Draft Measure Specifications: SNF Healthcare-Associated Infections Requiring Hospitalizations for the SNF QRP

Mary Madison, RN, RAC-CT, CDP 
Clinical Consultant – Briggs Healthcare

Skilled Nursing Facility (SNF) Healthcare-Associated Infections (HAI) Measure Call for Public Comment

The Centers for Medicare & Medicaid Services (CMS) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) is seeking input from the public as part of the measure development process. CMS has posted Draft Measure Specifications: SNF Healthcare-Associated Infections Requiring Hospitalizations for the SNF QRP (SNF HAI measure).  This document contains conceptual and technical measure information and provides a link to the Final Technical Expert Panel Summary Report: Development of a Healthcare-Associated Infections Quality Measure for the SNF QRP for the public’s review.  Please review both of these documents and give us your feedback via the email:  SNFQualityQuestions@cms.hhs.gov.  

CMS would also like to announce the SNF HAI measure will be a part of the Measures Under Consideration list later this year and it is our intention to present this measure for pre-rulemaking review at the Measure Applications Partnership Post-Acute Care/Long-Term Care Workgroup meeting in December.  CMS will be providing Confidential Dry Run Reports to alert each SNF of their SNF HAI performance score based on these draft measure specifications later this summer. 

The full Draft Measure Specification documents is available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/PC-Currently-Accepting-Comments (see last line of this blog for direct hyperlink to the specific document).

The Call for Public Comment period opens on September 14, 2020 and closes on October 14, 2020.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Acumen to develop a claims-based quality measure of healthcare-associated infections (HAIs) for the SNF QRP. The contract name is Quality Reporting Program Support for the Long-Term Care Hospital, Inpatient Rehabilitation Facility, Skilled Nursing Facility/Nursing Facility QRPs and Nursing Home Compare (PAC QRP) Support. The contract number is 75FCMC18D0015. As part of its measure development process, Acumen requests interested parties to submit comments on the candidate or concept measures that may be suitable for this project.

Project Objectives:

  • Develop a healthcare-associated infections quality measure for the SNF QRP under the meaningful measure domain: Making Care Safer by Reducing Harm Caused in the Delivery of Care.
  • Specify the target population, including the exclusion criteria.
  • Identify risk adjustment variables and the approach for risk adjustment.
  • Gather feedback on the importance, feasibility, usability, and potential impact of calculating a HAI measure.
  • Identify additional guidance required for implementation in the SNF QRP.

This is a 67-page document.