J.2-B_HQI_Statement_fo_Work.docx

Hospital Quality Initiatives Measure Implementation Support

Measure & Instrument Development and Support (MIDS)

Task Order Statement of Work J.2-A HQI Statement of Work

RFP-CMS-MIDS-2013-0001

Statement of Work

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Statement of Work (SoW) Hospital Quality Initiatives (HQI) Measure Implementation Support

CHAPTER 1. SCOPE

1.A. Background

This Statement of Work (SOW) outlines the tasks that the Contractor shall perform to support the Centers for Medicare & Medicaid Services (CMS) in managing public reporting for the Hospital Quality Initiatives (HQI) launched by CMS in 2005. The HQI includes but is not limited to the hospital Inpatient Quality Reporting (IQR) Program, the Hospital Outpatient Quality Reporting Program (HOQR), Hospital Value Based Purchasing (VBP) and Hospital Compare. CMS established the two quality data reporting programs under the authority of and to meet the statuary requirements of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, the Deficit Reduction Act (DRA) of 2005 and the Tax Relief Health Care Act (TRHCA) of 2006. Hospital VBP was authorized by Section 3001 of the Patient Protection and Affordable Care Act.

MMA of 2003 and DRA of 2005

The MMA of 2003 Section 500(c) requires hospitals to submit quality measure data to CMS in order to receive their full Annual Payment Update (APU). The Act further requires that CMS make the measure data available to the public. Given the MMA authority, CMS established the Hospital OQR Program that collects, validates, and posts the Hospital Quality Measures on Hospital Compare (HC), www.hospitalcompare.medicare.gov. The MMA required the Inpatient Prospective Payment System (IPPS)/subsection (d) hospitals to submit data on 10 “core” Process of Care Measures; the DRA of 2005 expanded the domains of quality measures to include Structure, Patient Satisfaction and Outcomes/Efficiency. To meet the requirements of the MMA and DRA, through the IPPS rulemaking process, CMS adopted and publicly reported measures incrementally over time from 10 measures initially to over 70 measures currently across the required domains.

The administration of the IQR program is established through the rulemaking process and described in the IPPS rule that is published for each fiscal year. As the IQR Program evolves, other federal agencies are joining the effort. CMS decided to adopt a select set of AHRQ (Agency for Healthcare Research and Quality) Inpatient Quality Indicators (IQIs) and Patient Safety Indicators (PSIs) for reporting in 2010. AHRQ has been working with CMS to adapt the measures for the Medicare population and to provide technical support to implement these measures. CMS recently began publicly reporting data from the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) in the areas of hospital-acquired infections.

TRHCA of 2006

TRHCA of 2006 required the Outpatient Prospective Payment System (OPPS)/subsection (d) hospitals to submit Outpatient Quality Measure Data to CMS in order to get their full APU. The Act further granted CMS the authority to establish HOQR to publicly report these measures on HC. A set of outpatient measures, seven chart-abstracted process of care and four imaging efficiency measures were publicly reported on Hospital Compare under HOQR in 2010. The administration of the HOQR program is established through the rulemaking process and described in the OPPS rule that is published for each calendar year.

The production and maintenance of the HC Website including IQR, OQR, VBP and other pay for reporting or pay for performance programs involves communication and collaboration with many CMS components and, in most cases, their contractors:

The Contractor will support QMHAG, specifically DHMM, to carry out tasks related to implementation of hospital quality measures. DHMM also regularly communicates and cooperates with several other external entities including but not limited to Hospital Stakeholders, AHRQ, and the CDC. Details are provided below.

1.B. Purpose

The purpose of this SOW is to obtain services to support DHMM in QMHAG in the management of measure implementation and public reporting for the HQI including IQR, OQR, VBP and Hospital Compare.

This TO SOW adheres to all tasks within the MIDS USOW Chapters. Those activities not specifically described in the MIDS USOW shall be specified in this TO SOW. Those activities/tasks within the MIDS 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.

