SUMMARY MINUTES
Thursday, December 10, 2015
2–3 p.m. ET
· Welcome and Announcements Mary Ann Jones
IQR Project Director
· Upcoming Education Programs Karen VanBourgondien
OQR/ASC SC Project Coordinator
o December 2015
v December 10 – IPF: “New Measures and Non-Measure Reporting – Part 2” Moved to January 21, 2016
v December 14 – VBP: “Hospital Value-Based Purchasing (VBP) Program Patient Safety Series: SSI Colon Surgery and SSI Abdominal Hysterectomy”
v December 16 – OQR and ASC: “The Lifecycle of Healthcare Quality Measures”
v December 16 – PCH: “Top Questions about the PPS-Exempt Cancer Hospital Quality Reporting Program”
v December 17 – eCQM: “QRDA Category I Standards Update for 2016 Hospital Reporting of eCQMs”
o January 2016
v January 7 – IPF: “Public Reporting Review and FY 2016 Measure Results”
v January 20 – OQR: “2016 Specifications Manual Updates”
v January 21 – IPF: “New Measures and Non-Measure Reporting – Part 2”
v January 26 – IQR: “HCAHPS Survey and Opioid Use and Prescription”
v January 27 – VBP: “Patient Safety Series: MRSA/CDI”
v January 27 – ASC: “2016 Specifications Manual Updates”
v January 28 – PCH: “Overview of PCHQR Program Manual”
v Date TBD – IQR: “IPPS Measure Waivers and Extraordinary Circumstances Exemption” (will also include information on how to file eCQM ECE’s)
v Date TBD – eCQM: “Pre-Submission Validation Application”
o QUESTIONS
v Will all of the education schedules be posted to the website?
§ All information is on the agenda and is normally posted within two weeks of the meeting.
§ A new measure, OP-33, is causing some stress. We are working on getting a webinar scheduled to handle all questions that might arise. This webinar is tentatively scheduled for February. The information will be included in the specifications manual, but it will not be detailed, so the webinar will be detailed for all those with questions.
v Can the time be included in the agenda?
§ If any webinar is missed, all information (the slides, the recordings, the entire word-for-word transcript, and the questions and answers) is posted on the website after the webinar
§ For Inpatient, in general, webinars are at 2 p.m. ET.
§ For Outpatient, there is a 10 a.m. ET and a 2 p.m. ET webinar, and for ASC, it is typically 2 p.m. ET.
v Can you expand on the January 26 “HCAHPS Survey and Opioid Use and Prescription”? Is that part of the HCAHPS now? Due to the way it is read, it looks as if the Opioid Use and Prescription is now part of the HCAHPS Survey.
§ They are two separate entities that will be briefed in the webinar.
v Is there something in the inpatient reporting about the Opioids?
§ This is the name that was provided to us by the HCAHPS Contractor; we will contact the contractor to see about having the name changed in order to reduce confusion with the providers.
· Outpatient Quality Reporting Update Melissa Barton
OQR/ASC Program Manager
v APU determinations have been determined for both programs (Hospital OQR and ASC).
§ The OQR lists have been posted to the QualityNet website.
§ The ASC lists are pending publication. The letters have been sent out, but they all need to be delivered before we post the list and send out a ListServe announcing that. Stay tuned for the ASC results to be posted.
§ There was a question about the web-based measures not being included on the two-year data provided on the Hospital OQR side.
· Those data are being compiled currently and should be available the first part of the new year.
o QUESTIONS
v On the last call, the CCN that wasn’t provided in the NHSN was discussed. Did that end up affecting the determinations for the ASCs that did not have that right?
§ Melissa replied that she thinks it did because there were some that did not report their NHSN data, so if there were an incorrect CCN or if it indicated “NA,” it wouldn’t have captured those data. We will be able to better determine once the reconsideration requests are submitted.
