Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare
The Centers for Medicare & Medicaid Services (CMS) would like to announce the Confidential Dry Run Reports containing FY 2018 and FY 2019 performance scores for the Skilled Nursing Facility Healthcare-Associated Infections Requiring Hospitalizations measure (SNF HAI measure) are now available.
Performance scores are based on the draft measure specifications posted on CMS Measure Management Public Comment page. Providers can view these reports in their Certification and Survey Provider Enhanced Reports (CASPER) provider shared folders. These reports are accompanied by a Data Dictionary defining key measure terms.
The purpose of these Confidential Dry Run Reports is to allow SNFs to become familiar with this measure and to inform them of their performance in comparison to their peers. It is important to recognize that HAIs in SNFs are not considered “never-events.” The goal of this risk-adjusted measure is to identify SNFs that have notably higher rates of HAIs and to statistically distinguish between SNFs that are either better than or worse than their peers in infection prevention and in infection management. SNFs may choose to incorporate this measure into their internal quality assurance activities to improve patient outcomes. Review and use of this measure information is strictly voluntary.
Please send any questions or feedback on this measure via email to: SNFQualityQuestions@cms.hhs.gov.
Check out my September 15, 2020 blog on the introduction of this draft measure. I provide a link to the 67-page document with the specifications; diagnoses used (ICD-10) for this measure and the dry run report are found starting on page 15 of the spec document.
I encourage you to download your report from your shared folder. You’ll find 2 tabs at the bottom of this Excel spreadsheet: Documentation and Provider Report. Be sure to review the information in the Documentation tab (it explains what you’ll see in your report) and utilize the draft measure specifications document (see paragraph directly above) when working with your Provider Report. These are the measure headings that will display on the report with your facility’s data beneath:
You’ll also see each Performance Year for data collection: