User Guide for Hospice Quality Reporting Data Collection

User Guide for

Hospice Quality Reporting
Data Collection
Reporting cycle:
Data Collection from October 1, 2012 – December 31, 2012
Data Submission January 1, 2013, and April 1, 2013
Annual Payment Update impact FY 2014

This User Guide is considered a draft until OMB approval of the data submission is received.

Table of Contents
Section I: Introduction ................................................................................................................................. 3
Purpose and Explanation of Data Collection ...................................................................................... 4
Who, What, When & How .................................................................................................................. 5
Important Information ......................................................................................................................... 7
Data Entry Site Availability: ......................................................................................................... 7
Frequently Asked Questions: ......................................................................................................... 7
Help Desk Contact Information: .................................................................................................... 7

Section II: The Structural Measure ............................................................................................................... 8
Background ......................................................................................................................................... 9
Structural Measure Data Collection: October 1 – December 31, 2012 ............................................. 10
Process for Structural Measure Data Collection ............................................................................... 12
Structural Measure Reporting: Data Submission January 1 – 31, 2013 ............................................ 18
Section III: NQF #0209 – Pain Measure..................................................................................................... 20
Background ....................................................................................................................................... 21
Implementing the NQF #0209 Pain Measure in Your Hospice Organization:
October 1 – December 31, 2012 .............................................................................................. 22
NQF #0209 Measure Reporting: January 1 – April 1, 2013 ............................................................. 29
Section IV: Appendices .............................................................................................................................. 33
Appendix A: Structural Measure Worksheet .................................................................................... 34
Appendix B: List of Quality Indicator Domains, Subdomains, and Topics with Examples ............. 39
Appendix C: NQF #0209 Measure Worksheet ................................................................................. 47
Appendix D: Glossary ....................................................................................................................... 48
Appendix E: Quality Reporting Timeline ......................................................................................... 49

Page 2 of 49

Section I:

Introduction

Page 3 of 49

Purpose and Explanation of Data Collection
As established by Section 3004 of the Affordable Care Act, hospice providers are required to report
quality data to the Centers for Medicare & Medicaid Services (CMS). Section 1814(i)(5)(A)(i) of the
Social Security Act requires that beginning with fiscal year (FY) 2014, and for each subsequent FY, the
market basket update shall be reduced by two percentage points for any provider that does not comply
with the quality data submission requirements with respect to that fiscal year. In the Hospice Wage Index
for Fiscal Year 2012 Final Rule (August 4, 2011), it was established that to meet the quality reporting
requirements for the FY 2014 payment determination, hospice providers shall report two measures:
1. the structural measure related to the content of their Quality Assessment and Performance
Improvement (QAPI) program and
2. the NQF #0209 Pain Measure.
The structural measure provides CMS with general information about the types of quality indicators that
are currently being used by hospice providers in their QAPI programs. The NQF #0209 Pain Measure
reflects the number of patients who report being uncomfortable because of pain at the initial assessment
(after admission to hospice services) who report that pain was brought to a comfortable level within 48
hours.
To avoid a reduction in the Annual Payment Update (APU) for FY 2014, all hospice providers that are
Medicare certified and have a valid CCN (CMS Certification Number; also known as the Medicare
Provider Number) as of October 1, 2012, are required to collect and submit data to CMS for both
measures. The level of performance is not a factor in determining the APU for FY2014.
Hospice providers must submit their structural measure data to CMS no later than January 31, 2013.
Providers must submit their facility-level, aggregate data for the NQF #0209 Pain Measure to CMS no
later than April 1, 2013. The data collection (look-back) period for both measures is October 1, 2012,
through December 31, 2012. Details of the data submission process will be provided on the Hospice
Quality Reporting Program (HQRP) CMS.gov website.

Page 4 of 49

Who, What, When & How
Who:
All hospice providers that are Medicare certified (have a valid CCN, or Medicare Provider Number) as of
October 1, 2012, are required to collect and submit data to CMS.
For Hospices with Multiple Locations:

•

Hospices will report data for both measures to CMS on a per-CCN basis.

– Hospice providers with multiple locations, sharing one CCN, should aggregate facility-level
data from all locations so the data entered on the CMS data entry site represent data for the
single CCN.
Eligible patients for measure reporting include the following:

•

All payers (Medicare, Medicaid, and private payers) and

•

All hospice provider settings (inpatient, home care, nursing home, assisted living facility, etc.)

What:
Hospice providers will report two measures. These measures are as follows:

•

A structural measure: provides CMS with general information about the kinds of patient carerelated quality indicators (QIs) used in hospice organizations’ QAPI programs. It is intended to
reflect which domains and topics of care providers include in their QAPI programs. Hospice
providers will select the domains/topics of care for which they have at least one quality indicator
using a drop-down menu. No numerical data or performance scores will be reported for the
structural measure.

•

The NQF #0209 Pain Measure: calculates the percentage of patients who report being
uncomfortable because of pain at the initial assessment (after admission to hospice services) who
report that pain was brought to a comfortable level within 48 hours. Hospice providers will
submit 7 facility-level, aggregate data elements to CMS for the NQF #0209 Pain Measure
reporting.

When:
There are two separate reporting deadlines for submitting the required data to CMS:

•

The structural measure must be submitted no later than January 31, 2013.

•

The NQF #0209 Pain Measure must be submitted no later than April 1, 2013.

The data collection period for both measures is October 1 – December 31, 2012.

Page 5 of 49

How:
•

Hospice providers will collect data for both measures October 1, 2012 – December 31, 2012.

•

Hospice providers will enter their data online and submit them to CMS using the data entry site.

The data entry site is not yet available for provider use.
The data entry site will go live for provider use on January 1, 2013.
For updates on data entry website location and availability, please check the “Spotlight and
Announcements” section of the CMS Hospice Quality Reporting Program website at:
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-QualityReporting/

•

Hospice providers may utilize vendors for their individual hospice provider data submission, but
CMS will not support batch submissions involving scripting or database imports for multiple
hospice providers from vendors.

Page 6 of 49

Import ant Information
Data Entry Site Availability:
This Data Collection User Guide will provide hospice providers with instruction only about
data collection for elements that will be required for CMS reporting.
THE DATA ENTRY WEBSITE IS NOT YET AVAILABLE FOR PROVIDER USE.
The site is scheduled to go live for provider use on January 1, 2013.
Availability of the data entry site along with a User Guide for Data Submission will be
announced on the “Spotlight and Announcements” section of the CMS HQRP site at:
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-QualityReporting/Spotlight.html
Frequently Asked Questions:
A Question + Answer document is available for provider download on the CMS HQRP website in
the “Spotlight and Announcements” section under “Downloads” at the bottom of the page. This
document contains frequently asked questions pertinent to FY 2014 Hospice Quality Reporting.
The document will be updated periodically as new questions are received at the Help Desk(s).
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-QualityReporting/Spotlight.html
Help Desk Contact Information:
There are two Help Desks to assist hospice providers with quality questions and technical issues:
1. Quality Help Desk: for issues pertaining to
• either of the required measures or
• reporting requirements, including who is required to report, hospices with multiple locations,
and/or CCN issues,
Please call or e-mail the Quality Help Desk at the following:
E-mail: HospiceQualityQuestions@cms.hhs.gov
Phone: 1-800-647-9670 (2 business day call-back service)
Hours: Monday – Friday 8:30 a.m. – 4:30 p.m. Eastern Time
*For quickest turnaround time with provider quality questions, please contact the Quality
Help Desk by e-mail.*
2.

Technical Help Desk: for technical website/data entry issues including
• finding the data entry site
• username/password issues
• website difficulty/error messages
Please call or e-mail the Technical Help Desk at the following:
E-mail: help@qtso.com
Phone: 1-877-201-4721
Hours: Monday – Friday 7:00 a.m. – 7:00 p.m. Central Time

Page 7 of 49

Section II:

The Structural Measure
Data Submission: January 1 – January 31, 2013

Page 8 of 49

Background
The structural measure is intended to indicate whether hospice providers include indicators specific to
patient care quality in their Quality Assessment and Performance Improvement (QAPI) programs.
Hospice providers shall provide information on these patient care-related quality indicators (QIs) by
selecting which patient care domains and topic areas they use. For the structural measure data submission,
hospice providers will answer three questions (Q1 – Q3).

•

Q1: First, providers will answer one Yes/No question related to the number of patient care-related
quality indicators (QIs) in their QAPI program.

•

Q2: Second, providers will indicate the domains of care the QIs in their QAPI program address.
Providers will use a checklist-style menu provided on the CMS data entry site to categorize QIs in
their QAPI program by domain and topic of care.

– The checklist on the data entry site was developed by CMS using data and experience from
the voluntary reporting period (October 1, 2011 – January 31, 2012), which provided a wealth
of information about the state of hospice providers’ QAPI programs and QIs. To make data
submission less burdensome for providers, CMS created a simplified web-based data
submission checklist-style menu that eliminated free-text descriptions of QIs. For Fiscal Year
(FY) 2014 reporting, hospice providers will use this checklist to enumerate types of QIs
included in their QAPI programs.

•

Q3: Third, hospice providers will indicate which data sources are used to collect data for QIs in
their QAPI program.

Hospice providers will complete and submit their answers to Q1 to Q3 to CMS no later than January 31,
2013. Please note, the primary objective of this structural measure is to provide CMS with the number,
type, and data source of all patient care-related QIs in your QAPI program; thus, the terms “data” and
“data collection” for structural measure reporting may be a misnomer given that hospice providers will
not report any numeric data for this measure.
Hospice providers will only be required to submit information on number, type, and data source of QIs
(Q1 – Q3 on the data entry site).
Hospice providers will NOT submit any information about individual QIs nor will they submit numeric
data or performance scores to CMS for the structural measure.

Page 9 of 49

Structural Measure Data Collection
October 1 – December 31, 2012
Data Collection Process. In order to have the necessary information to accurately answer Q1 to Q3,
providers will need to use the process outlined in Figure 1 and explained in further detail in the section
immediately following it. In general, hospice providers will need to complete the following steps in order
to have the necessary data to comply with reporting requirements:
1. Compile a list of all QIs in your QAPI program.
2. Determine whether each QI is eligible for inclusion in structural measure reporting.
3. For each eligible QI, select the appropriate domain and topic of care under which it falls.
4. Determine the data source for each eligible QI.
To facilitate this “data collection” process, hospice providers may complete Appendix A: Structural
Measure Worksheet in this User Guide. It is highly recommended that providers complete the Appendix
A worksheet; having a completed worksheet will expedite the data submission process once the data entry
site goes live on January 1, 2013. See Figure 1 below for additional details.

Page 10 of 49

Figure 1. 4-Step Process for Structural Measure Data Collection

Steps I to IV are explained in further detail in the following pages.

Page 11 of 49

Process for Structural Measure Data Collection
In order to have the necessary information to comply with structural measure reporting, it is
recommended that hospice providers complete Steps I to IV outlined below. Please note, some of the
steps below make use of Appendix A: Structural Measure Worksheet. Providers may wish to have a copy
of Appendix A readily available for completion. The Appendix A worksheet is formatted to match Q1 to
Q3 as they will appear on the data entry site, therefore it is highly recommended that providers
complete Appendix A prior to data entry site availability to facilitate the data entry process.
I.

Compile a complete listing of all Quality Indicators (QIs) in your hospice
organization’s QAPI program.

Before hospice providers can begin data submission for the structural measure, each provider will need to
know information about all QIs in their QAPI program. Having a complete list of all QIs will facilitate
this process.
II. Determine eligibility of each QI for inclusion in structural measure reporting using the
three criteria outlined below.
For each QI, hospice providers will need to determine whether the indicator is eligible for inclusion in
structural measure reporting. In order to include a QI for structural measure reporting, it must meet three
basic criteria, listed and detailed below. If you answer no to any of the following three questions, the
QI should not be included in structural measure reporting.
Criterion 1. Is this a quality indicator? If you answer “yes,” proceed to Criterion 2, below. If you
answer “no,” this indicator is not eligible for inclusion in structural measure reporting.
A quality indicator is defined as a metric used to track quality of care. It should be clearly
defined and measureable.

•

Example: Patient care goals, such as “all patients will be free of pain” are NOT quality indicators
because they are goals, as opposed to clearly defined and measureable indicators. Alternatively,
an example of a good quality indicator would be “percent of patients that are screened for pain
within 48 hours of admission.”

Criterion 2. Is this quality indicator patient care-related? If you answer “yes,” proceed to Criterion 3,
below. If you answer “no,” this indicator is not eligible for inclusion in structural measure reporting.
Patient care-related indicators include patient care domains such as management of physical or
psychosocial symptoms, or patient preferences. They might also address topics such as care
coordination, patient safety, or medication errors.

•

Patient care-related quality indicators may address topics such as

– symptom management (e.g., pain, dyspnea, nausea, anxiety, depression);

Page 12 of 49

– care coordination, such as management of transitions or communication between staff and
with other providers;

– patient safety, such as falls, medication errors, or infections; and
– care provision in accordance with documented patient/family preferences, such as presence of
documentation of advance directives or surrogate decision makers.

•

Examples of patient care-related indicators include

– percent of patients screened for pain during the initial assessment;
– percent of patients receiving opioids who have a bowel regimen established;
– percent of respondents who reported they feel confident they know what to do to take care of
the patient;

– percent of respondents who reported that they received enough instruction from the hospice
team regarding patient safety;

– number of medication errors per 1,000 patient days; and
– number of falls per 1,000 patient days.
•

Organizational or business-related quality indicators are NOT patient care-related. Such
indicators include

– staff turnover rates,
– patient contact hours,
– employee training,
– length of stay/service, and
– patient primary diagnosis.
These types of indicators are NOT patient care-related and should not be included in structural measure
reporting.
For additional information and examples of patient care-related indicators, please see Appendix B.
Criterion 3. Was this quality indicator in place between October 1 and December 31, 2012?
If you answer “yes,” proceed to Step III, below. If you answer “no,” this indicator is not eligible for
inclusion in structural measure reporting.
Do not include Quality Indicators that you stopped using before October 1, 2012, or any indicators
added to your QAPI program after December 31, 2012. Please note, an indicator could be “in
place” from October 1 – December 31, 2012 but not necessarily calculated during that time
frame. For example, if you have an indicator that you calculate annually at the end of each fiscal year
(September 30), that indicator could be “in place” and eligible for structural measure reporting,
despite the fact it was not calculated during the reporting period (October 1 – December 31, 2012).

Page 13 of 49

If you answer “yes” to all three preceding criteria, then your quality indicator is eligible for inclusion in
structural measure reporting. Hospice providers should tally a total count of all eligible QIs, because this
information will be used for structural measure reporting.

III. For each eligible QI, indicate the appropriate domain and topic of care it addresses
using Appendix A: Structural Measure Worksheet and/or Appendix B: List of
Domains, Subdomains, and Topic of Care with Examples.
Using the checklist provided in the “Q2 data” portion of the Appendix A: Structural Measure Worksheet,
providers should indicate the domain/topic of care each eligible QI addresses. The checklist was created
based on data received from over 900 hospice providers during the voluntary data submission period and
was designed to reflect domains of care included in QAPI programs, as reported by hospice providers.
More detailed instructions for completing the “Q2 data” portion of the Appendix A worksheet are
provided below.
1. Using the “Q2 data” portion of Appendix A, for each eligible QI, first identify the proper domain
and/or subdomain of care under which it falls. There are 10 primary domains of care; 3 domains
also have subdomains to make navigation of the checklist easier:
Primary Domains of Care
1. Patient Safety

2. Physical Symptom Management

Relevant Subdomains

•
•
•
•
•
•
•
•
•
•
•
•

Infections
Falls
Medication safety
Pressure ulcers/wounds
Oxygen safety
Patient safety or incidents, general
Patient/family ratings of care re: patient safety
Pain
Dyspnea
Nausea
Bowel management
Physical symptoms, other

3. Care Coordination and Transitions

N/A

4. Patient/Family Preferences

N/A

5. Communication/Education

N/A

Page 14 of 49

Primary Domains of Care

Relevant Subdomains

6. Patient/Family Experience/Ratings of Care
and/or Services

N/A

7. Spiritual

N/A

8. Structure and Process of Care

N/A
• Depression
• Anxiety
• Assessment and management of social support
• Assessment and management of psychosocial
distress
• Other psychosocial

9. Psychosocial

10. Grief, Bereavement, and Emotional Support

N/A

2. Under each domain and/or subdomain of care, there are corresponding topics of care, denoted
with a checkbox. Select the appropriate topic of care for each eligible QI.

•

If you are unsure under which domain/topic of care a particular QI falls, please use Appendix
B as a reference. It contains a listing of each domain, subdomain, and topic of care, along
with relevant examples for each topic. Relevant QI examples for each topic are in italics.

•

Please note, because each checkbox is intended to represent a topic area – not specific QIs in
your QAPI program – a single checkmark on the Appendix A worksheet may represent
more than one QI. This means the total number of checkmarks on your worksheet may not
correlate directly to the number of QIs in your QAPI program. Please do not check off
additional topics to make the number of checkmarks on your worksheet directly match the
number of QIs in your QAPI program.

– For example: if you have 1 or more indicators about pain symptom control/comfort,
select the topic box under the pain subdomain labeled “symptom control/comfort.”

▪

It is possible you may have more than one indicator for a topic area: for example, if
you have more than one indicator about pain control and comfort, check the box next
to that topic within the pain subdomain one time.

Page 15 of 49

IV. Determine data sources for the eligible QIs in your QAPI program.
After mapping each QI to the checklist, hospice providers will also need to know the data source for their
eligible QIs. Data sources include the following:

•

Electronic Medical Record (EMR): any computer-based system used to manage a patient’s
medical record. Systems may be purchased from EMR vendors or internally developed by
providers.

•

Paper Medical Record: a paper-based system used to manage a patient’s medical record.

•

Family survey/questionnaire: any survey or questionnaire (phone-, paper-, or electronic-based)
where the family or caregiver is asked about the hospice care process, including family/caregiver
report of the patient’s experience of care. Examples of family survey/questionnaires include the
Family Evaluation of Hospice Care (FEHC) Survey or other FEHC-like surveys. Family surveys
are usually taken after patient discharge.

•

Patient survey/questionnaire: any survey/questionnaire (phone-, paper-, or electronic-based)
where the patient is asked about his or her experience with the process of care. A requirement for
patient surveys is that the patient is asked to self-report on his/her experience with the care
process; any survey or questionnaire given after patient discharge is likely a family/caregiver
survey, not a patient survey/questionnaire.

•

Incident report/log: any log or report that tracks incidents or occurrences in a hospice
organization including, but not limited to, falls, injury, medication errors/adverse events,
infections, hospitalizations, and pressure ulcers/wounds. Incident reports/logs can track events
involving hospice patients or hospice employees.

Providers will record data sources for their eligible QIs in the “Q3 data” portion of the Appendix A
worksheet.

•

Please note, when completing the “Q3 data” portion of Appendix A, you are permitted to select
more than one data source. Each data source you will include is not intended to correspond to any
of your individual QIs. You should select a data source if you use that data source in the
calculation of at least one (or even part of one) QI.

– For example, if the data source for your pain management QIs is an Electronic Medical
Record and the source for your falls QI is an incident report or log, you would select the two
boxes on the online form for Electronic Medical Record (EMR) and Incident report/log.
If one QI is calculated from two data sources—for example, a pain measure that combines clinical outcome
(or pain scores, obtained from an electronic medical record) and patient/family satisfaction with pain
management (obtained from family survey/questionnaire)—select both data sources.

Page 16 of 49

After completing Steps I to IV, outlined above, the Appendix A worksheet will contain all of the
information necessary to complete the CMS data entry for the structural measure. Hospice providers
should retain the Appendix A worksheet to use during the data entry process.
Please note, the data entry site is not yet available for provider use.
The site is scheduled to go live for provider use on January 1, 2013.
This Guide is intended only to provide hospice providers with details on data collection processes
for these three questions. A Data Submission User Guide will be made available once the data
entry site is available for provider use. Data entry will consist of three questions (Q1 to Q3),
outlined in the following pages.

Page 17 of 49

Structural Measure Reporting
Data Submission: January 1 – January 31, 2013
The three questions for structural measure data submission, as they will appear on the data entry site, are
outlined below. Providers that used the Appendix A worksheet should have the worksheet available for
responding to Q1 to Q3.
THE DATA ENTRY SITE IS NOT YET AVAILABLE FOR PROVIDER USE.
The Data Entry Site is scheduled to go live for provider use on January 1, 2013.
Availability of the data entry site and a User Guide for Data Submission will be announced in the
“Spotlight and Announcements” section of the CMS Hospice Quality Reporting Program site at:
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-QualityReporting/Spotlight.html
For Hospice Providers with Multiple Locations:

•

Hospice providers will report data to CMS on a per-CCN basis.

– Hospice providers with multiple locations, sharing one CCN, should aggregate facilitylevel data from all locations so the data entered on the CMS data entry site represent data for
the single CCN.
Q1: Does your hospice have a Quality Assessment and Performance Improvement
(QAPI) program that includes three or more quality indicators (QIs) related to patient
care?
1. Select “yes” or “no” based on the structure and content of your hospice organization's QAPI
program.

