1. June 20, 2013 Infection Prevention Power Hour

2. IPPS/LTCH PPS Proposed Rule Summary Includes proposals for seven different quality reporting and payment programs Select headlines: – HAC Reduction (penalty) Program - All of it – Readmissions – Updated measures and expansion to 2 additional conditions in FY 2015 – IQR – Electronic reporting option – VBP – new measures and measure domain realignment Comments due on June 25, 2013 2

3. Hospital Acquired Conditions Beginning FY 2015, financial penalty for being in the top quartile of national HAC rates – 1 percent reduction to Medicare payments for all discharges. – Includes: Inpatient PPS, SCHs, and Indian Health Services – Excludes: CAHs, LTCHs, cancer hospitals, IRFs, IPFs, 9 © 2013 American Hospital Association

4. HAC Measures Domain 1, Option 1: Individual PSIs Domain 1, Option 2: Composite PSI Domain 2: HAI Measures  Pressure ulcer (PSI 3)# *  Volume of foreign object left in the body (PSI 5)  Iatrogenic Pneumothorax rate (PSI 6)*  Postoperative physiologic and metabolic derangement rate (PSI 10)# *  Postoperative pulmonary embolism (PE) or deep vein thrombosis rate (DVT) (PSI 12)  Accidental puncture and laceration rate (PSI 15) PSI-90 (Composite comprised of the following 8 PSIs):  Pressure ulcer rate (PSI 3)# *  Iatrogenic Pneumothorax rate (PSI 6)*  Central venous catheter- related blood stream infection rate (PSI 7)# *  Postoperative hip fracture rate (PSI 8)# *  Postoperative pulmonary embolism (PE) or deep vein thrombosis rate (DVT) (PSI 12)  Postoperative sepsis rate (PSI 13)# *  Wound dehiscence rate (PSI 14)# *  Accidental puncture and laceration rate (PSI 15)  Central Line-associated Blood Stream Infection (CLABSI) (FY 2015 onward)%  Catheter-associated Urinary Tract Infection (CAUTI) (FY 2015 onward)%  Surgical Site Infection (SSI) (FY 2016 onward):% o SSI Following Colon Surgery o SSI Following Abdominal Hysterectomy  Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia (FY 2017 onward) %  Clostridium difficile (FY 2017 onward)% # = Not NQF-endorsed * = Not reviewed by the Measure Applications Partnership (MAP) %= Overlaps with finalize or proposed VBP measure 10 © 2013 American Hospital Association

5. HAC: Scoring Methodology Performance on each measure split into quartiles…. Percentile above 75 th percentile Number of Points Assigned for measure 1 st -10 th 1 11 th – 20 th 2 21 st – 30 th 3 31 st – 40 th 4 41 st – 50 th 5 51 st – 60 th 6 61 st – 70 th 7 71 st – 80 th 8 81 st – 90 th 9 91 st – 100 th 10 … with hospitals then assigned points depending on the decile of performance on each measure 11 Top quartile scores then divided into deciles… © 2013 American Hospital Association

6. HAC Reduction Program: Assigning Points 8 © 2013 American Hospital Association

7. HAC Reduction Program: Areas of Concern and Analysis The measures – Not all are NQF-endorsed, – Not all reviewed by the MAP Scoring methodology – Is it sufficient to blunt the effect of rarely occurring events? – AHA conducting an analysis to determine spread of performance on measures, and impact to hospitals Double penalty (or conflicting signals about penalties) – CAUTI and CLABSI in VBP and HAC 10 © 2013 American Hospital Association

8. Hospital Readmissions Reduction Program: FY 2014 and 2015 Proposals FY 2014 Penalty increases to 2%, per statute Planned readmissions algorithm incorporated into existing measures to exclude planned readmissions Always excludes transplant surgery, OB delivery, maintenance chemotherapy and rehab Possible exclusion of non-acute readmits for planned procedures No exclusion for readmits for acute illness or complications FY 2015 Penalty increases to 3%, per statute Addition of two measures COPD readmissions Total hip/Total Knee readmissions 11

9. Inpatient Quality Reporting OUT Aspirin prescribed at discharge for AMI Statin prescribed at discharge for AMI Angiotensin converting enzyme Inhibitors / angiotensin receptor blockers (ACEI/ARB drugs) for left ventricular systolic dysfunction Surgery patients with perioperative temperature management PN-3b – Blood culture performed in the emergency department prior to first antibiotic received in hospital HF-1 – Discharge instructions IMM-1 – Immunization for pneumonia (guidelines have changes) Participation in a systematic clinical database registry for stroke care (stroke measures render this unnecessary) Claims based Vascular Associated infection and CAUTI(End 2012, remove FY 2014) 16 © 2013 American Hospital Association

10. New Reporting IN 30-day risk standardized COPD readmission 30-day risk standardized COPD mortality 30-day risk standardized stroke readmission 30-day risk standardized stroke mortality AMI payment per episode of care Expand CAUTI and CLABSI to non-ICU areas

11. Inpatient Quality Reporting (IQR): Validation Process Timing: Quarters shifted to allow for more timely determination of annual payment update Selection of measures: Will validate 12 process of care, and add MRSA and C Diff to HAI validation in FY 2016 Number of records: Will reduce the number of records validated per hospital for HAI measures Electronic submission of records selected for validation will be allowed 18 © 2013 American Hospital Association

12. Value-Based Purchasing (VBP) FY 2016 and FY 2017 Measure Proposals Three clinical process measures removed for FY 2016 – AMI-8a (primary PCI within 90 minutes of hospital arrival) – dropped due to being topped out; – PN-3b (blood cultures performed in the emergency department prior to initial antibiotic received in hospital) – no longer NQF-endorsed – HF-1 (discharge instructions – no longer NQF-endorsed Three new measures added for FY 2016 – IMM-2 (Influenza Vaccination for inpatients 6 months and older); – Catheter-associated urinary tract infections; and – Surgical site infections Two new measure for FY 2017 – Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia – Clostridium difficile (C Diff). 19 © 2013 American Hospital Association

13. Proposed Domain Weighting for FY 2016 VBP Program Measure Domain FY 2013 Final FY 2014 Final FY 2015 Final FY 2016 Proposed Process 70%45%20%10% Patient Experience 30% 25% Outcomes 0%25%30%40% Efficiency 0% 20%25% 20 © 2013 American Hospital Association

14. Proposed Realignment of Domain for FY 2017 VBP Program CMS proposes a realignment of domains and measures within the domains to align with the National Quality Strategy priority areas Specific measures are remapped to the new domains As alternative, CMS proposes the same domains and weighting as the FY 2016 VBP program DomainWeight Safety (CLABSI, CAUTI)15% Clinical Care:  Clinical Care – Outcomes  Clinical Care – Process 35%  25%  15% Efficiency and Cost Reduction25% Patient and Caregiver Centered Experience of Care / Care Coordination 25% 21 © 2013 American Hospital Association

15. VBP Disaster / Extraordinary Circumstances Waiver CMS proposes a waiver process for hospitals that have faced natural disasters or other extenuating circumstances CMS would have the authority to waive a hospital from the VBP program in the fiscal year during which a hospital’s performance period data is likely affected Hospitals would be required to submit a request within 30 days of the occurrence of the extraordinary circumstance, and simultaneously with the IQR waiver 22 © 2013 American Hospital Association

16. Inpatient Psychiatric Facility Quality Reporting Program (IPFQR) IPFs and licensed psychiatric distinct part units reimbursed under the IPF PPS must report on quality measures to receive full annual payment update beginning in FY 2014 – FY 2014 and FY 2015 program use the HBIPS measures from the Joint Commission Eligible institutions. – Free-standing Psychiatric Hospitals, including government- operated Psychiatric Hospitals – Licensed Distinct Part Psychiatric Units of acute care hospitals and critical access hospitals 23 © 2013 American Hospital Association

17. IPFQR: FY 2016 Measurement Proposals Not yet NQF-endorsed (NQF review underway) – SUB-1 – Alcohol Use Screening Percentage of patients 18 years of age and older who are screened for unhealthy alcohol use during an inpatient stay. – SUB-4—Alcohol and Drug Use: Assessing Status after discharge Assesses whether discharged patients are contacted between 7 and 30 days after hospital discharge to collect information about their alcohol or drug use FUH – Follow up after Hospitalization for Mental Illness (NQF- endorsed) – Assesses the percentage of discharges for patients hospitalized for mental health disorders who subsequently had outpatient treatment 24 © 2013 American Hospital Association

18. Long-Term Care Hospital Quality Reporting (LTCHQR) Submit quality measures for FY 2014 and beyond Compliance is tied to 2 percent of the annual update MeasureFY 2014FY 2015FY 2016FY 2017 FY 2018 Central-Line Associated Blood Stream Infection (CLABSI) XXXXX Catheter-Associated Urinary Tract Infection (CAUTI) XXXXX Percent of nursing home residents with pressure ulcers that are new or worsened XXXXX Percent of nursing home residents who were assessed and appropriately given the seasonal influenza vaccine -- XXX Influenza vaccination coverage among healthcare personnel -- XXX Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia PP Clostridium difficile (C Diff) PP Unplanned all-cause, all condition readmissions to LTCHs and acute care hospitals PP Percent of residents experiencing one or more falls with major injury (Long stay) P X = Previously Finalized P = Proposed 26 © 2013 American Hospital Association

19. LTCHQR Proposals – Areas of Concern Proposed measures not ready to use in LTCHs – The measures proposed for FY 2017 and FY 2018 received a “support direction” vote from the MAP MRSA and C Diff are NQF-endorsed but not fully tested in LTCHs 27 © 2013 American Hospital Association

20. LTCHQR Proposals – Measure Updates Healthcare personnel flu vaccination measure: reporting periods changed so that they reflect a full flu season – FY 2016: Oct. 1, 2014 – Mar. 31, 2015 (due May 15, 2016) – FY 2017: Oct. 1, 2015 – Mar. 31, 2016 (due May 15, 2016) Patient flu vaccination measure – Change in reporting timelines for FY 2016 and FY 2017 to reflect the implementation of LTCH CARE Tool (see the Regulatory Advisory) – Public reporting to reflect flu season time periods, though data collection must take place for all specified periods © 2013 American Hospital Association

21. No Reporting Changes OP Ambulatory Surgery Center Inpatient Rehab Facilities

22. Resources 2014 Proposed Rule http://www.gpo.gov/fdsys/pkg/FR-2013-05-10/pdf/2013- 10234.pdf

23. Denise M. Flook, RN, MPH, CIC Vice President, Infection Prevention and Staff Engagement dflook@gha.org 770-249-4518