Appendix_A_-_CMS_Assessment_Data_Element_Library_Governance_Framework.pdf

Appendix A

Centers for Medicare & Medicaid Services

Strategic Program Development and Operational Oversight for the ACA §3004 Quality Reporting Programs: Long-Term Care Hospitals, Inpatient

Rehabilitation Facilities, and Hospices

CMS Assessment (Data Element) Library Governance Framework

Final

Version 1.0

November 16, 2014

Final

Table of Contents

1. Introduction

2. Purpose

3. CMS Assessment Data Element Library Governance Stages

4. Library Governance Support Team and Librarian

5. Library Data Governance Process

6. CMS Assessment Library Governance Stages, Steps, and Timeframes

6.1 Stage 1: Library Change Request (CR) / Issue Is Submitted / Discovered

6.2 Stage 2: Convene Library Management Workgroup to Discuss Library CR / Issues

6.3 Stage 3: Determine Feasibility of Recommended Library Updates

6.4 Stage 4: Present Recommended Library Updates / Issues to CALDC

6.5 Stage 5: Maintain Log of Library CR / Issues / Updates

7. Summary

Appendix A. Initial Business Process Models

Appendix B. CMS Assessment (Data Element) Library Data Council Charter

B.1 Membership B.2 CMS Assessment Library Data Council Oversight Structure B.3 Decision-Making Process B.4 Change Control Process B.5 Members (omitted) B.6 Post-Acute Care Program Rules & Regulations

Appendix C. Proposed Change Request Form

Appendix D. Change Request Checklist

Acronyms

CMS Assessment (Data Element) Library Governance Framework i Version 1.0 November 16, 2014

List of Figures

Figure 1. Governance Stages

Figure 2. Library Data Governance Process

Figure 3. Library Change Request Process Business Process Model (BPM)

Figure 4. CALDC Meeting BPM

Figure 5. Issue Resolution BPM

Figure 6. Library Update BPM

Figure 7. Library Oversight Structure

Figure 8. Proposed Library Decision Process

Figure 9. Data Library Change Control Process

Figure 10. Proposed Change Request Form

Figure 11. Change Request Checklist

List of Tables

Table 1. Stage 1: Library Change Request / Issue Is Submitted / Discovered

Table 2. Stage 2: Convene Library Management Workgroup to Discuss Library CR / Issues

Table 3. Stage 3: Determine Feasibility of Recommended Library Updates

Table 4. Stage 4: Present Recommended Library Updates / Issues to CALDC

Table 5. Stage 5: Maintain Log of Library CR / Issues / Updates

CMS Assessment (Data Element) Library Governance Framework i

1. Introduction The Centers for Medicare & Medicaid Services (CMS) Assessment (Data Element) Library (“Library”) governance process is a critical component of establishing an authoritative source for standardized assessment data elements and their associated health information technology (IT) interoperability standards. CMS and stakeholders may use these assessment data elements and the associated health IT standards for assessment and electronic health record (EHR) data exchange across care settings, including long-term (LT), acute and post-acute care (PAC), and home and community-based services (HCBS).

As noted in the August 2013 CMS Data Governance and Policy Analysis Report, data governance can be defined as:

The discipline of administering data and information assets across an organization through formal oversight of the people, processes, technologies and lines of business that influence data and information outcomes to drive business performance.1

The Data Governance Framework included in this document provides recommended governance features for establishing the initial Library data governance, including governance stages, steps, actions, timeframes, and involved parties to initiate, manage, update, and communicate the Library data governance activities and related artifacts.

For the Library implementation to be successful and its ongoing usage to be an asset to the agency, it is vital that CMS apply a robust but supple data governance approach. Ensuring the right resources and leadership are available and engaged will increase the likelihood of the Library’s success. In addition, implementing a structure and process that can evolve as needed will also help achieve the goal of a collaborative, inclusive, efficient, and effective data governance process. This Framework also allows the Library data governance process to work within the current CMS data governance ecosystem by providing a clear path for data governance issue resolution.

The importance of these data governance fundamentals is also noted in Essential Practices for Data Governance in Healthcare:

A Data Governance Committee should practice a cultural philosophy that believes in governing data to the least extent necessary to achieve the greatest common good. … The best approach is to start off with a broad vision and framework, but limited application, and expand the governance function incrementally, only as needed, and no more.