•

Answer “Yes” if your hospice organization’s QAPI program included 3 or more patient carerelated quality indicators from October 1, 2012, to December 31, 2012.

•

Answer “No” if your hospice organization’s QAPI program included fewer than 3 patient carerelated quality indicators during the reporting period October 1, 2012, to December 31, 2012.

– If you used the Appendix A worksheet, enter the number you recorded in the “Q1 data”
section of the worksheet.
Q2: If your hospice’s QAPI program includes at least one patient care-related quality
indicator, include each indicator using the form provided below.
1. Select the appropriate topic box if you have at least one indicator in that topic area.

•

For example: if you have 1 or more indicators about pain symptom control/comfort, select the
topic box under the pain subdomain labeled “symptom control/comfort.”

– It is possible you may have more than one indicator for a topic area: for example, if you have
more than one indicator about pain control and comfort, check the box next to that topic
within the pain subdomain one time.

Page 18 of 49

•

If you feel that one of your QAPI indicators could fit into more than one topic box, read the
explanation and examples in Appendix B to see if one domain “fits” better than another.

– It does not matter which topic box you use to represent the indicator. To avoid double
counting of quality indicators, please choose only one topic box. Do not also enter it under
the other domain/topic.
Please note: Because a single selection on the form can represent more than one quality indicator, the
total number of selections on the online form may not directly correspond to the number of quality
indicators in your hospice organization’s QAPI program. Please do not select extra topic boxes to
make the number of checkmarks equal the number of quality indicators in your hospice organization’s
QAPI program.

•

This list should reflect your QAPI indicators from October 1, 2012 to December 31, 2012.

– Do NOT include quality indicators that you stopped using before October 1, 2012, or any
quality indicators that became part of your QAPI program after December 31, 2012.
If you used the Appendix A worksheet, use the checklist you completed in the “Q2 data” portion of the
worksheet to complete Q2 on the data entry site.
Q3: Please indicate the data source(s) for your QAPI indicators. Check all that apply.
1. If you entered any indicators into the checklist in Q2, select any data sources used to calculate
your hospice organization’s patient care-related quality indicators. Choices for data sources
include the following:

•
•
•
•
•

Electronic Medical Record (EMR)
Paper medical record
Family survey/questionnaire
Patient survey/questionnaire
Incident report/log

For Q3 you are permitted to select more than one answer. Please note, the answers you will include in
Q3 are not intended to correspond to any of your individual QAPI indicators. You should select a data
source if you use that data source in the calculation of at least one (or even part of one) QAPI
indicator.
If you completed the Appendix A worksheet, use the completed checklist in the “Q3 data” portion of the
worksheet to complete Q3 on the data entry site.

Page 19 of 49

Section III:

NQF #0209 – Pain Measure
Data Collection: October 1, 2012 – December 31, 2012
Data Submission: January 1, 2013 – April 1, 2013

Page 20 of 49

Background
The NQF #0209 Pain Measure was re-endorsed by the National Quality Forum (NQF) in February 2012.
It measures the percentage of patients who report being uncomfortable because of pain at the initial
assessment (after admission to hospice) who report that pain was brought to a comfortable level within 48
hours. By implementing this measure, hospice providers are able to determine what percentage of their
patient population is admitted with pain and how well that pain is managed in the early days of hospice
care. This measure is particularly significant to hospice care as it addresses a basic aspect of hospice
practice—pain management—and ensures integration of patient choice for desired level of treatment with
the care process by incorporating the patient’s own pain goals and perception of his or her own degree of
comfort. Because the measure incorporates both patient preference and measure outcomes, it is useful and
meaningful for consumers, providers, and payers.

For measure specifications and details, please visit NQF:
http://www.qualityforum.org/MeasureDetails.aspx?actid=0&SubmissionId=457#k=0209. Additional
details about how to use/implement this measure are available from the measure steward, National
Hospice and Palliative Care Organization (NHPCO):
http://www.nhpco.org/i4a/pages/Index.cfm?pageID=3376.

Page 21 of 49

Implementing the NQF #0209 Pain Measure in
Your Hospice Organization
Data Collection: October 1, 2012 – December 31, 2012
In order to submit data for the NQF #0209 Pain Measure for the purposes of the CMS Hospice Quality
Reporting Program (HQRP), hospice providers will generate and record NQF #0209 Measure data on all
admissions from October 1 to December 31, 2012 (fourth quarter of 2012). Details on the data that are
required for collection in order to comply with CMS specifications are outlined later in this section,
beginning with “Step One: Generate.”
After the data collection period ends on December 31, 2012, the data submission phase will begin. The
NQF #0209 data submission phase will be January 1, 2013, to April 1, 2013. During this time, hospice
providers will retrieve all of their NQF #0209 data that were collected during the fourth quarter of 2012,
aggregate them, and report the seven data elements to CMS no later than April 1, 2013. The seven data
elements are discussed later in this section, in NQF #0209 Measure Reporting.
As previously stated, the NQF #0209 Pain Measure calculates the percentage of patients who report being
uncomfortable because of pain at the initial assessment (after admission to hospice services) who report
that pain was bought to a comfortable level within 48 hours. Data for the measure are generated by asking
patients two comfort questions:

•

The initial comfort question “Are you uncomfortable because of pain?” is asked at the time of
initial assessment

•

The follow-up comfort question “Was your pain brought to a comfortable level within 48 hours
of the start of hospice care?” is asked within 48 to 72 hours after initial pain assessment.

To comply with CMS requirements, these two questions will be asked (and responses documented) for all
admissions from October 1 to December 31, 2012.
Measure Implementation. In order to have the necessary data elements to calculate the measure and
comply with reporting requirements, hospice providers will need to implement the measure using the
three broad steps outlined in Figure 2 below. The steps are

•

Generate: collecting the necessary data

•

Record: recording collected data

•

Retrieve and Report: retrieving collected data, aggregating it, and submitting to CMS

Page 22 of 49

Figure 2. Steps for implementing the NQF #0209 Pain Measure

Detailed instructions for how to fully complete each of the three implementation steps
(Generate, Record, and Retrieve & Report) are outlined in the following pages.

Page 23 of 49

Step 1. Generate:

Collecting the data
October 1, 2012 – December 31, 2012
In order for hospice providers to generate the necessary data and comply with CMS reporting
requirements, providers should complete the following steps (Steps 1 to 3, below) for each admission,
October 1 to December 31, 2012. Please note, in addition to following the steps outlined below,
hospice providers will also need to know the total number of admissions from October 1 to
December 31, 2012, in order to comply with reporting requirements.
Which patients are eligible for NQF #0209 measure reporting?
For the purposes of CMS NQF #0209 reporting, “all admissions” is defined as “all patients who
are new to your hospice or readmitted to your hospice after an interruption in service provision
from October 1 – December 26*, 2012.” Any patient that fits the above definition of a “new”
admission should be considered for inclusion in the NQF #0209 measure. Patients who are
transferred from another hospice provider to your hospice organization should also be considered
for inclusion in the measure.
Additionally, all payers (Medicare, Medicaid, and private payers) are eligible for measure
reporting, as are all hospice settings (inpatient, home care, and nursing home hospice patients).
*Please note: in order to allow providers the full window to ask the follow-up comfort question
by then end of the data collection period (11:59 PM on December 31, 2012), a patient must be
admitted no later than 11:59 PM on December 26, 2012 to be included in NQF #0209 Measure
Reporting for this reporting period.
To generate the necessary data for NQF #0209 measure reporting, hospice providers should collect
measure data using the following steps:
1. Determine NQF #0209 measure eligibility. At the initial nursing assessment, determine whether
patient is eligible for measure inclusion by answering the following questions:

•

Is the patient able to communicate and understand the language of the person asking the
question?

