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 for a complete definition of which hospitals and facilities must submit which specific sets of data.

MHDO makes these data available annually. The next scheduled release is June 2014 for the third quarter of 2013 data.

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.

Summary of Changes to Chapter 270 will assist those looking for the specific changes to Chapter 270 - Uniform Reporting System for Health Care Quality Data Sets.

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 Regarding Rule Chapter 270 and Future Reporting 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. As many of you know these measures will become voluntary reporting measures with CMS effective January 1, 2015 with the exception of SCIP-4-Inf (Cardiac Surgery Patients With Controlled Postoperative Blood Glucose).

Hospitals are required to report their 2013-Q3 and 2013-Q4 data for all the current SCIP measures as defined in rule chapter 270 by the respective deadlines in 2015. As of New Year's Day, Maine hospitals will only be required to collect (and then later report) data for the SCIP-Inf-4 measure.

The 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 Surgery patients on beta-blocker therapy prior to arrival who received a beta-blocker during the perioperative period (Measure steward – CMS);

SCIP-Inf-1a-h Prophylactic antibiotic received within one hour prior to surgical incision – overall rate and seven subcategory surgery rates (coronary artery bypass graft, cardiac surgery, hip arthroplasty, knee arthroplasty, colon surgery, hysterectomy, and vascular surgery) (Measure steward – CMS);

SCIP-Inf-2a-h Prophylactic antibiotic selection for surgical patients – overall rate and seven subcategory surgery rates (coronary artery bypass graft, cardiac surgery, hip arthroplasty, knee arthroplasty, colon surgery, hysterectomy, and vascular surgery) (Measure steward – CMS);

SCIP-Inf-3a-h Prophylactic antibiotics discontinued within 24 hours after surgery end time – overall rate and seven subcategory surgery rates (coronary artery bypass graft, cardiac surgery, hip arthroplasty, knee arthroplasty, colon surgery, hysterectomy, and vascular surgery) (Measure steward – CMS);

SCIP-Inf-09 Urinary catheter removed on postoperative day I (POD 1) or postoperative day 2 (POD 2) (Measure steward – CMS);

SCIP-VTE-2 Surgery patients who received appropriate venous thromboembolism (VTE) prophylaxis within 24 hours prior to surgery to 24 hours after surgery (Measure steward – CMS).

The MHDO will continue to enforce the collection of SCIP-Inf-4 (again, consistent with the measure steward).

Lastly, we will we merge the SCIP-Inf-4 measure onto the MHDO HAI form and ask hospitals to leave that part blank if you have nothing to report. Please do not hesitate to contact me with any questions and or concerns.
Karynlee

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.

New Version Released - New SCIP Submission Form which no longer includes Inf-10 measure is available as of 10/10/14.

10/7/14 Revision of the SCIP Measures Submittal Form

Corrections were made to the SCIP data submittal form based on feedback received. Resubmissions are not required if the previous form was used.

9/30/14 Guidelines to Submit SCIP Measures

Here are guidelines to submit SCIP Measures to MHDO. The form for submittal will be available in the next day or two.

9/10/14 Message From MHDO

Due to the suddenness of the announcement yesterday that the new QIO will not be submitting Maine hospital SCIP data to the MHDO, the MHDO is taking the following steps:

  • The hospital deadline for submitting 2014-Q1 Chapter 270 SCIP measures data to MHDO has been extended to October 15th
  • MHDO will seek the advice of Maine hospitals to develop the simplest and least burdensome method for submitting Chapter 270 SCIP measures data to MHDO. Please e-mail any suggestions, advice or comments to kimberly.wing@maine.gov
  • MHDO will publish and distribute new SCIP data submission instructions and, if necessary, a SCIP data submission form the week of October 1st.
  • MHDO will provide interim guidance on SCIP data collection including a list and description of the data elements your hospital will need to submit. This guidance will be available on the MHDO website the week of September 22nd.

Sept. 9, 2014 Message From MHA

The new QIO, HealthCentric Advisors also known as the New England Quality Innovation Network, has been advised by CMS that they will not have any access to the CMS inpatient or outpatient data other than what is available on the CMS website. In lieu of this, all Maine hospitals must now submit their own SCIP data to the Maine Health Data Organization each quarter, as required under Chapter 270.

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