PPS-Exempt Cancer
Hospital Quality Reporting Program.
- Impact on quality of care for patients:This measure
provides the proportion of patients who died from cancer and were
admitted to the ICU in the last 30 days of life.
- Preliminary analysis result: Support for Rulemaking
- Notes:
- Proportion of patients who died from cancer not admitted to
hospice (MUC ID: MUC16-275)
- Description: Proportion of patients who died from cancer
not admitted to hospice
- Preliminary analysis summary
- Contribution to program measure set:The measure is not
specified and tested at the facility level in the hospital setting.
The Palliative Care and End-of-Life Standing Committee, CSAC and the
NQF Executive Committee recommended the measure for endorsement at
the group/clinician level in the ambulatory care setting. The
measure should be specified, tested and NQF endorsed at the facility
level in the hospital setting for the PPS-Exempt Cancer Hospital
Quality Reporting Program.
- Impact on quality of care for patients:This measure
provides the proportion of patients who died from cancer and were
not admitted to hospice.
- Preliminary analysis result: Refine and Resubmit for
Rulemaking
- Notes:
- Proportion of patients who died from cancer receiving
chemotherapy in the last 14 days of life (MUC ID: MUC16-271)
- Description: Proportion of patients who died from cancer
receiving chemotherapy in the last 14 days of life
- Preliminary analysis summary
- Contribution to program measure set:The measure has not
been specified and tested at the facility level in the hospital
setting. The Palliative Care and End-of-Life Standing Committee,
CSAC and the NQF Executive Committee recommended the measure for
endorsement at the group/clinician level in the ambulatory care
setting. The measure should be specified, tested and NQF endorsed at
the facility level in the hospital setting for the PPS-Exempt Cancer
Hospital Quality Reporting Program.
- Impact on quality of care for patients:The measure
provides patients with the proportion of cancer patients who receive
chemotherapy in the last 14 days of life.
- Preliminary analysis result: Refine and Resubmit
- Notes:
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12:30 pm |
Lunch |
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1:00 pm |
Overview of the Ambulatory Surgery Center Quality
Reporting (ASCQR) Program |
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1:10 pm |
Opportunity for Public Comment on Measures Under
Consideration for ASCQR |
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1:20 pm |
Pre-Rulemaking Input Ambulatory Surgical Center Quality Reporting
(ASCQR)—Consent Calendar 3 |
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Jeff Jacobs, The Society of Thoracic Surgeons Marisa Valdes, Baylor
Scott & White Health |
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Programs under consideration: Ambulatory Surgical Center Quality
Reporting Program
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- Ambulatory Breast Procedure Surgical Site Infection (SSI) Outcome
Measure (MUC ID: MUC16-155)
- Description: This measure is for the risk-adjusted
Standardized Infection Ratio (SIR) for all Surgical Site Infections
(SSIs) following breast procedures conducted at ambulatory surgery
centers (ASCs) among adult patients (ages 18 - 108 years) and reported
to the Centers for Disease Control and Prevention (CDC) National
Healthcare Safety Network (NHSN). The measure compares the reported
number of surgical site infections observed at an ASC with a predicted
value based on nationally aggregated data. The measure was developed
collaboratively by the CDC, the Ambulatory Surgery Center Quality
Collaboration (ASC QC), and the Colorado Department of Public Health
and Environment. CDC is the measure steward.
- Preliminary analysis summary
- Contribution to program measure set:This is a fully
developed measure and is currently under review by the Patient
Safety Standing Committee for NQF endorsement. The Committee
recommended the measure for endorsement. The measure should
complete the consensus development process (CDP) and receive NQF
endorsement.
- Impact on quality of care for patients:Improved care and
a decrease in the number of surgical site infections (SSIs) for
patients undergoing breast procedures at ambulatory surgical care
centers.
- Preliminary analysis result: Conditional Support for
Rulemaking
- Notes:
- Hospital Visits after Orthopedic Ambulatory Surgical Center
Procedures (MUC ID: MUC16-152)
- Description: **As of 12/2 testing for this measure has been
completed**** The measure score is an ASC-level rate of unplanned
hospital visits within 7 days of an orthopedic procedure performed at
an ASC.
- Preliminary analysis summary
- Contribution to program measure set:This measure is fully
developed and specified andaligns with NQF #2539: Rate of
Risk-Standardized, All-Cause, Unplanned Hospital Visits within 7
Days of an Outpatient Colonoscopy Among Medicare Fee-for-Service
(FFS) Patients Aged 65 Years and Older and MUC16-153: Hospital
Visits following Urology Ambulatory Surgical Center Procedures.
Testing results should demonstrate reliability and validity at the
facility level in the ambulatory surgical setting. This measure
should be submitted to NQF for review and endorsement.
- Impact on quality of care for patients:Improved care,
care transitions and minimal unplanned hospital visits within 7 days
following orthopedic procedures performed in the ambulatory surgical
care setting.
- Preliminary analysis result: Refine and Resubmit Prior to
Rulemaking
- Notes:
- Hospital Visits after Urology Ambulatory Surgical Center
Procedures (MUC ID: MUC16-153)
- Description: **As of 12/2 testing for this measure has been
completed**** The measure score is an ASC-level rate of unplanned
hospital visits within 7 days of a urology procedure performed at an
ASC.
- Preliminary analysis summary
- Contribution to program measure set:This measure is fully
developed and specified andaligns with NQF #2539: Rate of
Risk-Standardized, All-Cause, Unplanned Hospital Visits within 7
Days of an Outpatient Colonoscopy Among Medicare Fee-for-Service
(FFS) Patients Aged 65 Years and Older and MUC16-152: Hospital
Visits following Orthopedic Ambulatory Surgical Center Procedures.
Testing results should demonstrate reliability and validity at the
facility level in the ambulatory surgical setting. This measure
should be submitted to NQF for review and endorsement.
- Impact on quality of care for patients:Improved care,
care transitions and minimal unplanned hospital visits within 7 days
following urology procedures performed in the ambulatory surgical
care setting.
- Preliminary analysis result: Refine and Resubmit Prior to
Rulemaking
- Notes:
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1:50 pm |
Overview of the Inpatient Psychiatric Facilities
Quality Reporting (IPFQR) Program |
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2:00 pm |
Opportunity for Public Comment on Measures Under
Consideration for IPFQR |
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2:10 pm |
Inpatient Psychiatric Facility Quality Reporting (IPFQR)—Consent
Calendar 4 |
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Frank Ghinassi, National Association of Psychiatric Health Systems
(NAPHS) Ann Marie Sullivan, Individual Subject Matter Expert Woody
Eisenberg, Pharmacy Quality Alliance |
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Programs under consideration: Inpatient Psychiatric Facility Quality
Reporting Program
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- Medication Continuation following Inpatient Psychiatric Discharge
(MUC ID: MUC16-048)
- Description: **As of 12/2 testing for this measure has been
completed**** This measure assesses whether psychiatric patients
admitted to an inpatient psychiatric facility (IPF) for major
depressive disorder (MDD), schizophrenia, or bipolar disorder (BD)
were dispensed a prescription for evidence-based medication within 30
days of discharge. The performance period for the measure is two
years.
- Preliminary analysis summary
- Contribution to program measure set:This measure is fully
developed, specified and undergoing testing. The testing results
should demonstrate reliability and validity at the facility level in
the hospital setting. The measure should be submitted to NQF for
review and endorsement.
- Impact on quality of care for patients:This measure
encourages inpatient psychiatric facilities to ensure that patients
with major depressive disorder (MDD), schizophrenia, or bipolar
disorder (BD) are dispensed a prescription for evidence-based
medication within 30 days of discharge.
- Preliminary analysis result: Refine and Resubmit Prior to
Rulemaking
- Notes:
- Identification of Opioid Use Disorder (MUC ID: MUC16-428)
- Description: The measure assesses the percentage of
patients admitted to an inpatient psychiatric facility who were
screened and evaluated for opioid use disorder.
- Preliminary analysis summary
- Contribution to program measure set:This measure is fully
developed, specified and undergoing field testing. The testing
results should demonstrate reliability and validity at the facility
level in the hospital setting. This measure should be submitted to
NQF for review and endorsement.
- Impact on quality of care for patients:This measure
encourages inpatient psychiatric facilities to screen patients for
an opioid use disorder.
