Tool Example

1. Completed by: Filing Location: Version: Date: Spectrum Systems HCC Tool Example Clinical Measures-Standards-Practices Grid Page 1 of 10 Basic Level • Instructions • Please identify with a “check” mark in the Collecting Data column if your facility is collecting data and note under Last Submission date when the data was last reported. Please leave Collecting Data blank if you are not collecting and do not plan to in the future. • If you are collecting data but not yet submitted note when the Future Submission Date will be. • If you are collecting but do not plan to report please note it in Will NOT Submit column. Please add any reasons in the Comments column • Once the grid has been filled out, please email back to Charles_denham@timt1.org or Fax to 512-479-1671. Description: The purpose of the Clinical Measures – Standards - Practices (MSP) grid is to inventory the data collection and submission that you institution is making to the different agencies and societies. For brevity, this grid does not include all the MSP, but the broad categories If you need the detail list of each Measure Standard or Practices required by the organizations listed on the grid, refer to the Web-based MSP Tool or the MSP Excel spreadsheet. Facility:

2. Completed by: Filing Location: Version: Date: Spectrum Systems HCC Tool Example Clinical Measures-Standards-Practices Grid Page 2 of 10 Basic Level Instruction: Please add Check mark and Date where appropriate Facility:

3. Completed by: Filing Location: Version: Date: Spectrum Systems HCC Tool Example Clinical Measures-Standards-Practices Grid Page 3 of 10 Basic Level Instruction: Please add Check mark and Date where appropriate Facility:

4. Completed by: Filing Location: Version: Date: Spectrum Systems HCC Tool Example Clinical Measures-Standards-Practices Grid Page 4 of 10 Basic Level Instruction: Please add Check mark and Date where appropriate Facility:

5. Completed by: Filing Location: Version: Date: Spectrum Systems HCC Tool Example Clinical Measures-Standards-Practices Grid Page 5 of 10 Basic Level Instruction: Please add Check mark and Date where appropriate Facility:

6. Completed by: Filing Location: Version: Date: Spectrum Systems HCC Tool Example Clinical Measures-Standards-Practices Grid Page 6 of 10 Basic Level Instruction: Please add Check mark and Date where appropriate Facility:

7. Completed by: Filing Location: Version: Date: Spectrum Systems HCC Tool Example Clinical Measures-Standards-Practices Grid Page 7 of 10 Basic Level Instruction: Please add Check mark and Date where appropriate Facility:

8. Completed by: Filing Location: Version: Date: Spectrum Systems HCC Tool Example Clinical Measures-Standards-Practices Grid Page 8 of 10 Basic Level Instruction: Please add Check mark and Date where appropriate Facility:

9. Completed by: Filing Location: Version: Date: Spectrum Systems HCC Tool Example Clinical Measures-Standards-Practices Grid Page 9 of 10 Basic Level Instruction: Please add Check mark and Date where appropriate Facility:

10. Completed by: Filing Location: Version: Date: Spectrum Systems HCC Tool Example Clinical Measures-Standards-Practices Grid Page 10 of 10 Basic Level Instruction: Please add Check mark and Date where appropriate Facility: