Form 100-2 HRSA 100-2 FY13 - Redesign

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Overview

Cover Page
HRSA 100-2-A DISCH BY PAYOR,ZIP
HRSA 100-2-B DISCH BY CHRON DI
HRSA 100-2-C HOSP LVL PAT SAFTY

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Sheet 1: Cover Page

Department of Health and Human Services						OMB No. 0915-0313
Health Resources and Services Administration						Expiration Date: 11/30/2013
	CHILDREN’S HOSPITALS GRADUATE MEDICAL EDUCATION PAYMENT PROGRAM ANNUAL REPORT FORM HRSA 100-2
	Public Burden Statement
	An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0313. Public reporting burden for the applicant for this collection of information is estimated to average 39.4 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14 33, Rockville, Maryland, 20857.

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

Department of Health and Human Services					OMB No. 0915-0313
Health Resources and Services Administration					Expiration Date: 11/30/2013
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:	12/31/12
1. DISCHARGES BY PAYOR
Provide the number of discharges for the academic year most recently completed (July 1, 2011 - June 30, 2012) 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 CHIP 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 CHIP
Medicare
Other Public (TRICARE, Indian Health Service)
Self-pay
Uncompensated Care
Total
2. DISCHARGES BY ZIP CODE
Please enter the number of discharges for the academic year most recently completed (July 1, 2011 - June 30, 2012) by zip code in the highlighted cell of the mock table provided as an example below. Also, include a separate CD that provides the number of inpatient discharges for the most recent academic year (July 1, 2011 - June 30, 2012) by city, state and zip code. The total number of inpatient discharges must equal total number of inpatient discharges documented in section one above. Please include the name and Medicare Provider Number of your hospital at the top of the listing and on the outside of the CD.
Zip Code (up to 9 digits, if possible)	City	State	No. of Inpatient Discharges
Zip Code 1	Roanoke	VA	12
Zip Code 2	Las Vegas	NV	40
Zip Code 3	Springfield	IL	32
Total

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Sheet 3: HRSA 100-2-B DISCH BY CHRON DI

Department of Health and Human Services				OMB No. 0915-0313
Health Resources and Services Administration				Expiration Date: 11/30/2013
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:	00-0000
Date of Report:	12/31/12
Please list the number of unique inpatient discharges, outpatient visits, and ER visits, by the ICD-9 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 4: HRSA 100-2-C HOSP LVL PAT SAFTY

Department of Health and Human Services				OMB No. 0915-0313
Health Resources and Services Administration			Expiration Date: 11/30/2013
Children's Hospitals Graduate Medical Education Payment Program
HRSA 100-2-C: Patient Safety Initiatives
Hospital Name:	0
Medicare provider number:	00-0000
Date of report:	12/31/12
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 (2011-2012) and if any changes in the initiatives have occurred since the previous academic year (2010-2011).
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.
	Part of the Hospital's Patient Safety Program in Most Recent Academic Year (2011-2012) ü=YES Blank=NO	Hospital has Made Changes in Initiative since the previous academic year (2010-2011) ü=YES Blank=NO	Reasons for Change	Benefits of Initiative
Root cause or error analysis
Chart audits
Rapid response team (RRT)
Voluntary and confidential error reporting system
Required error reporting system
Mandatory error disclosure
Standardization of drug dosing
Computerized physician order entry
Logic-based forcing functions in computerized physician order entry (e.g., screen for inaccurate data entry, drug interactions, etc.)
Automatic drug dispensing linked to computerized physician order entry
Elimination of look-alike and sound-alike meds
Electronic medical records
Institution of protocols/guidelines
Reducing hand-offs
Availability of translators
Formalized support mechanisms for residents that err and harm or kill a patient
Logs and literature reviews regarding analysis of errors to be included in each resident's portfolio.
Resident participation in quality assurance committees
Other (specify):