- Preliminary analysis result: Refine and Resubmit Prior to
Rulemaking
- Notes:
- Medication Reconciliation at Admission (MUC ID: MUC16-049)
- Description: **As of 12/2 testing for this measure has been
completed**** ****Changed from requiring reconciliation within 24
hours to requiring reconciliation within 48 hours as of 12/1/16****
This measure assesses the average completeness of medication
reconciliations conducted within 24 hours of admission to an inpatient
facility.
- Preliminary analysis summary
- Contribution to program measure set:This measure is fully
developed, specified and undergoing field testing. The testing
results should demonstrate reliability and validity at the facility
level in the hospital setting. This measure should be submitted to
NQF for review and endorsement.
- Impact on quality of care for patients:This measure
encourages inpatient psychiatric facilities to complete adequate
medication reconciliation within 24 hours of
admission.
- Preliminary analysis result: Refine and Resubmit Prior to
Rulemaking
- Notes:
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2:45 pm |
Break |
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3:00 pm |
Overview of the Hospital Outpatient Quality
Reporting Program (HOQR) |
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3:10 pm |
Opportunity for Public Comment on Measures Under
Consideration for HOQR |
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3:20 pm |
Pre-Rulemaking Input Measure on Hospital Outpatient Quality Reporting
(OQR)—Consent Calendar 5 |
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Lee Fleisher, Individual Subject Matter Expert Jack Jordan, Individual
Subject Matter Expert |
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Programs under consideration: Hospital Outpatient Quality Reporting
Program
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- Median Time from ED Arrival to ED Departure for Discharged ED
Patients (MUC ID: MUC16-055)
- Description: Median elapsed time from emergency department
arrival to emergency room departure for patients discharged from the
emergency department
- Preliminary analysis summary
- Contribution to program measure set:This eMeasure is
fully developed, tested and currently implemented in IQR. This
eMeasure uses EHR data rather than chart abstracted data to
determine patient arrival and discharge times in the emergency
department. Testing data should be provided demonstrating that this
eMeasure more accurately determines patient arrival and discharge
times compared to the chart abstracted version of the measure (NQF
#0496) currently in the HOQR and HIQR programs. This eMeasure
should be submitted to NQF for review and endorsement.
- Impact on quality of care for patients:Reducing the
median time from ED arrival to the time of departure from the
emergency room potentially improves access to care specific to the
patient condition and increases the capability to provide additional
treatment.
- Preliminary analysis result: Conditional Support for
Rulemaking
- Notes:
- Median Time to Pain Management for Long Bone Fracture (MUC
ID: MUC16-056)
- Description: Median time from emergency department arrival
to time of initial oral, nasal or parenteral pain medication
administration for emergency department patients with a principal
diagnosis of long bone fracture (LBF)
- Preliminary analysis summary
- Contribution to program measure set:The measure is
currently in the Hospital Outpatient Quality Reporting (HOQR)
program. The NQF Musculoskeletal Steering Committee agreed that the
evidence supporting this measure is insufficient. The measure was
de-endorsed in 2014.
- Impact on quality of care for patients:This measure
captures the median time to pain medication administration for long
bone fractures for patients in the ED. Median time for pain
medication administration does not indicate adequate pain management
in the ED related to long bone fractures.
- Preliminary analysis result: Do Not Support for
Rulemaking
- Notes:
- Safe Use of Opioids – Concurrent Prescribing (MUC ID:
MUC16-167)
- Description: Patients age 18 years and older with active,
concurrent prescriptions for opioids at discharge, or patients with
active, concurrent prescriptions for an opioid and benzodiazepine at
discharge from a hospital-based encounter (inpatient, ED,
outpatient)
- Preliminary analysis summary
- Contribution to program measure set:This newly developed
eMeasure was tested at the facility level in the emergency
department setting and currently undergoing field testing. The
testing results should demonstrate reliability and validity in the
outpatient setting for HOQR. The measure should be submitted to NQF
for review and endorsement.
- Impact on quality of care for patients:This measure
encourages outpatient facilities to identify patients discharged
with concurrent prescriptions of opioids or opioids and
benzodiazepines and discourage prescriptions for two or more
different opioids or opioids and benzodiazepines
concurrently.
- Preliminary analysis result: Refine and Resubmit Prior to
Rulemaking
- Notes:
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3:40 pm |
Feedback on Current Measure Sets for ESRD QIP,
PCHQR, ASCQR, IPFQR, Readmissions, HACs, and OQR |
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4:40 pm |
Opportunity for Public Comment |
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4:55 pm |
Summary of Day |
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Kate McQueston, Project Manager
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5:00 pm |
Adjourn |
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Day 2 |
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8:30 am |
Breakfast |
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9:00 am |
Welcome and Review of Day 1 |
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Cristie Upshaw Travis, MAP Hospital Workgroup Co-Chair; Ronald
Walters, MAP Hospital Workgroup Co-Chair; Melissa Mariñelarena, Senior
Director, NQF
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9:15 am |
PROMIS Discussion |
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Ashley Wilder Smith, PhD, MPH, National Cancer Institute
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10:15 am |
Overview of the Hospital Inpatient Quality Reporting
(HIQR) Program and Medicare and Medicaid EHR Incentive Program for
Hospitals and Critical Access Hospitals (CAHs) (Meaningful Use) |
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10:25 am |
Opportunity for Public Comment on Measures Under
Consideration for HIQR and Medicare and Medicaid EHR Incentive Program for
Hospitals and Critical Access Hospitals (CAHs) (Meaningful Use) |
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10:35 am |
Pre-Rulemaking Input Measure Sets: Hospital Inpatient Quality
Reporting (IQR) and Medicare and Medicaid EHR Incentive Program for
Hospitals and Critical Access Hospitals (CAHs) (Meaningful Use)—Consent
Calendar 6 |
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Marsha Manning, University of Michigan David Engler, America's
Essential Hospitals Jennifer Eames Huff, Mothers Against Medical Error
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Programs under consideration:
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- Alcohol & Other Drug Use Disorder Treatment Provided or
Offered at Discharge and Alcohol & Other Drug Use Disorder Treatment
at Discharge (MUC ID: MUC16-180)
- Description: The measure is reported as an overall rate
which includes all hospitalized patients 18 years of age and older to
whom alcohol or drug use disorder treatment was provided, or offered
and refused, at the time of hospital discharge, and a second rate, a
subset of the first, which includes only those patients who received
alcohol or drug use disorder treatment at discharge. The Provided or
Offered rate (SUB-3) describes patients who are identified with
alcohol or drug use disorder who receive or refuse at discharge a
prescription for FDA-approved medications for alcohol or drug use
disorder, OR who receive or refuse a referral for addictions
treatment.
- Preliminary analysis summary
- Contribution to program measure set:This measure is
NQF-endorsed at the facility level in the hospital/acute care
setting. This measure is currently in the IPFQR program. However,
no scientific evidence provided to demonstrate that patients who
received a prescription at discharge for the treatment of alcohol or
drug use disorder or a referral for addictions treatment received
treatment after discharge.
- Impact on quality of care for patients:This measure
encourages hospitals to provide patients with a prescription for the
treatment of alcohol or drug use disorder or a referral for
addictions treatment.
- Preliminary analysis result: Do Not Support for
Rulemaking
- Notes:
- Alcohol Use Brief Intervention Provided or Offered and Alcohol
Use Brief Intervention (MUC ID: MUC16-178)
- Description: The measure is reported as an overall rate
which includes all hospitalized patients 18 years of age and older to
whom a brief intervention was provided, or offered and refused, and a
second rate, a subset of the first, which includes only those patients
who received a brief intervention. The Provided or Offered rate
(SUB-2), describes patients who screened positive for unhealthy
alcohol use who received or refused a brief intervention during the
hospital stay. The Alcohol Use Brief Intervention (SUB-2a) rate
describes only those who received the brief intervention during the
hospital stay. Those who refused are not included. These measures are
intended to be used as part of a set of 4 linked measures addressing
Substance Use (SUB-1 Alcohol Use Screening ; SUB-2 Alcohol Use Brief
Intervention Provided or Offered; SUB-3 Alcohol and Other Drug Use
Disorder Treatment Provided or Offered at Discharge; SUB-4 Alcohol and
Drug Use: Assessing Status after Discharge [temporarily suspended]).
- Preliminary analysis summary
- Contribution to program measure set:This measure is
NQF-endorsed at the facility level in the hospital/acute care
setting. This measure is currently in the IPFQR program; no
implementation issues have been identified.
