CMS Updates Website and Adds New Measures to IRF Compare

New quality measures have been added to the IRF Compare website in order to assist consumers, although some measures are not included.

The Inpatient Rehabilitation Facility (IRFs) Prospective Payment System for federal fiscal year 2018 final rule published Aug. 3, 2017 included the addition of additional quality measures to the IRF Quality Compare Website by fall 2018.  On Dec. 12, 2017 the Centers for Medicare & Medicaid Services (CMS) released a fact sheet notifying IRFs that the IRF Compare Website was refreshed with four of those measures.

Newly Added Measures

The new measures include the following:

• Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccination (NQF #0680)
  Data Collection Period: July 1, 2015 – June 30, 2016 (displayed as Oct. 1, 2015 – March 31, 2016)
• Influenza Vaccination among Healthcare Personnel (NQF #0431)
  Data Collection Period: July 1, 2015 – June 30, 2016 (displayed as Oct. 1, 2015 – March 31, 2016)
• National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Methicillin Resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF #1716)
  Data Collection Period: Jan. 1, 2016 – Dec. 31, 2016
• National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Clostridium Difficile Infection (CDI) Outcome Measure (NQF #1717)
  Data Collection Period: Jan. 1, 2016 – Dec. 31, 2016

Measures Currently on Display

• Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678)
  Data Collection Period: Jan. 1, 2016 – Dec. 31, 2016
• National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure (NQF #0138)
  Data Collection Period: Jan. 1, 2016 – Dec. 31, 2016
• All Cause Unplanned 30-day post-IRF Discharge Readmission Measure (NQF #2502)
  Data Collection Period: Jan. 1, 2014 – Dec. 31, 2015

Meaningful to Consumer

Today’s consumers are concerned about quality care in the healthcare system and frequently use Medicare’s “Compare” sites to provide information for healthcare choices.  Admissions to post-acute care facilities including IRFs are generally planned to follow an acute stay and patients and families can research data prior to making a placement decision.  The IRF Compare site includes a list of the most common conditions treated as well as the quality data listed above. The data is provided to the consumer in table format showing the individual IRFs performance as compared to the national average.  Additionally, as is true for the other Medicare’s “Compare” sites, the consumer can create a side-by-side table comparing up to three facilities with the national average. 

How IRFs Should Utilize this Data

Check your data.  Prior to final publication, IRFs are provided an opportunity to review and correct data.  Take advantage of this opportunity so that your performance is accurately reflected.  Additionally, IRFs can compare themselves to peer organizations to see how their data compares within the community.  And, when the organization’s performance is lower than desired, the organization can utilize this data as part of its overall Quality Assurance and Performance Improvement activities to focus on areas that might be of concern.

What’s Noteworthy?

While the availability of information to the public on IRF Compare is relatively recent, what’s surprising is what’s “missing” from the data.  To date, indicators that have long been important to IRFs – discharge to home, level of functional improvement – have not been added although we expect to see some of these in the future.