– Please note, if a qualified interpreter is being used and the patient is able to relay his or
her answer to the comfort question(s) through the interpreter, this is enough to surmount
the language barrier and the patient should be included in the measure if the following
two conditions are met.

•

Is the patient able to self-report?

•

Is the patient 18 years of age or older?

If you answer “no” to any of the three preceding questions, the patient should not be included in
the measure.
2. Ask the initial comfort question. If you answered “yes” to all three preceding questions, at the
initial nursing assessment, prior to pain assessment and initiation of any interventions, ask the
question “Are you uncomfortable because of pain?”

•

This question will generate the data that will be included in the measure denominator.

Page 24 of 49

•

Remember: you cannot interpret a patient’s nonverbal response based on observation or use
the response of any other person such as a staff or family member (excluding the use of
qualified interpreters) to substitute as a self-report answer to this question.

•

This question should be asked during the initial nursing assessment and it is this question that
will trigger the 48-hour comfort “countdown.” In other words, the 48-hour time frame for
the measure should reflect the 48-hour period following the initial nursing assessment,
not the admission to hospice, if these two events occurred at different times.

3. Ask the follow-up comfort question. After asking the initial comfort question, contact the patient
48 to 72 hours after initial pain assessment and ask the follow-up question “Was your pain
brought to a comfortable level within 48 hours?”

•

This question will generate the data that will be included in the measure numerator (the top
portion of the fraction).

– Please note: this question will only be asked of patients who answered “yes” to the
initial comfort question. If a patient was originally excluded from the measure or
answered “no” to the initial comfort question, do not ask the follow-up question for
the measure.

•

As above, you cannot interpret a patient’s nonverbal response or use the response of any
other person as a substitute for patient self-report (excluding the use of qualified interpreters).

•

If at the time you ask the follow-up question, the patient is no longer able to self-report,
document the reason; these patients will be excluded from the numerator. Reasons include

– Discharge (live or due to death)
– Condition deteriorated—patient no longer able to communicate/self-report
– Other (with explanation)
•

Hospice providers must contact the patient at some point between 48 to 72 hours after the
initial assessment to ask the follow-up question.

– The follow-up question cannot be asked earlier than 48 hours after the initial assessment
•

Hospices should make every effort to contact the patient sometime between 48 and 72 hours
after the initial pain assessment to ask the measure follow-up question. At times it may not be
possible to contact the patient within the 48–72-hour time frame (e.g., the patient is sleeping
and the family caregiver asks that the hospice call back later). Therefore, the 48–72 hour time
frame can be defined as 2–3 days. Given this time frame, hospices should ask patients the
follow-up question by midnight of the third day. So, the follow-up question could be asked
anytime on the third day (i.e., time frame for including patient response in the measure does
not “close” at 3 pm of the third day, but extends to midnight of the third day).

Page 25 of 49

To be able to have the necessary data to comply with the CMS requirement, hospice providers should
complete “Data Generation” steps 1 to 3 on all admissions from October 1, 2012 to December 31, 2012.
If you are already using the NQF #0209 Pain Measure in your QAPI program, verify that your data
collection process is in compliance with CMS #0209 Measure reporting requirements to submit your
aggregate, facility-level fourth-quarter seven data elements (specified in the Retrieving and Reporting the
data section below) to CMS.
Some Important Notes and Frequently Asked Questions for Generating NQF #0209 Data:
Data collection for the NQF #0209 Measure is to be based only on the measure specifications set
forth above.

•

•

Hospice providers can exclude patients from the measure only for reasons set forth in the
measure specifications. These reasons are as follows: denominator exclusions—language
barrier, unable to self-report, less than 18 years of age; numerator exclusions—discharge (live
or due to death), condition deterioration/patient no longer able to communicate/self-report,
other with explanation.
– A hospice provider cannot exclude a patient from the measure for reasons such as
these:
▪ Patient states he/she is uncomfortable because of pain, but refuses intervention.
▪ Patient states he/she is uncomfortable because of chronic pain (pain he/she may have
had for years before admission to hospice), not terminal pain (pain related to terminal
illness/diagnosis).
▪ Patient diagnosis.
The NQF #0209 Pain Measure is not a substitute for good pain management
practices/protocols. Measure specifications should not dictate how a hospice provider
manages a patient’s pain.
– The follow-up comfort question should not be asked prior to 48 hours.
▪ A hospice provider may follow up with a patient before the 48- to 72-hour mark; this
is good pain management practice, but whatever questions the hospice provider asks
of the patient at these interim follow-ups and any data recorded at these interim
follow-ups should not be included in measure calculation.

Step 2. Record:

Recording the data
October 1, 2012 – December 31, 2012
Concurrent with data collection/generation, hospice providers will need to document or record their data.
Providers should document the answers to initial and follow-up comfort questions and/or any exclusions
in the patient chart, measure worksheet, or initial assessment form. Recording the data will occur in two
main steps (see below). For CMS measure reporting, data recording should take place on all admissions
from October 1 to December 31, 2012.
1. Record the denominator.

•

Document patient response to question “Are you uncomfortable because of pain?” OR

Page 26 of 49

•

Document reason for not meeting eligibility requirements—these patients will be
denominator-based exclusions and will not be eligible for inclusion in the measure at all.
Reasons for not meeting eligibility requirements are as follows:

– Unable to self-report
– Less than 18 years of age
– Language barrier
•

Providers must record either patient response to the initial question OR the reason for not
meeting eligibility requirements; otherwise, data for that patient will be considered “missing”
and will not count towards any of the seven data elements

2. Record the numerator.

•

Document patient response to question “Was your pain brought to a comfortable level within
48 hours?” OR

•

Document reason for inability to self-report—these patients will be numerator-based
exclusions. Reasons include the following:

– Discharge (live or due to death)
– Condition deteriorated/no longer able to communicate
– Other (with explanation)
•

Providers must record either patient response to the follow-up question OR the reason for
inability to self-report; otherwise, data for that patient will be considered “missing” and will
not count towards any of the seven data elements

In order to have the necessary data to comply with the CMS requirements for NQF #0209 data
submission, hospice providers should record these data on all admissions from October 1, 2012, to
December 31, 2012.