- Impact on quality of care for patients:This measure
encourages hospitals to provide brief interventions to patients with
unhealthy alcohol use.
- Preliminary analysis result: Support for Rulemaking
- Notes:
- Alcohol Use Screening (MUC ID: MUC16-179)
- Description: Hospitalized patients 18 years of age and
older who are screened within the first three days of admission using
a validated screening questionnaire for unhealthy alcohol use. This
measure is intended to be used as part of a set of 4 linked measures
addressing Substance Use (SUB-1 Alcohol Use Screening; SUB-2 Alcohol
Use Brief Intervention Provided or Offered; SUB-3 Alcohol and Other
Drug Use Disorder Treatment Provided or Offered at Discharge; SUB-4
Alcohol and Drug Use: Assessing Status after Discharge [temporarily
suspended]).
- Preliminary analysis summary
- Contribution to program measure set:This measure is
NQF-endorsed at the facility level in the hospital/acute care
setting. This measure is currently in the IPFQR program and publicly
reported on Hospital Compare. No implementation issues have been
identified.
- Impact on quality of care for patients:This measure
encourages hospitals to screen patients for unhealthy alcohol use.
- Preliminary analysis result: Support for Rulemaking
- Notes:
- Patient Panel Smoking Prevalence IQR (MUC ID: MUC16-068)
- Description: Percentage of hospital patient panel who
currently smoke according to the EHR structured data
- Preliminary analysis summary
- Contribution to program measure set:This measure is not
fully developed and tested in the acute inpatient setting. A more
comprehensive measure, MUC16-50 Tobacco Use Screening (TOB-1), that
likely captures smoking status has been proposed for IQR.
- Impact on quality of care for patients:A more
comprehensive measure that focuses on tobacco screening improves the
quality of tobacco-cessation interventions patients receive while
hospitalized.
- Preliminary analysis result: Do Not Support for
Rulemaking
- Notes:
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11:00 am |
Break |
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11:15 am |
IQR Continued—Consent Calendar 7 |
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Kimberly Glassman, Nursing Alliance for Quality CareNancy Foster,
American Hospital Association Martin Hatlie, Project Patient Care Mimi
Huizinga, Premier, Inc. |
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Programs under consideration:
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- Follow-Up After Hospitalization for Mental Illness (MUC ID:
MUC16-165)
- Description: The percentage of discharges for patients 6
years of age and older who were hospitalized for treatment of selected
mental illness diagnoses and who had an outpatient visit, an intensive
outpatient encounter or partial hospitalization with a mental health
practitioner. Two rates are reported: - The percentage of discharges
for which the patient received follow-up within 30 days of discharge
- The percentage of discharges for which the patient received
follow-up within 7 days of discharge.
- Preliminary analysis summary
- Contribution to program measure set:This measure, NQF
#0576, is specified and tested at the health plan level; therefore,
performance on the measure cannot be attributed to the facility as
currently specified. Additionally, problems encountered with the
initial measure results in the IPFQR program should be resolved
prior to implementing the measure in additional programs.
- Impact on quality of care for patients:This measure can
help bridge the gap between the inpatient setting and outpatient
treatment services for individuals with serious mental illness.
- Preliminary analysis result: Refine and Resubmit Prior to
Rulemaking
- Notes:
- Measure of Quality of Informed Consent Documents for
Hospital-Performed, Elective Procedures (MUC ID: MUC16-262)
- Description: The measure estimates the hospital-level
quality of informed consent documents for elective procedures for
fee-for-service (FFS) Medicare patients. The outcome is defined as the
quality of the informed consent document, as evaluated using an
instrument developed for this purpose, the Abstraction Tool. A sample
of hospitals’ informed consent documents are evaluated and
hospital-level performance will be derived by aggregating these
individual informed consent document quality scores. The measure is
broadly applicable to a range of procedures, including elective
cardiac, orthopedic, and urological procedures, that are performed in
the hospital.
- Preliminary analysis summary
- Contribution to program measure set:The measure is the
first step towards improving the practice of informed consent
through quality measurement, and may compliment or serve as a
platform for other measures of high-quality, patient-centered
decision making. The reliability testing results should demonstrate
hospital-level reliability. In addition, the measure should be
submitted to NQF for review and endorsement.
- Impact on quality of care for patients:Consistent and
patient-centered standards based on existing guidelines for informed
consent can lead to improved patient autonomy, patient safety, and
high-quality decision making.
- Preliminary analysis result: Refine and Resubmit Prior to
Rulemaking
- Notes:
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IQR Continued—Consent Calendar 8 |
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Brock Slabach, National Rural Health Association Andrea Benin,
Children's Hospital Association Wei Ying, Blue Cross Blue Shield of
Massachusetts Karen Shehade, Medtronic-Minimally Invasive Therapy Group
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Programs under consideration:
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- Appropriate Documentation of a Malnutrition Diagnosis (MUC
ID: MUC16-344)
- Description: Appropriate documentation of a malnutrition
diagnosis for patients age 65 and older admitted to inpatient care who
are found to be malnourished based on a nutrition assessment.
- Preliminary analysis summary
- Contribution to program measure set:This measure is
currently under review in NQF’s Health and Well-Being 2015-2017
project. The Standing Committee agreed that the evidence provided
to support the measure was not sufficient. The measure did not pass
the Evidence criterion and was not recommended for NQF endorsement.
- Impact on quality of care for patients:This measure
encourages documentation of a malnutrition diagnosis for patients =
65 years who have a completed nutrition assessment in their medical
record.
- Preliminary analysis result: Do Not Support for
Rulemaking
- Notes:
- Completion of a Malnutrition Screening within 24 Hours of
Admission (MUC ID: MUC16-294)
- Description: Completion of a malnutrition screening using a
validated screening tool to determine if a patient is at-risk for
malnutrition, within 24 hours of admission to the hospital.
- Preliminary analysis summary
- Contribution to program measure set:This measure is
currently under review in NQF’s Health and Well-Being 2015-2017
project. The Standing Committee did not reach consensus on the
Evidence Criterion during the in-person meeting in September. The
measure must pass the evidence criterion and be recommended for
endorsement.
- Impact on quality of care for patients:This measure
encourages documentation of a malnutrition screening within 24 hours
for patients >18 years admitted into the acute inpatient care
setting, which is the first step in nutrition care.
- Preliminary analysis result: Conditional Support for
Rulemaking
- Notes:
- Completion of a Nutrition Assessment for Patients Identified as
At-Risk for Malnutrition within 24 Hours of a Malnutrition Screening
(MUC ID: MUC16-296)
- Description: Patients age 65 years and older identified as
at-risk for malnutrition based on a malnutrition screening who have a
nutrition assessment documented in the medical record within 24 hours
of the most recent malnutrition screening.
- Preliminary analysis summary
- Contribution to program measure set:This measure is
currently under review in NQF’s Health and Well-Being 2015-2017
project. The Standing Committee did not reach consensus on the
Evidence Criterion during the in-person meeting in September. The
measure must pass the evidence criterion and be recommended for
endorsement.
- Impact on quality of care for patients:This measure
encourages documentation of a malnutrition assessment within 24
hours of the most recent malnutrition screening for patients = 65
years so that a dietitian can subsequently recommend a nutrition
care plan that includes appropriate interventions to address the
patient's malnutrition.
- Preliminary analysis result: Conditional Support for
Rulemaking
- Notes:
- Nutrition Care Plan for Patients Identified as Malnourished after
a Completed Nutrition Assessment (MUC ID: MUC16-372)
- Description: Documentation of a nutrition care plan for
those patients age 65 and older admitted to inpatient care who are
found to be malnourished based on a completed nutrition
assessment
- Preliminary analysis summary
- Contribution to program measure set:This measure is
currently under review in NQF’s Health and Well-Being 2015-2017
project. The Standing Committee did not reach consensus on the
Validity Criterion during the in-person meeting in September. The
measure must pass the validity criterion and be recommended for
endorsement.
- Impact on quality of care for patients:This measure
encourages documentation of a nutrition care plan for patients = 65
years with a finding of malnutrition. The Nutrition care plan may
include completed assessment results, treatment goals,
prioritization based on treatment severity, prescribed
treatment/intervention, identification of members of the care team
and a timeline for patient follow-up.
- Preliminary analysis result: Conditional Support for
Rulemaking
- Notes:
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12:30 pm |
Lunch |
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1:00 pm |
IQR Continued—Consent Calendar 9 |
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Gregory Alexander, Individual Subject Matter Expert Lindsey Wisham,
Individual Subject Matter Expert Lee Fleisher, Individual Subject Matter
Expert Jack Jordan, Individual Subject Matter Expert |
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Programs under consideration:
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- Safe Use of Opioids – Concurrent Prescribing (MUC ID:
MUC16-167)
- Description: Patients age 18 years and older with active,
concurrent prescriptions for opioids at discharge, or patients with
active, concurrent prescriptions for an opioid and benzodiazepine at
discharge from a hospital-based encounter (inpatient, ED,
outpatient)
- Preliminary analysis summary
- Contribution to program measure set:This newly developed
eMeasure was tested at the facility level in the emergency
department setting and currently undergoing field testing. The
testing results should demonstrate reliability and validity in the
hospital setting for IQR. The measure should be submitted to NQF
for review and endorsement.
- Impact on quality of care for patients:This measure
encourages hospitals to identify patients discharged with concurrent
prescriptions of opioids or opioids and benzodiazepines and
discourage prescriptions for two or more different opioids or
opioids and benzodiazepines concurrently.
- Preliminary analysis result: Refine and Resubmit Prior to
Rulemaking
- Notes:
- Influenza Immunization (IMM-2) (MUC ID: MUC16-053)
- Description: Inpatients age 6 months and older discharged
during October, November, December, January, February or March who are
screened for influenza vaccine status and vaccinated prior to
discharge if indicated.
- Preliminary analysis summary
- Contribution to program measure set:The Health and
Well-Being Standing Committee acknowledged the importance of this
hospital-based measure, but did not believe the narrowing
performance gaps were clinically significant in the chart-abstracted
version of the measure (#1659). No data/evidence provided
demonstrating that this eMeasure addresses a performance gap in
IQR.
- Impact on quality of care for patients:Approximately
94.0% of acute-care hospitalized patients are screened and
vaccinated for influenza prior to discharge based on data from the
chart-abstracted version of this measure (#1659). No evidence was
provided that this eMeasure will increase the percentage of patients
receiving influenza vaccine.
- Preliminary analysis result: Do Not Support for
Rulemaking
- Notes:
- Tobacco Use Screening (TOB-1) (MUC ID: MUC16-050)
- Description: This measure assesses the proportion of
hospitalized adult patients who were comprehensively screened (or
refused screening) within 3 days prior through 1 day after admission
for tobacco use within the 30 days prior to the screening.
- Preliminary analysis summary
- Contribution to program measure set:This eMeasure is
fully developed and specified at the facility level in the hospital
setting. The measure is undergoing field testing. The testing
results should demonstrate reliability and validity in the acute
care setting. The eMeasure should be submitted to NQF for review
and endorsement.
- Impact on quality of care for patients:This measure
encourages hospitals to ask all patients if they use tobacco and
document their tobacco use status on a regular basis.
- Preliminary analysis result: Refine and Resubmit Prior to
Rulemaking
- Notes:
- Use of Antipsychotics in Older Adults in the Inpatient Hospital
Setting (MUC ID: MUC16-041)
- Description: Proportion of inpatient hospitalizations for
patients 65 years of age and older who do not demonstrate a threat to
themselves or others but who receive antipsychotic medication
therapy.
- Preliminary analysis summary
- Contribution to program measure set:This newly developed
eMeasure is fully developed and specified. The measure is currently
undergoing field testing. The testing results should demonstrate
reliability and validity at the facility level in the hospital
setting. In addition, the measure should be submitted to NQF for
review and endorsement.
- Impact on quality of care for patients:This measure
encourages hospitals against using antipsychotics as a standard
first line of treatment for patients experiencing aggressive
behavior unless they present a threat to themselves or their
caregivers.
- Preliminary analysis result: Refine and Resubmit Prior to
Rulemaking
- Notes:
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2:00 pm |
Feedback on Current Measure Sets for IQR and
VBP |
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2:45 pm |
Opportunity for Public Comment |
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2:55 pm |
Wrap Up and Next Steps |
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Kate McQueston, Project Manager
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3:00 pm |
Adjourn |
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