chgme 100-2 chgme 100-2

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Overview

HRSA 100-2-A DISCH BY PAYOR,ZIP
HRSA 100-2-B DISCH BY CHRON DI
HRSA 100-2-C HOSP LVL PAT SAFTY
HRSA 100-2-D HOSP LVL CHNG PROG

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Sheet 1: HRSA 100-2-A DISCH BY PAYOR,ZIP

Department of Health and Human Services					OMB No.
Health Resources and Services Administration					Expiration Date: xx/xx/200x
Children's Hospitals Graduate Medical Education Payment Program
HRSA 100-2-A: Discharge Data by Payor and Zip Code
Hospital Name:
Medicare Provider Number:
Date of Report:	(mm/dd/yy)
1. DISCHARGES BY PAYOR
Provide the number of discharges for the academic year most recently completed for each of the following payment groups. Include all Medicaid payments including Medicaid managed care and any other Medicaid payments under the Medicaid and/or SCHIP category. Self-pay refers to patients who have made out-of-pocket payments for services. Uncompensated care means care for which the hospital receives no payment. Do not include lab services under Outpatient Visits. See detailed guidance for complete instructions.
Payor	Inpatient Discharges	Outpatient Visits	Emergency Department Visits
Private Insurance
Medicaid and/or SCHIP
Medicare
Other Public (TRICARE, Indian Health Service)
Self-pay
Uncompensated Care
Total	0	0	0
2. DISCHARGES BY ZIP CODE
Please include a separate CD that provides the number of discharges for the most recent academic year by city, state and zip code. A three-line mock table is provided below as an example.
Zip Code (up to 9 digits, if possible)	City	State	No. of Inpatient Discharges
Zip Code 1
Zip Code 2
Zip Code 3

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Sheet 2: HRSA 100-2-B DISCH BY CHRON DI

Department of Health and Human Services				OMB No.
Health Resources and Services Administration				Expiration Date: xx/xx/200x
Children's Hospitals Graduate Medical Education Payment Program
HRSA 100-2-B: Discharge Data Aggregated by Selected Chronic
Diseases
Hospital Name:	0
Medicare Provider Number:	0
Date of Report:	(mm/dd/yy)
Please list the number of unique inpatient discharges, outpatient visits, and ER visits, by the ICD9 codes provided in the table below. Primary and all secondary diagnoses should be included when preparing the table. Please note that at-risk neonates are identified using V codes for low birth weight. Do not include lab services under Outpatient Visits. See detailed guidance for complete instructions.
Chronic Disease	ICD-9 Codes	Inpatient Discharges	Outpatient Visits	Emergency Department Visits
AIDS (incl HIV positive)	042, V08, 0795
Arthropathies (excl infectious, joint pain)	710, 712-718, 720-723, 725-728,731-39, V49
Asthma	493
Cardiac disease	392-454, 456-458
Cerebral palsy and other paralyses	342-344
CNS disorders (excl epilepsy, paralyses)	324-341, 347-349, V48
Congenital anomalies (excl spina bifida)	740, 742-59, 771
Cystic fibrosis and other	277
Diabetes Mellitus	250
Endocrine, other than diabetes	252-259
Epilepsy	345; 780.39
Gastroenteritis, colitis & malabsorption	555-7, 579,V44
Hematologic (sickle cell, excl, anemia)	281-289; excluding 285.9
Mental Retardation	317-319
Metabolic/immune disorders	270-275, 279
Neoplasms	140-215, 217-239, V10
Neuromuscular disorders (incl polio)	350-359, 045-049,138
Dental diseases	520-522, 524-526
Renal failure	582-589
Spina bifida	741
Thyroid disease	240-246
Neonatal	V21.30-V21.35
Psychiatric/mental health	295-316

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Sheet 3: HRSA 100-2-C HOSP LVL PAT SAFTY

Department of Health and Human Services				OMB No.
Health Resources and Services Administration			Expiration Date: xx/xx/200x
Children's Hospitals Graduate Medical Education Payment Program
HRSA 100-2-C: Patient Safety Initiatives
Hospital Name:	0
Medicare provider number:	0
Date of report:	(mm/dd/yy)
For each of the following patient safety initiatives, indicate whether your children’s hospital had any of the listed initiatives in place in the most recently completed academic year and if any changes in the initiatives have occurred since the year you first began receiving CHGME payments.
Please indicate the rationale for any changes in the initiative (i.e., newly introduced, eliminated, enhanced) and list the benefits of the changes, including, for example, but not limited to, increases in medical knowledge; improvements in clinical competence; increased awareness of psychosocial and behavioral aspects of health and illness; increased awareness of the availability of community resources. See detailed guidance for complete instructions.
	Area Addressed in Most Recent Academic Year	Hospital has made Changes in Initiative since CHGME Funding Began (1999/2000 Academic Year)	Reasons for Change	Benefits of Initiative
Root cause or error analysis	0	0
Chart audits	0	0
Rapid response team (RRT)	0	0
Voluntary and confidential error reporting system	0	0
Required error reporting system	0	0
Mandatory error disclosure	0	0
Standardization of drug dosing	0	0
Computerized physician order entry	0	0
Logic-based forcing functions in computerized physician order entry (e.g., screen for inaccurate data entry, drug interactions, etc.)	0	0
Automatic drug dispensing linked to computerized physician order entry	0	0
Elimination of look-alike and sound-alike meds	1	0
Electronic medical records	1	0
Institution of protocols/guidelines	0	0
Reducing hand-offs	0	0
Availability of translators	0	0
Formalized support mechanisms for residents that err and harm or kill a patient	0	0
Logs and literature reviews regarding analysis of errors to be included in each resident's portfolio.	0	0
Resident participation in quality assurance committees	0	0
Other (specify)_________	0	0

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Sheet 4: HRSA 100-2-D HOSP LVL CHNG PROG

Department of Health and Human Services			OMB No.
Health Resources and Services Administration		Expiration Date: xx/xx/200x
Children's Hospitals Graduate Medical Education Payment Program
HRSA 100-2-D: Changes in GME Programs
Hospital Name:	0
Medicare provider number:	0
Date of report:	(mm/dd/yy)
For each of the programs listed below, please check the box if your children’s hospital participated in the training of residents in such programs in the first year that your children’s hospital received CH GME Payment Program funding and in the residency academic year most recently completed. “Participated in training” is broadly defined to include acting as a sponsoring institution, major participating institution, or a rotational site.
Please indicate the rationale for any changes and the benefits of the change, including but not limited to, increases in medical knowledge; improvements in clinical competence; increased awareness of psychosocial and behavioral aspects of health and illness; increased awareness of the availability of community resources; increased ability to function as a medical home provider; improvements in patient care and outcomes and promotion of leadership skills. See detailed guidance for complete instructions.
	Area Addressed in Year that CHGME Funding Began	Program Added since the Year CHGME Funding Began	Program Dropped since the Year CHGME Funding Began
Primary Care Programs
Family Medicine	0	0	0
Pediatrics	0	0	0
Please indicate the reasons for the change(s) in primary care training programs and benefits of the change to the community, patients, and trainees.
Combined Programs
Internal Medicine Pediatrics	0	0	0
Pediatrics/Dermatology	0	0	0
Pediatrics/Emergency Medicine	0	0	0
Pediatrics/Medical Genetics	0	0	0
Pediatrics/Physical Medicine and Rehab	0	0	0
Pediatrics/Psychiatry/Child & Adolescent Psychology	0	0	0
Please indicate below the reasons for the change(s), if any, in combined programs and benefits of the change to the community, patients, and trainees.
Pediatric Medical Subspecialties
Adolescent Medicine Pediatrics	0	0	0
Child Abuse Pediatrics	0	0	0
Developmental Behavioral Pediatrics	0	0	0
Hospice and Palliative Medicine	0	0	0
Medical Toxicology	0	0	0
Neonatal-Perinatal Medicine	0	0	0
Neurodevelopmental Disabilities	0	0	0
Pediatric Allergy Immunology	0	0	0
Pediatric Cardiology	0	0	0
Pediatric Critical Care Medicine	0	0	0
Pediatric Emergency Medicine	0	0	0
Pediatric Endocrinology	0	0	0
Pediatric Gastroenterology	0	0	0
Pediatric Hematology/Oncology	0	0	0
Pediatric Infectious Disease	0	0	0
Pediatric Nephrology	0	0	0
Pediatric Pulmonology	0	0	0
Pediatric Rheumatology	0	0	0
Pediatric Transplant Hepatology	0	0	0
Pediatric Sleep Medicine	0	0	0
Pediatric Sports Medicine	0	0	0
Please indicate below the reasons for the change(s), if any, in pediatric medical subspecialties and the benefits of the change(s) to the community, patients, and trainees.
Pediatric Surgical Subspecialties
Pediatric Cardiothoracic Surgery	0	0	0
Pediatric Neurosurgery	0	0	0
Pediatric Ophthalmology	0	0	0
Pediatric Orthopedics	0	0	0
Pediatric Otolaryngology	0	0	0
Pediatric Surgery	0	0	0
Pediatric Urology	0	0	0
Please indicate the reasons for the change(s) in pediatric surgical subspecialties and the benefits of the change(s) to the community, patients, and trainees.
Other Specialties
Child and Adolescent Psychiatry	0	0	0
Child Neurology	0	0	0
Emergency Medicine (Pediatric)a	0	0	0
Pediatric Anesthesiology	0	0	0
Pediatric Dermatology	0	0	0
Pediatric Pathology	0	0	0
Pediatric Radiology	0	0	0
Pediatric Rehabilitation Medicine	0	0	0
Please indicate below the reasons for the change(s), if any, in other specialties and the benefits of the change(s) to the community, patients, and trainees.
General (Non-pediatric) Specialties
Allergy Immunology	0	0	0
Anesthesiology	0	0	0
Colon & Rectal Surgery	0	0	0
Dermatology	0	0	0
Emergency Medicine	0	0	0
Medical Genetics	0	0	0
Neurological Surgery	0	0	0
Neurology	0	0	0
Nuclear Medicine	0	0	0
Obstetrics and Gynecology	0	0	0
Ophthalmology	0	0	0
Orthopedic Surgery	0	0	0
Otolaryngology	0	0	0
Pathology	0	0	0
Physical Medicine & Rehabilitation	0	0	0
Plastic Surgery	0	0	0
Preventive Medicine	0	0	0
Psychiatry	0	0	0
Radiology	0	0	0
Surgery	0	0	0
Thoracic Surgery	0	0	0
Please indicate below the reasons for the change(s), if any, in general (non-pediatric) specialties and the benefits of the change(s) to the community, patients, and trainees.
Urology	0	0	0
Other (specify):__________________	0	0	0
Other (specify):__________________	0	0	0
Other (specify):__________________	0	0	0
a. Refers to program in which residents first completed an emergency medicine residency followed by a pediatric emergency medicine fellowship versus initially completing a pediatric residency followed by a pediatric emergency medicine fellowship.