Quality Reporting & Improvement

Quality Reporting and Improvement – Hospitals

Improving Individual Patient Care Overview

Accurate Data About Hospital Reporting

Good data means more transparency about the state of quality and safety at America’s hospitals. The clinical data QIOs guide hospitals in collecting are the same data CMS uses to populate the Hospital Compare website, which is designed to help consumers choose where to receive care. They also are the same data CMS will use to calculate hospitals’ value-based payment rates. Just as they have in the past, QIOs will offer technical assistance to all Medicare-participating hospitals for reporting inpatient and outpatient quality data to CMS. This includes help with the reporting tool, updates on measure definitions and reporting procedures, and responsiveness to facility-specific issues and questions.

Qsource provides technical assistance to Tennessee hospitals to improve their quality of care related to Medicare programs such as the Hospital Inpatient Quality Reporting (IQR) Program and the Hospital Outpatient Quality Reporting (OQR) Program. We train hospitals on these efforts and help healthcare professionals implement and monitor these quality improvement efforts.

We educate hospitals on Hospital IQR and/or OQR program requirements and assist hospitals to improve their quality in areas including:

• Validation
• Hospital IQR and OQR program measures
• Reporting of measure data
• Improving on care related to Hospital IQR and OQR program measures for purposes of improving care for Medicare beneficiaries

We also assist Critical Access Hospitals, rural facilities and other hospitals that do not participate in the Hospital IQR and/or OQR programs but that want to submit quality data to CMS for purposes of public reporting. Such assistance includes promotion and outreach to hospitals not currently reporting data on Hospital IQR and/or OQR program measures and educating new and current hospitals about the following:

• CMS abstraction tools
• Inpatient and Outpatient data warehouse infrastructure
• Measure and submission feedback reports
• Hospital IQR and OQR program reporting requirements (e.g., maintain a QualityNet Security Administrator, sign a participation form, etc.)
• Abstraction accuracy

Qsource also provides feedback to hospitals on areas for improvement related to topics addressed by Hospital IQR and/or OQR program measures by using information from patient level data analysis located in the applicable CMS data warehouse, in accordance with all applicable statutory laws, regulations, and guidance.