NQF

Version Number: 12.8
Meeting Date: December 4, 2019

Measure Applications Partnership
Hospital Workgroup Discussion Guide

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Agenda

Agenda Synopsis

Time Session
December 4, 2019  
8:30 AM   Breakfast
9:00 AM   Welcome and Review of Meeting Objectives
9:15 AM   CMS Opening Remarks and Meaningful Measures Update
10:15 AM   Overview of Pre-Rulemaking Approach
10:45 AM   Break
11:00 AM   Prospective Payment System (PPS)-Exempt Cancer Hospital Quality Reporting (PCHQR) Program Measures
12:30 PM   Lunch
1:00 PM   Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program Measure
1:45 PM   End-Stage Renal Disease Quality Incentive Program (ESRD QIP) Measure
2:30 PM   Break
2:45 PM   Hospital Inpatient Quality Reporting (IQR) Program and Medicare and Medicaid Promoting Interoperability Program for Eligible Hospitals and Critical Access Hospitals (CAHs) Measures
4:00 PM   Opportunity for Public Comment
4:15 PM   Summary of Day and Next Steps
4:30 PM   Adjourn for the Day


Full Agenda

December 4, 2019  
8:30 AM   Breakfast
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9:00 AM   Welcome and Review of Meeting Objectives
R. Sean Morrison, MAP Hospital Workgroup Co-chair
Cristie Upshaw Travis, MAP Hospital Workgroup Co-chair
Sam Stolpe, Senior Director, NQF
Taroon Amin, Consultant, NQF
Elisa Munthali, Senior Vice President, Quality Measurement, NQF

9:15 AM   CMS Opening Remarks and Meaningful Measures Update
Michelle Schreiber, QMVIG Group Director, CMS


10:15 AM   Overview of Pre-Rulemaking Approach
Sam Stolpe
Madison Jung, Project Manager, NQF

10:45 AM   Break
11:00 AM   Prospective Payment System (PPS)-Exempt Cancer Hospital Quality Reporting (PCHQR) Program Measures
Measures under consideration:
  1. National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection Outcome Measure (MUC ID: MUC2019-18)
    • Description: Standardized Infection Ratio (SIR) of healthcare-associated, catheter-associated urinary tract infections (UTI) will be calculated among patients in bedded inpatient care locations, except level II or level III neonatal intensive care units (NICU). This includes acute care general hospitals, long-term acute care hospitals, rehabilitation hospitals, oncology hospitals, and behavior health hospitals. (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This NQF endorsed measure is currently included in PCHQR and addresses the Meaningful Measure Area of healthcare-associated infections not currently included in PCHQR. The risk-adjustment model for this measure was updated and the measure was submitted and re-endorsed by the NQF Patient Safety Standing Committee in the CDP Spring 2019 Cycle. The measure is otherwise identical to the existing measure in PCHQR.
      • Impact on quality of care for patients:This measure enourages the measurement and prevention of a serious adverse outcome caused by CAUTIs for patients in cancer hospitals.CAUTI is the most common type of healthcare-associated infection, accounting for more than 30% of acute care hospital infections. 13,000 deaths are associated with UTIs each year. There are estimated to be 449,334 CAUTI events per year. Each CAUTI is associated with the medical cost of $758. A total of over $340 million spent in health care is attributable to the incident of CAUTI in the U.S. each year (Klevens et al., 2007).
    • Preliminary analysis result: Support for Rulemaking


  2. National Healthcare Safety Network (NHSN) Central Line Associated Bloodstream Infection Outcome Measure (MUC ID: MUC2019-19)
    • Description: Standardized Infection Ratio (SIR) and Adjusted Ranking Metric (ARM) of healthcare-associated, central line-associated bloodstream infections (CLABSI) will be calculated among patients in bedded inpatient care locations. (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This NQF endorsed measure is currently included in PCHQR and addresses the Meaningful Measure Area of healthcare-associated infections. The risk-adjustment model for this measure was updated and the measure was submitted and re-endorsed by the NQF Patient Safety Standing Committee in the CDP Spring 2019 Cycle. The measure is otherwise identical to the existing measure in PCHQR.
      • Impact on quality of care for patients:This measure enourages the measurement and prevention of a serious adverse outcome caused by CLASBIs for patients in cancer hospitals.Central line-associated bloodstream infections (CLABSI) are associated with significant morbidity, mortality, and costs. Patients in intensive care units (ICUs) are at an increased risk for CLABSI, because 48 percent of ICU patients have indwelling central venous catheters, accounting for 15 million central line days per year in U.S. ICUs. Assuming an average CLABSI rate of 5.3 per 1,000 catheter days and an attributable mortality of 18 percent (0-35 percent), as many as 28,000 patients die from CLABSI annually in U.S. ICUs (AHRQ, 2018).
    • Preliminary analysis result: Support for Rulemaking


12:30 PM   Lunch
1:00 PM   Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program Measure
Measures under consideration:
  1. Follow-Up After Psychiatric Hospitalization (MUC ID: MUC2019-22)
    • Description: The Follow-Up After Psychiatric Hospitalization measure assesses the percentage of inpatient discharges with principal diagnoses of select mental illness or substance use disorders (SUD) for which the patient received a follow-up visit for treatment of mental illness or SUD. Two rates are reported:1. Percentage of discharges for which the patient received follow-up within 7 days of discharge2. Percentage of discharges for which the patient received follow-up within 30 days of dischargeThe performance period used to identify denominator cases is 12 months. Data from the performance period and 30 days after are used to identify follow-up visits in the numerator. (Measure Specifications)
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:The Follow-Up After Psychiatric Hospitalization (FAPH) measure is an expansion of the existing Inpatient Psychiatric Facility Quality Reporting program Follow-Up After Hospitalization for Mental Illness (IPFQR FUH) measure that was adapted from the NQF #0576. During the 2017 comprehensive review of NQF #0576, the NQF Behavioral Health Standing Committee (BHSC) recommended expanding the measure population to include patients hospitalized for drug and alcohol disorders because those patients also require follow-up care post-discharge. This fully tested and specified claims-based process measure should be submitted to NQF for endorsement review.
      • Impact on quality of care for patients:The Follow-Up After Psychiatric Hospitalization measure can enhance compliance with clinical guidelines as facilities will receive better scores by conducting follow-up visits with discharged patients, thus improving the continuity of care and monitoring of patients.
    • Preliminary analysis result: Conditional Support for Rulemaking


1:45 PM   End-Stage Renal Disease Quality Incentive Program (ESRD QIP) Measure
Measures under consideration:
  1. Standardized Transfusion Ratio for Dialysis Facilities (MUC ID: MUC2019-64)
    • Description: The risk adjusted facility level transfusion ratio (STR) is specified for all adult dialysis patients. It is a ratio of the number of eligible red blood cell transfusion events observed in patients dialyzing at a facility, to the number of eligible transfusion events that would be expected under a national norm, after accounting for the patient characteristics within each facility. Eligible transfusions are those that do not have any claims pertaining to the comorbidities identified for exclusion, in the one year look back period prior to each observation window.This measure is calculated as a ratio, but can also be expressed as a rate. (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is based on NQF #2979, which is currently included in the ESRD QIP program. The measure has undergone substantial updates related to the codes used in the transfusion definition and the handling of Medicare Advantage. The measure addresses the Meaningful Measure Area of management of chronic conditions for ESRD QIP. This updated and re-specified claims-based outcome measure has been submitted endorsement review by the NQF Renal Standing Committee in CDP Fall Cycle 2019. Conditional support pending NQF review and endorsement.
      • Impact on quality of care for patients:This measure encourages the appropriate prevention and management of anemia for patients in dialysis facilities.
    • Preliminary analysis result: Conditional Support for Rulemaking


2:30 PM   Break
2:45 PM   Hospital Inpatient Quality Reporting (IQR) Program and Medicare and Medicaid Promoting Interoperability Program for Eligible Hospitals and Critical Access Hospitals (CAHs) Measures
Measures under consideration:
  1. Maternal Morbidity (MUC ID: MUC2019-114)
    • Description: Structural Measure to address severe maternal morbidity in the inpatient hospital setting. (Measure Specifications)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:While the Hospital Inpatient Quality Reporting program does not currently include any measures assessing maternal morbidity, the measure is a structural measure without evidence on how participation in a QI collaborative can improve maternal morbidity, or that attestation to the same is indicative of maternal care quality and better outcomes. The developer should complete measure development and submit to NQF for review and endorsement.
      • Impact on quality of care for patients:Participation in QI initiatives should be undertaken by hospitals to share best practices and drive improvement in clinical care. It is unclear how participation in these QI initiatives will impact outcomes most important to patients, or how strong the links between attestation and actual quality care are. Efforts should be undertaken to develop quality outcome measures that address severe morbidity and mortality rates during delivery and the postpartum period.
    • Preliminary analysis result: Do Not Support for Rulemaking


  2. Hospital Harm - Severe Hyperglycemia (MUC ID: MUC2019-26)
    • Description: This measure assesses the proportion of hospital days with a severe hyperglycemic event for hospitalized patients 18 or older who have a diagnosis of diabetes mellitus, have received at least one administration of insulin or an anti-diabetic medication during the hospital admission, or have had an elevated blood glucose level (>200 mg/dL) during their hospital admission. (Measure Specifications)
    • Public comments received: 5
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This fully developed and specified measure addresses the priority area of preventable healthcare harm for the IQR program. IQR currently does not include a measure that assesses severe hyperglycemia events that are largely avoidable through proper glycemic monitoring and intervention.This measure has been submitted for endorsement review to the NQF Patient Safety Standing Committee in CDP Fall Cycle 2019. Conditional support pending NQF review and endorsement.
      • Impact on quality of care for patients:Measuring hyperglycemia events in the hospital setting will provide hospitals with a reliable and timely measurement of their hyperglycemia event rates. With a systematic EHR-based hospital harm measure in place, hospitals can more reliably assess harm reduction efforts and modify their improvement efforts in near real-time (Falciglia et al., 2009).
    • Preliminary analysis result: Conditional Support for Rulemaking


4:00 PM   Opportunity for Public Comment
4:15 PM   Summary of Day and Next Steps
R. Sean Morrison
Cristie Upshaw Travis
Jordan Hirsch

4:30 PM   Adjourn for the Day

Appendix A: Measure Information

Measure Index

End-Stage Renal Disease Quality Incentive Program

Hospital Inpatient Quality Reporting (IQR) Program and Medicare and Medicaid Promoting Interoperability Program for Eligible Hospitals and Critical Access Hospitals (CAHs)

