Chapter 270 Quality Data

Hospital and ambulatory surgical facilities must report quality metrics for:

  • patients who receive a principle diagnosis of:
    • Acute Myocardial Infarction (AMI)
    • Heart Failure (HF)
    • Pneumonia (PN)
  • surgical patients receiving one of the selected surgeries specified in the most current version of the CMS Specifications Manual for National Hospital Quality Measures
  • healthcare associated infection (HAI) rates and compliance with evidence-based interventions
  • nursing-sensitive patient-centered (NSPC) health care outcome measures and other nursing system-centered health care quality metrics
  • care transition measure (CTM) quality metrics based on 3-Item Care Transition Measure (CTM) survey instrument

See Rule Chapter 270 on our rules page for a complete definition of which hospitals and facilities must submit which specific sets of data.

MHDO makes these data available annually.

Quality Data Submission Instructions and Resources

When is your data due? Deadlines for the various data sets can be found under "Submission Requirements", Section 7 of Rule Chapter 270, which is on our rules page.

Surgical Care Improvement Program (SCIP) Measures -

SCIP Submission Form

1/13/15 MHDO Announcement in Response to CMS' Suspension of SCIP Inf-4 Measure Collection:

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:

  1. Effective with July 1, 2014 discharges, we are no longer enforcing the collection of SCIP-Inf-4
  2. As of January 1, 2015 we are no longer enforcing the collection of the other SCIP measures defined in Chapter 270.

Please do not hesitate to contact Karynlee Harrington at Karynlee.harrington@maine.gov 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):

  • SCIP-Card-2, SCIP-Inf-1a-h, SCIP-Inf-2a-h,SCIP-Inf-3a-h, SCIP-Inf-09 and SCIP-VTE-2

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.

Care Transition Measure (CTM-3) Data

Download the Care Transition Measure Data transmittal file (.xls) to your computer. After its completion, save the file utilizing the correct naming convention, and attach to an email addressed to Quality Submissions.

For detailed information about the CTM measures, download the CTM Data Microspecifications Manual revised November 2013.

Healthcare Associated Infection (HAI) Data

NEW October 2014 Download the October 2014 edition of the Healthcare Associated Infection Data transmittal file (.xls) to your computer. After completing the form, you can automatically save the file to your desktop and email it to Quality Submissions by clicking the form's SAVE AND EMAIL button.

For assistance completing the submission see the HAI Data Microspecifications Manual revised November 2013.

Nursing Sensitive Indicators (NSI)

Download the Nursing Sensitive Indicators transmittal workbook (.xls) to your computer. After its completion, save and attach the file to an email addressed to Quality Submissions.

For excel workbook instructions, download the instructions document.

For detailed information about the NSI measures, download the NSI Microspecifications Manual revised November 2013.

Links to Other Quality Data Resources