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Data Validation - Overview
Assuring data accuracy is vital to public reporting programs. The Centers for Medicare & Medicaid Services (CMS) assesses the accuracy of chart-abstracted and Healthcare-Associated Infections (HAI) data submitted to the Hospital Inpatient Quality Reporting (IQR) Program through the validation process. CMS verifies on a quarterly basis that hospital-abstracted data submitted to the Clinical Warehouse and data submitted to the National Healthcare Safety Network (NHSN) can be reproduced by a trained abstractor using a standardized protocol.
CMS performs a random and targeted selection of Inpatient Prospective Payment Systems (IPPS) hospitals on an annual basis. The random selection of 400 hospitals for Fiscal Year (FY) 2019 occurred in November of 2016. In April/May of 2017, an additional targeted provider sample of up to 200 hospitals will be selected, based on CMS targeting criteria as outlined in the FY 2014 IPPS/Long-Term Care Hospital Prospective Payment System (LTCH PPS) Final Rule (78 FR 50833 through 50834). The quarters included in FY 2019 validation are third quarter 2016 (3Q16), fourth quarter 2016 (4Q16), first quarter 2017 (1Q17), and second quarter 2017 (2Q17).
As described in the FY 2015 IPPS/LTCH PPS final rule (79 FR 50266), all chart-abstracted measure topic areas included in the Hospital IQR Program, with the exception of the Perinatal Care topic area, are automatically included in the validation process. This topic area is not included because the Elective Delivery PC-01 (NQF#0469) measure is reported in aggregate form, which is not consistent with the rest of the patient-level validation process.
CMS will validate up to eight cases for clinical process of care measures per quarter per hospital. Cases are randomly selected from data submitted to the warehouse by the hospital. The measures available for this validation fiscal year are: Stroke (STK), Emergency Department (ED), Immunization (IMM), Venous Thromboembolism (VTE), and Sepsis (SEP). Below is a list of the clinical process of care measures available to be validated in each quarter of FY 2019:
- 3Q16 - STK, ED, IMM, VTE, SEP
- 4Q16 - STK, ED, IMM, VTE, SEP
- 1Q17 - ED, IMM, VTE, SEP
- 2Q17 - ED, IMM, VTE, SEP
CMS will validate up to ten candidate HAI cases total per quarter per hospital. CMS will validate candidate cases sampled for the following HAI measures: central line-associated blood stream infection (CLABSI), catheter-associated urinary tract Infection (CAUTI), Methicillin-Resistant Staphylococcus Aureus (MRSA) laboratory-identified (LabID) events, Clostridium difficile Infection (CDI) LabID events, and Surgical Site Infection (SSI).
Hospitals selected for FY 2019 validation will provide two of four lists of positive cultures each quarter. Hospitals will submit either (but not all four):
- CLABSI and CAUTI Validation Templates or
- MRSA and CDI Validation Templates
Refer to Data Validation Resources for the most current versions of the Validation Templates.
CMS will randomly assign half of the hospitals selected for FY 2019 validation to submit CLABSI and CAUTI Validation Templates and the other half of hospitals will be assigned to submit MRSA and CDI Validation Templates. CMS will select up to four candidate HAI cases per hospital from each of the assigned Validation Templates. CMS will also select up to two candidate SSI cases from Medicare claims data for patients who had colon surgeries or abdominal hysterectomies that appear suspicious of infection. Hospitals do not fill out templates for SSI cases. When there are not enough candidate cases for any one specific infection to meet the targeted number of cases, CMS will select candidate cases from other infection types to meet sample size targets.
Medical Record Request
Each quarter, the Clinical Data Abstraction Center (CDAC) will send hospitals a written request using Federal Express Certified Mail to submit a patient medical record for each case that CMS selected for validation. IQR hospitals have 30 days from the original request date to submit requested records to CDAC. Hospitals have the option to submit the requested medical records in paper format, on removable media, or via the QualityNet Secure Portal Secure File Transfer application. Records not received by the specified due date are not eligible for abstraction and will be scored a “zero”. For more information regarding medical records requested by the CDAC, refer to CDAC Information.
A hospital’s list of cases selected for validation each quarter, including all available patient identifiers, can be accessed via the QualityNet Secure Portal by a registered user. Please note that this report can take several business days after original request date to become available. To access the report:
- Log in to the QualityNet Secure Portal
- Select [My Reports] followed by [Run Reports]
- Select [IQR Program: Hospital Reporting – Data Validation Reports]
- Select [Hospital Data Validation – Case Selection Report]
It typically takes approximately 4 months after each quarter’s submission deadline for hospitals to see their validation results for the quarter. Hospital staff with the Reports role will receive email notification when their Validation Case Detail and Validation Summary reports become available to run. The reports provide the validation results of abstraction determined by the CDAC on each selected case.
Educational ReviewsWithin 30 days of validation results being posted on the My Reports section of the QualityNet Secure Portal, if a hospital has a question or needs further clarification on a particular outcome, the hospital may request an educational review. Please note quarterly validation results will not be changed as a result of an educational review. For more information regarding the educational review process, refer to Educational Reviews.
For FY 2019, the finalized validation process for chart-abstracted measures includes two separate validation strata:
- Healthcare-associated infection (HAI), weighed at 66.7%; and
- Other/Clinical Process of Care, weighed at 33.3%.
At the end of the Fiscal Year, Annual Payment Update (APU) results are expected to be released in April or May (for FY 2019, this will be April or May 2018). CMS calculates a total score reflecting a weighted average of two individual scores for the reliability of the clinical process of care and HAI measure sets. After the scores are combined, CMS computes a confidence interval around the combined score. If the upper bound of this confidence interval is 75 percent or higher, the hospital will pass the Hospital IQR Program validation requirement; if the Confidence Interval is below 75 percent, the hospital will fail the Hospital IQR Program validation requirement.If a hospital does not meet the overall validation requirement, the hospital will not receive full APU. For additional information regarding APU reduction, refer to the APU Recipients page of QualityNet. Hospitals that fail validation will also automatically be selected for validation in the next fiscal year.
Refer to Data Validation Resources for more information regarding the validation process.