Quality Reporting:
Initiatives at the Federal and State Level
Presented by:
Richard Schirmer, MBA, FACHE
July 2012
THA – Who We Are
 The Texas Hospital Association is a nonprofit trade
association representing Texas hospitals and health
systems. In addition to providing a unified voice for
health care, THA serves its 500+ members with timely
information, data analysis, education on essential
operational requirements, networking and leadership
opportunities.
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THA – What We Do
 Since its founding in 1930, THA has grown and evolved
with the hospital industry itself. Today, THA is the leading
advocacy organization for Texas hospitals. The
Association’s staff is committed to helping hospitals
navigate the complex, ever-changing legislative and
regulatory environment, while working toward common
solutions for better health care policy at the state and
federal levels.
 THA also serves as a resource for the State of Texas in
the areas of disaster planning and response, data
services and regulatory development.
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Executive Summary…..
Plethora of Quality Initiatives
 pleth·o·ra
 noun
 1. overabundance; excess: a plethora of
advice and a paucity of assistance.
 2. Pathology Archaic . a morbid condition due
to excess of red corpuscles in the blood or
increase in the quantity of blood.
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Impact of Quality Initiatives
Improving quality helps bottom line
– Venous Thromboembolism Prophylaxis
– Beta Blockers for AMI
– Prophylactic antibiotics prior to surgery
Improving quality worsens bottom line
– Eliminating 39 weeks elective deliveries
Let’s do what is best for the PATIENT-we ALL have
a vested interest!!!!!!
Steve Berkowitz MD
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Federal Initiatives: Affordable Care Act
HAC
Bundled
Payment
VBP
Readmissions
ACA
ACOs
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Federal Quality Based Payment Reforms
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Federal Initiatives: Readmissions
HAC
VBP
Readmissions
ACA
Bundled
Payment
ACOs
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Federal Initiatives: Readmissions
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Federal Initiatives: Readmissions
• Y1 - CMS proposes existing 30-day
readmissions measures (over 3 yrs)
 Heart attack, heart failure, pneumonia
• Hospitals with “excess” readmissions penalized up to
1% in FY 2013 on all Medicare discharges
• ACA: exclude unrelated, planned.
CMS’ proposal fails to do so.
• CMS proposes that hospitals with
fewer than 25 discharges for each
condition be excluded
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Patient Compliance Is Never An Issue
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What Happens If You Remove Cost From
The Equation?
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Federal Initiatives: Value Based Purchasing
HAC
VBP
Readmissions
ACA
Bundled
Payment
ACOs
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VBP Quality Measures: 2013
 For FY 2013, CMS finalized 13 total
measures
– 13 process measures
– HCAHPS patient satisfactions-8 measures
– Patient outcomes-2014-3 measures
 For FY 2013, performance measured
July 1, 2011 – March 31, 2012
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Scoring Hospitals’ VBP Performance
 Hospitals will receive the higher of their attainment or
improvement score on each measure
 Score on each domain equals points earned out of
total possible points
 FY 2013 payment based on:
HCAHPS 30%
Process 70%
FY 2014 payment based on:
HCAHPS 30%
Outcomes 25%
(30%)
Process
45% (20%)
Efficiency
0% (20%)
 Payment details next year
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Federal Initiatives: Hospital Acquired Conditions
HAC
VBP
Readmissions
ACA
Bundled
Payment
ACOs
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Hospital Acquired Conditions
ACA imposes financial penalties on hospitals
with high HAC rate.
 Current-Reduced payments to hospital where
one of 8 HACs was not present on admission.
 VBP Policy-Proposed for October 2013.
Recently withdrawn
 HAC Policy-Beginning October 2014, hospitals
with HAC rate in bottom quartile of national
average (i.e. high rate) will suffer a 1% payment
reduction for ALL Medicare inpatient DRGs.
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Preventable Hospital Acquired Conditions
 Foreign Object After Surgery
 Air Embolism
 Blood Incompatibility
 Pressure Ulcers (Stage III and IV)
 Falls and Trauma
 Vascular Catheter Associated Infections
 Catheter Associated UTI
 Poor Glycemic Control
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State Initiatives
Patient
Identification
System
PPR/PPC
HAI Reporting
Texas
Tx Institute
for Quality
and Patient
Safety
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State Initiatives: HAI Reporting
Patient
Identification
System
PPR/PPC
HAI Reporting
Texas
Tx Institute
for Quality
and Patient
Safety
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Mandatory State Reporting of Healthcareassociated Infections
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Who must report?
