Each hospital or their agent must report data to the US CDC’s NHSN for specific healthcare associated infection (HAI) quality metrics, MRSA blood specimen Lab ID Event data for all facility-wide inpatients (FacWideIN), and data for Clostridium difficile Lab ID Events for all facility-wide inpatients (FacWideIN) in accordance with NHSN specifications.
Each hospital or their agent must report data to the MHDO for specific nursing-sensitive patient-centered (NSPC) health care quality data as defined by National Database for Nursing Quality Indicators (NDNQI) and the Joint commission.
Note: Links to Resources can be found at the bottom of this page.7/5/23 Recording of June 29th Webinar is Available
The recording of the webinar held 6/29/23 can be found on YouTube here: https://youtu.be/rXTdcixR2K86/29/23 Webinar Regarding Three New HAI Measures Due with Q3 2023 Data
The webinar will be held virtually via Zoom from 1:00 - 2:00 pm. Connection information and presentation deck are below.
The original effective date for reporting these new measures under MHDO Rule Chapter 270 Uniform Reporting System for Health Care Quality Data Sets was January 1, 2020, however, to minimize administrative burden during the early years of the pandemic, the MHDO board made the decision to suspend the enforcement of Rule Chapter 270 Section 2. B. Now, over two years after the original effective date, the reporting requirement will become effective July 1, 2023.
Note: A webinar will be held in early May to review the new reporting requirements.
For all patients identified as eligible cases in the specific denominator and numerator categories specified by NHSN, each hospital, or their agent, shall submit to the US CDC’s National Healthcare Safety Network (NHSN), data for the following healthcare associated infection (HAI) quality metrics in accordance with NHSN specifications, beginning with all qualifying events on or after July 1, 2023.
|HAI-6||Catheter-associated urinary tract infection (CAUTI) rates for adult and pediatric patients in intensive care units, medical units, surgical units, medical/surgical units, mixed acuity units and rehabilitation units||Data must be submitted through NHSN||National Healthcare Safety Network (NHSN) Patient Safety Component Manual Chapter 7|
|HAI-7||Surgical Site Infection data for patients undergoing inpatient knee prosthesis (arthroplasty of the knee) surgical procedures (KPRO)||Data must be submitted through NHSN||National Healthcare Safety Network (NHSN) Patient Safety Component Manual Chapter 9|
|HAI-8||Surgical Site Infection data for patients undergoing inpatient hip prosthesis (arthroplasty of the hip) surgical procedures (HPRO)||Data must be submitted through NHSN||National Healthcare Safety Network (NHSN) Patient Safety Component Manual Chapter 9|
On 7/28/21 NSI data submitters were notified that beginning with Q3 2021 data, counting Method 1 will no longer be an option. Below is a summation of the correspondence.
After reviewing recent NSI data submissions an issue has been identified regarding the patient days counting methods hospitals are using to report falls for NSI measures NSPC-2 Number of patient falls per patient days and NSPC-3 Number of patient falls with injuries. Several hospitals are utilizing Method 1 (Midnight Census) for patient days when counting and reporting the number of falls. As described and defined by the National Database for Nursing Quality Indicators (NDNQI), this method is restricted to hospital units that have only inpatient admissions. Method 1 is not appropriate for facilities with both inpatient and short stay patients since only inpatients are counted for total patient days (the denominator for these measures). As a result, hospitals using Method 1 that treat both inpatient and short stay patients may be undercounting patient days and thus artificially inflating Patient Falls and Falls with Injury rates. This will negatively impact comparisons over time and between hospitals.
In light of this, the Method 1 tab will be removed from MHDO’s NSI Transmittal Workbook starting with Q3 2021 submissions. Hospitals will need to use one of the following methods defined by NDNQI.
Important Note and Next Steps: Beginning with Q3 2021 MHDO data submissions and for data submissions thereafter, you must download the most recent version of the NSI Transmittal Workbook (5.0) which will be found lower on this page under "How to submit data to MHDO" or in the MHDO hospital data submission portal under Guides. MHDO will no longer accept data submissions on outdated forms or if the transmittal form has been altered in any way.04/23/20 Chapter 270 Quality Data Reporting Deadlines Extended
In light of the significant challenges that hospitals are facing during the COVID-19 pandemic, the MHDO has agreed to extend data reporting deadlines for the hospital data submission requirements defined in MHDO Rule Chapter 270, Uniform Reporting System for Health Care Quality Data Sets.
MHDO will suspend the enforcement of the current deadlines described in Rule Chapter 270 with the following revised submission dates:
Please do not hesitate to contact Kimberly Bonsant with any questions.
|Q1||Jan, Feb, Mar||August 15th|
|Q2||Apr, May, June||November 15th|
|Q3||July, Aug, Sept||February 15th|
|Q4||Oct, Nov Dec||May 15th|
Go to the Hospital Data Portal at https://mhdo.maine.gov/hospital_portal to download the form you need, and once complete simply upload.
If you prefer, the Nursing Sensitive Indicators Transmittal Workbook (Version 5.01) can be downloaded here for completion prior to submitting to the portal.
Many find the NSI Microspecifications Manual (Version 4.1) helpful as it contains information regarding technical issues.
Note: For assistance with the new portal, see the Chapter 270 User Manual under the "Help" section in the Hospital Data Portal or download the Chapter 270 User Manual here if you prefer.
The MHDO Help Desk is available for any technical/system issue you may encounter. Support is available during regular business hours (8 a.m. – 5 p.m. EDT, Monday – Friday). You will receive a phone call or an e-mail within two hours of your request. Toll-free Phone: (866) 451-5876 or Email: firstname.lastname@example.org.
Questions regarding completion of the forms, deadlines or requests for extensions can be directed to Kimberly Bonsant, Hospital Compliance Officer, MHDO at email@example.com or (207) 287-2296.
The MHDO board of directors adopted an updated version of Rule Chapter 270, which replaced the current version of the Rule as of June 22, 2019. You can access a copy of the updated Rule on our Statute and Rules page. Below is a summary of several key changes to this rule.
A webinar was held from 2:00 - 2:30 to discuss requirements and steps involved with the new MHDO submission system for HAI and NSI data. A demonstration of logging in, submitting a file, and verifying its receipt was provided. You may download the PowerPoint Deck now, and check back in a few weeks for the recorded webinar.New 7/26/17 Online Quality Data Submissions Portal Now Available for the Submission of HAI and NSI data
Hospitals can now submit their HAI and NSI data transmittal workbooks via the online portal at https://mhdo.maine.gov/hospital_portal. Simply register, login and upload your reports.9/6/16 Message from the MHDO Executive Director Re: Rule Chapter 270
Earlier this spring the Maine Legislature approved changes to Rule Chapter 270 - the rule that governs the submission of healthcare quality data to the Maine Health Data Organization (MHDO). Many of the changes to Chapter 270 align with changes at the federal level. As a reminder the changes to Chapter 270 went into effect as of June 1, 2016. This means the changes in the rule take effect beginning with data collected on and after July 1, 2016 (2016-Q3). A more detailed overview of these changes can be found on our rules page.
The following is a list of the key provisions that were deleted from Chapter 270:
Hospitals are still required to collect NSI data for the following three measures:
NSI Data Submittal Workbook:
Note: Both versions of the NSI Data Submittal Workbook and the new version of the NSI Microspecifications Manual are available on this page under How to submit data.
Other Key Changes to Chapter 270 include:
Lastly, in an effort to align Rule Chapter 270 with the appropriate measure steward the following clarification is being made to section 2(C).
Each hospital shall submit to the US CDC’s National Healthcare Safety Network (NHSN) MRSA data for blood only Lab ID Event, for all inpatients (facility-wide) in accordance with NHSN specifications no later than January 1, 2014. (Measure steward - NHSN).
If you have any questions please contact Kim Wing at firstname.lastname@example.org. Thank you. Karynlee2/08/16 Message from the MHDO Executive Director Re: Our New NSI Microspecifications Manual & NSI Data Transmittal Workbook
I am pleased to announce that we have finalized our 2016 version of our new NSI Microspecifications Manual with two important clarifications regarding the counting of patient days. We are also releasing a new version (2.0) of our NSI Data Transmittal Workbook in Excel. Thanks to those of you that provided feedback on the workbook-we hope this version is easier to use.