Additional Requirements/More Specific Description IAW with section 2.C, Coordination:

The Contractor shall provide administrative and logistical support to the following regularly occurring meetings:

a. Hospital Stakeholder staff-level calls (12/yr, no phone lines)

b. Department of Defense (DoD) - TRICARE (12/yr, 10 phone lines)

c. Veterans Health Administration (VHA) (12/yr, 10 phone lines)

d. Hospital Communication and Coordination Workgroup (HCCW) (24/yr, no phone lines)

e. Hospital Compare CMS and Contractors (24/yr, no phone lines)

f. Hospital Compare Managers (6/yr, no phone lines)

The Contractor shall prepare meeting agendas, meeting minutes, reports and briefing materials including tracking decisions made in meetings, disseminating information to relevant participants, and researching information to shed light on specific issues. The Contractor shall also coordinate meetings with external entities (e.g., Hospital Stakeholders, VHA,) and internal entities (e.g., CMS components, CMS contractors, CMS management) related to hospital public reporting for the development of public reporting requirements and Investment Life Cycle (ILC) processes. There will be up to four ad hoc meetings per month for which the Contractor shall provide administrative support.

Deliverable 47 Meeting Agendas - Coordination with external and internal entities to gather agenda items. Develop and preparing agendas and minutes for dissemination to the group. This deliverable is ongoing with agendas disseminated five (5) days prior to meetings.

Deliverable 48 Meeting Minutes-approved final minutes distributed within seven (7) days of the meeting.

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

The Contractor shall host two (2) Joint Application Development meetings. These meetings shall take place in January and July. The purpose of these meetings is to focus on topics such as strategic planning, data flow, data integrity, business requirements or other topics as specified by CMS. Each JAD shall last one business day and will be held at the CMS Central Office. Attendees shall include CMS staff and their contractors involved in public reporting. The Contractor shall be required to coordinate meeting dates/times with CMS staff and contractors, gather agenda items and other supporting documentation develop agenda, and take minutes. The Contractor shall provide approved documents to attendees in person and set up a Webinar for those who cannot attend in person.

Deliverable 49 JAD Preparation - Coordination with external and internal entities to gather agenda items. Develop and preparing agendas documents for dissemination to the group seven (7) days before the meeting.

Deliverable 50 JAD Minutes and Action Items - The Contractor shall prepare minutes and action items of the JADs and submit for approval within 10 days after the JAD.

CHAPTER 3. ENVIRONMENTAL SCAN/EMPIRICAL REVIEW

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

CHAPTER 4. QUALITY MEASURE DEVELOPMENT & REEVALUATION

IAW Chapter 4 of the MIDS USOW, the Contractor shall carry out all work/tasks described in sections 4.A.2. Work/tasks required in sections 4.A, 4.A.1, 4.A.3, 4.A.4, 4.A.5, 4.A.6 and 4.B are not required for this SOW.

Additional Requirements/More Specific Details IAW section 4.A.2, Public Comment:

The Contractor shall retrieve, review, categorize, summarize, and disseminate public comments received in response to the IPPS and OPPS proposed rules or others, related to IQR, OQR and VBP Incentive Programs. Following publication of the proposed IPPS and OPPS rules, the Contractor shall retrieve all public comments submitted to the Federal Docket Management System (FDMS) that relate to IQR and OQR Incentive Programs available at http://www.fdms.gov and/or posted on Regulations.gov (http://www.regulations.gov) The Contractor shall review and summarize the individual comments, categorizing each comment by the topic(s) addressed and provide the IQR, OQR and VBP (or other) incentive program subject matter expert (SME) with a count and a summary of comments received by topics. CMS will provide a list of topics and format for each of the related rules.

Deliverable Number 51 Public Comment Support – Provide to each SME a count and summary of relevant comments received by topics. Because of the nature of rule comments, the Contractor shall be required to submit a summary report on Friday of each week during the comment period. If there are no new comments within a given week, the Contractor shall not have to submit an updated report. Historically, more comments come into the FDMS system towards the end of the comment period, than earlier in the comment period. Therefore, CMS may require the Contractor to deliver a report 2 times per week in the final 2 weeks of the comment period if needed.