 Long-term acute care hospitals that have an adult or
neonatal intensive care unit (ICU) or critical care unit
(CCU)
 Critical access hospitals with ICU/CCU/NICU and/or that
perform National Healthcare Safety Network (NHSN)
surgical procedures
 General hospitals (adult, pediatric, adolescent) with
ICU/CCU/NICU and/or that perform National Healthcare
Safety Network (NHSN) surgical procedures
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Reporting of HAIs
 Central line-associated bloodstream
infections in hospital special care settings
 Surgical site infections
– Adult general hospitals and ASCs: colon surgeries, hip
& knee arthroplasties, abdominal & vaginal
hysterectomies, vascular procedures, and coronary
artery bypass grafts
– Pediatric/adolescent general hospitals:
ventriculoperitoneal shunt procedures (including
revisions and removal), cardiac procedures 9excluding
thoracic) and spinal surgeries with instrumentation
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Public Access to Data
 Compile and make available to the public a
summary, by health care facility
 Publish the summary at least annually and
place on website
 Allow health care facilities to submit concise
written comments
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Phased In Reporting
 Phase in reporting beginning in October of
2011
– All facilities report: central line-associated
bloodstream infections
– Surgical centers and general hospitals report:
knee arthroplasties
 Knee arthroplasties ICD-9th Revision codes. Knee prosthesis – 00.80-00.84, 81.54 and
81.55
– Pediatric/adolescent hospitals report:
ventricularoperitoneal shunts
 Ventriculoperitoneal shunts ICD-9th Revision codes. Ventriculoperitoneal shunts including
revision and removal of shunt – 02.2, 02.32-02.35, 02.39, 02.42, 04.43 and 54.95
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Phased In Reporting
 Beginning in January 2012
– Surgical centers and general hospitals report:
hip arthroplasties and coronary artery bypass
grafts
– Pediatric/adolescent hospitals report: cardiac
procedures
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Phased In Reporting
 Beginning January 2013
– Surgical centers and general hospitals report:
abdominal & vaginal hysterectomies, colon
surgeries, and vascular procedures
– Pediatric/adolescent hospitals report: spinal
surgeries with instrumentation
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How to Report
 National Healthcare Safety Network (NHSN) developed
and sustained by the Centers for Disease Control &
Prevention will be the designated reporting system.
 §200.3(e). Facilities shall report HAI data on patients who are
admitted to the facility for inpatient treatment of a surgical site
infections associated with a procedure listed in §200.4 of this title
within 30 calendar days of the procedure or within 1 year of the
procedure if the procedure involved an implant.
 §200.3(e)(2). If the facility treating the patient did not perform the
surgery, the treating facility shall notify the facility that performed,
document the notification, and maintain this documentation for audit
proposes.
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Future Activities
 What will be implemented at a later date
– Reporting of respiratory syncytial virus
– Receiving reports from the public
– Reporting of preventable adverse events (PAE)
 An event included in the list of serious events identified
by the National Quality Forum
 An event or condition for which the Medicare program will
not provide additional payment to the facility.
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State Initiatives: Patient Identification System
Patient
Identification
System
PPR/PPC
HAI Reporting
Texas
Tx Institute
for Quality
and Patient
Safety
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Patient Identification System
Texas DSHS is required to develop a statewide
standardized patient risk identification system
that will allow hospital personnel to readily identify a
patient with a specific medical risk.
Each hospital will be required to implement the state
identification system unless they are allowed an
exemption because the hospital adopts a different
identification system that is evidenced based. SB 7
(82nd Session). May potentially include colored
wristband ID initiative developed by SA Hospital
Council several years ago.
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Patient Identification System
 Three mandatory colors (AHA’s Alert Colors)
– Red-Allergies
– Yellow-Fall Risk
– Purple-DNR
 Two optional colors
– Green-Latex Allergy
– Pink-Restricted Extremity
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Coming Attractions-MD Related
 MD feedback reports (200+ MDs)-2010
 MD feedback reports (Iowa, Kansas,
Missouri, Nebraska) – all MDs
 Most of claims based measures depend on
patient compliance to some degree (fill
prescription or keep appointment)
 Implementation of value modifier in 2015 may
increase participation in 2012 (payment
impact)
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In Conclusion……..
Questions?
Richard Schirmer, MBA, FACHE
Vice President, Health Care Policy Analysis
Texas Hospital Association
rschirmer@tha.org
512/465-1056
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