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Hospital Quality Reporting and Improvement
Important Dates
* January 5, 2012 - January 11, 2012 - Third Quarter 2011 HCAHPS Review/Correction Period
* January 12, 2012 - CMS Hospital Open Door Forum
* January 18, 2012 - Provider conference call, "Specifications Manual Changes-New Measures," presented by FMQAI. Call-in information and details to be announced. Please save the date.
* January 17, 2012 - Due date for Q2 2011 medical records for Validation to the Clinical
* January 19, 2012 - Anticipated refresh of CMS' Hospital Compare Web site.
* February 1, 2012 - Submission deadline for Q3 2011 Hospital IQR Population & Sampling counts to the QIO Clinical Warehouse.
* February 1, 2012 - Submission deadline for Q3 2011 Hospital OQR abstraction/cases to the QIO Clinical Warehouse.
* February 15, 2012 - Submission deadline for Q3 2011 Hospital IQR Clinical Process Measures to the QIO Clinical Warehouse. This is also the submission deadline for Q3 2011 CLABSI data to NHSN.
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HCAHPS Review and Correction Period
The HCAHPS Review and Correction period for Quarter 3, 2011 discharges began immediately following the January 4, 2012 data submission deadline. Both the HCAHPS Warehouse and Online tool and the HCAHPS Data Review and Correction report are now available on My Quality Net.
The HCAHPS Data Review and Correction report displays a frequency distribution of every variable submitted and accepted into the warehouse for the quarter as part of the HCAHPS Survey. The report allows the submitter to determine whether any submitted data are incorrect or missing and provides the opportunity to re-submit corrected data before the review and correction period deadline ends January 11, 2012.
For questions regarding specific HCAHPS hospital data or technical assistance, contact the HCAHPS Project Team at hcahps@azqio.sdps.org or call (888) 884-4007.
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QualityNet and Quality Measures Updates
Reminder: New measure collection required: January 1, 2012 discharges
* Emergency Department (ED-1) Median Time From ED Arrival to Time of Departure
* Emergency Department (ED-2) Median Time From Admit Decision to Time of Departure
* Immunization (IMM-1) Pneumococcal Vaccination
* Immunization (IMM- 2) Influenza Vaccination
* Global Initial Patient Population & Sampling WebEx training and transcript (12/21/11)
* Healthcare Associated Infections (HAIs): Catheter-Associated Urinary Tract Infection (CAUTI) and Surgical Site Infection (SSI) required beginning with January 1, 2012 events, for FY 2014 payment determination via National Healthcare Safety Network (NHSN).
Specifications Manual for National Hospital Inpatient Quality Measures Released
Specifications Manual for National Hospital Inpatient Quality Measures, Version 4.1 effective for July 1, 2012 discharges has been released on QualityNet. Important updates include revisions to Appendix A ICD-9-CM Code Tables and Appendix C Medication Tables.
Specifications Manual for National Hospital Inpatient Quality Measures, Version 4.0c, effective for January 1, 2012 discharges has been released on QualityNet. This addendum corrects the SCIP-VTE-1& 2 algorithms so that cases with Length Of Stay greater than or equal to 2 days are included in these measures and remove ICD-9-CM Procedure Code 45.82 that was inadvertently added to table 5.25 in Appendix A.
New Questions and Answers Tool available
The Centers for Medicare & Medicaid Services (CMS) has replaced the QualityNet Quest Frequency Asked Question system with a new Questions and Answers Tool for Inpatient Hospital Reporting (HR).
The new tool is accessible from the Questions and Answers sidebar in the right column of the QualityNet home page. A link to the Questions and Answers tool for Outpatient Hospital Reporting can also be found in the same sidebar.
Electronic Health Record Incentive Reporting Pilot 2012
For more information, click here.
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Healthcare-Associated Infection (HAI) Updates Operational Guidance for Reporting HAIs
NHSN Newsletter_December 2011
Tools and Resources
Hospital Inpatient Quality Reporting (IQR) Program
Calendar, January 2012
QualityNet Resources for FY 2013 Payment Determination
* Reporting Quarters used for Payment Determination
* Program Changes for Fiscal Year (FY) 2013
Hospital Outpatient Quality Reporting (OQR) Program
OQR Abstraction Paper Tools, January 1, 2012 - June 30, 2012 encounters
Measures for CY 2012 Payment Determination
Hospital OQR News, Special Edition
Healthcare-Associated Infection (HAI) Updates
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January 2012 