The Data Governance Committee should be a subcommittee to an existing governance structure, with the influence necessary to institute inevitably controversial changes to workflows, resolve data quality conflicts, and develop complex data acquisition strategies to support the strategic clinical and financial optimization of the organization.2

1 J. Orr, Data Governance for the Executive. Senna Publishing, LLC, 2011.

2 D. Sanders, 7 Essential Practices for Data Governance in Healthcare, August 21, 2013.

http://www.healthcatalyst.com/healthcare-data-governance-practices. Accessed 07/24/2014.

CMS Assessment (Data Element) Library Governance Framework 1 http://www.healthcatalyst.com/healthcare-data-governance-practices

This Library Data Governance Framework takes into account these essential elements and aligns with the broader CMS data governance policies.

2. Purpose The purpose of this Library Data Governance Framework is to illustrate and describe the following recommended data governance process components: proposed Data Governance Process Stages, Business Process Models (Appendix A), the approved CMS Assessment Library Data Council (CALDC) Charter (Appendix B), the Draft Change Request (CR) Form (Appendix C), and CR Checklist (Appendix D). These Library Data Governance Framework components follow the essential fundamentals of data governance and CMS data governance goals.

3. CMS Assessment Data Element Library Governance Stages The initial phase of the CMS Assessment Data Element Library governance process defines five proposed stages, as shown in Figure 1 and described below.

Figure 1. Governance Stages

• Stage 1: A Library change request (CR) or issue item may be submitted by anyone within CMS for consideration by the CALDC governance process, including assessment instrument/data set stakeholders, (i.e., assessment instrument/item set stewards and their measure development contractors). The Governance Support Team (GST) will review the CR and ensure the request is complete so that it can then be forwarded on to the Workgroup (WGs)—i.e., the Library Management Workgroup (LMWG). In the event that a CR submission is not complete, the GST will communicate with the submitter and provide feedback about any issues associated with CR submission. Once the CR submission is complete, the GST will give the LMWG leadership the request.

• Stage 2: The WGs, initially the LMWG, will convene as needed to discuss the Library CR/issue item and determine a course of action: either request additional information, approve the change request, or refer unresolved issues to CALDC.

• Stage 3: For Library CRs recommended to move forward for item set updates, the LMWG will ensure that the change is appropriate—e.g., that it doesn’t create an item duplication or miss an opportunity for harmonizing. The LMWG will evaluate the time-frame needed for the update to the item set(s) and identify the associated Library update and coordination surrounding the update activity.

CMS Assessment (Data Element) Library Governance Framework 2

• Stage 4: The outcome of LMWG deliberations and Library coordination will be presented to the CALDC for approval. Any issues requiring further attention by the CALDC will be addressed.

• Stage 5: Approved Library CRs and versioning will be logged and prepared for implementation in the next Library and Assessment Instruments versions.

4. Library Governance Support Team and Librarian A Library GST and Librarian (roles which could be supported by contractors) will be identified and responsible for the following activities:

• Logging, vetting, and communicating all incoming CRs from CMS stakeholders for changes to the Library via the Library CR/Issue Tracker, WG communication mechanisms, and/or other sources of Library CR/issue input

• Communicating CR/issue status with the submitter of the Library CR/issue item as well as the appropriate WG (i.e., Library Management, Stewards, Standards, Communications) as the CR/item proceeds through the governance process

• Coordinating LMWG/CALDC meetings

• Supporting the CALDC WG (initially, the LMWG) Leads in representing Library issues to the CALDC for deliberation on decisions and confirmation of other decisions.

CALDC serves as an executive Library governance board; unresolved issues may be escalated to Center for Medicare (CM)/Center for Clinical Standards and Quality (CCSQ) data governance boards.

• Identifying and tracking timelines related to Library updates for item set changes due to approved CRs

• Handling other tracking issues related to the Library

CMS Assessment (Data Element) Library Governance Framework 3

5. Library Data Governance Process

Figure 2. Library Data Governance Process

CMS Assessment (Data Element) Library Governance Framework 4

Centers for Medicare & Medicaid Services CMS Assessment Library Governance Stages, Steps, and Timeframes

6. CMS Assessment Library Governance Stages, Steps, and Timeframes

6.1 Stage 1: Library Change Request (CR) / Issue Is Submitted / Discovered

Table 1. Stage 1: Library Change Request / Issue Is Submitted / Discovered Step Description Actor Action Timeframe Notes

1.1 Submit/discover

Library CR/issue CMS staff (i.e., Assessment instrument / data set steward, measure developer, stakeholder.

Can include CMS contractor staff.)

CR/issue brought to Library GST’s attention

Anytime CR and issue items may be outcomes from current Assessment Instrument / Data Set Joint Application Development (JAD) sessions, regulatory requirements, or technical enhancements.