CHAPTER 5. INSTRUMENT/ITEM DEVELOPMENT

CHAPTER 6. TESTING/VALIDATION

CHAPTER 7. REPORTS/APPROVAL PACKAGES

IAW Chapter 7 of the MIDS USOW, the Contractor shall carry out all work/tasks described in sections 7.A. – 7.I.

CHAPTER 8. IMPLEMENTATION, PRODUCTION & ASSESSMENT

Chapter 9. PUBLIC REPORTING/COMPARE SITES

IAW Chapter 9 of the MIDS SOW, the Contractor shall carry out all work/tasks described in sections 9.A., 9.B., 9.C., 9.F-I. Work/tasks required in sections 9.D and 9.E.are not required for this TO SOW.

Additional Requirements/More Specific Description IAW section 9.B., Content Management/Support:

The Contractor shall verify/maintain reference/background website content regarding Hospital Compare to include (but not limited to):

· HospitalCompare.hhs.gov (includes footnote references as directed by the GTL and excludes measure data, Hospital Consumer Assessment of Health Providers and Systems (HCAHPS) results and Medicare Payment and Volume (MPV) data)

· QualityNet.org

· Hospital Quality Initiative pages on CMS.gov

The Contractor shall review and maintain website textual content and downloadable files documentation on a quarterly basis in collaboration with other CMS components. The goal of this activity is to ensure that the information is up-to-date, complete and accurate and that, to the extent possible, users of the data are fully informed about the data. In general, the contractor shall conduct information gathering, documentation and development of content language and recommendations. Additional related tasks may be requested by the GTL. All proposed content must follow the Plain Writing Act, which can be found at: http://www.plainlanguage.gov/plLaw/index.cfm. The Contractor shall propose changes for approval by CMS that if approved, will be implemented in collaboration with contractors for other CMS Websites (e.g., HospitalCompare.medicare.gov and CMS.gov) or the Quality `Net Website contractor (for QualityNet.org).

Deliverable Number 52 Content Management and Support - Reports that summarize the Contractor’s reviews and propose maintenance updates of Website content. These reports are due quarterly 45 days prior to website release/refresh.

At the direction of CMS, the Contractor shall undertake consumer testing of the Hospital Compare content prior to public release. Consumer testing of more than nine participants requires the submission of a Paperwork Reduction Act (PRA) package for Office of Management and Budget (OMB) clearance, which may require up to six months.

Consumer testing involves the development of test scripts, content and logistical support. Consumers should consist of a mix of various users of the website data including Medicare Beneficiaries, consumer advocates, physicians, nurses and other clinicians. On occasion, members of the media, hospitals associations or hospital leadership may be solicited for feedback at the direction of CMS.

Deliverable number 53 Consumer Testing - The Contractor shall work with CMS to identify and submit for approval a list of locations for consumer testing. This should be done at least 1 month prior to testing.

Deliverable number 54 Consumer Testing Materials – The Contractor shall submit testing materials for CMS approval two weeks prior to testing

Deliverable number 55 Consumer Testing Report - The Contractor shall provide a report of consumer testing results within two weeks of testing conclusion. This report shall contain results of testing and recommendations gleaned from testing.

IAW section 9.C., Provider Preview:

The Contractor shall respond to questions that are submitted to CMS regarding HC in general, measures reported on HC in particular and the HC downloadable files.

The Contractor shall provide an E-mailbox to receive questions. In addition, the Contractor shall triage Qs & As (Questions and Answers) about measure specifications and measure results, including hospital-specific results to measures developers and production contractors, e.g., registries, the CDC and AHRQ.

On average, CMS receives about 20 questions per week, but that number is expected to increase based upon an increase in the number and types of measures, and sources of data.