All hospitals are now required to indicate their patient day counting method by choosing from the new pull-down menu near the top of the “Data Submittal Worksheet” summary tab.
Lastly, please save your worksheet by using the SAVE TO DESKTOP pink button on the “Data Submittal Worksheet” tab. This will automatically save a correctly named copy of your NSI data file to your Windows Desktop.
Please contact Kim Wing at Kimberly.Wing@maine.gov with any questions or concerns.
- Karynlee12/30/15 To: All Maine Hospital Association Quality and IP Contacts Re: Healthcare Associated Infection (HAI) Data
The Maine Health Data Organization (MHDO) has released a new version of the MHDO HAI Data Transmittal Workbook and the HAI Microspecifications Manual, both of which can be found under Healthcare Associated Infection (HAI) Data below.
The data transmittal workbook and the manual have been revised to conform with the current CMS Inpatient Quality Data reporting requirements for the HAI-1 (CLABSI infection rate) measure which went into effect on January 1, 2015.
MHDO's requirements for HAI-1 data reporting were previously limited to patients in ICUs for hospitals that had an ICU and to patients in Mixed Acuity Units for hospitals that did not have an ICU.
Beginning with the 2016-QTR1 reporting period on January 1, 2016, MHDO will require HAI-1 data reporting for patients in all adult and pediatric ICUs, Medical Units, Surgical Units and Medical/Surgical Units.Hospitals that do not have an ICU, Medical Unit, Surgical Unit or Medical/Surgical Unit should substitute all adult and pediatric patients in their Mixed Acuity Unit(s), including patients in swing beds.
Please note that the denominator criteria for the four other Chapter 270 HAI measures (HAI-2 through HAI-5) have not changed.
Lastly per request, MHDO removed the two questions at the top of the HAI data transmittal workbook that asked for the total number of central line days and ventilator days over the prior 12 months. These questions have been replaced by a reminder that the 12-month number of central line days and 12-month number of ventilator days each determine which sampling method your hospital should use for collecting central line bundle compliance data and ventilator bundle compliance data in the upcoming quarter.
For more information, please refer to the HAI Data Microspecifications Manual or contact the MHDO at 207-287-9900 or 287-6722.
Consistent with the recent announcement by CMS, the MHDO will suspend the collection of SCIP–Inf-4 as of Quarter 3 (Q3) 2014. Meaning, hospitals will not need to report SCIP-Inf-4 for Q3 2014 and Q4 2014 reporting periods. Consistent with our earlier notification regarding the other SCIP measures, hospitals will need to report for Q3 2014 and Q4 2014 reporting period. Bottom line:
Please do not hesitate to contact Karynlee Harrington at Karynlee.email@example.com or Kim Wing at Kimberly.Wing@maine.gov with any questions.12/24/14 MHDO Announcement in Response to CMS' Suspension of the Majority of SCIP Measures
The MHDO Board of Directors voted at the December 18th board meeting to align with the decision made by CMS regarding the Surgical Care Improvement Project (SCIP) measures. Effective January 1, 2015 many of the measures will become voluntary reporting measures with CMS; therefore MHDO will suspend the enforcement of data collection effective January 1, 2015 for the following SCIP measures consistent with the action of the measure steward (CMS):
Important: The MHDO will continue to enforce the collection of SCIP-Inf-4 (again, consistent with the measure steward).10/10/14 MHDO Announcement: Suspension of data collection for SCIP-Inf-10
Pursuant to Sections 2 and 11 Rule Chapter 270, and CMS' decision, announced in the Revisions to Version 4.3 of the CMS Specifications Manual for National Hospital Quality Measures, to retire the SCIP-Inf-10 (perioperative temperature management) the Maine Health Data Organization (MHDO) will suspend collection of SCIP-Inf-10 numerator and denominator data for the 2014-Q1 reporting period forward.
As always, we welcome your questions and suggestions. Please send them to Kimberly.Bonsant@maine.gov.