3701-14-02 Reporting of hospital performance measures.

(A) Beginning in 2007, not later than the first day of each April and the first day of each October, each hospital shall submit information to the director of health, on the form provided in the appendix to this rule, showing the hospital’s performance in meeting each of the service measures specified in this rule.

(1) The information submitted by April first shall reflect the hospital’s performance in meeting the measures over a twelve month period ending on September thirtieth of the previous calendar year.

(2) The information submitted by October first shall reflect the hospital’s performance in meeting the measures during a twelve-month period commencing on April first of the previous calendar year and ending on March thirty-first of the reporting year.

(B) In submitting the information required by this rule, each hospital shall do the following:

(1) Submit the information for the hospital’s services regardless of who pays the charges incurred for the services;

(2) Except as provided for in paragraph (B)(5) of this rule, for each measure for which the information is submitted, use the form and specifications for the measure that the entity that developed or endorsed the measure recommends be used for the measure for the twelve-month period for which information is being submitted;

(3) For each measure for which information is submitted, indicate whether the denominator used in calculating the measure is:

(a) Zero; or

(b) Less than twenty-five.

(4) Except as provided for in paragraph (B)(5) of this rule, adjust for risk, as needed, the information for a particular measure in accordance with the risk adjustment methodology that the entity that developed or endorsed the measure recommends be used for the measure for the twelve-month period for which information is being submitted; and

(5) If the form and specifications for the measure or the risk adjustment methodology specified in paragraphs (B)(2) and (B)(4) of this rule changed during the twelve month reporting period, the hospital shall use the form and specifications or risk adjustment methodology that was recommended by the entity for the last quarter of the twelve-month period being submitted.

(1) The agency for health care research and quality’s patient safety indicators for iatrogenic pneumothorax (neonate, pediatric and adult) and for post-operative respiratory failure (pediatric and adult);

(2) The centers for medicare and medicaid services’ pneumonia measures for pneumococcal vaccination and for blood culture before initial antibiotic;

(3) The national quality forum’s measures aspirin at arrival for acute myocardial infarction (AMI) and for beta blocker at arrival for AMI; and

(4) The joint commission on accreditation of healthcare organizations’ heart failure measures for left ventricular function assessment and for angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) for left ventricular systolic dysfunction.

(D) A hospital may include with the information submitted under this rule commentary explaining any major anomalies with the submitted information. The hospital shall submit the commentary on the form provided in the appendix to this rule. Any release of the data disclosed under this rule identifying the hospital shall include the commentary, if any, submitted by the hospital pursuant to this paragraph.

(E) The chief executive officer or designee of each hospital shall submit the signed affidavit provided in appendix to this rule, affirming that the data submitted is accurate. If the data is submitted electronically, the act of submission shall be construed as affirmation of accuracy.

(F) A hospital may request to verify the accuracy of the information submitted to the director pursuant to this rule no later than fourteen days after the hospital submits its information. Corrections of the information received by the director no later than thirty days after the reporting period deadline prescribed by paragraphs (A)(1) and (A)(2) of this rule shall be included in the final reports made available to the public under paragraph (G) of this rule.

(G) Not later than ninety days after a hospital submits information to the director under this rule, the director shall make the submitted information available for sale to any interested person or government entity.

(H) If the director discovers errors in the information submitted or a hospital representative provides corrections to the director after the reported information is made available to the public pursuant to paragraph (G) of this rule, the director shall note the errors and respective corrections as caveats to the final reports on subsequent releases. If a hospital representative provides corrections of errors thirty days after the reporting deadline but prior to the date the information is made available to the public pursuant to paragraph (G) of this rule the director may note the errors and respective correction as caveats to the final reports on subsequent releases.

(I) Under no circumstances shall the name or social security number of a patient, physician, or dentist be included in the information submitted under this rule.

(J) If a hospital fails to timely submit the information required by this rule, the director may apply to the court of common pleas of the county in which a hospital is located for a temporary or permanent injunction restraining the hospital from failure to comply with this rule.

Appendix

Annual Hospital Disclosure Quality Measures Reporting Form

E-Mail to the Ohio Department of Health

Report Period: April 1, 20 to March 31, 20

October 1, 20 to September 30, 20

Schedule A. Identification

1. Name of Hospital

2. Hospital Number

3. Medicare Provider Number

4. Address

5. City

6. County

7. ZIP Code

8. Telephone Number – -

9. Name of Person Completing this Form

10. Telephone Number of Person Completing Form – -

11. E-mail Address of Person Completing Form

Schedule B. Quality measures. If your percentage is 0%, please type 0 in the form.

Percentage Denominator LESS THAN 25? Denominator= 0?

Aspirin at Arrival for Acute Myocardial Infarction

Beta Blocker at Arrival for Acute Myocardial Infarction

Pneumococcal Vaccination for Pneumonia

Blood Culture before Initial Antibiotic for Pneumonia

ACEI or ARB for LVSD for Heart Failure

Evaluation of LVS function for Heart Failure

Iatrogenic pneumothorax – neonate

Iatrogenic pneumothorax – pediatric

Iatrogenic pneumothorax – adult

Postoperative respiratory failure – pediatric

Postoperative respiratory failure – adult

Comments (attach extra pages as necessary):

Affidavit

Certification by the hospital’s chief executive officer.

I hereby certify that the information disclosed in accordance with section 3727.34 of the Ohio Revised Code and rule 3701-14-02 of the Administrative Code is true to the best of my knowledge.

Signature ___________________________________________________________________

Type Name:

Type Title:

Date Signed:

Sworn to me and subscribed to in my presence, this ______________ day of _________________, 20_______.

Notary Public _________________________________________________________________

Effective: 01/27/2007

R.C. 119.032 review dates: 01/15/2012

Promulgated Under: 119.03

Statutory Authority: 3727.41

Rule Amplifies: 3227.33, 3727.35. 3727.36, 3727.37, 3727.40, 3727.41, 3727.45