3701-14-03 Hospital performance measures reporting requirements.

(A) Except as otherwise provided in this rule, commencing with the first reporting deadline that occurs at least ninety days after the effective date of this rule, each hospital shall submit information to the director, in accordance with the provisions of rules 3701-14-02 to 3701-14-04 of the Administrative Code, showing the hospital's performance in meeting each of the measures specified in appendix A to rule 3701-14-04 of the Administrative Code.

(1) Not later than the first day of each April, each hospital shall submit information reflecting, by quarter, the hospital's performance in meeting the measures over the twelve month reporting period ending on June thirtieth of the previous calendar year. Hospitals that have already submitted the performance measures for the first two quarters of this reporting period shall only submit information reflecting the hospital's performance in meeting the measures for the third and fourth quarters of this reporting period. The third and fourth quarters of this reporting period are the first and second calendar quarters of the previous calendar year.

(2) Not later than the first day of each October, each hospital shall submit information reflecting, by quarter, the hospital's performance in meeting the measures over the previous calendar year. Hospitals that have already submitted the performance measures for the first two quarters of the reporting period shall only submit information reflecting the hospital's performance in meeting the measures for the third and fourth calendar quarters of the previous calendar year.

(3) If the first reporting deadline that occurs at least ninety days after the effective date of this rule is October 1, 2009, each hospital shall submit information reflecting, by quarter, the hospital's performance in meeting the measures specified in rule 3701-14-04 of the Administrative Code for all of calendar year 2008.

(4) Children's hospitals are exempted from reporting a performance, quality or service measure for patients eighteen years of age or older.

(5) Hospitals that are not currently participating in the hospital consumer assessment of healthcare providers and systems shall commence reporting the HCAHPS measures beginning October 2011.

(6) Hospitals that are not stroke centers certified by the joint commission shall commence reporting the stroke measures beginning October 2012.

(B) In addition to the measures required to be reported in paragraph (A) of this rule:

(1) Beginning October 2010, each hospital shall report annually each October, the health care provider influenza vaccination information in appendix B to rule 3701-14-04 of the Administrative Code for the flu season beginning on September first of the previous calendar year and ending on March thirty-first of the reporting year; and

(2) Beginning October 2011, each hospital shall submit, in accordance with paragraph (A) of this rule, information reflecting the hospital's performance in meeting the perinatal and pediatric measures specified in appendix E to rule 3701-14-04 of the Administrative Code.

(C) The hand-washing program and infection control staff information shall be reported and updated once each reporting time period in April and October reflecting the information as of the end of the fourth quarter of the reporting period.

(D) The AMI thirty-day mortality measure shall be reported once annually each October reflecting the twelve month reporting period ending on June thirtieth of the previous calendar year.

(E) The following perinatal measures shall be calculated by the department from the birth records submitted by each hospital pursuant to section 3705.02 of the Revised Code:

(1) Infants under fifteen hundred grams not delivered at the appropriate level of care;

(2) Appropriate use of antenatal steroids; and

(3) Caesarean rate for low-risk first birth women.

(F) In submitting the information, each hospital shall do all of the following:

(1) Submit information for each measure electronically, in a manner prescribed by the director, through the department's website created for this purpose:

(a) If a hospital does not provide the service that is the subject of a performance, quality, or service measure, the hospital shall not enter any data for that measure.

(b) If a hospital commences operation or starts serving a new population in the middle of a calendar quarter, the hospital shall not enter any data for the partial quarter, but shall submit the performance measure information starting with the first full quarter of hospital operation or serving the new population.

(2) Submit the following identifying information:

(a) The hospital's name, address, hospital registration number issued pursuant to section 3701.07 of the Revised Code, medicare provider number, if applicable, and the hospital's main telephone number; and

(b) The name of the person submitting the information and a telephone number and e-mail address for that person.

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

(4) Submit the numerator and denominator for each performance measure that is calculated as a per cent or rate; and

(5) Unless otherwise provided in rules 3701-14-03 and 3701-14-04 of the Administrative Code:

(a) Use the specifications for the measure that the entity that developed or endorsed the measure recommends be used for each quarter in the reporting period for which information is being submitted;

(b) If the specifications permit use of a sampling methodology, indicate if sampling is used to calculate the measure; and

(c) 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 each quarter of the reporting period for which information is being submitted.

(G) Under no circumstances shall the name or social security number of a patient, physician, or dentist, or any other health care practitioner, be included in the information submitted under this rule.

(H) A hospital may include comments regarding the measures when submitting the information under rules 3701-14-02 to 3701-14-04 of the Administrative Code. The hospital's commentary shall be included in the display of the hospital's information on the department's internet website.

(I) The director may waive the reporting of a measure if the director determines that the entity that created or endorsed the measure has failed to timely make available updates to the measure, has materially altered the measure in such a way to make reporting or calculation of the measure unreasonably difficult, or has discontinued the measure.

(J) A hospital may verify the accuracy of, and make corrections to, the information submitted to the director or calculated by the department pursuant to rules 3701-14-02 to 3701-14-04 of the Administrative Code anytime prior to the data being made available to the public under paragraph (M) of this rule.

(K) A hospital shall submit amended data for the surgical site infection measures required to be reported if a procedure was performed in a period that has already been reported and an infection related to that procedure is detected subsequent to the initial submission of information:

(1) Within thirty days after the operative procedure if no implant is left in place; or

(2) Within three hundred sixty-five days after the operative procedure if an implant is left in place.

(L) The director may audit any information submitted to the director under section 3727.22 of the Revised Code and rules 3701-14-02 to 3701-14-04 of the Administrative Code, including information adjusted for risk. The director may accept the audit reports from the CMS and the joint commission that are pertinent to their measures, if the director determines the audit reports are representative of the reporting period in question.

(M) 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 and available on the department's internet website. The director shall:

(1) Exclude from sale and from the website, and not otherwise make available to the public, information that compromises patient privacy; and

(2) Exclude from the website, a hospital's information for a particular measure if the hospital's caseload is determined by the director to be insufficient to make the information a reliable indicator of the hospital's quality. The director shall consider the specifications manual issued by CMS and the joint commission when making this determination.

(N) If a hospital fails to timely submit the information required by rules 3701-14-02 to 3701-14-04 of the Administrative Code, 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 these rules.

Replaces: 3701-14-02

Five Year Review (FYR) Dates: 09/17/2014 and 09/15/2019
Promulgated Under: 119.03
Statutory Authority: 3727.41
Rule Amplifies: 3727.33 , 3727.331 , 3727.35 , 3727.39 , 3727.40 , 3727.41
Prior Effective Dates: 1/27/2007, 6/9/09