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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

IRF Compare 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 IRF Compare:

  • All-Cause Unplanned Readmission Measure for 30 Days Post-Discharge from Long-Term Care Hospitals (NQF #2512)
    • Data Collection Period: January 1, 2014 – December 31, 2015
  • Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (NQF # 0678)
    • Data Collection Period: January 1, 2016 – December 31, 2016
  • National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection (CAUTI)   Outcome Measure (NQF # 0138)
    • Data Collection Period: January 1, 2016 – December 31, 2016
  • Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccination (NQF #0680)
    • Data Collection Period: July 1, 2015 – June 30, 2016 (displayed as October 1, 2015 – March 31, 2016)
  • Influenza Vaccination among Healthcare Personnel (NQF #0431)
    • Data Collection Period: July 1, 2015 – June 30, 2016 (displayed as October 1, 2015 – March 31, 2016)
  • National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Methicillin resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF #1716)
    • Data Collection Period: January 1, 2016 – December 31, 2016
  • National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure (NQF #1717)
    • Data Collection Period: January 1, 2016 – December 31, 2016

Updates:

March 07, 2018 

IRF Provider Preview Reports- Now Available

Inpatient Rehabilitation Facility (IRF) Provider Preview Reports are now available.  Providers have the opportunity to review their performance data on quality measures based on Quarter 3 -2016 to Quarter 2 - 2017 data, prior to the June 2018 IRF Compare refresh, during which this data will be publicly displayed.

Providers have until April 5, 2018 to review their performance data.

Corrections to the underlying data will not be permitted during this time. However, providers can request a CMS review during the preview period if they believe their data is inaccurate. 

For more information:

March 02, 2018

The March 2018 quarterly Inpatient Rehabilitation Facility (IRF) Compare refresh, including quality measure results based on data submitted to CMS between Q2 2016 – Q1 2017, is now available. Visit IRF Compare to view the data. 

January 16, 2018

IRF Preview Reports: Flu Measure Error

CMS identified an error with the data displayed on the IRF Provider Preview Reports released on December 4, 2017, and related to the March 2018 refresh of the IRF Compare website.  The December 2017 Preview Reports incorrectly included data from a reporting period different than that identified in the reports’ headers.  This error affected the following quality measures: 

  1. Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (NQF #0680)
  2. Influenza Vaccination Coverage among Healthcare Personnel (NQF #0431).

The IRF Provider Preview Report headers indicated that data for these measures represented patient assessment data for admissions and/or discharges that occurred between the dates of July 1, 2015 and June 30, 2016.  However, the data displayed on the reports was for the period July 1, 2016 through June 30, 2017.  Because of this discrepancy, CMS will be suppressing the display of this data for these two measures in the March 2018 IRF Compare refresh.  Providers that have questions about this suppression should submit their inquiries to the IRF Public Reporting helpdesk: IRFPRquestions@cms.hhs.gov.

January 04, 2018

New Guidance on How to Update IRF Demographic Data

The demographic data displayed on the Provider Preview Reports and on Inpatient Rehabilitation Facility Compare is generated from information stored in the Automated Survey Processing Environment (ASPEN) system.

If inaccurate demographic data is included on the Preview Report or on IRF Compare, facilities need to contact their Medicare Administrative Contractor (MAC) for assistance. When requesting updates to your demographic data, it is important to specify that you want your data within the ASPEN system updated, instead of referring to your data on the Compare site.

View the How to Update IRF Demographic Data 1-4-18 PDF in the downloads section.

Please note- updates to IRF Provider demographic information do not happen in real time and can take up to 6-months to appear on IRF Compare.

December 12, 2017

IRF Compare Quarterly Refresh 

The December 2017 quarterly IRF Compare refresh, including new quality measure results based on data submitted to CMS is now available. Visit IRF Compare to view the data. 

The following new measures were added to IRF Compare:

  1. Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccination (NQF #0680)
  2. Influenza Vaccination among Healthcare Personnel (NQF #0431)
  3. National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Methicillin resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF #1716)
  4. National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure (NQF #1717)

December 5, 2017

IRFs now have the opportunity to review their performance data on each quality measure based on Quarter 2 -2016 to Quarter 1 - 2017 data, prior to the March 2018 IRF Compare refresh.

Providers have until January 3, 2018 to review their performance data.

View the Preview Report Access Instructions.

September 1, 2017

IRF Compare Quarterly Refresh 

The September 2017 quarterly Inpatient Rehabilitation Facility (IRF) Compare refresh, including quality measure results based on data submitted to CMS between Q4 2015 – Q3 2016, is now available. Visit IRF Compare to view the data. 

September 1, 2017

IRF QRP Provider Preview Reports Now Available

IRFs now have the opportunity to review their performance data on each quality measure based on Quarter 1 -2016 to Quarter 4 - 2016 data, prior to the December 2017 IRF Compare refresh.

Providers have 30 days to review their performance data (September 1, 2017 through September 30, 2017).

View the Preview Report Access Instructions.

June 21, 2017

IRF Fact Sheet Now Available

A new Inpatient Rehabilitation Facility (IRF) fact sheet is now available in the downloads section below. This fact sheet contains information related to IRF Compare and how the site can serve as a resource to providers in understanding their current quality ratings. The fact sheet also suggest approaches to communicating with patients and family members about how the Compare site can inform their decision making process.

June 06, 2017

IRF Compare Quarterly Refresh 

The June 2017 quarterly Inpatient Rehabilitation Facility (IRF) Compare refresh, including quality measure results based on data submitted to CMS between Q3 2015 – Q2 2016, is now available. Visit IRF Compare to view the data. 

June 1, 2017

IRF QRP Provider Preview Reports Now Available

IRFs now have the opportunity to review their performance data on each quality measure based on Quarter 4 -2015 to Quarter 3 - 2016 data, prior to the September 2017 IRF Compare refresh, during which this data will be publicly displayed.

Providers have 30 days (June 1, 2017 through June 30, 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.

March 21, 2017

The March 2017 quarterly Inpatient Rehabilitation Facility (IRF) Compare refresh, including Healthcare-acquired infection (HAI) measures performance data, are now available. View IRF Compare to view the data.

March 01, 2017

IRF QRP Provider Preview Reports Now Available

IRFs now have the opportunity to review their performance data on each quality measure based on Quarter 3 -2015 to Quarter 2 - 2016 data, prior to the June 2017 IRF Compare refresh, during which this data will be publicly displayed.

Providers have 30 days (March 1, 2017 through March 30, 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.

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.