1.2 Acknowledge

Library CR/issue

Library GST Review Library CR submission:

1. Reply to CR/issue with an acknowledgement

2. Provide feedback of any issues associated with CR submission

3. Log status in CR/Issue Tracker

4. Notify LMWG Leads of CR/issue

Within 24 hours of receipt

Follows business days and government holiday schedule

1.3 Review Library

CR/issue

LMWG Lead Review Library CR/issue and determine course of action:

1. Answer3 and close issue

2. Reply with request for further information/explanation of question

3. Refer to LMWG (Stage 2) for approval/resolution

At coordinated time, following receipt

Closed issues exit the governance process; replies to a request for further explanation receive a response within 36 hours with course of action—closed or referred to CALDC for approval/issue resolution (Stage 2).

3 The LMWG leadership will triage routine and urgent CR and Issues and prepare for LMWG discussions as needed.

CMS Assessment (Data Element) Library Governance Framework 5

Centers for Medicare & Medicaid Services CMS Assessment Library Governance Stages, Steps, and Timeframes

Step Description Actor Action Timeframe Notes

1.4 Send reply

about Library CR/issue submission

Library GST Reply to submitter via email and log status in CR/Issue Tracker

Within 36 hours of receipt

Follows business days and government holiday schedule

1.5 Distribute list of

Library CR/issue submissions

Library GST Deliver list of all Library CR/issues submitted and their status to LMWG

Monthly Distribution will coincide with process for distributing agendas

1.6 Maintain list of

Library CR/issue status

Library GST Maintain all Library CR/issues As needed Maintained CR/issues versioning log; versioning incorporated in Library capability requirements

6.2 Stage 2: Convene Library Management Workgroup to Discuss Library CR / Issues

Table 2. Stage 2: Convene Library Management Workgroup to Discuss Library CR / Issues Step Description Actor Action Timeframe Notes

2.1 Prepare Library CR/

issues for LMWG Library GST Prepare CR submission background, context, relationship to assessment instrument / data sets, description of modifications (if any) for discussion, and implications for Library updates

Prior to 2.2

2.2 Distribute agenda

and list of CR/issues to

LMWG

Library GST and LMWG Leads

Deliver agenda and Library CR/issues submitted

5 business days prior to monthly meeting

Library CR/issues that are not received and reviewed 5 business days prior to the LMWG meeting will not be included in discussion;

exceptions for urgent issues will be made at the request of LMWG Leads.

CMS Assessment (Data Element) Library Governance Framework 6

Centers for Medicare & Medicaid Services CMS Assessment Library Governance Stages, Steps, and Timeframes

Step Description Actor Action Timeframe Notes

2.3 Convene LMWG Library GST and

LMWG Leads Discuss Library CR/issues and determine course of action4:

1. Conduct further research5

2. Recommend Library update

3. Do not recommend Library update

4. Refer to CALDC for issue resolution

Monthly

LMWG

meeting

Some issues may require further research, and the GST/LMWG Leads may contact the issue’s submitter for more information.

2.4 Distribute summary

of Library CR/issues discussed to

CALDC

Library GST and LMWG Leads

Deliver list of all Library CR/issues discussed by the LMWG and the discussion outcomes / recommendations to CALDC

2 business days following

LMWG

meeting

In the event that the CALDC has disagreement or concern with the LMWG recommendations, the issue will be escalated to the appropriate CM/CCSQ Data Governance Forum to discuss and determine an appropriate course of action. (Note Step 4.5)

2.5 Communicate

CR/issues not recommended as Library updates to the issue submitter

Library GST Reply to submitter with outcome of CALDC, and log status in CR/Issue Tracker

5 business days, following

LMWG

meeting

As noted in 2.4, if there is disagreement or concern with the outcome, the issue submitter will be notified that the issue is being escalated to the appropriate CM/CCSQ Data Governance Forum to discuss and determine an appropriate course of action. (Note Step 4.5)

2.6 Maintain list of

Library CR/issues discussed

Library GST Maintain list of all Library CR/issues discussed by CALDC and their status

5 business days, following

CALDC

meeting

This list will be handled through CR/Issue Tracker.

4 As needed, a framework with criteria for decision-making will be developed to guide CALDC WG recommendations. To begin, a consensus will be sought to determine a CR/issue’s course of action. Where there may be notable disagreement or concern indicated by a LMWG member, this perspective will be represented in the LMWG summary of the discussion to inform CALDC.

5 Coordination with terminology/standards development organizations and change cost assessment will be undertaken as needed.

CMS Assessment (Data Element) Library Governance Framework 7

Centers for Medicare & Medicaid Services CMS Assessment Library Governance Stages, Steps, and Timeframes

6.3 Stage 3: Determine Feasibility of Recommended Library Updates

Table 3. Stage 3: Determine Feasibility of Recommended Library Updates Step Description Actor Action Timeframe Notes

3.1 LMWG

recommends Library updates

Librarian Library GST

Summarize recommended Library updates and distribute to Stewards, LMWG, and CALDC (and others as appropriate)

2 business days following Library WG meeting

This step ensures that issues recommended for Library updates are

(1) reviewed for Library incorporation feasibility, and (2) coordinated with the Assessment Instrument / Data Set development schedule.

3.2 Discuss

recommended Library updates with Stewards WG

Library GST Librarian

Conduct meeting with Stewards and LMWG/representatives to determine if the recommended Library update would result in required Assessment Instrument / Data Sets update; if yes, determine feasibility and timing

5-7 business days following

LMWG

meeting

In the event a recommended Library update is not feasible for Assessment Instrument / Data Set adoption— given timing or technical requirements—the issue will be monitored for future incorporation opportunities.

3.3 Distribute

summary of Library CR/issues discussed

Library GST Librarian

Deliver summary of discussion outcomes to CALDC

2 business days following meeting

In the event that the Stewards/LMWG have disagreement or concern with the discussion outcome, the issue will be escalated to CALDC to determine an appropriate course of action.

3.4 Notify Library

CR/issue submitter

Library GST Reply to submitter with outcome of LMWG representatives discussion and log status in CR/Issue Tracker

5 business days, following

CALDC

review

As noted in 3.3, if there is disagreement or concern with the outcome, the issue submitter will be notified of the issue’s next steps.

3.5 Maintain list of

Library CR/issues discussed

Library GST Maintain list of all Library CR/issues discussed by CALDC and their status

5 business days, following

CALDC

meeting

This list will be handled through CR/Issue Tracker.

CMS Assessment (Data Element) Library Governance Framework 8

Centers for Medicare & Medicaid Services CMS Assessment Library Governance Stages, Steps, and Timeframes

6.4 Stage 4: Present Recommended Library Updates / Issues to CALDC

Table 4. Stage 4: Present Recommended Library Updates / Issues to CALDC Step Description Actor Action Timeframe Notes

4.1 Prepare Library-

recommended updates for presentation to

CALDC

Library GST LMWG Leads

Prepare issue’s background, context, relationship to Assessment Instrument / Data Sets, description of modifications, and Library incorporation plan

Prior to 4.2

4.2 Provide agenda

items and list of recommended updates and schedule with

CALDC

Library GST LMWG Leads

Deliver agenda items and recommended Library updates

5 business days prior to meeting

Schedule to be coordinated with CALDC; distribution to be performed by Library GST

4.3 Present

recommended updates or actions

Library GST

LMWG

CALDC

Discuss Library update recommendations and determine course of action:

1. Approve

2. Do not approve

3. Call for further discussion or information

CALDC

meeting

If further discussion or information is required, the Library GST and appropriate LMWG Leads will prepare the materials and agenda for a second cycle of review.

4.4 Distribute summary

of Library updates discussed

Library GST LMWG Leads

Deliver list of all Library issues discussed by CALDC and their outcomes

2 business days following

CALDC

meeting

4.5 Notify Library issue

submitter

Library GST Reply to submitter with outcome of LMWG/CALDC discussion and log status in CR/Issue Tracker

3 business days following

CALDC

meeting

The issue submitter will be notified of the outcome.

In the event that CALDC has disagreement or concern with the discussion outcome, the issue will be escalated to the CCSQ/CM Data Governance Forum to determine an appropriate course of action.

CMS Assessment (Data Element) Library Governance Framework 9

Centers for Medicare & Medicaid Services CMS Assessment Library Governance Stages, Steps, and Timeframes

Step Description Actor Action Timeframe Notes

4.6 Maintain list of

Library updates Library GST Librarian

Distribute outcome of CALDC discussion

3 business days following

CALDC

meeting

List will be maintained through the CR/Issue Tracker. The Library Repository will also maintain versioned data elements.

6.5 Stage 5: Maintain Log of Library CR / Issues / Updates

Table 5. Stage 5: Maintain Log of Library CR / Issues / Updates Step Description Actor Action Timeframe Notes

5.1 Enter CR/issue

update in CR/Issue Tracker

Library GST For Library updates approved by CALDC and ongoing issue resolution, enter information to track update

3 business days following

CALDC

meeting

List will be maintained through the CR/Issue Tracker. The Library Repository will also maintain versioned data elements.

CMS Assessment (Data Element) Library Governance Framework 10

7. Summary Establishing a coordinated CALDC data governance process is a critical success factor the Library.

The mission of the Library, as defined in the Library Charter, is to create a comprehensive, electronic, distributable, and authoritative source for CMS assessment data. The Library will be the authoritative source for the standardized assessment data elements and associated standards that CMS and stakeholders use for assessment and EHR data exchange across care settings, including LT, PAC, and HCBS. The CALDC will also provide guidance, direction, and issue resolution for developing and maintaining the Library.

For the Library implementation to be successful and its ongoing usage to be an asset to the agency, it is vital that CMS apply a robust but supple data governance approach. Ensuring the right resources and leadership are available and engaged will increase the likelihood of the Library’s success. In addition, implementing a structure and process that can evolve as needed, based on feedback and lessons learned, will also help achieve the goal of a collaborative, inclusive, efficient, and effective data governance process. This framework also allows the Library data governance process to work within the current CMS data governance ecosystem by providing a clear path for data governance issue resolution.

CMS Assessment (Data Element) Library Governance Framework 11

Appendix A. Initial Business Process Models

Figure 3. Library Change Request Process Business Process Model (BPM)

CMS Assessment (Data Element) Library Governance Framework 12

Centers for Medicare & Medicaid Services Initial Business Process Models

Figure 4. CALDC Meeting BPM

CMS Assessment (Data Element) Library Governance Framework 13

Figure 5. Issue Resolution BPM

CMS Assessment (Data Element) Library Governance Framework 14

Figure 6. Library Update BPM

CMS Assessment (Data Element) Library Governance Framework 15

Appendix B. CMS Assessment (Data Element) Library Data Council Charter

Mission: To create a comprehensive, electronic, distributable and authoritative source for CMS assessment data.

The CMS Assessment (Data Element) Library Data Council (CALDC) will provide guidance, direction and issue resolution to the development and maintenance of the CMS Assessment Data Element Library (Library). This Library will be the authoritative source for the standardized, assessment data elements and associated standards used by CMS for assessment and electronic health record (EHR) data exchange across care settings, including but not limited to Long-Term (LT), Acute and Post-Acute Care (PAC) and Home and Community-Based Services (HCBS).

Background: Standardized, assessment-based data (patients/residents/persons) has the ability to enable significant strides towards harmonizing information requested by CMS from across the spectrum of care services and settings that is to be used for purposes including but not limited to: quality measurement, Medicare payment determination, care planning and other regulatory purposes, e.g., facility survey. (See Appendix F for post-acute care rules and regulations.)

In addition, standardization will serve to support provider exchange of electronic health information.

Standardization of data and alignment of standards are the foundation for interoperable EHR implementation in disparate settings. This has the potential to impact global change across the healthcare system including community based services. Compatible standards facilitate improvements related to reducing overall provider burden by allowing the use and reuse of appropriate healthcare data. By supporting eventual development of compatible EHRs based on these standards, data collected by CMS could then be reused and transferred between care settings, as well as enabling clinical decision support.

Thus, standardization has implications with regards to improving care coordination, payment methodology and payment reform, quality improvement, and research. Improvements could be applied to ensure care coordination and quality improvement across various care delivery settings including but not limited to acute care hospitals, ambulatory settings, and inpatient rehabilitation facilities (IRFs), long-term care hospitals (LTCHs), skilled nursing facilities (SNFs), nursing facilities (NFs), end-stage renal disease (ESRD) facilities, home health agencies (HHAs), hospice care and HCBS.

CMS Assessment (Data Element) Library Governance Framework 16

Centers for Medicare & Medicaid Services CMS Assessment (Data Element) Library Data Council Charter

Goals: The goals of the Library include:

• To facilitate the maintenance of uniformity across CMS assessments and quality measures

• To establish an authoritative resource for patient assessment data elements

• To promote the sharing of electronic patient assessment data sets and information standards

• To influence and support industry efforts to promote EHR interoperability and care coordination

Board Purpose: The purpose of CALDC is to:

• Provide guidance in alignment with federal and national initiatives

• Support timely issue resolution through escalation

• Create a formal direction for overseeing updates to the Library

– Set Library goals and objectives

– Identify Library Workgroup (WG) structure, suggest members, and associated charters as needed

Responsibilities: The CALDC is responsible for:

• Ensuring appropriate membership representation

• Approving publishing standards that support the mission of the Library

• Resolving escalated issues

• Receiving, reviewing and approving change requests

• Providing guidance on outreach to various Stakeholders

• Establishing WGs as needed – See Appendix C

– Establish initial WG – Library Management Workgroup (LMWG) which will provide analysis and change requests for the data elements, make recommendations, and elevate decisions for sign off by the Council.

