Hospital Quality Data (Chapter 270)

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.

The Submission 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.

Important Announcements

2/08/16 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.

Overview of Changes in the Manual

  • "Patient Days" refers to all patients, not just inpatients: The new edition of the NSI Manual clarifies some confusion that may have been caused by the titles of the two falls measures (NSPC-2 and NSPC-3) and the two nursing-care-hours-per-patient-day measures (NSSC-5 and NSSC-6) as they appeared in earlier editions of the NSI Microspecifications Manual and the Excel-based NSI Data Transmittal Workbook. Although the instructions appearing in the manual and on the form make clear that you should count the number of patient days for all patients, including outpatients or other short stay patients, the measure titles mistakenly referred to “Inpatient Days”. Short stay days are the equivalent of taking the number of short stay hours and dividing by 24. The American Nurses Association (ANA), the measure steward for all four measures, offers several options for counting short stay days.
  • The ANA has discontinued the use of one of the five options for counting patient days: The ANA has discontinued their patient day counting Method 3, "Midnight Census plus Patient Days from Average Short Stay Hours". Beginning with the 2016-Q2 data reporting period, hospitals may still use Method 1, 2, 4 or 5. You can locate more information about each method by referring to the NSI Microspecifications Manual. Note: Beginning with the 2016-Q2 reporting period, all hospitals must include short stay days in their patient day calculations, and include outpatient falls in the falls and falls with injury measures. Hospitals that have already submitted or collected NSI data based on inpatient days only for any reporting period prior to 2016-Q2 do not need to re-submit.

Improvements to the NSI Data Transmittal Workbook

  • No more redundant data entry: We have greatly reduced redundant data entry when utilizing the “Data Submittal Worksheet”. For example the spreadsheet automatically copies the number of Patient Days for NSPC-2 (Falls with Injury) to the three other cells where it appears. Also when you enter the number of RN care hours for NSSC-1, LPN hours for NSSC-2 and UAP care hours for NSSC-3, the spreadsheet automatically calculates Total Nursing Care Hours and enters it in each of the five locations where it belongs.
  • Locked cells and easier navigation: All calculated cells have been highlighted in green and locked to prevent users from accidently overwriting their contents. In fact, every cell has been locked except for data entry cells. This means you can now navigate each spreadsheet tab by using the TAB key.
  • You can now hide unused rows with one click: We’ve also added a new HIDE UNUSED ROWS button, which when clicked, will check each row to see if you have entered your hospital’s internal name (in Column B) for that row’s hospital unit. If the internal unit name is blank the row gets hidden. By displaying only the rows that you’re using, we hope to make it easier and faster to navigate the form. What if the button hides a row that you discover you need to use? It’s easy, just click the UNHIDE ALL ROWS button to make all the rows reappear. Enter your hospital’s internal name for the missing unit and then click the HIDE UNUSED ROWS button again to return to data entry.
  • When you enter the internal unit name on the “NSPC-1 Pressure Ulcer – Required” tab, Excel will copy that unit name to all the other data entry tabs in the Workbook.

Other Changes

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.

- Karynlee

12/30/15 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.

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.

Links to Other Quality Data Resources