Inpatient Psychiatric Facility Quality Reporting Program

Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program


Full Measure Information

Standardized Transfusion Ratio for Dialysis Facilities (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC2019-64)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The Medicare ESRD Program requires Medicare certified dialysis facilities to manage the anemia of CKD as one of their responsibilities under the Conditions for Coverage (1). In addition, the Medicare ESRD Program has included payment for ESAs in dialysis facility reimbursement since 1989. It is notable that inclusion of ESAs in dialysis program payment was associated with a dramatic reduction in the use of blood transfusions in the US chronic dialysis population (2-3). Recently, reliance on achieved hemoglobin concentration as an indicator of successful anemia management in this population has been de-emphasized and use of other clinically meaningful outcomes, such as transfusion avoidance, have been recommended as alternate measures of anemia management (4-7).
Best dialysis provider practice should include effective anemia management algorithms that focus on 1) prevention and treatment of iron deficiency, inflammation and other causes of ESA resistance, 2) use of the lowest dose of ESAs that achieves an appropriate target hemoglobin that is consistent with FDA guidelines and current best practices, and 3) education of patients, their families and medical providers to avoid unnecessary blood transfusion so that risk of allosensitization is minimized, eliminating or reducing one preventable barrier to successful kidney transplantation.
The decision to transfuse blood is intended to improve or correct the pathophysiologic consequences of severe anemia, defined by achieved hemoglobin or hematocrit%, in a specific clinical context for each patient situation (8). Consensus guidelines in the U.S. and other consensus guidelines defining appropriate use of blood transfusions are based, in large part, on the severity of anemia (9-11). Given the role of hemoglobin as a clinical outcome that defines anemia as well as forms a basis for consensus recommendations regarding use of blood transfusion, it is not surprising that the presence of decreased hemoglobin concentration is a strong predictor of subsequent risk for blood transfusion in multiple settings, including chronic dialysis (12-21). For example, Gilbertson, et al found a nearly four-fold higher risk-adjusted transfusion rate in dialysis patients with achieved hemoglobin <10 gm/dl compared to those with >10 gm/dl hemoglobin. (19) In addition to achieved hemoglobin, other factors related to dialysis facility practices, including the facility’s response to their patients achieved hemoglobin, may influence blood transfusion risk in the chronic dialysis population (22, 25). In an observational study recently published by Molony, et al (2016) comparing different facility level titration practices, among patients with hemoglobin <10 and those with hemoglobin>11, they found increased transfusion risk in patients with larger ESA dose reductions and smaller dose escalations, and reduced transfusion risk in patients with larger ESA dose increases and smaller dose reductions (25). The authors reported no clinically meaningful differences in all-cause or cause-specific hospitalization events across groups.
The Food and Drug Administration position defining the primary indication of ESA use in the CKD population is for transfusion avoidance, reflecting the assessment of the relative risks and benefits of ESA use versus blood transfusion. Several historical studies, and one recent research study reviewed by Obrador and Macdougall, document the specific risks of allosensitization after blood transfusion and the potential for transfusion-associated allosensitization to interfere with timely kidney transplantation. (23) A recent analysis demonstrated increased odds ratios for allosensitization associated with transfusion, particularly for men and parous women. That study also demonstrated a 28% reduction in likelihood of transplantation in transfused individuals, based on a multivariate risk-adjusted statistical model. (24) REFERENCES1. ESRD Facility Conditions for Coverage. https://www.cms.gov/Center/Special-Topic/End-Stage-Renal-Disease-ESRD-Center.html. 2. Eschbach et al. Recombinant Human Erythropoietin in Anemic Patients with End-Stage Renal Disease. Results of a Phase III Multicenter Clinical Trial. Annals of Internal Medicine. 1989;111:992-1000.3. Powe et al. Early dosing practices and effectiveness of recombinant human erythropoietin. Kidney International, Vol. 43 (1993), pp. 1125—1133. 4. FDA Drug Safety Communication: Modified dosing recommendations to improve the safe use of Erythropoiesis-Stimulating Agents (ESAs) in chronic kidney disease. http://www.fda.gov/Drugs/DrugSafety/ucm259639.htm. 5. Kidney Disease: Improving Global Outcomes (KDIGO) Anemia Work Group. KDIGO Clinical Practice Guideline for Anemia in Chronic Kidney Disease. Kidney inter., Suppl. 2012; 2: 279–335. http://www.kdigo.org/clinical_practice_guidelines/pdf/KDIGO-Anemia%20GL.pdf.6. Kliger et al. KDOQI US Commentary on the 2012 KDIGO Clinical Practice Guideline for Anemia in CKD. Am J Kidney Dis. 62(5):849-859. 7. Berns, Jeffrey S., Moving Away From Hemoglobin-Based Anemia Performance Measures in Dialysis Patients. Am J Kidney Dis. 2014;64(4):486-488. 8. Whitman, Shreay, Gitlin, van Oijen, & Spiegel. Clinical Factors and the Decision to Transfuse Chronic Dialysis Patients. Clin J Am Soc Nephrol 8: ccc–ccc, 2013. doi: 10.2215/CJN.00160113. 9. Carson et al. Red Blood Cell Transfusion: A Clinical Practice Guideline From the AABB. Ann Intern Med. 2012;157:49-58. 10. American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Practice guidelines for perioperative blood transfusion and adjuvant therapies: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Anesthesiology. 2006;105:198–208. 11. Munoz et al. “Fit to flyâ€; overcoming barriers to preoperative haemoglobin optimization in surgical patients. Br J Anaesth. 2015 Jul;115(1):15-24. 12. Dunne, Malone, Tracy, Gannon, and Napolitano. Perioperative Anemia: An Independent Risk Factor for Infection, Mortality, and Resource Utilization in Surgery. Journal of Surgical Research 102, 237-244 (2002). 13. Covin R, O'Brien M, Grunwald G, Brimhall B, Sethi G, Walczak S, Reiquam W, Rajagopalan C, Shroyer AL Factors affecting transfusion of fresh frozen plasma, platelets, and red blood cells during elective coronary artery bypass graft surgery. Arch Pathol Lab Med. 2003 Apr;127(4):415-23. 14. Jans et al. Role of preoperative anemia for risk of transfusion and postoperative morbidity in fast-track hip and knee arthroplasty. Transfusion. 2014 Mar;54(3):717-26.15. Saleh et al. Allogenic Blood Transfusion Following Total Hip Arthroplasty: Results from the Nationwide Inpatient Sample, 2000 to 2009. J Bone Joint Surg Am. 2014;96:e155(1-10).16. Ejaz, Spolverato, Kim, Frank, and Pawlik. Variations in triggers and use of perioperative blood transfusions in major gastrointestinal surgery. Br. J. Surg. 2014 Oct;101(11):1424-33.17. Foley, Curtis, & Parfrey. Hemoglobin Targets and Blood Transfusions in Hemodialysis Patients without Symptomatic Cardiac Disease Receiving Erythropoietin Therapy. Clin J Am Soc Nephrol 3: 1669–1675, 2008. doi: 10.2215/CJN.02100508. 18. Hirth, Turenne, Wilk et al. Blood transfusion practices in dialysis patients in a dynamic regulatory environment. Am J Kidney Dis. 2014 Oct;64(4):616-21. doi: 10.1053/j.ajkd.2014.01.011. Epub 2014 Feb. 19. Gilbertson, Monda, Bradbury & Collins. RBC Transfusions Among Hemodialysis Patients (1999-2010): Influence of Hemoglobin Concentrations Below 10 g/dL. Am J Kidney Dis. 2013; Volume 62 , Issue 5 , 919 – 928.20. Collins et al. Effect of Facility-Level Hemoglobin Concentration on Dialysis Patient Risk of Transfusion. Am J Kidney Dis. 2014; 63(6):997-1006. 21. Cappell et al. Red blood cell (RBC) transfusion rates among US chronic dialysis patients during changes to Medicare end-stage renal disease (ESRD) reimbursement systems and erythropoiesis stimulating agent (ESA) labels. BMC Nephrology 2014, 15:116. 22. House AA, Pham B, Pagé DE. Transfusion and recombinant human erythropoietin requirements differ between dialysis modalities. Nephrol Dial Transplant. 1998 Jul;13(7):1763-9. 23. Obrador and Macdougall. Effect of Red Cell Transfusions on Future Kidney Transplantation. Clin J Am Soc Nephrol 8: 852–860, 2013.24. Ibrahim, et al. Blood transfusions in kidney transplant candidates are common and associated with adverse outcomes. Clin Transplant 2011: 25: 653–659. 25. Molony, et al. Effects of epoetin alfa titration practices, implemented after changes to product labeling, on hemoglobin levels, transfusion use, and hospitalization rates. Am J Kidney Dis 2016: epub before print (published online March 12, 2016).