Membership: The CALDC will be comprised of data owner and expert technical advisors authorized to make business decisions related to the Library development and deployment. The CALDC will be co-chaired by representatives from DCPAC and DQSAS. The CALDC shall initially consist of individual member representatives from various stakeholder groups and subject matter experts as maintained in “Appendix A. Membership” of this charter.

Functions: The CALDC will meet monthly at a regularly scheduled time or as needed to:

• Review the status of the Library planning and development

• Report out to all CMS Centers

• Be briefed by representatives of the WGs

• Serve as primary interface to external stakeholders

CMS Assessment (Data Element) Library Governance Framework 17

Decision Making:

The CALDC will discuss recommendations and escalated decisions and issues from the WGs. CALDC will escalate issues to the Quality Measurement Task Force (QMTF) and to CM management. CALDC will communicate decision via CALDC meetings notes. The DQSAS will not operationalize changes that have not been approved by the CALDC. See Appendix C for details on Decision Making Process.

If a decision outcome requires a change, the change control process is initiated.

See Appendix D for workflow details on Change Control Process.

Deliverables: Meeting Notes, Reports of Decisions, and system updates for Library Updates

Meeting Coordination:

The CALDC Co-chairs will meet with contractors and WG Leads (as appropriate) in advance of each CALDC meeting to discuss the proposed meeting agenda and identify any issues needing Council attention/resolution.

Meeting materials for consideration by the CALDC will be received no later than 24 hours prior to the meeting and will be channeled through the CALDC Co-chairs. Contracting Officer’s Representatives (CORs) and Government Task Leads (GTLs) must coordinate attendance and participation by their contract leads. It is recommended that contracts that involve assessment data analysis, quality measurement development, or other support function, in which contract activities are dependent upon the use of standardized data elements include provisions for Council participation and adherence in their statements of work.

Duration: The CALDC will remain standing through the development and duration of the Library. The Charter will be reviewed on an annual basis and updated as appropriate.

Approval: This Charter was reviewed and had unanimous approval by the CALDC and stakeholders on 06/11/2014.

B.1 Membership Initial membership is sub-divided into two groups: the Council (CALDC) and Workgroup (LMWG). As appropriate, a member may be part of both groups. For example, a member may have the technical expertise needed for analysis in the Workgroup and have the authority for making decision at the management level.

Selection process:

Co-Chairs: The CALDC will be co-chaired by representatives from DCPAC and DQSAS.

Individual CALDC members: Potential members are nominated based on their experience, area of representation, and authority to make decisions for their component. At minimum, the Council will include representation from the following key stakeholders:

• Center for Clinical Standards and Quality (CCSQ)

CMS Assessment (Data Element) Library Governance Framework 18

– Division of Chronic & Post-Acute Care (DCPAC)

– Division of Quality Systems for Assessments and Surveys (DQSAS)

– Survey and Certification Group (SCG)

♦ Division of Nursing Homes (DNH) ♦ Division of Continuing Care Providers (DCCP)

• Center for Medicaid and Children’s Health Insurance Program (CHIP) Services (CMCS)

– Disabled and Elderly Health Programs Group (DEHPG)

• Center for Medicare (CM)

– Division for Institutional Post-Acute Care (DIPAC)

– Division of Home Health and Hospice (DHHH)

• Center for Medicare and Medicaid Innovation (CMMI)

Individual LMWG members: Potential members will include technical expert advisers and/or data owners. They are nominated based on their experience and area of representation. At a minimum, the Council will include representation from the following key stakeholders:

• Center for Clinical Standards and Quality (CCSQ)

– Division of Chronic & Post-Acute Care (DCPAC)

– Division of Quality Systems for Assessments and Surveys (DQSAS)

– Survey and Certification Group (SCG)

♦ Division of Nursing Homes (DNH) ♦ Division of Continuing Care Providers (DCCP)

• Center for Medicaid and Children’s Health Insurance Program (CHIP) Services (CMCS)

– Disabled and Elderly Health Programs Group (DEHPG)

• Center for Medicare (CM)

– Division for Institutional Post-Acute Care (DIPAC)

– Division of Home Health and Hospice (DHHH)

• Center for Medicare and Medicaid Innovation (CMMI)

Term: A Council member will be recertified by the Center every 1 year on a determined timetable. A Workgroup member will be recertified by the Center every 1 year on a determined timetable. Co-chairs will serve on the CALDC for a 6-month term before recertification.