Deliverable Number 56 Q&A Support – The Contractor shall provide responses to questions that are submitted to CMS regarding HC and the downloadable files. Questions are referred or answered within three (3) business days of receipt. If referred, the Contractor shall follow-up with one or more subject matter experts within two (2) business days. The Contractor shall answer all questions within seven (7) business days of receipt.

Deliverable Number 57 Q&A Report - Provide CMS with a table containing all Qs&As and responses with the monthly report.

IAW section 9.F, Communications Material:

The Contractor shall provide administrative support for the preparation of press releases, fact sheets, talking points, Qs&As, FAQs (Frequently Asked Questions), etc., for each HC Update.

The Contractor shall provide ongoing technical support to QMHAG, Business Operations Group (BOS) and the Office of Communication (OC) in the preparation of press releases, fact sheets, talking points, Qs&As, etc. related to HC updates as necessary. This subtask includes participation in meetings, fact gathering and drafting of documents that may be converted into Press Releases, FAQs, and Fact Sheets, for example, by the CMS Office of Communication.

Specifically:

1. Engage in roll-out activities for new measures based upon non-traditional data sources.

1. Develop a communications plan with the CCSQ and OC in preparation for a roll-out of new measures based upon non-traditional data sources.

1. Prepare a set of frequently asked questions related to hospital measure sets that do not currently have them. For example, measures derived from registries data and the NHSN (CDC) may not have a fully developed set of FAQs. The MIDS Contractor shall work with the registry or NHSN to develop a set of FAQs.

1. Participate in other roll-out activities as directed by the GTL.

Deliverable Number 58 Roll out Materials - Provide technical support to QMHAG, CCSQ and OC related to HC updates on an ongoing, but intermittent (generally up to four times per year) basis. Quarterly, generally beginning three (2) months prior to a HC update and ending with the HC update.

IAW section, 9.G., User Acceptance Testing:

The Contractor shall participate in User Acceptance Testing (UAT) of website content before it is made public. With each quarterly release, the site will require user testing before going live. The Contractor will be required to develop a testing plan based on the content that is in scope. Measures that may need testing include the process of care, HAI (Hospital Acquired Infections), and other items as directed by CMS. As part of UAT, the Contractor shall also review the language and content, including data collection dates and other static documents and email the findings to the web team no later than close of business (COB) each day of UAT. A final UAT report shall be submitted to the GTL no later than 7 days after completion of UAT.

Deliverable Number 59 User Acceptance Testing - Provide UAT report submitted to the web team each day of UAT by COB. The format for the report will be provided by the web team.

Deliverable Number 60 User Acceptance Testing Report - Provide a comprehensive review and report of all UAT findings to the GTL no later than seven days after completion of UAT.

IAW section 9.H, Public Reporting Timeline:

The Contractor shall develop an overall public reporting timeline and data flow diagrams for Hospital Compare. Currently, there are several (see Examples below) components and contracts contributing content to the Hospital Compare Website. In general, the Program Management & Business Requirements Contractor, PMBR releases their timeline which shall be distributed to the HC team for concurrence of the dates. The Contractor shall gather the various component timelines and content descriptions to reflect an integrated overall Hospital Compare (HC) Timeline for every release/refresh cycle. A ‘release’ occurs when new content or measures are added to the Website and the data are updated. A ‘refresh’ occurs when nothing new is added but the data are updated.

Examples:

· Inpatient and Outpatient Preview and Final Files Timelines from the Program Management and Business Requirements

· Quality Tools Data Refresh/Release Schedule from the Office of Communication, Web and New Media Group

· Data Collection and Submission Schedule from the QualityNet.org Website

The Contractor shall provide on a quarterly basis overall HC public reporting timelines that contain information including major milestones and deliverables, responsible entities and dates. In general, overlapping timelines for two or three public reporting cycles will exist at any point in time as planning for each HC update begins about nine months in advance.

Deliverable Number 61 Timelines - Overall Public Reporting Timelines for Hospital Compare. Due Quarterly within seven business days after each public reporting timeline becomes available from the Program Management & Business Requirements Contractor.

CHAPTER 10. ACCESS TO SYSTEMS/DATA

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.