Summary of NQF Endorsement Review




Maternal Morbidity (Program: Hospital Inpatient Quality Reporting (IQR) Program and Medicare and Medicaid Promoting Interoperability Program for Eligible Hospitals and Critical Access Hospitals (CAHs); MUC ID: MUC2019-114)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The rationale for this measure to address Severe Maternal Morbidity (SMM) is that SMM is increasing at an alarming rate in the U.S. Rates have nearly doubled over the past decade. Evidence shows that there is a high rate of preventability of SMM and 60% of maternal deaths are preventable. Identification and effective treatment of SMM are very essential to prevent conditions that lead to maternal mortality. There are currently no quality measures that address maternal morbidity as a whole and the CMS Office of the Administrator (OA) is very dedicated in addressing this healthcare crisis. The structural measure will evaluate how many hospitals and health systems are working within any type of quality improvement collaborative which has proven to help prevent and manage SMM. This measure will eventually be replaced by a comprehensive outcome measure.


Hospital Harm - Severe Hyperglycemia (Program: Hospital Inpatient Quality Reporting (IQR) Program and Medicare and Medicaid Promoting Interoperability Program for Eligible Hospitals and Critical Access Hospitals (CAHs); MUC ID: MUC2019-26)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Severe hyperglycemia - an extremely elevated blood glucose level - is significantly associated with a range of harms, including increased in-hospital mortality, infection rates, and hospital length of stay.5-9 Moreover, the rate of severe hyperglycemia varies across hospitals, suggesting opportunities for improvement in inpatient glycemic management.10 The rate of inpatient hyperglycemia can be considered a marker for quality of hospital care, since inpatient hyperglycemia is largely avoidable with proper glycemic management. The use of evidence-based standardized protocols and insulin management protocols have been shown to improve glycemic control and safety.11-12References:5. Falciglia M, Freyberg RW, Almenoff PL, D'Alessio DA, Render ML. Hyperglycemia-Related Mortality in Critically Ill Patients Varies with Admission Diagnosis. Crit Care Med. 2009;37(12):3001-3009. 6. King JT, Jr., Goulet JL, Perkal MF, Rosenthal RA. Glycemic Control and Infections in Patients with Diabetes Undergoing Noncardiac Surgery. Ann Surg. 2011;253(1):158-165. 7. Pasquel FJ, Spiegelman R, McCauley M, et al. Hyperglycemia During Total Parenteral Nutrition: An Important Marker of PoorOutcome and Mortality in Hospitalized Patients. Diabetes Care. 2010;33(4):739-741. 8. Rady MY, Johnson DJ, Patel BM, Larson JS, Helmers RA. Influence of Individual Characteristics on Outcome of Glycemic Control in Intensive Care Unit Patients With or Without Diabetes Mellitus. Mayo Clin Proc. 2005;80(12):1558-1567. 9. Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: An Independent Marker of In-Hospital Mortality in Patients with Undiagnosed Diabetes. J Clin Endocrinol Metab. 2002;87(3):978-982. 10. Swanson CM, Potter DJ, Kongable GL, Cook CB. Update on Inpatient Glycemic Control in Hospitals in the United States. Endocr Pract. 2011;17(6):853-861. 11. Donihi AC, DiNardo MM, DeVita MA, Korytkowski MT. Use of a Standardized Protocol to Decrease Medication Errors and Adverse Events Related to Sliding Scale Insulin. Qual Saf Health Care. 2006;15(2):89-91. 12. Maynard G, Kulasa K, Ramos P, et al. Impact of a Hypoglycemia Reduction Bundle and a Systems Approach to Inpatient Glycemic Management. Endocr Pract. 2015;21(4):355-367.


Follow-Up After Psychiatric Hospitalization (Program: Inpatient Psychiatric Facility Quality Reporting Program; MUC ID: MUC2019-22)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Studies have found that readmission rates for those with psychiatric diagnoses are lower if patients receive follow-up visits within 30 days of discharge. A 2017 study found that receipt of a follow-up visit within 30 days of hospital discharge lowered the readmission risk during days 31 to 120 for patients with schizophrenia and for patients with bipolar disorder. Similarly, a 2018 study observed that among patients discharged with schizophrenia, psychiatric readmission rates on days 31-180 were lower if the patient saw a primary care physician or psychiatrist within 30 days of discharge.Inpatient psychiatric facilities can influence rates of follow-up care for patients hospitalized for mental illness or SUD. Interventions that have been shown effective in the literature include following up with letters or telephone calls, discussing barriers to attending the first outpatient post-discharge appointment with the patient, and serving as a contact for questions or concerns between discharge and the first outpatient appointment. Three studies reported that with certain interventions facilities achieved follow-up rates of 88 percent or more, compared to the national 30-day follow-up rate of approximately 54 percent observed in the current Inpatient Psychiatric Facility Quality Reporting program's Follow-Up After Hospitalization for Mental Illness measure for Medicare FFS discharges between July 1, 2015 and June 30, 2016.


National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection Outcome Measure (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC2019-18)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Evidence that this measure promotes CAUTI prevention activities that will lead to improved patient outcomes including reduction of avoidable medical costs, and patient morbidity and mortality through reduced need for antimicrobials and reduced length of stay.

Summary of NQF Endorsement Review




National Healthcare Safety Network (NHSN) Central Line Associated Bloodstream Infection Outcome Measure (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC2019-19)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
A substantial body of peer-reviewed studies and reviews document that CLABSI can be minimized through proper management of the central line. Efforts to improve central line insertion and maintenance practices, with early discontinuance of lines are recommended. These efforts result in decreased morbidity and mortality and reduced healthcare costs.Use of this measure to track CLABSIs through a nationalized standard for HAI monitoring, leads to improved patient outcomes and provides a mechanism for identifying improvements and evaluating prevention efforts.

Summary of NQF Endorsement Review





Appendix B: Program Summaries

The material in this appendix was drawn from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2019.

Program Index


Full Program Summaries

Ambulatory Surgical Center Quality Reporting Program 
The material in this appendix was drawn from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2019.

Program History and Structure: The Ambulatory Surgical Center Quality Reporting Program (ASCQR) was established under the authority provided by Section 109(b) of the Medicare Improvements and Extension Act of 2006, Division B, Title I of the Tax Relief and Health Care Act (TRHCA) of 2006. The statute provides the authority for requiring ASCs paid under the ASC fee schedule (ASCFS) to report on process, structure, outcomes, patient experience of care, efficiency, and costs of care measures. ASCs receive a 2.0 percentage point payment penalty to their ASCFS annual payment update for not meeting program requirements. CMS implemented this program so that payment determinations were effective beginning with the Calendar Year (CY) 2014 payment update.

