(CMS-10210) 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
Hospital Inpatient Quality Reporting Supporting Statement A_3.12.2015_Revised_NO4.6.2015_CLEAN.docx	Supporting Statement A	Uploaded 2015-06-03	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: 201506-0938-004
Status: Historical Inactive	Previous ICR Reference No: 201504-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No: 21471
Title: (CMS-10210) 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: 07/30/2015
	Date Received in OIRA: 06/12/2015
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is not approved at this time. Prior to publication of the final rule, the agency should provide to OMB a summary of all comments received on the proposed information collection and identify any changes made in response to these comments.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2018	36 Months From Approved	05/31/2018
Responses	17,600	0	17,600
Time Burden (Hours)	6,050,000	0	6,050,000
Cost Burden (Dollars)	0	0	0

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Abstract: In the FY 2016 IPPS Rule, we are proposing to add eight new measures to the Hospital IQR Program measure set and remove nine measures from the Hospital IQR Program measure set, beginning with FY 2018. We are also proposing to require IPPS hospitals to report 16 measures electronically. Additionally, we are updating our burden estimates due to the availability of more recent data. Using data on chart-abstracted measures from the 3rd quarter in 2013 through the 2nd quarter in 2014, we have revised our burden estimate assumptions to include updates to the number of records reported per measure set, as well as the time associated with data collection.

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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-AS41	Proposed rulemaking	80 FR 24323	04/30/2015

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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, CMS-10210, CMS-10210, CMS-10210	Data Accuracy and Completeness Form ,   Hospital VPB Review and Corrections Form ,   Extraordinary Circumstances Form ,   Inpatient Withholding Data form ,   IQR Measure Exception Form ,   IQR Notice of Participation Form ,   IQR Reconsideration Request Form ,   CAUTI Validation Template ,   CDI Validation Template ,   CLABSI Validation Template ,   MRSA Validation Template ,   Validation Review for Reconsideration Request ,   VBP Appeal Request Form

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

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: This program has increased the number of measures included in its data collection requirements. The added measures support adherence to: Section 1886(b)(3)(B)(viii) of the SSA, which required the expansion of the IQR program between FY 2008-2012; Section 3013 of ACA, which modified Section 931 of the Public Health Service Act by requiring CMS to "identify, not less often than triennially, gaps where no quality measures exist and existing quality measures that need improvement, updating or expansion"; and Section 1886(o) of the SSA, which requires CMS to use data reported through the IQR for its VBP program.

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Annual Cost to Federal Government: $10,050,000

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: 06/12/2015

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