Measurement & Data Reporting

Data reporting is required by the Centers for Medicare & Medicaid Services (CMS) for all hospital engagement network participating hospitals and is critical to meeting our shared goals and celebrating success. The California Hospital Engagement Network measurement strategy is to ensure hospitals meet the requirements, and to track and monitor hospital improvement in the 10 clinical areas of focus. A key component of this strategy is the collaboration between CHA, the Health Research & Educational Trust (HRET) and our partners at the state and regional level to minimize the additional reporting burden placed on participating hospitals. The California Hospital Engagement Network measurement strategy is designed to build upon existing federal and state mandatory measurement activities, and to target measures we know are important in driving improvement throughout an organization.

To assist you in meeting the CMS data reporting requirements discussed below, please download the Getting Started Checklist for Data Reporting (PDF) developed by the California Hospital Engagement Network. Hospitals are encouraged to take action by July 31, 2012.

Step One: Confirm Clinical Areas for Improvement

Hospitals are encouraged to participate in at least two or more clinical areas  and select readmissions as one area of focus.  Hospitals may add additional clinical areas for improvement at any point during this project.

Step Two: Identify Measures to Report

Hospitals must report at least one process measure and one outcome measure for each clinical area.  For example, if a hospital chooses to work on Readmissions and Adverse Drug Events (Step 1), hospitals would need to report 4 measures in these areas (2 proces

Using the list of California target measures (Excel), identify the measures your facility will report for each clinical area of improvement.

Baseline data requirements: CMS is requesting baseline data for any period prior to 2012, with the following exceptions:

  • If a hospital chooses a new focus area and does not have baseline data on a process or outcome measure, baseline data is not required.
  • Ideal baseline data for readmissions and infections is 2010 data.

Step Three: Select How You Will Report Data

There are four options for reporting data. You may choose to use one or more of the options depending on the clinical areas chosen for improvement. There is no cost to hospitals for the transfer of data under any of these options. Hospitals should report baseline data and authorize the transfer of data through these other organizations by July 31, 2012.

Option 1: Report via the HRET Comprehensive Data System (CDS)

Hospitals may choose to report directly into HRET CDS for all measures or only those measures not currently being reported to another organization.

  • Request a login ID and password for CDS from CHA
  • Designate a data contact person responsible for monthly reporting
  • Report baseline data by July 31
  • Report data to HRET on a monthly basis, within 30 days following the close of a month

Additional Resources for HRET CDS include:

For additional questions regarding CDS you can email HRET Data Support  or call the Data Support Hotline at 312-373-0137

Option 2: Report via the National Healthcare Safety Network (NHSN)

Hospitals are required via federal and/or state mandate to report data to NHSN for three clinical areas: surgical site infections, central line-associated blood stream infections (CLABSI), and catheter-associated urinary tract infection (CAUTI). While not mandated, the NHSN system also captures data for ventilator-associated pneumonia (VAP). You can authorize the automatic transfer of this data to HRET.

  • Identify the appropriate individual within the hospital that manages data reporting to NHSN
  • Download instructions for conferring rights and confer rights to NHSN
  • Continue reporting to NHSN on a monthly basis and this data will be sent to HRET on your behalf

Note: The instructions for conferring rights are general for hospitals that will be conferring all their data in NHSN.  If your hospital has chosen to confer rights for only certain data, please note:

  1. You will see that conferring rights is done by TOPIC AREA. All the N/A boxes are UNCHECKED. Therefore, CHECK the N/A box for the topic areas that you do not want HRET to upload into CDS for purposes of calculating specific measures in that topic area.
  2. As a second step, please send an email to HENdatasupport@aha.org with the measure(s) that you would like HRET to calculate from the NHSN data.   Please include the reference number from the HRET Encyclopedia of Measures to ensure the appropriate measures are uploaded by HRET.
Option 3: Report via the Collaborative Alliance for Nursing Outcomes (CALNOC)

Hospitals that participate in the CALNOC program already report process and outcome measures for falls and pressure ulcers. Data reported by current CALNOC participants can be transferred on a quarterly basis to HRET.

  • Identify the CALNOC Site Coordinator in your hospital and discuss this reporting option
  • Go to the CALNOC website click on the Hospital Login tab located on the top left of the page. After you login to CALNOC, go to “Quick Links”
  • Select the link: “CA Hospital Engagement Network” and download and complete the release form. The deadline to submit the release form to CALNOC is July 31, 2012
  • Forms should be sent via e-mail to tony.sung@calnoc.org or faxed to (888) 586-1994
  • Questions: Contact Jackie Guillory, Community Coordinator, CALNOC at jackie.guillory@calnoc.org or (888) 586-1994
  • Continue reporting to CALNOC and this data will be sent to HRET on your behalf
Option 4: Report via the California Maternal Quality Care Collaborative (CMQCC)

CMQCC is an initiative aimed at assisting hospitals in the area of obstetrical harm, including early elective delivery. They have recently established the Maternal Data Center to assist hospitals with generating several key OB measures — using a mechanism that substantially minimizes hospital data collection burden. Hospitals that participate in CMQCC can authorize the transfer of OB data to HRET.

  • Questions: Contact Anne Castles at CMQCC at acastles@cmqcc.org or (626) 639-3044, or visit http://www.cmqcc.org to learn more about participating.
  • Continue reporting to CMQCC and this data will be sent to HRET on your behalf.
Option 5: Report via the Health Services Advisory Group (HSAG)

To assist you in meeting your reporting requirements in the Hospital Engagement Network project, The Health Services Advisory Group (HSAG) has agreed to provide HRET with thirty (30) day readmission data for the following measures:

  • AMI (READ 76)
  • Heart Failure (READ 77)
  • Pneumonia (READ 78)
  • All Cause (READ 75)

In order for HSAG to release the readmission data, you will need to complete the authorization form, sign it manually, and return it by facsimile or e-mail.

  • Completed forms should be addressed to: Jennifer Wieckowski, MSG, HSAG-California Program Director, Care Transistions at jwieckowski@hsag.com or by fax (818) 409-0835.