High Priority Domains for Future Measure Consideration:

CMS identified the following categories as high-priority for future measure consideration:

  1. Making Care Safer
  2. Person and Family Engagement
  3. Best Practice of Healthy Living
  4. Effective Prevention and Treatment a. Surgical outcome measures
  5. Making Care Affordable
  6. Communication/Care Coordination

Measure Requirements:

CMS applies criteria for measures that may be considered for potential adoption in the ASCQR. At a minimum, the following requirements will be considered in selecting measures for ASCQR implementation:

  1. Measure must adhere to CMS statutory requirements.
    1. Measures are required to reflect consensus among affected parties, and to the extent feasible, be endorsed by the national consensus entity with a contract under Section 1890(a) of the Social Security Act
    2. The Secretary may select a measure in an area or topic in which a feasible and practical measure has not been endorsed, by the entity with a contract under Section 1890(a) of the Social Security Act, as long as endorsed measures have been given due consideration
  2. Measure must address a NQS priority/CMS strategy goal, with preference for measures addressing the high priority domains for future measure consideration.
  3. Measure must address an important condition/topic for which there is analytic evidence that a performance gap exists and that measure implementation can lead to improvement in desired outcomes, costs, or resource utilization.
  4. Measure must be field tested for the ASC clinical setting.
  5. Measure that is clinically useful.
  6. Reporting of measure limits data collection and submission burden since many ASCs are small facilities with limited staffing.
  7. Measure must supply sufficient case numbers for differentiation of ASC performance.
  8. Measure must promote alignment across HHS and CMS programs.
  9. Measure steward will provide CMS with technical assistance and clarifications on the measure as needed.

Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

End-Stage Renal Disease Quality Incentive Program 
The material in this appendix was drawn from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2019.

Program History and Structure: For more than 30 years, monitoring the quality of care provided to end-stage renal disease (ESRD) patients by dialysis facilities has been an important component of the Medicare ESRD payment system. The ESRD quality incentive program (QIP) is the most recent step in fostering improved patient outcomes by establishing incentives for dialysis facilities to meet or exceed performance standards established by CMS. The ESRD QIP is authorized by section 1881(h) of the Social Security Act, which was added by section 153(c) of Medicare Improvements for Patients and Providers (MIPPA) Act (the Act). CMS established the ESRD QIP for Payment Year (PY) 2012, the initial year of the program in which payment reductions were applied, in two rules published in the Federal Register on August 12, 2010, and January 5, 2011 (75 FR 49030 and 76 FR 628, respectively). Subsequently, CMS published rules in the Federal Register detailing the QIP requirements for PY 2013 through FY 2016. Most recently, CMS published a rule on November 6, 2014 in the Federal Register (79 FR 66119), providing the ESRD QIP requirements for PY2017 and PY 2018, with the intention of providing an additional year between finalization of the rule and implementation in future rules. Section 1881(h) of the Act requires the Secretary to establish an ESRD QIP by (i) selecting measures; (ii) establishing the performance standards that apply to the individual measures; (iii) specifying a performance period with respect to a year; (iv) developing a methodology for assessing the total performance of each facility based on the performance standards with respect to the measures for a performance period; and (v) applying an appropriate payment reduction to facilities that do not meet or exceed the established Total Performance Score (TPS).

High Priority Domains for Future Measure Consideration:

CMS identified the following 3 domains as high-priority for future measure consideration:

  1. Care Coordination: ESRD patients constitute a vulnerable population that depends on a large quantity and variety medication and frequent utilization of multiple providers, suggesting medication reconciliation is a critical issue. Dialysis facilities also play a substantial role in preparing dialysis patients for kidney transplants, and coordination of dialysis-related services among transient patients has consequences for a non-trivial proportion of the ESRD dialysis population.
  2. Safety: ESRD patients are frequently immune-compromised, and experience high rates of blood stream infections, vascular access-related infections, and mortality. Additionally, some medications provided to treat ESRD patients may cause harmful side effects such as heart disease and a dynamic bone disease. Recently, oral-only medications were excluded from the bundle payment, increasing need for quality measures that protect against overutilization of oral-only medications.
  3. Patient- and Caregiver-Centered Experience of Care: Sustaining and recovering patient quality of life was among the original goals of the Medicare ESRD QIP. This includes such issues as physical function, independence, and cognition. Quality of Life measures should also consider the life goals of the particular patient where feasible, to the point of including Patient-Reported Outcomes.

Measure Requirements:

  1. Measures for anemia management reflecting FDA labeling, as well as measures for dialysis adequacy.
  2. Measure(s) of patient satisfaction, to the extent feasible.
  3. Measures of iron management, bone mineral metabolism, and vascular access, to the extent feasible.
  4. Measures should be NQF endorsed, save where due consideration is given to endorsed measures of the same specified area or medical topic.
  5. Must include measures considering unique treatment needs of children and young adults.
  6. May incorporate Medicare claims and/or CROWNWeb data, alternative data sources will be considered dependent upon available infrastructure.

Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

Hospital Acquired Condition Reduction Program 
The material in this appendix was drawn from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2019.

Program History and Structure: Section 3008 of the Patient Protection and Affordable Care Act of 2010 (ACA) established the Hospital- Acquired Condition Reduction Program (HACRP). Created under Section 1886(p) of the Social Security Act (the Act), the HACRP provides an incentive for hospitals to reduce the number of HACs. Effective Fiscal Year (FY) 2014 and beyond, the HACRP requires the Secretary to make payment adjustments to applicable hospitals that rank in the top quartile of all subsection (d) hospitals relative to a national average of HACs acquired during an applicable hospital stay. HACs include a condition identified in subsection 1886(d)(4)(D)(iv) of the Act and any other condition determined appropriate by the Secretary. Section 1886(p)(6)(C) of the Act requires the HAC information be posted on the Hospital Compare website. CMS finalized in the FY 2019 IPPS/LTCH PPS final rule a scoring methodology change that removed domains and assigns equal weighting to each measure for which a hospital has a measure beginning with the FY 2020 HACRP. The program currently uses the CMS Patient Safety Indicator 90 (CMS PSI 90) and five Healthcare-Associated Infections (HAI) as collected by the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN). The measures in HACRP are categorized under the Meaningful Measure area of “Make Care Safer by Reducing Harm Caused in the Delivery of Care.” The Total HAC Score is the sum of the equally weighted average of the hospital’s measure scores.

