Fact Sheets


Details for: CMS PROPOSALS TO IMPROVE QUALITY OF CARE DURING HOSPITAL INPATIENT STAYS



For Immediate Release: Tuesday, April 24, 2012
Contact: CMS Media Relations
202-690-6145


CMS PROPOSALS TO IMPROVE QUALITY OF CARE DURING HOSPITAL INPATIENT STAYS

OVERVIEW:  On Apr. 24, 2012, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would update Medicare payment policies and rates for inpatient stays in acute care hospitals under the Inpatient Prospective Payment System (IPPS) and hospitals paid under the Long-Term Care Hospitals (LTCH) Prospective Payment System (PPS) in Fiscal Year (FY) 2013.  The proposed rule also proposes the payment update that would be used to calculate FY 2013 target amounts for certain hospitals excluded from the IPPS, such as cancer and children’s hospitals, and religious nonmedical health care institutions.  The proposed rule, which would apply to approximately 3,400 acute care hospitals and approximately 430 LTCHs, would generally be effective for discharges occurring on or after October 1, 2012. 

In addition to promoting accurate payment for inpatient services to Medicare beneficiaries, the proposed rule would strengthen the Hospital Inpatient Quality Reporting (IQR) Program, propose new policies and measures for the Hospital Value-Based Purchasing (VBP) Program, and establish the framework for two new quality reporting programs that will apply to hospitals paid under the Inpatient Psychiatric Facility (IPF) PPS and PPS-Exempt Cancer Hospitals.  It also proposes requirements for the Ambulatory Surgical Center (ASC) quality data reporting program effective for the Calendar Year (CY) 2014 payment determination.

This fact sheet discusses major quality-related provisions of the proposed rule.  A separate fact sheet on proposed payment changes is available on the CMS Web page at:

           www.cms.gov/apps/media/fact_sheets.asp.

BACKGROUND: The Hospital IQR Program and the Hospital-Acquired Conditions (HACs) payment policy represent significant steps toward implementing value-based purchasing (VBP) in Medicare.  VBP is intended to transform Medicare from a passive payer for services to a prudent purchaser of services, paying not just for quantity of services but for quality as well.

The Hospital IQR Program grew out of the Hospital Quality Initiative developed by CMS in consultation with hospital groups.  Participation in the program is voluntary, but the Medicare law now requires CMS to adjust payments to hospitals that do not participate successfully by reducing their annual payment updates by 2.0 percentage points.  Since the implementation of the financial penalty, hospital participation has increased to well over 99 percent of Medicare-participating hospitals that are reimbursed under the IPPS.

Measures reported under the IQR Program are published on the Hospital Compare Web site (http://www.hospitalcompare.hhs.gov/), and may later be adopted for use in the Hospital VBP Program that was mandated by the Affordable Care Act and that will affect payment rates to hospitals beginning in FY 2013. 

PROPOSED CHANGES TO THE HOSPITAL IQR PROGRAM:

The Hospital IQR Program measure set has grown from a starter set of 10 quality measures in 2004 to the current set of 72 quality measures.  These measures include chart-abstracted measures (e.g., heart attack, heart failure, pneumonia, surgical care improvement), claims-based measures (e.g., mortality and readmissions measures for heart attack, heart failure, pneumonia); AHRQ Patient Safety Indicators and Inpatient Quality Indicators; HACs; one survey-based measure (e.g., patient experience of care), immunization measures, and structural measures.

Proposed changes to the measures to be reported:  The proposals for the Hospital IQR Program in the FY 2013 IPPS/LTCH proposed rule are intended to reduce burden on hospitals, create a more streamlined measure set, and improve care through increased focus on perinatal care, surgical complications for hip and knee replacement procedures, readmissions, and care transitions.  The proposed rule includes proposals that would reduce the number of measures in the IQR program from 72 to 59 for the FY 2015 payment determination, and 60 for the FY 2016 payment determination.  Specifically, CMS is proposing to remove one chart-abstracted measure and 16 claims-based measures.  CMS is proposing to adopt three claims-based measures, one chart-abstracted measure on perinatal care, one structural measure, and to add care transition measure items to the existing “patient experience of care” survey.  See Appendix A for a complete list of the proposed Hospital IQR measures,

