(CMS-10210) Hospital Reporting Initiative--Hospital Quality Measures

Forms and Documents

Document Name	Status
Form CMS-10210 Quality Measures and Procedures for Hospital Reporting of Quality Data Form and Instruction	Modified
CMS-10210 FY 2017 IPPS Final Rule HIQR SS part A - final.docx Supporting Statement A	2017-01-23

IC Document Collections

IC ID	Document Title	Status
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: 201609-0938-002
Status: Historical Active	Previous ICR Reference No: 201511-0938-001
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: Approved with change	Conclusion Date: 01/24/2017
	Date Received in OIRA: 09/14/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2020	36 Months From Approved	08/31/2019
Responses	17,600	0	17,600
Time Burden (Hours)	3,681,023	0	7,951,695
Cost Burden (Dollars)	0	0	0

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Abstract: In the FY 2017 IPPS/LTCH PPS Final Rule, we are finalizing the addition of four new measures for the Hospital Inpatient Quality Reporting (IQR) Program measure set and removal of fifteen measures from the Hospital IQR Program measure set, beginning with the FY 2019 payment determination. We also are finalizing to require hospitals to submit all four quarters of electronic clinical quality measure (eCQM) data on 8 measures on an annual basis by the end of the two months following the end of the reporting period calendar year (i.e., by February 28, 2018 for the CY 2017 reporting period). Additionally, we are finalizing to modify our existing validation process to include the validation of eCQM data. Lastly, we are finalizsing an update our Extraordinary Circumstances Extensions/Exemptions (ECE) policy by: (1) extending the general ECE request deadline for non-eCQM circumstances from 30 to 90 calendar days following an extraordinary circumstance; and (2) establishing a separate submission deadline for ECE requests with respect to eCQM reporting circumstances of April 1st following the end of the reporting calendar year. Finally, 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 2014 through the 2nd quarter in 2015, we have revised our burden estimate assumptions to include updates to the estimated time per record and 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-AS77	Final or interim final rulemaking	81 FR 56761	08/22/2016

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 24945	04/27/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 56761	08/22/2016
Did the Agency receive public comments on this ICR? No

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

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, 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 ,   HVBP CMS Independent Review Form

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	17,600	17,600	0	0	0	0
Annual Time Burden (Hours)	3,681,023	7,951,695	0	-4,270,672	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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: Miscellaneous Actions

Short Statement: For the FY 2019 payment determination, we estimate a total burden decrease of 1,717,444 hours associated with our finalized policy change (i.e., removal of measures, addition of measures, and expansion of the validation process) and also as a result of updated measure collection calculations (i.e., the amount of time to collect data for a certain measure set).

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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: 09/14/2016

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