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IRF Quality Public Reporting

 Background:

Section 3004(b) of the Affordable Care Act established the IRF Quality Reporting Program (QRP). In addition, The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) requires the reporting of standardized patient assessment data on quality, resource use, and other measures by Post-Acute Care (PAC) providers, including skilled nursing facilities, home health agencies, inpatient rehabilitation facilities, and long-term care hospitals.

IRF Compare Website Now Live

December 14, 2016, CMS unveiled the new IRF Compare website. This new tool takes reported data and puts it into a format that can be used more readily by the public to get a snapshot of the quality of care each facility provides. For instance, this tool will help families compare some key quality metrics, such as pressure ulcers and readmissions, for over 1,100 IRFs across the nation. The following quality measures are reported on the new Compare site for IRFs:

  • Percent of residents or patients with pressure ulcers that are new or worsened (short stay) - NQF #0678
  • All-cause unplanned readmission measure for 30 days post-discharge from Inpatient Rehabilitation Facilities - NQF #2502 

Procedures for requesting CMS review of an IRF’s measure data:

CMS encourages IRFs to review their data as provided in the Preview Reports.  If an IRF disagrees with performance data (numerator, denominator, or quality metric) contained within their Preview Report, they will have an opportunity to request review of that data by CMS.  In order to make such a request, IRFs must adhere to the process outlined below:

  • Requests for CMS review of data may be submitted to CMS beginning on the day the provider preview reports are issued in IRF CASPER folders, and may be submitted through 11:59:59 p.m. PST on day 30 of the preview period
  • CMS will not accept any requests for review of data that are submitted after the posted deadline, which falls on the last day of the preview period.
  • IRFs are required to submit their request to CMS via email with the subject line: “IRF Public Reporting Request for Review of Data” and include the IRF CMS Certification Number (CCN) (e.g., IRF Public Reporting Request for Review of Data, XXXXXX).  The request must be sent to the following email address: IRFPRquestions@cms.hhs.gov.  
  • The email request must include the following information:
    o IRF CMS Certification Number (CCN)
    o IRF Business Name
    o IRF Business Address
    o CEO or CEO-designated representative contact information including: name, email address, telephone number, and physical mailing address
    o Information supporting the IRF’s belief that the data contained within the IRF’s Preview Report is erroneous (numerator, denominator, or quality metric), including, but not limited to, the following:
     Quality measures affected, and aspects of quality measures affected (numerator, denominator, quality metric)   
  • IRFs will receive an email confirming receipt of their request.
  • CMS will review all requests and provide a response outlining the decision via email.  Please note that IRF-identified errors in data resulting from inaccurate data submissions that an IRF failed to correct will not be corrected.  CMS will not consider correcting quality measure calculations that IRFs find to be inaccurate due to missing data that was submitted beyond the applicable quarterly data submission deadline.  
  • Data that CMS decides/agrees to correct will be corrected and displayed during the subsequent quarterly release of IRF quality data on IRF Compare.

Please note: The only method for submitting a request to CMS for review of your Preview Report data is via email. Requests submitted by any other means will not be reviewed. CMS will not review any requests that include protected health information (PHI) in the request being submitted to CMS for review.

Updates:

December 12, 2016

IRF QRP Provider Preview Reports Now Available

IRFs now have the opportunity to review their performance data on each quality measure based on Quarter 2 -2015 to Quarter 1 - 2016 data prior to public display on IRF Compare in spring 2017.

Providers have 30 days (December 11, 2016 through January 10, 2017) to review their performance data. As finalized in the FY 2017 IRF PPS final rule, corrections to the underlying data will not be permitted during this time; however, IRFs may request CMS review of the data contained within their Preview Report, should they believe it to be inaccurate. Directions on how to retrieve these reports can be found in the Download section of this webpage.

As a reminder- providers will be unable to use NHSN to verify the accuracy of the HAI SIR data contained within their preview reports for the Compare sites during the 30-day preview period.  IRFs must use an alternative method to calculate and verify their HAI SIR data, until such time as the NHSN system is updated by the CDC.   

For further information and to assist LTCHs in understanding the use of the rebaselined data and how to monitor their quality data using the new baseline, including an alternative method for calculating and verifying their HAI SIR data, view the PDF Provider Messaging_Rebaselining_IRF_December Final, in the downloads section of this webpage.

October 21, 2016

IRF Public Reporting Update - CDC & NHSN Rebaseline Guidance

 As noted in the Rebaseline Timeline posted in the June 2016 NHSN Newsletter, the CDC submitted standardized infection ratios (SIRs) to CMS using the new 2015 baseline starting with 2016 Q1 data. The IRF QRP Preview Reports released on September 1, 2016 contained CY2015 healthcare-associated infection (HAI) SIRs in accordance with the new NHSN baselines based on nationally collected data from 2015.  However, providers were unable to use NHSN to verify the accuracy of the HAI data contained within their preview reports for the Compare sites during the 30-day preview period established for this purpose. Consequently, CMS will begin publically displaying the NHSN HAI data on the Compare sites for IRFs and LTCHs in the next quarterly refresh in spring 2017 instead of in fall 2016.

 For further information and to assist IRFs in understanding the use of the rebaselined data and how to monitor their quality data using the new baseline, we have posted a document titled IRF and LTCH Public Reporting Update - CDC & NHSN Rebaseline Guidance. This document is accessible by selecting the link with this title under the Downloads section of this webpage below.

Resources:

Sign up for IRF QRP updates today!
IRF Public Reporting helpdesk:  IRFPRquestions@cms.hhs.gov

IRF QRP Training:

NHSN: Transition to the 2015 Rebaseline Guidance for IRF and LTCHs Webinar

When: Wednesday, November 16, 2016

Time: 1:00 PM- 2:00 PM Eastern Time

Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) is the nation’s most widely used healthcare-associated infection (HAI) tracking system. CDC is implementing a new national baseline for HAIs that are reported to NHSN. On December 10, 2016, NHSN Users will be able to run Standardized Infection Ratios (SIRs) for 2015 and 2016 under both the old baseline, and the new baseline. Data for 2017 and forward will be available under the new baseline only.

During this webinar, CDC explains the new HAI models, as they relate to Long-Term Care Hospitals (LTCHs) and Inpatient Rehabilitation Facilities (IRFs), and will discuss the reason HAI data contained within IRF and LTCH Preview Reports may not align with the data in NHSN for the same target period. 

Webinar Materials:

Presentation

Written Transcript

Audio Recording - Coming Soon

August 19, 2016

IRF & LTCH Quality Reporting Program: Public Reporting Webinar

When: Tuesday, August 23, 2016

Time: 1:30 PM - 3:00 PM Eastern Time

During this webinar, CMS will discuss the Preview Reports for IRFs and LTCHs that will be available to providers in the near future. Participants will gain an understanding of how to access these reports, how to interpret the contents of these reports, and what to do if they believe their report contains an error.

Webinar Materials

Please continue to check this webpage for updates.

Downloads