Proposed Program Requirements for the FY 2014 Update:  The CMS is proposing to reduce burden and simplify the validation requirements for the IQR program measures.  Because more than 99% of sampled hospitals were validated as reporting accurate data in the most recent year, CMS is proposing to reduce the annual random sample from 800 hospitals to 400 hospitals.  CMS is also proposing to increase the targeted sample to up to 200 hospitals to review potential reporting anomalies.  The targeted sample would include, for example, hospitals meeting CMS reporting requirements near the minimum accuracy threshold, and hospitals with large increases in their scores on quality measures.

These proposals would help ensure that accurate quality data are used on the Hospital Compare website and in the Hospital VBP Program. 

LTCH Quality Reporting Program proposals: CMS is proposing the measures that will be used in the FY 2014 quality reporting program for LTCHs for the FY 2015 payment determination year. In addition, CMS proposes five new quality measures for the FY 2016 payment determination year. These new measures are: 1) Percent of Nursing Home Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short-Stay); 2) Percent of Residents Assessed and Appropriately Given the Pneumococcal Vaccine (Short-Stay); 3) Influenza Vaccination Coverage among Healthcare Personnel; 4)Ventilator Bundle; and 5) Restraint Rate per 1,000 Patient Days.

The LTCH Quality Reporting Program ties a portion of an LTCH's payment to its participation in the Program. LTCHs that do not comply with the new LTCH quality reporting program will see their yearly Federal update payments reduced by two percentage points beginning in FY 2014.

PROPOSALS FOR NEW QUALITY REPORTING PROGRAMS:

Sections 3005 and 10322 of the Affordable Care Act called for CMS to create new quality reporting programs for two types of hospitals that are exempt from payment under the IPPS.  These include 11 hospitals that have been exempted from the IPPS as cancer hospitals and as IPFs.  This proposed rule would implement both of those programs. 

Specifically, CMS is proposing an initial set of five quality measures and program requirements for reporting in FY 2013 by IPPS-Exempt Cancer Hospitals.  The proposed measures include two healthcare-associated infection (HAI) measures developed by the Centers for Disease Control and Prevention (CDC) — Central Line Associated Blood Stream Infection and Catheter Associated Urinary Tract Infection—along with three cancer “process of care” measures on chemotherapy and hormone therapy developed by the American College of Surgeons. 

CMS is also proposing a new quality data reporting program for IPFs that would reduce the IPF-PPS annual payment update by 2.0 percentage points for IPFs that do not comply with the quality data submission requirements.   For this program, CMS is proposing an initial set of six “process of care” quality measures for reporting in FY 2013 for the FY 2014 payment update.  The six proposed measures focus on administration of antipsychotic medications, use of restraints, hours of patient seclusion, creation of post-discharge continuing care plans,  and transmission of those plans to subsequent care providers after discharge.  These measures were developed by the Joint Commission. 

See Appendix B for the proposed measure for reporting by cancer hospitals and IPFs.

PROPOSALS FOR ASC QUALITY REPORTING PROGRAM

CMS is also proposing several requirements for the ASC Quality Reporting Program relating to the measures that were finalized for the CYs 2014, 2015, and 2016 payment determinations in the CY 2012 Outpatient Prospective Payment System/ASC Payment System final rule with comment period that appeared in the Nov. 30, 2011 Federal Register.  Specifically, CMS is proposing new administrative, data completeness, and extraordinary circumstance waivers or extension request requirements, as well as a reconsideration process.  ASCs that fail to report quality data or to comply with these requirements will incur a 2.0 percentage point reduction in their annual payment update for that payment determination year, beginning in CY 2014.  Data collection for the CY 2014 payment determination will begin with services furnished on Oct. 1, 2012.

PROPOSALS TO UPDATE HACS LIST:

The HACs payment policy, which was mandated by the Deficit Reduction Act of 2005, prevents hospitals from being paid at the higher MS-DRG rate for patients with complications or major complications if the sole reason for the higher payment is the occurrence, during the beneficiary’s hospital stay, of one of the conditions on the HACs list.