High Priority Domains for Future Measure Consideration:

For FY 2018 federal rulemaking, CMS may propose the adoption, removal, and/or suspensionof measures for fiscal years 2019 and beyond of the HACRP. CMS identified the following topics as areas within the NQS priority of “Making Care Safer” for future measure consideration:

Making Care Safer:

  1. Measures that meet the Measure Requirements below that are electronic Clinical Quality Measures (eCQMs)
  2. Measures that address adverse drug events during the inpatient stay
  3. Measures that address ventilator-associated events
  4. Additional surgical site infection locations that are not already covered within an existing measure in the program
  5. Outcome risk-adjusted measures that capture outcomes from hospital-acquired conditions and are risk-adjusted to account for patient and/or facility differences (e.g., multiple comorbidities, patient care location)
  6. Measures that address diagnostic errors such as harm from receiving improper tests or treatment, harm from not receiving proper tests or treatment, harm from failure to diagnose, or harm from improper diagnosis
  7. Measure that address causes of hospital harm such as an all-cause harm measure or a measure that encompasses multiple harms
  8. Measures that demonstrate safety and/or high reliability practices and outcomes

Measure Requirements:

CMS applies criteria for measures that may be considered for potential adoption in the HACRP. At a minimum, the following requirements must be met for consideration in the HACRP:

Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

Hospital Inpatient Quality Reporting (IQR) Program and Medicare and Medicaid Promoting Interoperability Program for Eligible Hospitals and Critical Access Hospitals (CAHs) 
The material in this appendix was drawn from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2019.

Program History and Structure: The Hospital Inpatient Quality Reporting (IQR) Program was established by Section 501(b) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and expanded by the Deficit Reduction Act of 2005. The program requires hospitals paid under the Inpatient Prospective Payment System (IPPS) to report on process, structure, outcome, patient experience of care, efficiency, and cost of care measures. Failure to meet the requirements of the Hospital IQR Program will result in a reduction by one-fourth to a hospital’s fiscal year IPPS annual payment update (the annual payment update includes inflation in costs of goods and services used by hospitals in treating Medicare patients). Hospitals that choose to not participate in the program receive a reduction by that same amount. Hospitals not included in the Hospital IQR Program, such as critical access hospitals and hospitals located in Puerto Rico and the U.S. Territories, are permitted to participate in voluntary quality reporting. Performance of quality measures are publicly reported on the CMS Hospital Compare website. The American Recovery and Reinvestment Act of 2009 amended Titles XVIII and XIX of the Social Security Act to authorize incentive payments to eligible hospitals (EHs) and critical access hospitals (CAHs) that participate in Promoting Interoperability, to promote the adoption and meaningful use of certified electronic health record (EHR) technology (CEHRT). EHs and CAHs are required to report on electronically-specified clinical quality measures (eCQMs) using CEHRT in order to qualify for incentive payments under the Medicare and Medicaid Promoting Interoperability Program. All Promoting Interoperability Program requirements related to eCQM reporting will be addressed in IPPS rulemaking including, but not limited to, new program requirements, reporting requirements, reporting and submission periods, reporting methods, alignment efforts between the Hospital IQR Program and the Medicare and Medicaid Promoting Interoperability Program for EHs and CAHs, and information regarding the eCQMs. Based on current alignment efforts, hospitals that successfully submit eCQM data to meet Hospital IQR Program requirements fulfill the Medicare and Medicaid Promoting Interoperability Program requirement for reporting of eCQMs with one submission.

High Priority Domains for Future Measure Consideration:

CMS identified the following categories as high-priority for future measure consideration:

  1. Strengthen Person and Family Engagement as Partners in their Care:
    1. Functional Outcomes
    2. Care is Personalized and Aligned with Patient's Goals
  2. Promote Effective Communication and Coordination of Care:
    1. Seamless Transfer of Health Information
  3. Promote Effective Prevention and Treatment of Chronic Disease:
    1. Prevention and Treatment of Opioid and Substance Use Disorders
    2. Make Care Safer by Reducing Harm Caused in the Delivery of Care:
      1. Preventable Healthcare Harm

Measure Requirements:

CMS applies criteria for measures that may be considered for potential adoption in the HIQR program. At a minimum, the following criteria will be considered in selecting measures for HIQR program implementation:

  1. Measure must adhere to CMS statutory requirements.
    1. Measures are required to reflect consensus among affected parties, and to the extent feasible, be endorsed by the national consensus entity with a contract underSection 1890(a) of the Social Security Act; currently the National Quality Forum(NQF)
    2. The Secretary may select a measure in an area or topic in which a feasible and practical measure has not been endorsed, by the entity with a contract under Section 1890(a)of the Social Security Act, as long as endorsed measures have been given due consideration
  2. If feasible, measure must be claims-based or an electronically specified clinical quality measure(eCQM).
    1. A Measure Authoring Tool (MAT) number must be provided for all eCQMs, createdin the HQMF format
    2. eCQMs must undergo reliability and validity testing including review of the logic and value sets by the CMS partners, including, but not limited to, MITRE and the National Library of Medicine
    3. eCQMs must have successfully passed feasibility testing
  3. Measure may not require reporting to a proprietary registry.
  4. Measure must address an important condition/topic for which there is analytic evidence thata performance gap exists and that measure implementation can lead to improvement indesired outcomes, costs, or resource utilization.
  5. Measure must be fully developed, tested, and validated in an acute inpatient setting.
  6. Measure must address a NQS priority/CMS strategy goal, with preference for measures addressing the high priority domains and/or measurement gaps for future measure consideration.
  7. Measure must address a Meaningful Measure area, with preference for measures addressing the high priority domains and/or measurement gaps for future measure consideration
  8. Measure must promote alignment across HHS and CMS programs.
  9. Measure steward will provide CMS with technical assistance and clarifications on the measure as needed.

Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

Hospital Outpatient Quality Reporting Program 
The material in this appendix was drawn from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2019.