Step 3. Retrieve and Report: Aggregating and submitting the data
January 1, 2013 – April 1, 2013
After the measure implementation and data collection phase ends on December 31, 2012, hospice
providers will enter the reporting and submission phase, which spans January 1, 2013 to April 1, 2013.
During this time, hospice providers will retrieve data collected in the fourth quarter of 2012, aggregate
them, and submit the seven data elements to CMS no later than April 1, 2013. Hospice providers will
submit seven pieces (elements) of numerical data to CMS for the NQF #0209 Pain Measure. CMS will
use these elements to calculate the NQF #0209 measure. Please note, hospice providers will not submit
the actual NQF #0209 Pain Measure percentage/hospice score. Although hospice providers can and
should calculate this percentage on their own for internal quality improvement purposes, the actual final
score will not be submitted by hospice providers to CMS. The hospice-level NQF #0209 score will be
automatically calculated for each hospice provider on the NQF #0209 CMS data entry site web page.

Page 27 of 49

Figure 3, below, details which questions in the data collection process correspond to the seven CMS data
elements. The seven data elements and how they will appear for submission on the CMS data entry site
are detailed in the pages following Figure 3.
Figure 3. NQF #0209 Data Collection Process

Page 28 of 49

NQF #0209 Measure Reporting
Data Submission January 1 – April 1, 2013
The seven data elements for NQF #0209 data submission, as they will appear on the data entry site, are
outlined beginning on the next page. Please see below for some important notes about NQF #0209 data
submission.

For Hospices Already Collecting the NQF #0209 Pain Measure Prior to October 1,
2012:
•

Please report the measure only as it is specified by NQF. If your hospice organization modifies
the measure in any way for internal purposes, including but not limited to

– collecting the measure on all patients, regardless of age or ability to self-report
– asking the follow-up comfort question outside of the 48- to 72-hour window,
•

please remember to collect data so that you can report the seven data elements to CMS as they are
specified above.

•

Please note, if you already submit NQF #0209 Pain Measure data to NHPCO, you must also
submit the seven reportable elements to CMS. NHPCO does not submit the seven elements to
CMS on your behalf. Hospice providers may choose to submit their NQF #0209 data to both
NHPCO and CMS.

For Hospice Providers with Multiple Locations:
•

Hospice providers will report data to CMS on a per-CCN basis.

– Hospice providers with multiple locations, sharing one CCN, should aggregate facilitylevel data from all locations so the data entered on the CMS data entry site represent data for
the single CCN.

THE DATA ENTRY SITE IS NOT YET AVAILABLE FOR PROVIDER USE.
The Data Entry Site is scheduled to go live for provider use on January 1, 2013.
Availability of the data entry site and a User Guide for Data Submission
will be announced in the “Spotlight and Announcements” section of the
CMS Hospice Quality Reporting Program site at:
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-QualityReporting/Spotlight.html

Page 29 of 49

To facilitate the NQF #0209 data entry/submission process, providers may wish to complete Appendix C:
NQF #0209 Data Submission Worksheet. The Appendix C worksheet is formatted to match Data Elements
1 – 7 as they will appear on the Data Entry Website. Therefore, it is highly recommended that providers
complete Appendix C prior to Data Entry Site availability to facilitate the data entry process. Providers
may wish to have a copy of Appendix C available for completion.
In order to allow providers the full window to ask the follow-up comfort question by then end of the data
collection period (11:59 PM on December 31, 2012), a patient must be admitted no later than 11:59 PM
on December 26, 2012 to be included in NQF #0209 Measure Reporting for this reporting period.

Data Element 1.
Enter the number of admissions during the data collection period (October 1, 2012 through
December 26, 2012)

•

Hospice providers should enter the total number of admissions from October 1 to December 26,
2012.

•

Providers should answer Data Elements 2-7 based on the patients included in the total number of
admissions for Data Element 1.

Data Element 2.
Pain Measure Denominator: Enter the number of patients who answered YES to the question
“Are you uncomfortable because of pain?” at the initial assessment (after admission to hospice
services) during the data collection period .

•

Include only the number of “yes” responses you generated and recorded in your patient records,
initial assessment forms, or on measure worksheets

Data Element 3.
Enter the number of patients who answered NO to the question “Are you uncomfortable
because of pain?” at initial assessment (after admission to hospice services) during the data
collection period

•

Include only the number of “no” responses you generated and recorded in your patient records or
on measure worksheets

Data Element 4.
Enter the number of patients excluded.

•

This data element is the number of patients who were determined ineligible for the measure (or
denominator/entire measure exclusions) at the initial nursing assessment because they were

– less than 18 years of age
– unable to self-report
– there was a language barrier
•

Data Element 4 counts should include only patients for whom data about age, self-report, or
language barrier were recorded.

•

Include only the number of exclusions you generated and recorded in your patient records or on
measure worksheets.

Page 30 of 49

Missing data for Data Elements 2, 3, or 4:

•

If no recorded documentation (“recorded documentation” including only a Yes/No answer to the
initial comfort question OR a documented reason that the patient was ineligible for the measure)
can be found, data for this patient are considered “missing.” Patients with “missing data” will not
be reported to CMS; these patients should not be counted towards Data Elements 2, 3, and/or 4.

– NOTE: Hospice organizations are encouraged to record missing data for internal quality
improvement purposes

Data Element 5.
Pain Measure Numerator: Enter the number of patients who answered YES to the follow-up
question “Was your pain brought to a comfortable level within 48 hours of the start of hospice
care?” during the data collection period.

•

Only include the number of “Yes” responses you generated and recorded in your patient records
or on measure worksheets.

Data Element 6.
Enter the number of patients who answered NO to the follow-up question “Was your pain
brought to a comfortable level within 48 hours of the start of hospice care?” during the data
collection period.

•

Include only the number of “no” responses you generated and recorded in your patient records or
on measure worksheets.

Data Element 7.
Enter the number of patients unable to self-report at follow-up.

•

This number will match the number of patients who were unable to self-report at follow-up (or
numerator exclusions) because they were

– discharged (live or due to death)
– condition deteriorated and patient is no longer able to communicate
– other (with explanation)
•

Data Element 7 counts should include only patients for whom data about inability to self-report at
follow-up (due to discharge, condition deterioration, or other with explanation) were recorded.

•

Include only the number of responses you generated and recorded in your patient records or on
measure worksheets.

Missing data for Data Elements 5, 6, and 7:

•

If no recorded documentation (“recorded documentation” including only a Yes/No answer to the
follow-up comfort question OR a documented reason why the patient was unable to self-report at
follow-up) can be found, data for this patient are considered “missing.” Patients with “missing
data” will not be reported to CMS; these patients should be counted towards Data Elements 5, 6,
and/or 7.

– NOTE: Hospice providers are encouraged to record missing data for internal quality
improvement purposes.

