J.11-B_Development _Reevaluation_and_Implementation_of_Hospital_Outcome_Efficiency_Measures_SOW.doc

J.11-B Development, Reevaluation and Implementation of Hospital Outcome/Efficiency Measures Statement of Work

RFP-CMS-MIDS-2013-0001

Measure & Instrument Development & Support (MIDS) Contractor

Development, Reevaluation and Implementation of Hospital Outcome/Efficiency Measures

Statement of Work (SOW) Base Year and Option Years 1, 2, 3 and 4 Development, Reevaluation and Implementation of Hospital Outcome/Efficiency Measures

CHAPTER 1. SCOPE

A. Background This project is to develop, reevaluate, and implement the Centers for Medicare and Medicaid Services (CMS) hospital outcome and efficiency measures.

Furthermore, this project supports the administration of the Quality Improvement Organizations Program (QIO). The Social Security Act, as set forth in Part B of Title XI - Section 1862(g), established the Utilization and Quality Control Peer Review Organization Program, now known as the Quality Improvement Organizations (QIOs) Program. The statutory mission of the QIO Program is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. This project will provide QIOs with hospital outcome measures to evaluate hospital performance in inpatient care and care transition from acute care hospitals to outpatient settings. The measures will also provide Medicare beneficiaries with timely and comparative information on hospital performance for their choice of care.

Moreover, the work under this contract aligns with the work and mission under Section 3025 (Hospital Readmission Reduction Program), Section 3001 (Hospital Value-Based Purchasing) and Section 10303 (Development of Outcome Measures) of Health Care Reform H.R. 3590, TITLE X, Strengthening Quality, Affordable Care for All Americans, Subtitle C – Provisions Related to Title III. These sections require the Secretary to develop 20 provider-level (hospitals, physicians and other providers) outcome measures. The measures shall include measurement for acute and chronic diseases and primary and preventative care for distinct patient populations (such as healthy children, chronically ill adults, or infirm, elderly individuals. The measures shall also include the full scope of services that comprise a cycle of care.

B. Purpose

The purpose of this MIDS Task Order (TO) is to obtain services for the development, re-evaluation, and implementation of the Centers for Medicare and Medicaid Services (CMS) outcome/efficiency measures in support of the CMS quality and payment programs/initiatives.

This TO SOW adheres to all tasks within the Measure and Instrument Development and Support (MIDS) Umbrella Statement of Work (USOW) Chapters. Those activities not specifically described in the MIDS USOW shall be specified in this TO SOW. Those tasks/activities within the USOW that are excluded or not required for this TO SOW shall be noted within this TO SOW.

CHAPTER 2. GENERAL REQUIREMENTS

In accordance with (IAW) Chapter 2 of the MIDS USOW, the contractor shall carry out all work/tasks described in sections 2.A. – 2.G. The work/tasks required in Section 2.C.3. - State Agencies for Survey and Certification - are not required for this TO SOW.

Additional Requirements/More Specific Description:

IAW section 2.C.1, Other MIDS Contractors:

The Contractor shall coordinate with and provide technical support to two sets of CMS Contractors:

· The CMS contractor(s) responsible for production of the outcome measures: The Contractor shall provide technical assistance in calculating the measures, updating the SAS code, creating the Hospital-Specific Reports for implementation of measures, and ensuring Quality Assurance of the data processing. The Contractor shall provide technical assistance in the form of participating in conference calls (weekly calls), reviewing reports (approximately 10 reports per contract year) and answering questions via email on the measures and the SAS code (approximately 12 questions per month).

· The CMS contractor(s) responsible for development and maintenance of Hospital Compare web site: The Contractor shall assist in developing the display of the outcome measures and consumer testing of the display language if needed. The Contractor shall provide technical assistance by participating in conference calls (weekly calls), reviewing drafts of display and the languages for consumer testing (10 drafts per contract year) and answering questions via email (approximately 4 questions per month).

IAW section 2.G, Ad hoc requests from CMS:

The Contractor shall conduct 7 ad hoc analyses per contract year. The following example illustrates the scope of the ad hoc analyses that CMS may request during the course of the contract year.

Examples:

1. Conduct analyses on the pattern of patient enrollment in the hospice program during hospitalization and 30 days after discharge for the cohort of the CMS hospital-wide readmission measure.

Chapter 3 – INFORMATION GATHERING IAW Chapter 3 of the MIDS USOW, the Contractor shall carry out all work/tasks described in sections 3.A through 3.E. The measures for which the Contractor shall perform these activities are provided in each Appendix as follows:

For Base Year, see measure details in Appendix A.

For Option Year 1, see measure details in Appendix B

For Option Year 2, see measure details in Appendix C

For Option Year 3, see measure details in Appendix D

For Option Year 4, see measure details in Appendix E Additional Requirements/More Specific Description:

IAW section 3.A., Environmental Scan:

The environmental scan shall include but not be limited to consideration of the attached “Framework for Outcome Measure Development: A White Paper” for new measure development.

For new measure development, a more comprehensive environmental scan and literature review is required, whereas for measure re-evaluation, the Contractor shall focus on specific methodological issues (such as adding or updating inclusion and exclusion criteria, planned readmissions, etc) with the purpose of updating the measures.

CHAPTER 4 – Quality Measure Development & Re-evaluation IAW Chapter 4 of the MIDS USOW, the contractor shall carry out all work/tasks described in sections 4.A through 4.C. The measures for which the Contractor shall perform these activities are provided in each Appendix as follows:

For Base Year, see measure details in Appendix A.

For Option Year 1, see measure details in Appendix B

For Option Year 2, see measure details in Appendix C

For Option Year 3, see measure details in Appendix D

For Option Year 4, see measure details in Appendix E Additional Requirements/More Specific Description:

IAW with sections 4.A, Quality Measure Development:

For new measure development based on the EHRs, the Contractor shall use this list of minimum data elements. The Contract may also use additional clinical data elements if necessary for condition-specific measures.

IAW with sections 4.A, Quality Measure Development and 4.B, Quality Measures Re-evaluation:

The Contractor shall use the statistical recommendations by the Committee of Presidents of Statistical Societies (COPSS) for development and re-evaluation of measures. Please see the attached report “Statistical Issues in Assessing Hospital Performance” by the COPSS.

CMS will provide the Contractor with the CMS administrative data (at patient level) for measure development, measure re-evaluation, and measure testing for all the outcome measures except the payment measures. For the payment measures, the Contractor shall purchase the CMS Chronic Data Warehouse (CCW) data through the ResDAC (resdac@umn.edu; www.resdac.org). In addition, the Contractor shall provide a complete set of slides on the measures (including information on the methodology and the data on hospital performance) upon completion of re-evaluation and development of the measures.

The Contractor shall provide technical support to other CMS Contractors that are developing similar measures (e.g. for different care settings) as needed. The coordination shall take place through conference calls (about 12 calls per contract year), presentations of measure methodology by the Contractor (up to 3 presentations per contract year) and Question and Answers via email (5 questions per month). The Contractor shall work with other CMS Contractors as needed to harmonize development and maintenance of similar measures. The effort of harmonization involves conference calls (10 calls per contract year) and reviewing and drafting reports (e.g. 5 drafts of the methodological issues in need of harmonization).

The Contractor shall brief CMS senior management at each milestone of measure development (such as Environmental Scan/Literature Review, Risk Adjustment Methodology, Hospital Performance, etc.) CMS will provide input on the measure development.

IAW section 4.A.2, Public Comment:

The Contractor shall assist CMS in rule making for CMS programs such as the Inpatient Quality Reporting program and Hospital Readmission Reduction program (Section 3025 of the Affordable Care Act). The Contractor shall draft the measure methodologies for the measures (see Appendix A) to be included in the CMS Inpatient Prospective Payment System/Long-term Care (IPPS/LTC) proposed and final rules. The Contractor shall revise the draft measure methodologies iteratively in response to the feedback from CMS and other offices in the Department of Health and Human Services (HHS) as well as the public comments during the rule making process. The Contractor shall plan to respond to 200 – 400 comments received regarding the measures proposed for each program per contract year (e.g., approximately 200 comments for the IPPS and 400 for Hospital Readmission Reduction program). The Contractor shall categorize and summarize the public comments by issue and draft the responses to be included in the final rule. Note that majority of the comments come to CMS on the last few days of the comment period. Therefore the Contractor shall summarize and provide the responses within 2 weeks.