Program History and Structure: The Hospital Outpatient Quality Reporting (HOQR) Program was established by Section 109 of the Tax Relief and Health Care Act (TRHCA) of 2006. The program requires subsection (d) hospitals providing outpatient services paid under the Outpatient Prospective Payment System (OPPS) to report on process, structure, outcomes, efficiency, costs of care, and patient experience of care. Hospitals receive a 2.0 percentage point reduction of their annual payment update (APU) under the Outpatient Prospective Payment System (OPPS) for non-participation in the program. Performance on quality measures is publicly reported on the CMS Hospital Compare website

High Priority Domains for Future Measure Consideration:

CMS identified the following categories as high-priority for future measure consideration:

  1. Making Care Safer
  2. Person and Family Engagement
  3. Best Practice of Healthy Living
  4. Effective Prevention and Treatment a. Surgical outcome measures
  5. Making Care Affordable
  6. Communication/Care Coordination

Measure Requirements: CMS applies criteria for measures that may be considered for potential adoption in the HOQR program. At a minimum, the following criteria will be considered in selecting measures for HOQR program implementation:

  1. Measure must adhere to CMS statutory requirements.
    1. Measures are required to reflect consensus among affected parties, and to the extent feasible, be endorsed by the national consensus entity with a contract under Section 1890(a) of the Social Security Act
    2. The Secretary may select a measure in an area or topic in which a feasible and practical measure has not been endorsed, by the entity with a contract under Section 1890(a) of the Social Security Act, as long as endorsed measures have been given due consideration
  2. Measure must address a NQS priority/CMS strategy goal, with preference for measures addressing the high priority domains for future measure consideration.
  3. Measure must address an important condition/topic for which there is analytic evidence that a performance gap exists and that measure implementation can lead to improvement in desired outcomes, costs, or resource utilization.
  4. Measure must be fully developed, tested, and validated in the hospital outpatient setting.
  5. Measure must promote alignment across HHS and CMS programs.
  6. Feasibility of Implementation: An evaluation of feasibility is based on factors including, but not limited to
    1. The level of burden associated with validating measure data, both for CMS and for the end user.
    2. Whether the identified CMS system for data collection is prepared to accommodate the proposed measure(s) and timeline for collection.
    3. The availability and practicability of measure specifications, e.g., measure specifications in the public domain.
    4. The level of burden the data collection system or methodology poses for an end user.
  7. Measure steward will provide CMS with technical assistance and clarifications on the measure as needed.

Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

Hospital Readmissions Reduction Program 
The material in this appendix was drawn from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2019.

Program History and Structure: Section 3025 of the Patient Protection and Affordable Care Act of 2010 (ACA) established the Hospital Readmissions Reduction Program (HRRP). Codified under Section 1886(q) of the Social Security Act (the Act), the HRRP provides an incentive for hospitals to reduce the number of excess readmissions that occur in their settings. Effective Fiscal Year (FY) 2012 and beyond, the HRRP requires the Secretaryto establish readmission measures for applicable conditions and to calculate an excess readmissionratio for each applicable condition, which will be used to determine a payment adjustment to those hospitals with excess readmissions. A readmission is defined as an admission to an acute care hospital within 30 days of a discharge from the same or another acute care hospital. A hospital’s excess readmission ratio measures a hospital’s readmission performance compared to the national average for the hospital’s set of patients with that applicable condition. Applicable conditions in the HRRP program currently include measures for acute myocardial infarction, heart failure, pneumonia, chronic obstructive pulmonary disease, elective total knee and total hip arthroplasty, and coronary artery bypass graft surgery. Planned readmissions are excluded from the excess readmission calculation. In the (FY) 2018 IPPS final rule, CMS changed the methodology to calculate the payment adjustment factor in accordance with the 21st Century Cures Act to assess penalties based on a hospital’s performance relative to other hospitals treating a similar proportion of Medicare patients who are also eligible for full Medicaid benefits (i.e. dual eligible) beginning with the (FY) 2019 program.

High Priority Domains for Future Measure Consideration:

CMS identified the following domains as high-priority for future measure consideration:

Measure Requirements:

CMS applies criteria for measures that may be considered for potential adoption in the HRRP. At a minimum, the following criteria and requirements must be met for consideration in the HRRP:

Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

Hospital Value-Based Purchasing Program 
The material in this appendix was drawn from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2019.

Program History and Structure: The Hospital Value-Based Purchasing (HVBP) Program was established by Section 3001(a) of the Affordable Care Act, under which value-based incentive payments are made each fiscal year to hospitals meeting performance standards established for a performance period for such fiscal year. The Secretary shall select measures, other than measures of readmissions, for purposes of the Program. In addition, a measure of Medicare Spending Per Beneficiary must be included. Measures are eligible for adoption in the HVBP Program based on the statutory requirements, including specification under the Hospital Inpatient Quality Reporting (IQR) Program and posting dates on the Hospital Compare website.

High Priority Domains for Future Measure Consideration:

CMS identified the following categories as high-priority for future measure consideration:

  1. Strengthen Person and Family Engagement as Partners in their Care:
    1. Functional Outcomes
  2. Promote Effective Prevention and Treatment of Chronic Disease:
    1. Prevention and Treatment of Opioid and Substance Use Disorders
    2. Risk Adjusted Mortality

Measure Requirements:

CMS applies criteria for measures that may be considered for potential adoption in the HVBP Program. At a minimum, the following criteria will be considered in selecting measures for HVBP Program implementation:

  1. Measure must adhere to CMS statutory requirements, including specification under the Hospital IQR Program and posting dates on the Hospital Compare website.
    • Measures are required to reflect consensus among affected parties, and to the extent feasible, be endorsed by the national consensus entity with a contract under Section 1890(a) of the Social Security Act; currently the National Quality Forum (NQF)
    • The Secretary may select a measure in an area or topic in which a feasible and practical measure has not been endorsed, by the entity with a contract under Section 1890(a) of the Social Security Act, as long as endorsed measures have been given due consideration
  2. Measure may not require reporting to a proprietary registry.
  3. Measure must address an important condition/topic for which there is analytic evidence that a performance gap exists and that measure implementation can lead to improvement in desired outcomes, costs, or resource utilization.
  4. Measure must be fully developed, tested, and validated in the acute inpatient setting.
  5. Measure must address a Meaningful Measure area, with preference for measures addressing the high priority domains and/or measurement gaps for future measure consideration.
  6. Measure must promote alignment across HHS and CMS programs.
  7. Measure steward will provide CMS with technical assistance and clarifications on the measure as needed.

Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

Inpatient Psychiatric Facility Quality Reporting Program 
The material in this appendix was drawn from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2019.

Program History and Structure: The Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program was established by Section 1886(s)(4) of the Social Security Act, as added by sections 3401(f)(4) and 10322(a) of the Patient Protection and Affordable Care Act (the Affordable Care Act). Under current regulations, the program requires participating inpatient psychiatric facilities (IPFs) to report on 13 quality measures or face a 2.0 percentage point reduction to their annual update. Reporting on these measures apply to payment determinations for Fiscal Year (FY) 2020 and beyond.

High Priority Domains for Future Measure Consideration:

CMS identified the following categories as high-priority for future measure consideration:

  1. Strengthen Person and Family Engagement as Partners in their Care
    1. Patient Experience and Functional Outcomes
    2. Depression Measure
    3. Patient's Experience of Care
  2. Make Care Safer by Reducing Harm Caused in the Delivery of Care
    1. Preventable Healthcare Harm

Measure Requirements: CMS applies criteria for measures that may be considered for potential adoption in the IPFQR. At a minimum, the following criteria will be considered in selecting measures for IPFQR implementation: Measure must adhere to CMS statutory requirements. Measures are required to reflect consensus among affected parties, and to the extent feasible, be endorsed by the national consensus entity with a contract under Section 1890(a) of the Social Security Act The Secretary may select a measure in an area or topic in which a feasible and practical measure has not been endorsed, by the entity with a contract under Section 1890(a) of the Social Security Act, as long as endorsed measures have been given due consideration Measure must address an important condition/topic for which there is analytic evidence that a performance gap exists and that measure implementation can lead to improvement in desired outcomes, costs, or resource utilization. The measure assesses meaningful performance differences between facilities. The measure addresses an aspect of care affecting a significant proportion of IPF patients. Measure must be fully developed, tested, and validated in the acute inpatient setting. Measure must address a Meaningful Measure area, with preference for measures addressing the high priority domains for future measure consideration. Measure must promote alignment across HHS and CMS programs. Measure steward will provide CMS with technical assistance and clarifications on the measure as needed.

Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program 
The material in this appendix was drawn from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2019.

Program History and Structure: Section 3005 of the Affordable Care Act added new subsections (a)(1)(W) and (k) to section 1866 of the Social Security Act (the Act). Section 1866(k) of the Act establishes a quality reporting program for hospitals described in section 1886(d)(1)(B)(v) of the Act (referred to as a “PPS-Exempt Cancer Hospital” or PCHQR). Section 1866(k)(1) of the Act states that, for FY 2014 and each subsequent fiscal year, a PCH shall submit data to the Secretary in accordance with section 1866(k)(2) of the Act with respect to such a fiscal year. In FY 2014 and each subsequent fiscal year, each hospital described in section 1886(d)(1)(B)(v) of the Act shall submit data to the Secretary on quality measures (QMs) specified under section 1866(k)(3) of the Act in a form and manner, and at a time, specified by the Secretary. The program requires PCHs to submit data for selected QMs to CMS. PCHQR is a voluntary quality reporting program, in which data will be publicly reported on a CMS website. In the FY 2012 IPPS rule, five NQF endorsed measures were adopted and finalized for the FY 2014 reporting period, which was the first year of the PCHQR. In the FY 2013 IPPS rule, one additional measure was adopted. Twelve new measures were adopted in the FY 2014 IPPS rule and one measure was adopted in theFY 2015 IPPS rule. Three new measures were adopted and six were removed in the FY 2016 IPPS rule. One measure was adopted in the FY 2017 IPPS rule. In the FY 2018 IPPS rule, four measures were adopted and three measures were removed. One measure was adopted and four measures were removed in the FY 2019 IPPS rule.

High Priority Domains for Future Measure Consideration:

CMS identified the following categories as high-priority for future measure consideration:

  1. Communication and Care Coordination
    • Measures regarding care coordination with other facilities and outpatient settings, such as hospice care.
    • Measures of the patient’s functional status, quality of life, and end of life.
  2. Making Care Affordable
    • Measures related to efficiency, appropriateness, and utilization (over/under-utilization) of cancer treatment modalities such as chemotherapy, radiation therapy, and imaging treatments.
  3. Person and Family Engagement
    • Measures related to patient-centered care planning, shared decision-making, and quality of life outcomes.
  4. Promote Effective Prevention and Treatment of Chronic Disease
    • Measures related to appropriate opioid prescribing and pain management best practices for cancer patients

Measure Requirements: The following requirements will be considered by CMS when selecting measures forprogram implementation: Measure is responsive to specific program goals and statutory requirements. Measures are required to reflect consensus among stakeholders, and to the extent feasible, be endorsed by the national consensus entity with a contract underSection 1890(a) of the Social Security Act; currently the National Quality Forum(NQF) The Secretary may select a measure in an area or topic in which a feasible and practical measure has not been endorsed, by the entity with a contract under Section 1890(a)of the Social Security Act, as long as endorsed measures have been given due consideration Measure specifications must be publicly available. Measure steward will provide CMS with technical assistance and clarifications on the measure as needed. Promote alignment with specific program attributes and across CMS and HHSprograms. Measure alignment should support the measurement across the patient’s episode of care, demonstrated by assessment of the person’s trajectory across providers and settings. Potential use of the measure in a program does not result in negative unintended consequences (e.g., inappropriate reduced lengths of stay, overuse or inappropriate use of care ortreatment, limiting access to care). Measures must be fully developed and tested, preferably in the PCHenvironment. Measures must be feasible to implement across PCHs, e.g., calculation, and reporting. Measure addresses an important condition/topic with a performance gap and has a strong scientific evidence base to demonstrate that the measure when implemented can lead to the desired outcomes and/or more appropriate costs. CMS has the resources to operationalize and maintain the measure.

Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.


Appendix C: Public Comments

Index of Measures (by Program)

All measures are included in the index, even if there were not any public comments about that measure for that program.

General Comments

End-Stage Renal Disease Quality Incentive Program

Hospital Inpatient Quality Reporting (IQR) Program and Medicare and Medicaid Promoting Interoperability Program for Eligible Hospitals and Critical Access Hospitals (CAHs)

Inpatient Psychiatric Facility Quality Reporting Program

Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program


Full Comments (Listed by Measure)

General
Maternal Morbidity and Mortality (Program: Hospital Inpatient Quality Reporting (IQR) Program and Medicare and Medicaid Promoting Interoperability Program for Eligible Hospitals and Critical Access Hospitals (CAHs); MUC ID: MUC2019-114)
Follow-Up After Psychiatric Hospitalization (Program: Inpatient Psychiatric Facility Quality Reporting Program; MUC ID: MUC2019-22)
Hospital Harm - Severe Hyperglycemia (Program: Hospital Inpatient Quality Reporting (IQR) Program and Medicare and Medicaid Promoting Interoperability Program for Eligible Hospitals and Critical Access Hospitals (CAHs); MUC ID: MUC2019-26)
Standardized Transfusion Ratio for Dialysis Facilities (Program: ; MUC ID: MUC2019-64)

Appendix D: Instructions and Help

If you have any problems navigating the discussion guide, please contact us at: maphospital@qualityforum.org

Navigating the Discussion Guide

Content


Appendix E: Instructions for Joining the Meeting Remotely

Remote Participation Instructions:

Streaming Audio Online Teleconference