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HQA Preview Reports now available

January 19, 2009

March 2009 Hospital Compare Preview Reports for the Hospital Quality Alliance (HQA) and Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) initiatives are now available to participating hospitals and Quality Improvement Organizations (QIOs) on My QualityNet.

The HQA Preview Reports will be available from January 19 through February 17, 2009. (To access the reports, you must be a registered My QualityNet user and have been assigned the QIO Clinical Data Warehouse Feedback Report role.) The data that displays in the Preview Reports will be reported on Hospital Compare, the Centers for Medicare & Medicaid Services' (CMS) website for Medicare beneficiaries and the general public, tentatively in March 2009.

Report information

For more information on the reporting of the Clinical Process Measures, 30-Day Risk-Standardized Mortality Measures, and HCAHPS Survey Measures, refer to the March 2009 Preview Report Help Summary, PDF. (The Help Summary can also be accessed by a registered My QualityNet user from the “Need Help” link that displays when users run an HQA Preview Report on My QualityNet.)

The Preview Reports include data for:

• Clinical Process Measures
• 30-day Risk-Standardized Mortality Outcome Measures
• HCAHPS (Hospital Consumer Assessment of Healthcare Providers & Systems) Survey Measures

Clinical Process Measures

The Clinical Process Measures reflect data submitted to the QIO Clinical Warehouse for discharges from Third Quarter 2007 through Second Quarter 2008. “AMI- 6, Beta-blocker at Arrival,” will be retired, effective with discharges after March 31, 2009. CMS will begin suppressing these data from public reporting and all relevant reports beginning with the March 2009 release of Hospital Compare. Data for SCIP-Inf-4 and SCIP-Inf-6 will be reported beginning with First Quarter 2008. The Preview Report will display “N/A” for the third and fourth quarters of 2007.

To meet RHQDAPU requirements, data from PN-5b must be submitted. For public reporting purposes, PN-5c results are being calculated from the PN-5b data. All hospitals may suppress PN-5c. PN-5b will not display on the Preview Report and will not be reported on Hospital Compare.

Hospitals may contact their QIO Hospital Reporting Contact for questions regarding the Clinical Process Measures.

30-Day Risk-Standardized Mortality Measures

The data for the 30-Day Risk-Standardized Mortality Measures for acute myocardial infarction (AMI), heart failure (HF), and pneumonia (PN) are based on administrative data from hospitalized, fee-for-service Medicare beneficiaries discharged from Third Quarter 2006 through Second Quarter 2007.  For information related to the 30-Day Risk-Standardized Mortality Measures, contact the Outcomes Measures implementation team at mortalitymeasures@mathematica-mpr.com.

HCAHPS (Hospital Consumer Assessment of Healthcare Providers & Systems) Survey Measures

HCAHPS data reflects four quarters of HCAHPS survey data for discharges (Third Quarter 2007 through Second Quarter 2008). Beginning with the March 2009 release, IPPS hospitals with a RHQDAPU pledge may no longer suppress (withhold from publication) their HCAHPS results.

For information related to the HCAHPS Measures, contact the HCAHPS Project Team at hcahps@azqio.sdps.org.

Data Suppression

To suppress data, hospitals must complete the HQA Request for Withholding Data from Public Reporting form and submit it to their QIO Hospital Reporting Contact no later than the QIO's close of business on February 17, 2009. It is recommended that hospitals alert their QIO Hospital Reporting Contact when faxing the request. Because a withholding request is applicable only for the current reporting period, HQA hospitals that suppressed data for one or more measures in December 2008 must submit a new form in order to continue suppression of the same measure(s).

Please note:Beginning with the March 2009 public reporting and forward, HCAHPS results from all Inpatient Prospective Payment System (IPPS) hospitals participating in the RHQDAPU program will be published on the Hospital Compare website. All hospitals will continue to receive a Preview Report prior to public reporting, and non-IPPS hospitals will continue to have the option of withholding their HCAHPS results from public reporting.