For updating measures, the Contractor shall update the changes to the measures (such as adding new planned readmissions or revising inclusion/exclusion criteria) that are finalized previously.

IAW section 4.A.5, Consensus-Based Entity Endorsement:

The Contractor shall conduct analyses within 1-2 weeks in response to the requests from the National Quality Forum (NQF) steering committees, public comments and/or appeal process. The following example illustrates the scope of potential analyses:

· Provide rationale and empirical analyses to support the argument that the approach of the CMS COPD (Chronic Obstructive Pulmonary Disease) mortality measure adequately accounts for patient preferences for end-of-life care in lieu of life-sustaining care.

Upon completion of development or re-evaluation of each measure at the end of the contract year, the Contractor shall prepare the NQF submission package for each measure to be submitted to the NQF for measure endorsement or update the next contract year.

IAW section 4.B., Quality Measures Reevaluation:

The Contractor shall provide the re-evaluation of the Hierarchical Condition Category (HCC) System for risk adjustment of the CMS outcome measures. CMS will provide the Contractor with the base HCC system for re-evaluation. Two CMS Program Offices, the Center for Drug and Health Plan Choice (CPC) and the Quality Measurement and Health Assessment Group (QMHAG), use the Hierarchical Condition Category (HCC) System as an integral part of their risk adjustment methodology for calculating payment for health plans and hospital quality of care measures for public reporting, respectively.

Section 4001 of the Balanced Budget Act (BBA) of 1997 authorizes the Secretary of the Department of Health and Human Services (HHS) to implement a risk adjustment methodology that accounts for variations in per capita costs based on health status and other demographic factors for payment. In response to this BBA mandate, CMS, supported by a contractor, developed the Hierarchical Condition Category (HCC) System to support the risk adjustment methodology in 2004. The purpose of the HCC algorithm is to group patient diagnosis codes on claims to define patient risk factors for risk adjustment. The CMS HCC algorithm first assigns 15,000+ ICD-9 diagnosis codes to 804 groupings (Diagnosis Groups) and then subsequently aggregates them into 189 clinically relevant categories. Since 2006, the CMS HCC contractor maintains 70 of the 189 HCC elements for use in the payment methodology for the Medicare Advantage plans yearly.

The CMS outcome measures build the patient risk factors based on the HCC system. The Contractor shall build on and expand the re-evaluation work that the CMS HCC contractor conducts under their contract with the Center for Medicare (for the 70 HCCs) to include all 189 HCCs for risk adjustment of the CMS outcome measures. Please visit www.qualitynet.org for the HCCs used for the CMS outcome measures.

CHAPTER 5. INSTRUMENT/ITEM DEVELOPMENT

This Chapter and the associated work and deliverables do not apply to this TO SOW.

CHAPTER 6. TESTING/VALIDATION

IAW Chapter 6 of the MIDS USOW, the contractor shall carry out all work/tasks as described in sections 6.A through 6.D. The measures for which the Contractor shall perform these activities are provided in each Appendix as follows:

For Base Year, see measure details in Appendix A.

For Option Year 1, see measure details in Appendix B

For Option Year 2, see measure details in Appendix C

For Option Year 3, see measure details in Appendix D

For Option Year 4, see measure details in Appendix E Additional Requirements/More Detailed Description:

IAW section 6.B., Types of Testing:

The Contractor shall conduct reliability and validity testing for the risk adjusted outcome measures. The Contractor shall consider these requirements and assess the need for these tests during the measure development or re-evaluation process.

CHAPTER 7. REPORTS/APPROVAL PACKAGES

IAW Chapter 7 of the MIDS USOW, the Contractor shall carry out all work/tasks as described in sections 7.A, 7.B, 7.C, 7.D, 7.E, 7.F, 7.G, 7.H, and 7.I.

CHAPTER 8. IMPLEMENTATION, PRODUCTION, & ASSESSMENT

IAW Chapter 8 of the MIDS USOW, the Contractor shall carry out all work/tasks described in sections 8.A and 8.C-8.E. Work/tasks required in section 8.B. are not required for this TO SOW.

The measures for which the Contractor shall perform these activities are provided in each Appendix as follows:

For Base Year, see measure details in Appendix A.

