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Inpatient Rehabilitation Facility (IRF) Compare Website - New Measures Added

Date
2017-12-12
Title
Inpatient Rehabilitation Facility (IRF) Compare Website - New Measures Added
Contact
press@cms.hhs.gov

Inpatient Rehabilitation Facility (IRF) Compare Website - New Measures Added
This fact sheet contains information about the Inpatient Rehabilitation Facility (IRF) compare website that was refreshed with new quality measures added on December 12, 2017.

Background 

Why is this information being released?

Section 3004(b) of the Affordable Care Act established the IRF Quality Reporting Program (QRP) and requires the Secretary of Health and Human Services to establish procedures for making quality data submitted by IRFs available to the public. The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) also requires public reporting of provider performance two years following the specified application date (the date data collection began). Historically, new items are added to the programs in the fall. This Compare refresh contains data from over 1,100 IRFs.

What 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)
    • Data Collection Period: July 1, 2015 – June 30, 2016 (displayed as October 1, 2015 – March 31, 2016)
  2. Influenza Vaccination among Healthcare Personnel (NQF #0431)
    • Data Collection Period: July 1, 2015 – June 30, 2016 (displayed as October 1, 2015 – March 31, 2016)
  3. 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
  4. 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

What measures are currently displayed on IRF Compare?

  1. Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678)
    • Data Collection Period: January 1, 2016 – December 31, 2016
  2. National Healthcare Safety Network (NHSN) Catheter Associated Urinary Tract Infection (CAUTI)  Outcome Measure (NQF #0138)
    • Data Collection Period: January 1, 2016 – December 31, 2016
  3. All Cause Unplanned 30 day post IRF Discharge Readmission Measure (NQF #2502)
    • Data Collection Period: January 1, 2014 – December 31, 2015

What is the source of the new publicly reported data?

  • Data for NQF #0680 is based upon patient assessments and were collected and submitted to CMS by IRF providers via the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI).
  • Data for NQF #0431, #1716, and #1717 were collected and submitted to CMS by IRF providers via the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN).

How is the data on the IRF Compare site relevant to consumers? How will they use the site?

IRF Compare takes quality measure data and puts them into a readily useful format for the public to get a snapshot of the quality of care provided by each hospital.

II. Summary of Findings for New Measures

IRF Measure Name and Description

National Rate of Quality Measure Performance (CY2016)

Patients assessed and given influenza vaccination

Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccination (NQF #0680)

91%**

Influenza Vaccination Coverage Among Healthcare Personnel

Influenza Vaccination Coverage Among Healthcare Personnel (NQF #0431)

84%**

Methicillin-resistant Staphylococcus aureus (MRSA) Bacterial Infection

National Healthcare Safety Network (NHSN) Facility-Wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF #1716)

1.18*

Clostridium difficile Infection (CDI)

National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure (NQF #1717)

1.16*

*Reported as National Standardized Infection Ratio (SIR)
** NQF #0680 and NQF #0431 are calculated based on July 1, 2015 through June 30, 2016 (displayed as October 1, 2015 – March 31, 2016)
The Standardized Infection Ratio (SIR) is the primary summary measure used by the National Healthcare Safety Network (NHSN) to track healthcare associated infections (HAIs).

II. Summary of Findings for Current Measures

IRF Measure Name and Description

National Rate of Quality Measure Performance (CY2015)

National Rate of Quality Measure Performance (CY2016)

Patients with New or Worsened Pressure Ulcers

Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (NQF # 0678)

0.8%

0.6%

Catheter-Associated Urinary Tract Infection (CAUTI)

National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection Outcome Measure (NQF # 0138)

1.007*

1.097*

30 Days All-Cause Unplanned Readmission

All-Cause Unplanned Readmission Measure for 30 Days Post-Discharge From Long-Term Care Hospitals (NQF #2502)

13.06%**

13.39%**

*Reported as National Standardized Infection Ratio (SIR)
**NQF #2502 is calculated based on two years of data. In the chart above CY2015 = January 1, 2013 through December 31, 2014 and CY2016 = January 1, 2014 through December 31, 2015
The Standardized Infection Ratio (SIR) is the primary summary measure used by the National Healthcare Safety Network (NHSN) to track healthcare associated infections (HAIs).

III. Resources Available to Providers

Where can I find more information about IRF Compare?

Help Desks

  • For questions about IRF-PAI data submissions or status of data submissions via CASPER reports, call 1-800-339-9313 or email help@qtso.com.
  • For questions about IRF quality data submitted to CMS via CDC’s NHSN, or NHSN Registration, email NHSN@cdc.gov.
  • For questions about IRF Public Reporting, email IRF Public Reporting helpdesk: IRFPRquestions@cms.hhs.gov.
  • Detailed guidance on how to run and interpret IRF-PAI provider reports can be found in Section 3 of the CASPER Reporting User’s Manual.  
  • For questions about quality measure calculation, data submission deadlines, or data items contained within the Quality Indicator section of the IRF-PAI, email IRF.Questions@cms.hhs.gov.
  • Subscribe to the Post-Acute Care Quality Reporting Program (PAC QRP) listserv for the latest IRF Quality Reporting Program information including but not limited to training, stakeholder engagement opportunities, and general updates about reporting requirements, quality measures, and reporting deadlines. 

IV. Additional Compare Sites

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