· Inpatient Quality Reporting Update Mary Ann Jones
IQR Project Director
o IPF Update (Presented by Evette Robinson)
v Starting this month, we will begin to send out communications to the IPF community regarding NHSN (the CDC’s National Healthcare Safety Network) registration in preparation for Influenza Vaccination Among Healthcare Personnel (HCP) measure data submission.
§ The first ListServe will go out within the next couple of weeks, and the intent is to encourage IPFs to register with NHSN as soon as possible, but no later than the first week of March 2016, to allow sufficient time to complete the registration process.
§ The ListServe will include links to helpful resources, and the IPFQR Program plans to present a refresher webinar in February to review the NHSN registration and HCP measure data submission processes.
§ All information and future webinars will be communicated via the IPF ListServe.
v Publication of the revised IPFQR Program manual and measure abstraction tools will be announced via ListServe later this month.
§ These tools and resources will include information about the new measures, including SUB-2/2a, TOB-3/3a, the transition record measures, as well as the screening for metabolic disorders measure.
o eCQM Deadline Extension
v Reminder to eligible hospitals participating in the Hospital Inpatient Quality Reporting (IQR) or the Medicare Electronic Health Record (EHR) Incentive Program - the deadline for the submission of electronic clinical quality measure (eCQM) data through the QualityNet Secure Portal has been extended from Monday, November 30, 2015, to Thursday, December 31, 2015, at 11:59 p.m. PT.
§ This extension is being granted to provide hospitals additional time to submit eCQM data.
§ This extension only applies to the eCQM voluntary submission option for the IQR Program and the e-Reporting option of clinical quality measure data for the Medicare EHR Incentive Program.
· The attestation deadline of February 29, 2016, is not impacted by this change, if hospitals choose to meet program requirements by this method.
· Questions and Closing Mary Ann Jones
IQR Project Director
v For the IPF units that are a part of a hospital, where the hospital has been reporting separately, will they need to register the IPF separately within NHSN?
§ Yes, IPF units that are housed within an acute care facility will need to register. They will need to have a designation within the main hospital. If there are any questions from facilities, they can be referred to a webinar on the website that was presented in April.
v When will the preview reports go out for the new FUH measure?
§ We are in the process of finalizing communication around that. It will include information on what to expect in the preview report, which will also be discussed in depth during the January 7 webinar.
· The preview period at this time will be January 12, 2016, on Hospital Compare.
v ASC APU has not been posted and the web-based measures have not been posted, but they will in January 2016?
§ For the ASC program for the APU lists, we anticipate the completion of delivery by today so that the lists can be posted by the end of the week. A ListServe will be sent out within the next couple of business days.
§ For the web-based measures, that is for Hospital OQR reports and will be available at the first part of the new year.
v Once the notification is made for APU, what is the process as far as looking at it and seeing which ASCs got their APU and which didn’t?
§ That will be posted under the ASC tab on QualityNet.
v The ASC data discussed in the last call (went over colonoscopy measures and how we were doing by state), thought that we were getting data soon.
§ Those data have been provided to the NCC. We do not currently have the timeframe that they will be uploaded to the Workbench.
v What is Outpatient 33?
· It is also called the “EBRT Measure,” and it stands for “External Beam Radiotherapy for Bone Metastases.”
o It is not in the Specifications Manual because it has just been finalized. It will be incorporated into the 9.0a Specifications Manual, which will be released in January 2016.
o There will be a webinar scheduled in February on this new measure to help with any questions.
v For the ASC data, was everything submitted or just 1-5, because as of yesterday they said that they were still waiting for the rest of it.
§ Everything should have been submitted, but we will follow up on it.
v Is the OP-33 Measure starting to be reported in Calendar Year 2017?
§ No, with it being a web-based measure, it will be reported annually, and the encounter dates will start January 1, 2016. That data entry will be entered in the year 2017 for payment year 2018.
· The next call is scheduled for Thursday, January 14, 2016, at 2 p.m. ET.
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