For Option Year 1, see measure details in Appendix B

For Option Year 2, see measure details in Appendix C

For Option Year 3, see measure details in Appendix D

For Option Year 4, see measure details in Appendix E Additional Requirements/More Specific Description:

IAW section 8.A., Implementation of Measures or Data Collection Vehicles/Assessment Instruments:

The Contractor is not required to implement data collection vehicles/assessment instruments. The Contractor shall implement the measures specified in Appendix A. In addition to the information provided in the Blue Print on how to implement measures, the Contractor shall review the CMS measure rollout materials (such as Fact Sheet, FAQs, etc.) and measure dry-run summary reports on www.qualitynet.org to better understand the CMS implementation process. The Contractor shall provide CMS senior management with descriptive analyses on hospital performance prior to rollout of the measures. The Contractor shall assist CMS in drafting highlights of hospital performance for press release if needed.

IAW section 8.D – Program, Measures, and Initiative Assessment:

The Contractor shall monitor the performance of the CMS outcome measures. The Contractor shall conduct analyses to support measure development and implementation and monitor the unintended consequences of measure implementation. The Contractor shall propose and develop analytical plans for the the analyses stated in 8.D. and conduct the analyses to update the CMS periodical/publication on CMS quality of care (please see the preliminary version - Medicare Hospital Quality Chartbook on http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/.

The Contractor shall conduct analyses/studies and provide recommendations on use or implementation of the measures. The Contractor may consider investigating the impact of implementation of readmission measures for public reporting and payment programs on safety net hospitals or health care of patients with low socio-economic status for the Base Year analysis. The purpose is to respond to stakeholders’ concern that the CMS measures by not controlling for socio-economic status at patient or hospital population level might potentially affect patient care.

Currently the CMS outcome measures are based on the ICD-9 codes on the claims. Majority of the measures are calculated using 3 years of data but some use 1 year of data (e.g., Hospital-Wide Readmission measure). When the transition to ICD-10 coding is complete for specific measures (i.e., the measures can be calculated based on the ICD-10 data), the Contractor shall analyze and examine the trend and pattern of the measure performance to ensure consistency or stable transition of measure performance for public reporting and payment programs.

In addition, the Contractor shall prepare 2-5 manuscripts for publishing in peer review journals. The manuscripts shall relate to the measures for implementation.

CHAPTER 9. PUBLIC REPORTING/COMPARE SITES

IAW Chapter 9 of the MIDS USOW, the Contractor shall carry out all work/tasks as describe in sections 9.A.- 9.I in the form of providing technical support related to the CMS outcome measures (see Appendix A). IAW 9.A.-9.I., the Contractor shall participate in conference calls (weekly) with other CMS contractors that are responsible for development and maintenance of the Hospital Compare web site. The Contractor shall provide input on the issues related to display of the outcome measures.

CHAPTER 10. ACCESS TO SYSTEMS/DATA

IAW Chapter 10 of the MIDS USOW, the Contractor shall carry out all work/tasks as describe in section 10.A.

CHAPTER 11. QUALITY ASSURANCE AND PERFORMANCE EVALUATION

In accordance with (IAW) Chapter 11 of the MIDS USOW, the Contractor shall carry out all work/tasks described in sections 11.A – 11.D., as applicable to the contractor.

A. Period-of-Performance: The Periods of Performance are as follows:

Base Year:

September 30, 2013 through September 29, 2014 Option Year 1:

September 30, 2014 through September 29, 2015 Option Year 2:

September 30, 2015 through September 29, 2016 Option Year 3:

September 30, 2016 through September 29, 2017 Option Year 4:

September 30, 2017 through September 29, 2018 B. Government Property: Not Applicable C. Key Personnel Requirements: Project Director, 2080 hours per contract year D. References:

· “Framework for Outcome Measure Development: A White Paper” by Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, April 2011.

· “Statistical Issues in Assessing Hospital Performance” by the Committee of Presidents of Statistical Societies (COPSS), November 28, 2011.

Appendix A: CMS Outcome Measures – Base Year The following lists the current CMS outcome measures. The Contractor shall develop and add new measures to the list yearly. The methodology reports of these measures can be found on www.qualitynet.org. The SAS code to produce these measures is available on request.