CMS is proposing to add Surgical Site Infection Following Cardiac Implantable Electronic Device (CIED) and Iatrogenic Pneumothorax with Venous Catheterization as conditions subject to the HAC payment provision for FY 2013.

More than 500,000 CIEDs are implanted each year in the United States, and 70 percent of CIED recipients are age 65 or older.  CIED therapy reduces morbidity and mortality in selected patients with cardiac rhythm disturbances.  However, the benefit of CIED therapy is somewhat reduced by complications following device placement, including infections.  Patients can present with early or late infections because of CIED placement. 

Pneumothorax is defined as the presence of air or gas in the space between the tissue of the lung and parietal pleura, or surface lining of the lung (the pleural cavity).  The presence of air in this space partially or completely collapses the lung and is life threatening.  Air can enter the intrapleural space through the chest wall.  Iatrogenic pneumothorax is a type of traumatic pneumothorax that results from infiltration into the pleural space during the course of a diagnostic or therapeutic medical intervention, such as needle placement for central line catheter guidance.

CMS is also proposing to add two codes, 999.32 (Bloodstream infection due to central catheter) and 999.33 (Local infection due to central venous catheter) to the existing Vascular Catheter-Associated Infection HAC Category.

See Appendix C for the complete list of proposed HACs.

PROPOSALS FOR HOSPITAL VBP PROGRAM:

The proposed rule includes a number of proposed policies related to the Hospital VBP Program. These proposals are intended to support the CMS three-part aim of better health care, better health in the entire population, and lower costs through improvement. 

Proposed Program Requirements for the FY 2013:  CMS is proposing important operational details for FY 2013, which is the first year in which value-based incentive payments will be made under the Hospital VBP Program.  The proposed rule makes proposals regarding when hospitals will receive:

  • Total Performance Scores;
  • The 1% reduction to base operating Diagnosis-Related Group (DRG) amounts; and
  • Value-based incentive payments.

CMS also proposes to establish a review and corrections process that will allow hospitals to correct their performance data before that data is made public on the Hospital Compare website and an administrative appeals process that will give hospitals an opportunity to appeal the calculation of the performance assessment their total performance score.

Proposed Program Requirements for FY 2015:  CMS is proposing several policies for the FY 2015 Hospital VBP Program, including:

  • Grouping and scoring measures in four domains: Clinical Process of Care, Patient Experience of Care, Outcome, and Efficiency.
  • New measures, including:
    •   One new Clinical Process of Care measure - Acute Myocardial Infarction, Statin Prescribed at Discharge (AMI-10);
    • Two new Outcome measures - Central Line Associated Blood Stream Infection (CLABSI) and the Patient Safety Indicator (PSI-90) composite measure; and
    • One new Efficiency measure - Medicare Spending per Beneficiary (MSPB-1)
  • Applicable minimum numbers of cases and measures for the expanded Outcome domain and the new Efficiency domain.
  • Proposed performance standards, including achievement thresholds and benchmarks for all proposed measures, as well as “floors” for all eight Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) dimensions.  We provided estimates of the performance standards based on the most recently available data and will update the standards in the Final Rule.
  • Proposed domain weighting for hospitals’ FY 2015 Total Performance Scores, which can be found in Appendix B of this fact sheet.

Proposed Program Requirements for FY 2016:  Additionally, CMS is proposing new domains which align with the National Quality Strategy for the Hospital VBP Program in FY 2016.  These proposals for FY 2016 would improve the links between patient outcomes, quality, safety, and lower cost with Medicare payment.  The six proposed domains, which map back to six priorities of the National Quality Strategy, are:

  • Clinical Care;
  • Person- and Caregiver-Centered Experience and Outcomes;
  • Safety;
  • Efficiency and Cost Reduction;
  • Care Coordination; and
  • Community/Population Health.

See Appendix D for a table of proposals for the Hospital VBP Program.

More information about the Hospital VBP Program is available online at http://www.cms.gov/hospital-value-based-purchasing.

CMS will accept comments on the proposed rule until June 25, 2012, and will respond to all comments in a final rule to be issued by August 1, 2012.  The proposed rule can be downloaded from the Federal Register at:

            http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1.

The proposed rule will appear in the May 11, 2012 Federal Register.

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APPENDIX A

MEASURES FOR REPORTING HOSPITAL INPATIENT QUALITY REPORTING PROGRAM (HIQR) FOR FY 2015 and FY 2016 PAYMENT UPDATES

 


Measure ID

Proposed Measure Description

Acute Myocardial Infarction (AMI) Measures

AMI-2

Aspirin prescribed at discharge

AMI-7a

Fibrinolytic (thrombolytic) agent received within 30 minutes of hospital arrival

AMI-8a

Timing of Receipt of Primary Percutaneous Coronary Intervention (PCI)

AMI-10

Statin Prescribed at Discharge

Heart Failure (HF) Measures

HF-1

Discharge instructions

HF-2

Evaluation of left ventricular systolic function

HF-3

Angiotensin Converting Enzyme Inhibitor (ACE-I) or Angiotensin II Receptor Blocker (ARB) for left ventricular systolic dysfunction

Stroke Measure (STK) Set

STK-1

VTE prophylaxis 

STK-2

Antithrombotic therapy for ischemic stroke

STK-3

Anticoagulation therapy for Afib/flutter

STK-4

Thrombolytic therapy for acute ischemic stroke

STK-5

Antithrombotic therapy by the end of hospital day 2

STK-6

Discharged on Statin

STK-8

Stroke education

STK-10

Assessed for rehab

Venous Thromboembolism (VTE) Measure Set

VTE-1

VTE prophylaxis

VTE-2

ICU VTE prophylaxis

VTE-3

VTE patients with anticoagulation overlap therapy

VTE-4

Patients receiving un-fractionated Heparin with doses/labs monitored by protocol

VTE-5

VTE discharge instructions

VTE-6

Incidence of potentially preventable VTE

Pneumonia (PN) Measures

PN-3b

  Blood culture performed in the emergency department prior to first antibiotic received in hospital

PN-6

Appropriate initial antibiotic selection

Surgical Care Improvement Project (SCIP) Measures

SCIP INF-1

Prophylactic antibiotic received within 1 hour prior to surgical incision

SCIP INF-2

Prophylactic antibiotic selection for surgical patients

SCIP INF-3

Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac surgery)

SCIP INF-4

Cardiac surgery patients with controlled 6AM postoperative serum glucose

SCIP INF-9

Postoperative urinary catheter removal on post operative day 1 or 2 with day of surgery being day zero

SCIP INF-10

Surgery patients with perioperative temperature management

SCIP Cardiovascular-2 

Surgery Patients on a Beta Blocker prior to arrival who received a Beta Blocker during the perioperative period

SCIP-VTE‑2

Surgery patients who received appropriate VTE prophylaxis within 24 hours pre/post surgery

Mortality Measures (Medicare Patients)

 

Acute Myocardial Infarction (AMI) 30-day mortality rate

 

Heart Failure (HF) 30-day mortality ­rate

 

Pneumonia (PN) 30-day mortality rate

Patients' Experience of Care Measures

 

HCAHPS survey (expanded to include one 3-item care transition set* and two new “About You” items)

Readmission Measures (Medicare Patients)

 

Acute Myocardial Infarction 30-day Risk Standardized Readmission Measure

 

Heart Failure 30-day Risk Standardized Readmission Measure

 

Pneumonia 30-day Risk Standardized Readmission Measure

 

30-day Risk Standardized Readmission following Total Hip/Total Knee Arthroplasty*

 

Hospital-Wide All-Cause Unplanned Readmission (HWR)*

AHRQ Patient Safety Indicators (PSIs) Composite Measures

 

Complication/patient safety for selected indicators (composite)

AHRQ PSI and Nursing Sensitive Care

PSI-4 

Death among surgical inpatients with serious treatable complications

Structural Measures

 

Participation in a Systematic Database for Cardiac Surgery

 

Participation in a Systematic Clinical Database Registry for Stroke Care

 

Participation in a Systematic Clinical Database Registry for Nursing Sensitive Care

 

Participation in a Systematic Clinical Database Registry for General Surgery

 

Safe Surgery Checklist Use **

Healthcare-Associated Infections Measures

 

Central Line Associated Bloodstream Infection

 

Surgical Site Infection

 

Catheter-Associated Urinary Tract Infection

 

MRSA Bacteremia

 

Clostridium difficile (C.Diff)

 

Healthcare Personnel Influenza Vaccination

Surgical Complications

 

Hip/Knee Complication: Hospital-level Risk-Standardized Complication Rate (RSCR ) following Elective Primary Total Hip Arthroplasty*

Emergency Department (ED) Throughput Measures

ED-1

Median time from emergency department arrival to time of departure from the emergency room for patients admitted to the hospital

ED-2

Median time from admit decision to time of departure from the emergency department for emergency department patients admitted to the inpatient status

Prevention: Global Immunization (IMM) Measures

 

Immunization for Influenza

 

Immunization for Pneumonia

Cost Efficiency

 

Medicare Spending per Beneficiary

Perinatal Care

 

Elective delivery prior to 39 completed weeks of gestation*

 

*  New measures/items proposed for FY 2015 payment determination and subsequent years

**  New measures proposed for FY 2016 payment determination and subsequent years

 

_______

APPENDIX B

PROPOSED MEASURES FOR FY 2014 INPATIENT PSYCHIATRIC FACILITY QUALITY REPORTING (IPFQR) PROGRAM

 

Proposed Quality Measures

National Quality Strategy Priority

NQF #

Measure ID

Measure Description

Patient Safety

0640

HBIPS-2

Hours of Physical Restraint Use

0641

HBIPS-3

Hours of Seclusion Use

Clinical Quality of Care

0552

HBIPS-4

Patients Discharged on Multiple Antipsychotic Medications

0560

HBIPS-5

Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification

Care Coordination

0557

HBIPS-6

Post-Discharge Continuing Care Plan Created

0558

HBIPS-7

Post-Discharge Continuing Care Plan Transmitted to Next Level of Care Provider Upon Discharge

 

PROPOSED MEASURES FOR FY 2014 PPS-EXEMPT CANCER HOSPITAL

QUALITY REPORTING (PCHQR) PROGRAM

 

Measure Steward

NQF #

Measure Description

American College of Surgeons’ Commission on Cancer

0223

Adjuvant chemotherapy is considered or administered within 4 months (120 days) of surgery to patients under the age of 80 with AJCC Stage III (lymph node positive) colon cancer

0559

Combination chemotherapy is considered or administered within 4 months  (120 days) of diagnosis for women under 70 with AJCC T1c, or Stage II or III hormone receptor negative breast cancer

0220

Adjuvant Hormonal Therapy

Centers for Disease Control & Prevention

0139

National Healthcare Safety Network (NHSN) Central Line-Associated Bloodstream Infection (CLABSI) Outcome Measure

0138

National Healthcare Safety Network (NHSN)Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure

 

________

Appendix C

HACS ADOPTED IN PREVIOUS RULEMAKING AND PROPOSED ADDITIONS FOR FY 2013

 


HAC

CC/MCC

(ICD-9-CM Codes)

HACS ADOPTED IN PREVIOUS RULEMAKING

Foreign Object Retained After Surgery

998.4 (CC)

998.7 (CC)

Air Embolism

999.1 (MCC)

Blood Incompatibility

ABO incompatibility reaction, unspecified

ABO incompatibility with hemolytic transfusion reaction not specified as acute or delayed

ABO incompatibility with acute hemolytic transfusion reaction

ABO incompatibility with delayed hemolytic transfusion reaction

Other ABO incompatibility reaction

 

999.60 (CC)

                              999.61 (CC)

999.62 (CC)

999.63 (CC)

999.69 (CC)

Pressure Ulcer Stages III & IV

707.23 (MCC)

707.24 (MCC)

Falls and Trauma:

  - Fracture

  - Dislocation

  - Intracranial Injury

  - Crushing Injury

  - Burn

  - Other Injuries

 

Codes within these ranges on the

CC/MCC list:

800-829

830-839

850-854

925-929

940-949

991-994

Catheter-Associated Urinary Tract Infection (UTI)

996.64 (CC)

Also excludes the following from acting as a CC/MCC:

112.2 (CC)

590.10 (CC)

590.11 (MCC)

590.2 (MCC)

590.3 (CC)

590.80 (CC)

590.81 (CC)

595.0 (CC)

597.0 (CC)

599.0 (CC)

Vascular Catheter-Associated Infection

999.31 (CC)

Manifestations of Poor Glycemic Control

250.10-250.13 (MCC)

250.20-250.23 (MCC)

251.0 (CC)

249.10-249.11 (MCC)

249.20-249.21 (MCC)

Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft (CABG)

519.2 (MCC)

And one of the following procedure codes:

36.10–36.19

Surgical Site Infection Following Certain Orthopedic Procedures

996.67 (CC)

998.59 (CC)

And one of the following procedure codes:  81.01-81.08, 81.23, 81.24, 81.31-81.38, 81.83, 81.85

Surgical Site Infection Following Bariatric Surgery for Obesity

Principal Diagnosis – 278.01

539.01 (CC)

539.81 (CC)

998.59 (CC)

And one of the following procedure codes:  44.38, 44.39, or 44.95

Deep Vein Thrombosis and Pulmonary Embolism Following Certain Orthopedic Procedures

415.11 (MCC)

415.13 (MCC)

415.19 (MCC)

453.40-453.42 (CC)

And one of the following procedure codes: 00.85-00.87, 81.51-81.52, or 81.54

ADDITIONAL HACS PROPOSED FOR FY 2013

Surgical Site Infection Following Cardiac Implantable Electronic Device (CIED)

996.67 (CC)

998.59 (CC)

And one of the following procedure codes:

00.50,00.51,00.52,00.53,00.54, 37.80,37.81,37.82, 37.83,37.85, 37.86, 37.87, 37.94, 37.96,37.98, 37.74, 37.75, 37.76, 37.77, 37.79, 37.89

Iatrogenic Pneumothorax with Venous Catheterization

512.1 (CC) (Iatrogenic pneumothorax) in combination with the associated procedure code 38.93 (Venous Catheterization)

 

________

APPENDIX D

PROPOSED QUALITY MEASURES FOR FY 2015 AND FY 2016 HOSPITAL

VALUE-BASED PURCHASING (HVBP) PROGRAM

Measure ID

Description

Clinical Process of Care Measures

AMI-7a

Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival

AMI-8a

Primary PCI Received Within 90 Minutes of Hospital Arrival

AMI-10

Statin Prescribed at Discharge**

HF-1

Discharge Instructions

PN-3b

Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital

PN-6

Initial Antibiotic Selection for CAP in Immunocompetent Patient

SCIP-Inf-1

Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision

SCIP-Inf-2

Prophylactic Antibiotic Selection for Surgical Patients

SCIP-Inf-3

Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time

SCIP-Inf-4

Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose

SCIP-Inf-9

Urinary Catheter Removed on Postoperative Day 1 or Postoperative Day 2

SCIP-Card-2

Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who Received a Beta-Blocker During the Perioperative Period

SCIP-VTE-2

Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxes Within 24 Hours Prior to Surgery to 24 Hours After Surgery

Patient Experience Measures

HCAHPS*

Hospital Consumer Assessment of Healthcare Providers and Systems Survey

Outcome Measures

AHRQ (PSI-90)

Complication/patient safety for selected indicators (composite)**

CLABSI

Central Line-Associated Blood Stream Infection+

MORT-30-AMI

Acute Myocardial Infarction (AMI) 30-day mortality rate

MORT-30-HF

Heart Failure (HF) 30-day mortality rate

MORT-30-PN

Pneumonia (PN) 30-day mortality rate

Efficiency Measures

MSPB-1

Medicare spending per beneficiary**

*Proposed dimensions of HCAHPS in the FY 2015 HVBP are Communication with Nurses, Communication with Doctors, Responsiveness of Hospital Staff, Pain Management, Communication about Medicines, Cleanliness and Quietness of Hospital Environment, Discharge Information and Overall Rating of Hospital. 

**CMS proposes these as new measures for the FY 2015 and FY 2016 program years for Hospital VBP.

+ We are proposing the CLABSI measure for the FY 2015 program year only.

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