Hospital and ambulatory surgical facilities must report quality metrics for:
See Rule Chapter 270 on our rules page for a complete definition of which hospitals and facilities must submit which specific sets of data.
When data submissions are due: Deadlines for the various data sets can be found under "Submission Requirements", Section 4 of Rule Chapter 270, which is on our Statute and Rules page.
How to submit data:
Where to send the data: Please send your data and/or questions to QualitySubmissions.MHDO@maine.gov.
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 email@example.com. 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.firstname.lastname@example.org 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.Wing@maine.gov.