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MORTALITY MEASURE

2. Mortality Measures. First Outcome MeasureIntroduced by CMS in December 2006RHQDAPU program requirement for full APU FY 2008 for PPS hospitals.NO DATA SUBMISSION is required on the part of hospitals.. 3. Mortality Measures. Risk Adjusted Algorithm Developed by statistician

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MORTALITY MEASURE

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    1. MORTALITY MEASURE

    2. 2 Mortality Measures First Outcome Measure Introduced by CMS in December 2006 RHQDAPU program requirement for full APU FY 2008 for PPS hospitals. NO DATA SUBMISSION is required on the part of hospitals.

    3. 3 Mortality Measures Risk Adjusted Algorithm Developed by statisticians over two years Accepted by the NQF AMI and HF only Provides range of expected mortality with demographic and medical condition considerations.

    4. 4 Mortality Measures Dry Run Reports provided Dec 2006 Calendar year 2003 data All PPS hospitals CAHs with data available also received a report with hospital specific data. CAHs with no data had a mock report available to them. Reports sent to Quality Net administrator(s) at each hospital Q-Net Exchange Inbox

    5. 5 Mortality Measures Purpose of the Dry Run Familiarity with format and contents NOT publicly reported Question and Comment period Ended Jan 15 650 comments received Response forthcoming

    6. 6 Mortality Measures Whats next? April 2007 AMI & HF mortality reports July 1, 2005 through June 30, 2006 Q-Net Administrators In box RHQDAPU & HQA hospitals 30 day preview period (aligned with measures) PN Mortality Measure pending

    7. 7 Mortality Measures Whats next? June 2007 Mortality Measure posted to Hospital Compare As Expected / Better than / Worse than Data Suppression PPS forfeits full APU HQA-only hospitals (section 1886d) may suppress CAHs may suppress

    8. HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems

    9. 9 HCAHPS Purpose To provide a nationally standardized method for reporting patients perspectives on care

    10. 10 HCAHPS RHQDAPU program requirement for full APU FY 2008 for PPS hospitals Voluntary for others Publicly Reported on Hospital Compare

    11. 11 HCAHPS Topics: Communication with doctors Communication with nurses Responsiveness of Hospital Staff Cleanliness and Quietness Pain management Communications about medications Discharge information

    12. 12 HCAHPS Collection: Integrate HCAHPS into an existing patient survey or Implement HCAHPS as a separate survey Mail, Telephone, a combination of the two or use of an automated response system. Random sample Non-psych > 18 years Overnight stay Monthly

    13. 13 HCAHPS Submission: Use an approved vendor or Collect and submit your own HCAHPS data Submit data to CMS quarterly 300 complete surveys per year (minimum 100 surveys per year for smaller hospitals)

    14. 14 HCAHPS Participation requirements: Select an approved vendor List of approved vendors on quality net

    15. 15 HCAHPS Participation requirements: Hospital authorizes vendor Hospital Q-Net Administrator assigns HCAHPS Vendor Authorization role Access the HCAHPS Vendor Authorization in Q-Net Exchange Hospital user selects the survey vendor.

    16. 16 HCAHPS Participation requirements: Attend HCAHPS training Mandatory for any party planning to administer the survey Hospital or Vendor Participate in both the Introduction to HCAHPS Training and HCAHPS Update Training; two day (4 hour) sessions Iowa Foundation for Medical Care (IFMC) https://ifmcevents.webex.com/ifmcevents/mywebex/default.php?Rnd3986=0.6574112525546858 At a minimum, the organization's Project Manager must attend training as a representative of the organization.

    17. 17 HCAHPS Participation requirements: Review the HCAHPS Quality Assurance Guidelines http://www.hcahpsonline.org/files/QAGuidelines.pdf Quality Assurance Plan (QAP) Participate and cooperate in all oversight activities conducted by the HCAHPS Project Team See the above guidelines Submit to hcahps@azqio.sdps.org Due Jan 16, 2007 for those in first Dry Run (Q2 06) Due date pending for those participating in second Dry Run March 2007.

    18. 18 HCAHPS Participation requirements: Participate in the HCAHPS Dry Run prior to HCAHPS Data Collection and Public Reporting. March 2007 Submit a formal pledge Summer 2007; details pending Attest to the accuracy of the organization's data collection, following guidelines set forth in the HCAHPS Quality Assurance Guidelines

    19. 19 HCAHPS TIMELINE: Feb 2006 Initial HCAHPS training sessions offered April through June 2006 First Dry Run October 1, 2006 Voluntary hospitals begin ongoing data collection

    20. 20 HCAHPS TIMELINE: Jan 31, 2007 Voluntary participants begin uploading data for Q3 06 Jan and Feb 2007 HCAHPS Initial Training offered online by the IFMC March 2007 Second Dry Run

    21. 21 HCAHPS TIMELINE: April 11, 2007 Data submission deadline for Q4 06 results for voluntary participants. May 2007 Update Training Webinar July 1, 2007 New hospitals begin ongoing collection of data

    22. 22 HCAHPS TIMELINE: July 13, 2007 Data submission deadline for Q1 07 results (Publicly Reported) Data submission deadline for March 2007 Dry Run results (NOT Publicly Reported) Summer 2007 All participants sign a pledge of participation

    23. 23 HCAHPS

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