Voting: Council members are considered voting members. Workgroup members are non-voting members.

CMS Assessment (Data Element) Library Governance Framework 19

B.2 CMS Assessment Library Data Council Oversight Structure

Figure 7. Library Oversight Structure

CMS Assessment (Data Element) Library Governance Framework 20

B.3 Decision-Making Process

Figure 8. Proposed Library Decision Process

B.4 Change Control Process

Figure 9. Data Library Change Control Process

CMS Assessment (Data Element) Library Governance Framework 21

B.5 Members (omitted) This section has been omitted from Appendix A.

B.6 Post-Acute Care Program Rules & Regulations

• Section 3004 of Patient Protection and Affordable Care Act H.R. 3590

Description: Title III – Improving the Quality and Efficiency of Health Care. Subtitle A

– Transforming the Health Care Delivery System. Part I – Linking Payment to Quality Outcomes under the Medicare Program. Section 3004 – Quality reporting for long-term care hospitals, inpatient rehabilitation hospitals, and hospice programs.

• American Recovery and Reinvestment Act of 2009 Description: Authorizes CMS to provide reimbursement incentives for eligible professionals and hospitals who are successful in becoming “meaningful users” of certified EHR technology.

• Section 5008 of the Deficit Reduction Act (DRA) (Public Law 109-171) Description: Congress required the Post-Acute Care Payment Reform Demonstration (PAC-PRD), which includes developing a single comprehensive patient assessment instrument that could be used in acute care hospitals and the four PAC settings of interest: long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies (HHAs). The work resulted in the creation of the CARE (Continuity Assessment Record and Evaluation) Tool.

• Medicare, Medicaid, and SCHIP (State Children's Health Insurance Program) Benefits Improvement and Protection Act of 2000 (BIPA) Description: Requires the HHS Secretary to submit a report to Congress on the development of standard instruments for the assessment of the health and functional status of Medicare patients who receive hospital, rehabilitation, SNF, or home health therapy, or other specified services.

• Medicare, Medicaid, and Balanced Budget Refinement Act of 1999 (BBRA) (Public Law. 106-113) BIPA (Public Law 106-55).

Description: Provides payment for both the operating and capital-related costs of hospital inpatient stays in LTCHs under Medicare Part A based on prospectively set rates.

Section 123 of the BBRA requires the prospective payment system (PPS) for LTCHs to be a per-discharge system with a diagnosis-related group (DRG)-based patient classification system that reflects the differences in patient resources and costs in LTCHs while maintaining budget neutrality. Section 307(b)(1) of BIPA, among other things, mandates that the Secretary shall examine, and may provide for, adjustments to payments under the LTCH PPS, including adjustments to DRG weights, area wage adjustments, geographic reclassification, outliers, updates, and a disproportionate share adjustment.

CMS Assessment (Data Element) Library Governance Framework 22

• Section 4421 of the Balanced Budget Act of 1997 (Public Law 105-33), as amended by section 125 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (Public Law 106-113), and by section 305 of the BIPA.

Description: Authorizes the implementation of a per-discharge PPS, through section 1886(j) of the Social Security Act, for inpatient rehabilitation hospitals and rehabilitation units—referred to as inpatient rehabilitation facilities (IRFs). The IRF PPS will utilize information from a patient assessment instrument (PAI) to classify patients into distinct groups based on clinical characteristics and expected resource needs. Separate payments are calculated for each group, including the application of case and facility-level adjustments.

• OASIS collection regulation (HCFA-3007-F) and OASIS reporting regulation

(HCFA-3006-IFC)

Description: Home health Outcome and Assessment Information Set (OASIS) collection and reporting regulations announced the effective date for the mandatory use, collection, encoding, and transmission of OASIS data for all Medicare/Medicaid patients receiving home health skilled services.

• Part 418 of Social Security Act of 1983 (42 U.S.C. 1302 and 1395hh) Description: Specifies services covered as hospice care and the conditions that a hospice program must meet to participate in the Medicare program. Subpart C – Conditions of Participation: Patient Care, updated June 5, 2008, includes the requirement to conduct initial and comprehensive assessment of the patient and provide an interdisciplinary group, care planning, and coordination of services.

