Maryland QBR Patient Safety Measures Data

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This dataset contains different Patient Safety Measures from Quality Based Reimbursement (QBR) Program for hospitals in Maryland. The Patient Safety measures include data for the base and performance periods for six different measures including: Central Line Associated Blood Stream Infection (CLABSI), Catheter Associated Urinary Tract Infection (CAUTI), Surgical Site Infection Colon (SSI Colon), Surgical Site Infection Hysterectomy (SSI Hyst), Clostridium Difficile (C.Diff.) and Methicillin Resistant Staphylococcus Aureus (MRSA).

Complexity

Maryland’s Quality-Based Reimbursement (QBR) program is in place since July 2009, it uses similar measures with the federal Medicare Value-Based Purchasing (VBP) program, which is in place since October 2012. Because of Maryland’s long-standing Medicare waiver for its all-payer hospital rate-setting system and the implementation of the QBR program, the Centers for Medicare & Medicaid Services (CMS) has given Maryland various special considerations, including annual exemption from the Medicare VBP program. The QBR program incentivizes quality improvement across a wide variety of quality measurement domains, including:
– Person and Community Engagement
– Clinical Care
– Patient Safety

On January 1, 2014 the State of Maryland entered into a new All-Payer Model demonstration contract with the Center for Medicare and Medicaid Innovation (CMMI). Among other provisions of the Model, the Centers for Medicare & Medicaid Services (CMS) will waive the VBP program requirements for Maryland hospitals, provided that the Maryland program “submits an annual report to the Secretary that provides satisfactory evidence that a similar program in the State for Regulated Maryland Hospitals achieves or surpasses the measured results in terms of patient health outcomes and cost savings.” The State must apply annually for this exemption from the national VBP program. The exemption from the CMS VBP program grants Maryland the continued flexibility to adapt its quality-based payment programs to focus on areas specific to Maryland hospitals. This exemption additionally enables Maryland to maintain its all-payer approach to quality-based payments to hospitals and continue to align the all-payer QBR program with the operational realities of the all-payer rate setting system.

Maryland’s QBR program, like the federal VBP program, holds 2% of hospital revenue at risk based on performance, and measures performance in clinical care, patient safety, and person and community engagement (previously “experience of care”) domains. Hospital performance is scored, as is done with VBP, by comparing performance period results for each measure to historical performance, and by using a threshold and benchmark to calculate points earned by each hospital; both improvement and points are calculated for each measure, and the better of the two scores are used to calculate each hospital’s total score for the program.

In this dataset, hospitals with less than 1 Predicted Case do not have a calculated Standardized Infection Ratio (SIR). Also, Dorchester and Easton were combined to calculate the SIR. The relative Benchmark and Threshold values for each of the Patient Safety measures are mentioned as follows:
– Central Line Associated Blood Stream Infection (CLABSI) – (Benchmark: N/A), (Threshold: 0.369)
– Catheter Associated Urinary Tract Infection (CAUTI) – (Benchmark: N/A), (Threshold: 0.497)
– Surgical Site Infection Colon (SSI Colon) – (Benchmark: N/A), (Threshold: 0.824)
– Surgical Site Infection Hysterectomy (SSI Hyst) – (Benchmark: N/A), (Threshold: 0.710)
– Clostridium Difficile (C.Diff.) – (Benchmark: 0.004), (Threshold: 0.805)
– Methicillin Resistant Staphylococcus Aureus (MRSA) – (Benchmark: N/A), (Threshold: 0.767)

Date Created

2014

Last Modified

2017-06-01

Version

2017-06-01

Update Frequency

Annual

Temporal Coverage

N/A

Spatial Coverage

Maryland

Source

John Snow Labs => The Maryland Health Services Cost Review Commission

Source License URL

John Snow Labs Standard License

Source License Requirements

N/A

Source Citation

N/A

Keywords

Quality Based Reimbursement (QBR), Maryland Quality Based Reimbursement Program, Quality Based Reimbursement Program, Value-Based Purchasing (VBP), VBP Program, Clinical Care, Patient Safety, Person and Community Engagement, Hospital Performance

Other Titles

RY2018 Patient Safety Data for Maryland Hospitals, Calculating Maryland QBR Patient Safety 2018 Data Using Base and Performance Periods

Name Description Type Constraints
Hospital_IDCMS certification number (CCN). Identification number of the hospital within the CMS dataset. The CCN for providers and suppliers is a 6 digit number. The first 2 digits identify the State in which the provider is located. The last 4 digits identify the type of facility.integerrequired : 1 level : Nominal
Hospital_NameName of the hospital (also referred to as the provider)stringrequired : 1
CLABSI_Base_Period_SIR_CY2014Refers to the Central Line Associated Blood Stream Infection (CLABSI) Standardized Infection Ratio (SIR) for Base Period 2014.numberlevel : Ratio
CLABSI_Base_Period_Predicted_Cases_CY2014Includes the Central Line Associated Blood Stream Infection (CLABSI) Base Period 2014 data for predicted cases.numberlevel : Ratio
CLABSI_Performance_SIR_2015Q4_2016Q3It refers to the Central Line Associated Blood Stream Infection (CLABSI) Performance Period (October 2015 - September 2016) data for Standardized Infection Ratio (SIR).numberlevel : Ratio
CLABSI_Performance_Predicted_Infections_2015Q4_2016Q3It refers to the Central Line Associated Blood Stream Infection (CLABSI) Performance Period (October 2015 - September 2016) data for Predicted Infections.numberlevel : Ratio
CAUTI_Base_Period_SIR_CY2015Refers to the Catheter Associated Urinary Tract Infection (CAUTI) Standardized Infection Ratio (SIR) for Base Period 2015.numberlevel : Ratio
CAUTI_Base_Predicted_Cases_CY2015Includes the Catheter Associated Urinary Tract Infection (CAUTI) Base Period 2015 data for predicted cases.numberlevel : Ratio
CAUTI_Performance_Period_SIR_2015Q4_2016Q3It refers to the Catheter Associated Urinary Tract Infection (CAUTI) Performance Period (October 2015 - September 2016) data for Standardized Infection Ratio (SIR).numberlevel : Ratio
CAUTI_Performance_Period_Predicted_Infections_2015Q4_2016Q3It refers to the Catheter Associated Urinary Tract Infection (CAUTI) Performance Period (October 2015 - September 2016) data for Predicted Infections.numberlevel : Ratio
SSI_Colon_Base_Period_SIR_CY2014Refers to the Surgical Site Infection Colon (SSI Colon) Standardized Infection Ratio (SIR) for Base Period 2014.numberlevel : Ratio
SSI_Colon_Base_Period_Predicted_Cases_CY2014Includes the Surgical Site Infection Colon (SSI Colon) Base Period 2014 data for predicted cases.numberlevel : Ratio
SSI_Colon_Performance_SIR_2015Q4_2016Q3It refers to the Surgical Site Infection Colon (SSI Colon) Performance Period (October 2015 - September 2016) data for Standardized Infection Ratio (SIR).numberlevel : Ratio
SSI_Colon_Performance_Predicted_Infections_2015Q4_2016Q3It refers to the Surgical Site Infection Colon (SSI Colon) Performance Period (October 2015 - September 2016) data for Predicted Infections.numberlevel : Ratio
SSI_Hyst_Base_Period_SIR_CY2014Refers to the Surgical Site Infection Hysterectomy (SSI Hyst) Standardized Infection Ratio (SIR) for Base Period 2014.numberlevel : Ratio
SSI_Hyst_Supplemental_Security_Income_Abdominal_Predicted_Cases_CY2014Includes the Surgical Site Infection Hysterectomy (SSI Hyst) Base Period 2014 data for Supplemental Security Income Abdominal predicted cases.numberlevel : Ratio
SSI_Hyst_Performance_SIR_2015Q4_2016Q3It refers to the Surgical Site Infection Hysterectomy (SSI Hyst) Performance Period (October 2015 - September 2016) data for Standardized Infection Ratio (SIR).numberlevel : Ratio
SSI_Hyst_Performance_Predicted_Infections_2015Q4_2016Q3It refers to the Surgical Site Infection Hysterectomy (SSI Hyst) Performance Period (October 2015 - September 2016) data for Predicted Infections.numberlevel : Ratio
Clostridium_Diffcile_Base_Period_SIR_CY2014Refers to the Clostridium Difficile (C.Diff.) Standardized Infection Ratio (SIR) for Base Period 2014.numberlevel : Ratio
Clostridium_Difficile_Predicted_Cases_CY2014Includes the Clostridium Difficile (C.Diff.) Base Period 2014 data for predicted cases.numberlevel : Ratio
Performance_Period_Clostridium_Difficile_SIR_2015Q4_2016Q3It refers to the Clostridium Difficile (C.Diff.) Performance Period (October 2015 - September 2016) data for Standardized Infection Ratio (SIR).numberlevel : Ratio
Clostridium_Difficile_Predicted_Cases_2015Q4_2016Q3It refers to the Clostridium Difficile (C.Diff.) Performance Period (October 2015 - September 2016) data for Predicted Infections.numberlevel : Ratio
MRSA_Base_Period_SIR_CY2014Refers to the Methicillin Resistant Staphylococcus Aureus (MRSA) Standardized Infection Ratio (SIR) for Base Period 2014.numberlevel : Ratio
MRSA_Base_Period_Predicted_Cases_CY2014Includes the Methicillin Resistant Staphylococcus Aureus (MRSA) Base Period 2014 data for predicted cases.numberlevel : Ratio
MRSA_Performance_Period_SIR_2015Q4_2016Q3It refers to the Methicillin Resistant Staphylococcus Aureus (MRSA) Performance Period (October 2015 - September 2016) data for Standardized Infection Ratio (SIR).numberlevel : Ratio
MRSA_Predicted_Cases_2015Q4_2016Q3It refers to the Methicillin Resistant Staphylococcus Aureus (MRSA) Performance Period (October 2015 - September 2016) data for Predicted Infections.numberlevel : Ratio
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