CMS Outcome Measures

FY2012 Measures

As of 2012, CMS has developed the following claims-based outcome measures:

1. Mortality and readmission measures for the conditions:

· Acute Myocardial Infarction (AMI)

· Heart Failure (HF)

· Pneumonia

· Chronic Obstructive Pulmonary Disease (COPD)

· Stroke

· Coronary Artery Bypass Graft (CABG)

2. Complications and readmission measures for:

· Hip/Knee replacement

3. Readmission measures:

· Hospital-Wide readmission measure

· Other vascular readmission measure

4. Payment measure

· AMI 30-day episode-of-care payment measure FY2013 Measures

By September 2013, CMS plans to complete development of the following new measures:

1. Functional status for Hip/Knee replacement

2. Episode-of-care payment measures for HF and Pneumonia

By September 2013, CMS plans to complete re-evaluation of the following measures:

Care Transition measures

· 30-day Post-Hospital Acute Myocardial Infarction (AMI) Discharge Care Transition Composite Measure

· 30-day Post-Hospital Heart Failure (HF) Discharge Care Transition Composite Measure

· 30-day Post-Hospital Pneumonia Discharge Care Transition Composite Measure Measures for Development, Re-evaluation and Implementation

Table A: MIDS CHAPTERS and Measures

· New measures for development (see CHAPTER 4 below)

· For ad hoc analyses as needed (see CHAPTER 2 )

· 1new eMeasure based on EHRs (including testing and e-specifying). The potential measure for development is “hospital-wide 30-day readmission eMeausre”

· FY2013 CMS outcome measures

· New measures for development (see CHAPTER 4)

AMI payment measure

· Readmission measures for AMI, HF and Pneumonia;

· Additional 2 new readmission measures to be determined by CMS

· 2 new readmission measures to be determined by CMS

Appendix B: CMS Outcome Measures – Option Year 1

FY2012 Measures

As of 2012, CMS has developed the following claims-based outcome measures:

1. Mortality and readmission measures for the conditions:

· Acute Myocardial Infarction (AMI)

· Heart Failure (HF)

· Pneumonia

· Chronic Obstructive Pulmonary Disease (COPD)

· Stroke

· Coronary Artery Bypass Graft (CABG)

2. Complications and readmission measures for:

· Hip/Knee replacement

3. Readmission measures:

· Hospital-Wide readmission measure

· Other vascular readmission measure

4. Payment measure

· AMI 30-day episode-of-care payment measure

FY2013 Measures

By September 2013, CMS plans to complete development of the following new measures:

1. Functional status for Hip/Knee replacement

2. Episode-of-care payment measures for HF and Pneumonia

By September 2013, CMS plans to complete re-evaluation of the following measures:

Care Transition measures

· 30-day Post-Hospital Acute Myocardial Infarction (AMI) Discharge Care Transition Composite Measure

· 30-day Post-Hospital Heart Failure (HF) Discharge Care Transition Composite Measure

· 30-day Post-Hospital Pneumonia Discharge Care Transition Composite Measure Measures for Development, Re-evaluation and Implementation

Table A: MIDS CHAPTERS and Measures

· New measures developed for Base Year for re-evaluation

· New measures for development (See CHAPTER 4 below)

· For ad hoc analyses as needed (see CHAPTER 2)

· New measures developed for Base Year for re-evaluation

· NQF review of the Base Year new measures

· New measures developed for Base Year for re-evaluation

· New measures for development (See CHAPTER 4 below)

· 2 additional new measures

· 2 new measures

Appendix C: CMS Outcome Measures – Option Year 2

As of 2012, CMS has developed the following outcome measures:

1. Mortality and readmission measures for the conditions:

· Acute Myocardial Infarction (AMI)

· Heart Failure (HF)

· Pneumonia

· Chronic Obstructive Pulmonary Disease (COPD)

· Stroke

· Coronary Artery Bypass Graft (CABG)

2. Complications and readmission measures for:

· Hip/Knee replacement

3. Readmission measures:

· Hospital-Wide readmission measure

· Other vascular readmission measure

4. Payment measure

· AMI 30-day episode-of-care payment measure

FY2013 Measures

By September 2013, CMS plans to complete development of the following new measures:

1. Functional status for Hip/Knee replacement

2. Episode-of-care payment measures for HF and Pneumonia

By September 2013, CMS plans to complete re-evaluation of the following measures:

Care Transition measures

· 30-day Post-Hospital Acute Myocardial Infarction (AMI) Discharge Care Transition Composite Measure

· 30-day Post-Hospital Heart Failure (HF) Discharge Care Transition Composite Measure

· 30-day Post-Hospital Pneumonia Discharge Care Transition Composite Measure Measures for Development, Re-evaluation and Implementation

Table A: MIDS CHAPTERS and Measures

· New measures developed for Base Year and Option Year 1 for re-evaluation as needed

· For ad hoc analyses as needed (see CHAPTER 2)

· New measures developed for Base Year and Option Year 1 for re-evaluation

· NQF review of the Option Year 1 new measures

· New measures developed for Base Year and Option Year 1 for re-evaluation

· 2 new measures

Appendix D: CMS Outcome Measures – Option Year 3

As of 2012, CMS has developed the following claims-based outcome measures:

1. Mortality and readmission measures for the conditions:

· Acute Myocardial Infarction (AMI)

· Heart Failure (HF)

· Pneumonia

· Chronic Obstructive Pulmonary Disease (COPD)

· Stroke

· Coronary Artery Bypass Graft (CABG)

2. Complications and readmission measures for:

· Hip/Knee replacement

3. Readmission measures:

· Hospital-Wide readmission measure

· Other vascular readmission measure

4. Payment measure

· AMI 30-day episode-of-care payment measure

FY2013 Measures

By September 2013, CMS plans to complete development of the following new measures:

1. Functional status for Hip/Knee replacement

2. Episode-of-care payment measures for HF and Pneumonia

By September 2013, CMS plans to complete re-evaluation of the following measures:

Care Transition measures

· 30-day Post-Hospital Acute Myocardial Infarction (AMI) Discharge Care Transition Composite Measure

· 30-day Post-Hospital Heart Failure (HF) Discharge Care Transition Composite Measure

· 30-day Post-Hospital Pneumonia Discharge Care Transition Composite Measure Measures for Development, Re-evaluation and Implementation

Table A: MIDS CHAPTERS and Measures

· New measures developed for Base Year and Option Years 1 & 2 for re-evaluation as needed

· For ad hoc analyses as needed (see CHAPTER )

· New measures developed for Base Year and Option Year 1 & 2 for re-evaluation

· NQF review of Option Year 2 new measures

· New measures developed for Base Year and Option Years 1 & 2 for re-evaluation

· 2 new measures

Appendix E: CMS Outcome Measures – Option Year 4

As of 2012, CMS has developed the following claims-based outcome measures:

1. Mortality and readmission measures for the conditions:

· Acute Myocardial Infarction (AMI)

· Heart Failure (HF)

· Pneumonia

· Chronic Obstructive Pulmonary Disease (COPD)

· Stroke

· Coronary Artery Bypass Graft (CABG)

2. Complications and readmission measures for:

· Hip/Knee replacement

3. Readmission measures:

· Hospital-Wide readmission measure

· Other vascular readmission measure

4. Payment measure

· AMI 30-day episode-of-care payment measure

FY2013 Measures

By September 2013, CMS plans to complete development of the following new measures:

1. Functional status for Hip/Knee replacement

2. Episode-of-care payment measures for HF and Pneumonia

By September 2013, CMS plans to complete re-evaluation of the following measures:

Care Transition measures

· 30-day Post-Hospital Acute Myocardial Infarction (AMI) Discharge Care Transition Composite Measure

· 30-day Post-Hospital Heart Failure (HF) Discharge Care Transition Composite Measure

· 30-day Post-Hospital Pneumonia Discharge Care Transition Composite Measure Measures for Development, Re-evaluation and Implementation

Table A: MIDS CHAPTERS and Measures

· New measures developed for Base Year and Option Years 1, 2 & 3 for re-evaluation as needed

· New measures for development (see CHAPTER 4 below)

· For ad hoc analyses as needed (see CHAPTER )

· New measures developed for Base Year and Option Years 1, 2 & 3 for re-evaluation

· NQF review of Option Year 3 new measures

· New measures developed for Base Year and Option Years 1, 2 & 3 for re-evaluation

· New measures for development (see CHAPTER 4 below)

· 2 new measures

MIDS TO SOW [Development, Reevaluation, and Implementation of Hospital Outcome/Efficiency Measures]

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