1. Affordable Care Act Section Inpatient Rehabilitation Facility Quality Reporting Program Provider Training
Caroline D. Gallaher, R.N., B.S.N, J.D.
CMS, Office of Clinical Standards and Quality
Division of Chronic & Post Acute Care
May 2, 2012
Baltimore, MD
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2. Welcome Thank you for taking the time to attend this session.
We have mutual goals:
Improve the health care services provided to patients.
Implement the ACA Section 3004 IRF Quality Reporting Program properly and with the least burden possible.
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3. Purpose & Goals of Training
After this training, participants will be able to:
Understand the requirements of the IRF Quality Reporting Program.
Correctly stage pressure ulcers and accurately code pressure ulcer data on the IRF-PAI.
Correctly report CAUTI data to CDC.
Describe resources available for assistance.
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4. Overview of the ACA Section 3004 Inpatient Rehabilitation Facility Quality Reporting Program
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5. Mandates of Section 3004
Section 3004 of the Patient Protection and Affordable Care Act (PPACA), was passed on March 23, 2010.
Requires that IRFs submit quality data to CMS in a form, manner and time specified by the Secretary.
IRFs that fail to submit the required quality data will receive a 2% reduction of the annual update to a standard Federal rate for discharges for the hospital during the rate year affected.
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6. How Quality Measures Are Selected and Quality Measure Data Used
Data submitted from IRF providers will be used to calculate quality measures and assess quality of care provided by IRFs.
The Centers for Medicare & Medicaid Services (CMS) selects the quality measures to be used in the IRF QRP, after giving significant consideration to input received from stakeholders and the public.
Quality measures are published through the MAP process and finalized though rulemaking.
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7. Measure Applications Partnership (MAP) Measure Selection Process
Created under authority of Sec of the Affordable Care Act.
The MAP is a public-private partnership convened by the National Quality Forum (NQF).
Providing input to the Department of Health and Human Services (HHS) on selecting performance measures for public reporting, performance-based payment programs, and other purposes.
MAP is designed to facilitate alignment of public- and private-sector uses of performance measures to further the National Quality Strategy’s (NQS) three-part aim of creating better, more affordable care and healthier people.
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8. Measure Applications Partnership (MAP) Measure Selection Process
Anticipated outcomes from MAP’s work include:
A more cohesive system of care delivery;
Better and more information for consumer decision-making;
Heightened accountability for clinicians and providers;
Higher value for spending by aligning payment with performance;
Reduced data collection and reporting burden through harmonizing measurement activities across public and private sectors; and
Improvement in the consistent provision of evidence-based care.
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9. National Strategy for Quality Improvement In Healthcare
Selection of measures is based, in part, on the priorities outlined in the National Strategy for Quality Improvement in Healthcare (available at: pdf)
Three Broad Aims:
Better Care
Healthy People/ Healthy Communities
Affordable Care
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10. Priorities of the National Strategy
Making care safer by reducing harm caused in the delivery of care.
Ensuring that each person and family are engaged as partners in their care.
Promoting effective communication and coordination of care.
Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.
Working with communities to promote wide use of best practices to enable healthy living.
Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.
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11. IRF QRP Quality Measures
In the FY2012 IRF PPS Rule*, two quality measures were selected for use in the IRF QRP:
New or Worsened Pressure Ulcers
And
2. Catheter-Associated Urinary Tract Infections (CAUTIs)
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12. Data Submission Pressure Ulcer Data:
New, mandatory pressure ulcer items included on the IRF- PAI in the “Quality Indicator Section.”
Other Quality Indicator items that had been voluntary in past have been deleted (respiratory status, pain, safety).
Updated IRF-PAI submission software (jIRVEN) will be available from CMS to support the 10/01/2012 release.
Same IRF-PAI submission process will be used.
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13. Data Submission (continued)
CAUTI Data:
Submitted online to the CDC’s National Healthcare Safety Network (NHSN).
IRFs that do not already report data to NHSN will be required to register as an NHSN user, take mandatory training, and submit a signed agreement allowing data to be sent to CMS.
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14. Changes to the IRF-PAI
The PUSH tool on the IRF-PAI has been replaced with updated pressure ulcer items (items 48A through 50D).
Although an IRF may decide not to submit pressure ulcer data (items 48A through 50D), failure to complete these items may result in payment reduction of two percentage points starting in Fiscal Year 2014.
Voluntary Quality Indicators have been removed
Respiratory Status
Pain
Safety
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17. Public Reporting
No timeline has been established for public reporting of IRF quality measure data.
Ultimately, IRF quality measure data will be publicly reported; but ONLY after each facility has been given a chance to review its results.
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18. Resources Ways to keep up-to-date on IRF QRP issues:
Join the CMS Listserv:
Check the IRF QRP Program Web site frequently:
Contact one of the help desks if you have any questions (see help desk slide).
Many provider associations provide updates.
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19. Resources The IRF Quality Reporting Program Website:
Includes technical information, an overview of the program, and links to materials.
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20. Help Desks For questions about: e-mail: IRF.questions@cms.hhs.gov
IRF-PAI data coding or IRF-PAI data submission:
Phone: or
CAUTI data or submission, NHSN Registration:
Quality measure calculation , data submission deadlines, the new pressure ulcer items:
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