• Section 1819 of Social Security Act of 1983(42 U.S.C. 1302 and 1395hh) Description: Specifies a minimum data set of core elements and common definitions for use by nursing facilities in conducting the assessments required under subsection (b)(3), and establishes guidelines for utilization of the data set. The Federal Nursing Home Reform Act from the 1987 Omnibus Budget Reconciliation Act (OBRA) creates a national minimum set of standards of care and rights for people living in certified nursing facilities.

CMS Assessment (Data Element) Library Governance Framework 23

Appendix C. Proposed Change Request Form

Figure 10. Proposed Change Request Form

Number of Stage 3 pressure ulcers.

yes no

Select theType of Assessment and associated Item Number in the Instrument. If the item appears in more than type of assessment, select all that apply.

Assessment Type Assessment Type Assessment Type Assessment Type

Does the edit change the intent of the item?

Is the item part of a proposed or final rule?

Select any Specification, Documentation or Policy affected:

CMS CALDC EDIT FORM V1

Name of Submitter:

Submitter email:

Name of Item:

Specify Change:

Type of Edit:

OR

Type of Edit:

Reason for Edit:

Does the edit impact other provider settings?

Does the change impact Item Set (s) unknown no

CMG payment specifications and documentation

M300C1

Admission Admission Admission

M300C1MDS Item Number:

OASIS - C Item Number: M1308.b

CALDC Edit Request Form

DRAFT

Section (move item to different section)

Number of Stage 3 pressure ulcers including undermining and tunneling

Date of Request:

5/14/2014

Provide clarity when staging the wound.

Item Subset(s):

Item Subset(s):

Item Subset(s):

Item Subset(s):

Submitting organization:

LTCH Item Number:

Item Number:

Section Label of item Response (add or delete)Item Language Response Language

CMS Assessment (Data Element) Library Governance Framework 24

Appendix D. Change Request Checklist

Figure 11. Change Request Checklist

CMS Assessment (Data Element) Library Governance Framework 25

Acronyms

Term Definition

AHRQ Agency for Healthcare Research and Quality

ASPE Assistant Secretary for Planning and Evaluation

BBRA Balanced Budget Refinement Act of 1999

BIPA Benefits Improvement and Protection Act of 2000

BPM Business Process Model

CALDC CMS Assessment Library Data Council

CARE Continuity Assessment Record and Evaluation

CCSQ Center for Clinical Standards and Quality

CM Center for Medicare

CMCS Center for Medicaid and Children’s Services

CMMI Center Medicare and Medicaid Innovation

CMS Centers for Medicare & Medicaid Services

COR Contracting Officer’s Representative

Council CMS Assessment Library Data Council

CR Change Request

CTR Contractor

DCCP Division of Continuing Care Providers

DCPAC Division of Chronic & Post-Acute Care

DEHPG Disabled and Elderly Health Programs Group

DHHH Division of Home Health and Hospice

DIPAC Division for Institutional Post-Acute Care

DNH Division of Nursing Homes

DQSAS Division of Quality Systems for Assessments and Surveys

DRA Deficit Reduction Act

DRG Diagnosis-Related Group

EHR Electronic Health Record

ESRD End-Stage Renal Disease

GST Governance Support Team

GTL Government Task Lead

CMS Assessment (Data Element) Library Governance Framework 26

Term Definition

HCBS Home and Community-Based Services

HHA Home Health Agency

HL7 Health Level 7

IRF Inpatient Rehabilitation Facility

IRF-PAI Inpatient Rehabilitation Facility Patient Assessment Instrument

ISG Information System Group

IT Information Technology

JAD Joint Application Development

Library CMS Assessment (Data Element) Library

LMWG Library Management Workgroup

LOINC Logical Observation Identifiers Names and Codes

LT Long-Term

LTCH Long-Term Care Hospital

MDS Minimum Data Set

NLM National Library of Medicine

NPUAP National Pressure Ulcer Advisory Panel

OASIS Outcome and Assessment Information Set

OBRA Omnibus Budget Reconciliation Act of 1987

ONC Office of the National Coordinator for Health IT

PAC Post-Acute Care

PAC-PRD Post-Acute Care Payment Reform Demonstration

PPS Prospective Payment System

QDM Quality Data Model

QMHAG Quality Measurement and Health Assessment Group

QMTF Quality Measurement Task Force

SCG Survey and Certification Group

SCHIP State Children’s Health Insurance Program

SME Subject Matter Expert

SNF Skilled Nursing Facility

SNOMED Systematized Nomenclature of Medicine

WG Workgroup

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