Page 31 of 49

Please note, only the seven data elements above are to be submitted to CMS for the NQF #0209 Pain
Measure. Your score will be automatically calculated for you and displayed based on the data you enter
into the website. Please feel free to write down your hospice organization’s facility-level Pain Measure
score for use in internal quality improvement initiatives. The NQF #0209 Measure facility-level score that
will displayed on the data entry site is calculated using the following fraction (Figure 4, below).
Figure 4. Fraction used in NQF#0209 Measure Calculation

Page 32 of 49

Section IV:

Appendices

Page 33 of 49

Appendix A: Structural Measure Worksheet

Appendix A: Structural Measure Worksheet
Q1 Data:
Q1: Does your hospice have a Quality Assessment and Performance Improvement (QAPI)
program that includes three or more quality indicators (QIs) related to patient care?
Enter the total number of eligible QIs in your QAPI program here:
________________________________.
This number will be used to answer Q1 on the structural measure portion of the data entry website.
Q2 Data:
Q2: If your hospice’s QAPI program includes at least one patient care-related quality indicator,
include each indicator using the form provided below.
Use the checklist, below, to indicate under which domain/topic of care each eligible QI falls. If you are
unsure under which domain/topic of care a particular QI falls, please use Appendix B as a reference.
Appendix B contains a listing of each domain, subdomain, and topic, including relevant examples.
Relevant QI examples for each topic are in italics.
The completed checklist will be used to answer Q2 on the structural measure portion of the data entry
site. The checklist below is structured exactly as it will appear on the data entry site.

Checklist of Quality Indicator Domains, Subdomains, and Topics
Domain 1: Patient Safety
Subdomain 1: Infections
Topics:
□ Infections – incidence/prevalence
□ Infections -treatment
□ Infections - other
Subdomain 2: Falls
Topics:
□ Falls – incidence/prevalence
□ Falls – risk screening/assessment
□ Falls – interventions
□ Falls prevention education
□ Falls – patient/family ratings
□ Falls - Other
Subdomain 3: Medication Safety
Topics:
□ Medication Error – incidence
□ Medication Adverse Events – incidence
□ Medication reconciliation and/or comprehensive medication review

Page 34 of 49

Appendix A: Structural Measure Worksheet

□
□
□

Medication patient/family education
Medication patient/family ratings
Medication - other

Subdomain 4: Pressure Ulcers/Wounds
Topics:
□ Pressure ulcers/wounds incidence/prevalence
□ Pressure ulcers – screening/risk assessment
□ Pressure ulcers prevention/intervention
□ Pressure ulcers/wounds - other
Subdomain 5: Oxygen Safety
Topics:
□ Oxygen Safety – risk assessment
□ Oxygen Safety – patient/family education
□ Oxygen Safety - other
Subdomain 6: Patient Safety or Incidents – general
Topics:
□ Tracking Incidents – broadly
□ Safety assessment/family education/interventions
Subdomain 7: Patient/Family Ratings of Care Regarding Patient Safety
Topics:
□ Patient/family ratings of patient safety
□ Patient/family ratings of instruction education about patient
Domain 2: Physical Symptom Management
Subdomain 1: Pain
Topics:
□ Screening
□ Assessment
□ Interventions/treatment
□ Symptom control/comfort
□ Management/control/comfort in last 1-2 weeks of life
□ Patient/family education
□ Patient/family experience/ratings of care
Subdomain 2: Dyspnea
Topics:
□ Screening
□ Assessment
□ Interventions/treatment
□ Symptom control/comfort
□ Management/control/comfort in last 1-2 weeks of life
□ Patient/family education
□ Patient/family experience/ratings of care
Subdomain 3: Nausea
Topics:
□ Screening
□ Assessment
□ Interventions/treatment
□ Symptom Control/comfort

Page 35 of 49

Appendix A: Structural Measure Worksheet

□
□
□

Management/control/comfort in last 1-2 weeks of life
Patient/family education
Patient/family experience/ratings of care

Subdomain 4: Bowel management
Topics:
□ Screening
□ Assessment
□ Interventions/treatment
□ Symptom Control/comfort
□ Management/control/comfort in last 1-2 weeks of life
□ Patient/family education
□ Patient/family experience/ratings of care
Subdomain 5: Physical Symptoms – Other
Topics:
□ Other
Domain 3: Care Coordination and transitions
Topics :
□ Care coordination among hospice care professionals
□ Care coordination between hospice and other professional care providers or settings
□ Transitions to other care settings
□ Transitions from other care settings
□ Family ratings of care coordination/transitions
□ Care coordination/transitions - other
Domain 4: Patient/family preferences
Topics:
□ Advance Directives/surrogate designation
□ Documenting patient/family preferences and goals of care
□ Meeting patient/family preferences and goals of care
Domain 5: Communication and Education
Topics:
□ Communication with patient/family regarding hospice care broadly
□ Family ratings of communication
□ Family education/communication about the dying process
□ Family/caregiver confidence
□ Family education about managing symptoms
□ Family education about equipment use
□ Family education about safety
□ Family education about Advance Directives/surrogate designation
Domain 6: Patient/Family Experience/Ratings of Care and/or Services
Topics:
□ Overall ratings/willingness to recommend
□ Patient personal care needs met
□ Respectful treatment
□ Improved comfort/well-being/quality of life
□ Evening/weekend on-call service
□ Volunteer Services
□ Family ratings of disciplines providing care

Page 36 of 49

Appendix A: Structural Measure Worksheet

Domain 7: Spiritual
Topics:
□ Screening/assessment/management of spiritual needs/issues
□ Patient/family experience/ratings of spiritual care
□ Spiritual care – other
Domain 8: Psychosocial
Subdomain 1: Depression
Topics:
□ Depression screening
□ Depression assessment
□ Depression interventions/treatment
□ Symptom control/comfort
□ Depression management/control/comfort in last 1-2 weeks of life
□ Patient/family education
□ Patient/family experience/ratings of care
Subdomain 2: Anxiety
Topics:
□ Anxiety screening
□ Anxiety assessment
□ Anxiety treatment/intervention
□ Symptom control/comfort
□ Anxiety management/control/comfort in last 1-2 weeks of life
□ Patient/family education
□ Anxiety patient/family experience/ratings of care
Subdomain 3: Assessment and management of social support
Topics:
□ Assessment and management of social support
Subdomain 4: Assessment and management of psychosocial distress
Topics:
□ Assessment and management of psychosocial distress
Subdomain 5: Other psychosocial
Topics:
□ Other psychosocial
Domain 9: Structure and Process of Care
Topics:
□ Visit frequency
□ Volunteer services
□ Other structures and processes of care
Domain 10: Grief, Bereavement, and Emotional Support
Topics:
□ Grief and bereavement assessment and care
□ Emotional care for patient/family before and/or at time of death
□ Emotional care for family after the death
□ Culturally sensitive caregiving

Page 37 of 49

Appendix A: Structural Measure Worksheet

Q3 Data:
Q3: Please indicate the data source(s) for your QAPI indicators. Check all that apply.
Use the data source checklist below to indicate the data sources used to collect eligible QIs in your
organization’s QAPI program. Providers may wish to use the instructions on pages 16-17 of the Guide to
facilitate completion of the data sources checklist.
•

The completed data source checklist will be used to answer Q3 on the structural measure portion
of the data entry site.

Data Source Checklist
(Check all that apply.)

