Hospital Reporting Initiative--Hospital Quality Measures

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10210 Quality Measures and Procedures for Hospital Reporting of Quality Data	Form and Instruction	Modified	Available
CMS-10210 Hospital Inpatient Quality Reporting PRA.docx	Supporting Statement A	Uploaded 2013-07-19	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
204350	Quality Measures and Procedures for Hospital Reporting of Quality Data	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1022	ICR Reference No: 201307-0938-012
Status: Historical Inactive	Previous ICR Reference No: 201210-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No: 20087
Title: Hospital Reporting Initiative--Hospital Quality Measures
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Comment filed on proposed rule and continue	Conclusion Date: 02/14/2014
	Date Received in OIRA: 07/22/2013
Terms of Clearance: Comment filed.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2016	36 Months From Approved	03/31/2016
Responses	17,600	0	17,600
Time Burden (Hours)	6,750,000	0	6,750,000
Cost Burden (Dollars)	0	0	0

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Abstract: The Hospital Inpatient Quality Reporting Program (IQR) program was first established to implement section 5001(b) of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) (Pub. L. 108-173), which authorized CMS to pay hospitals that successfully reported quality measures a higher annual update to their payment rates. It builds on a voluntary Inpatient Quality Reporting program which remains in effect. The Hospital IQR program formerly known as the Reporting Hospital Quality Data for Annual Payment Update program, began with an initial set of 10 measures. Section 5001(a) of the Deficit Reduction Act of 2005 (DRA) (Pub. L. 109-171) revised the mechanism used to update the standardized amount for payment for hospital inpatient operating costs. This is reflected in Sections 1886(b)(3)(B)(viii)(I) and (II) of the Social Security Act which provide that the annual payment update (APU) will be reduced for any "subsection (d) hospital" that does not submit certain quality data in a form and manner, and at a time, specified by the Secretary. Section 5001(a) of the DRA also expanded the scope of IQR, requiring CMS to add new measures. Sections 1886(b)(3)(B)(viii)(III) through (V) of the Social Security Act, required CMS to "adopt the baseline set of performance measures as set forth in the November 2005 report by the Institute of Medicine of the National Academy of Sciences", instructed the Secretary to "add other measures that reflect consensus among affected parties", and allowed the Secretary to "replace any measures or indicators in appropriate cases". When adding new measures, the law required CMS when "feasible and practical" to select measures put forward by "one or more national consensus building entities".

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Authorizing Statute(s): PL: Pub.L. 108 - 173 5001(b) Name of Law: Medicare Prescription Drug, Improvement and Modernization Act of 2003
   PL: Pub.L. 111 - 148 3001 Name of Law: Affordable Care Act
   PL: Pub.L. 109 - 171 5001(a) Name of Law: Hospital Quality Improvement
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AR12	Proposed rulemaking	78 FR 27485	05/10/2013

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Quality Measures and Procedures for Hospital Reporting of Quality Data	CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210	Reconsideration Reqeust Paper Form ,   Reconsideration Request Online Form ,   Hospital Value-Based Program Appeal Request Form ,   Hospital Value Based Review and Correction Request Form ,   Hospital Value-Based Purchasing Program Appeal Request Form ,   Hosptial Value-Based Purchasing Review and Corrections Request Form ,   Proposed FY2016 Validation Template for CDI ,   Proposed FY2016 Positive Blood Culture Template ,   Proposed FY2016 Positive Urine Culture Template ,   Proposed FY2016 Validation Template for MRSA

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Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Using Information Technology

Short Statement: CMS program reduces the reporting burden for quality of care information collected by allowing hospitals to abstract data directly into electronic systems in lieu of submitting paper charts, or to utilize electronic data that they already report to JCO for accreditation.

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Annual Cost to Federal Government: $9,550,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/22/2013

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