□
□
□
□
□

Electronic Medical Record (EMR)
Paper medical record
Family survey/questionnaire
Patient survey/questionnaire
Incident report/log

Page 38 of 49

Appendix B: List of Quality Indicator Domains, Subdomains, and Topics with Examples

Appendix B: List of Quality Indicator Domains,
Subdomains, and Topics with Examples
Providers may use this checklist as a reference for completing the “Q2 Data” portion of the Appendix
A worksheet.
Domain 1: Patient Safety
Sub-domain 1: Infections
Topics:
□ Infections – incidence/prevalence*
Example: Includes Catheter-Associated Urinary Tract Infection (CAUTI),
Central Line-Associated Bloodstream Infection (CLABSI), Urinary Tract Infection (UTI),
nosocomial infections, employee infection surveillance, vascular device infections,
wound/pressure ulcer infections.
□ Infections – treatment
Example: Includes indicators that track use of antibiotics, and other aspects of appropriate
management of infections.
□ Infections – other
Subdomain 2: Falls
Topics:
□ Falls – incidence/prevalence
Example: Indicators tracking number of falls (e.g., falls with injury per 1,000 patient days).
□ Falls – risk screening/assessment
Example: Percent of patients with falls risk screening or comprehensive falls assessment.
□ Falls – interventions
Example: Percent of patients with plan of care (POC) that includes interventions to mitigate
falls risk.
□ Falls prevention education
Example: Indicators tracking falls prevention education for patient/family/caregivers.
□ Falls – patient/family ratings
Example: Indicators that capture ratings of safety related to falls.
□ Falls – Other
Subdomain 3: Medication Safety
Topics:
□ Medication error – incidence
Example: Indicators tracking number of medication errors/variances (e.g., medication errors
per 1,000 patient days).
□ Medication adverse events – incidence
Example: Indicators tracking number of adverse events (e.g., adverse drug reactions).
□ Medication reconciliation and/or comprehensive medication review
Example: Indicators tracking medication reconciliation/medication review processes of care
(e.g., percent of patients who had a comprehensive medication review on admission as well as
time of recertification).
□ Medication – patient/family education
Example: Indicators tracking patient/family education re: safe administration of medications,
general review of the medication regimen, use of comfort pack, proper disposal of medications.

Page 39 of 49

Appendix B: List of Quality Indicator Domains, Subdomains, and Topics with Examples

□
□

Medication patient/family ratings
Example: Indicators tracking patient /family ratings of pharmacy, pharmacy team, timeliness of
meds, etc.
Medication – other

Subdomain 4: Pressure Ulcers/Wounds
Topics:
□ Pressure ulcers/wounds – incidence/prevalence
Example: Indicators tracking the number of wounds and/or pressure ulcers (e.g., potentially
avoidable event: wounds per 1,000 patient days).
□ Pressure ulcers – screening/risk assessment
Example: Patients who were screened for integumentary risk factors.
□ Pressure ulcers prevention/intervention
Example: Percentage of admissions in which the plan of care includes pressure ulcer
prevention intervention.
□ Pressure ulcers/wounds – other
Subdomain 5: Oxygen Safety
Topics:
□ Oxygen safety – risk assessment
Example: Indicators tracking the completion of fire hazard/oxygen safety risk screening or
assessment.
□ Oxygen safety – patient/family education
Example: Indicators tracking patient/family education re: safe use of oxygen equipment in the
home, risk reduction, etc.
□ Oxygen safety – other
Subdomain 6: Patient Safety or Incidents – General
Topics:
□ Tracking incidents – broadly
Example: Indicators tracking patient safety and other incidents (e.g., PEACE measure tracking
various incidents per 100 patient days: falls, complaints, Durable Medical Equipment (DME)
issues, medication errors) not covered under other topics above.
□ Safety assessment/family education/interventions
Example: Indicators tracking completion of screenings/assessments/education and other
interventions aimed at improving safety (e.g., percent of patients with comprehensive safety
assessment) not covered under other topics above.
Subdomain 7: Patient/Family Ratings of Care Regarding Patient Safety
Topics:
□ Patient/family ratings of patient safety
Example: Family rating on how well hospice improved the overall safety of the patient.
□ Patient/family ratings of instruction education about patient
Example: Percentage of families who reported that they received enough instruction from the
hospice team regarding patient safety.
Domain 2: Physical Symptom Management
Subdomain 1: Pain
Topics:
□ Screening
Example: Screening for presence/absence and/or severity of symptom.

Page 40 of 49

Appendix B: List of Quality Indicator Domains, Subdomains, and Topics with Examples

□
□
□
□
□
□

Assessment
Example: Comprehensive assessment of symptom; includes assessment of patient
preferences/goals re: management of the symptom.
Interventions/treatment
Example: Indicators tracking the initiation of treatment (e.g., interventions started within
certain timeframe of screening or assessment) or other aspects of treatment and interventions
to relieve symptom.
Symptom control/comfort
Example: Indicators of improvement in the symptom following intervention (e.g., indicators of
symptom control, comfort).
Management/control/comfort in last 1-2 weeks of life
Example: Indicators of level of symptoms and management in the last 1-2 weeks of life.
Patient/family education
Example: Indicators related to completing patient/family education related to symptom
management. Does not include patient/family ratings of education.
Patient/family experience/ratings of care
Example: Indicators of patient and/or family ratings of amount of care, quality of care, amount
of relief from symptoms.

Subdomain 2: Dyspnea
Topics:
□ Screening
Example: Screening for presence/absence and/or severity of symptom.
□ Assessment
Example: Comprehensive assessment of symptom; includes assessment of patient
preferences/goals re: management of the symptom.
□ Interventions/treatment
Example: Indicators tracking the initiation of treatment (e.g., interventions started within
certain timeframe of screening or assessment) or other aspects of treatment and interventions
to relieve symptom.
□ Symptom control/comfort
Example: Indicators of improvement in the symptom following intervention (e.g., indicators of
symptom control, comfort).
□ Management/control/comfort in last 1-2 weeks of life
Example: Indicators of level of symptoms and management in the last 1-2 weeks of life.
□ Patient/family education
Example: Indicators related to completing patient/family education related to symptom
management. Does not include patient/family ratings of education.
□ Patient/family experience/ratings of care
Example: Indicators of patient and/or family ratings of amount of care, quality of care, amount
of relief from symptoms, adequacy of education provided.
Subdomain 3: Nausea
Topics:
□ Screening
Example: Screening for presence/absence and/or severity of symptom.
□ Assessment
Example: Comprehensive assessment of symptom; includes assessment of patient
preferences/goals re: management of the symptom.
□ Interventions/treatment

Page 41 of 49

Appendix B: List of Quality Indicator Domains, Subdomains, and Topics with Examples

□
□
□
□

Example: Indicators tracking the initiation of treatment (e.g., interventions started within
certain timeframe of screening or assessment) or other aspects of treatment and interventions
to relieve symptom.
Symptom control/comfort
Example: Indicators of improvement in the symptom following intervention (e.g., indicators of
symptom control, comfort).
Management/control/comfort in last 1-2 weeks of life
Example: Indicators of level of symptoms and management in the last 1-2 weeks of life.
Patient/family education
Example: Indicators related to completing patient/family education related to symptom
management. Does not include patient/family ratings of education.
Patient/family experience/ratings of care
Example: Indicators of patient and/or family ratings of amount of care, quality of care, amount
of relief from symptoms, adequacy of education provided.

Subdomain 4: Bowel Management
Topics:
□ Screening
Example: Screening for presence/absence and/or severity of symptoms including constipation,
diarrhea, constipation in the presence of opioids.
□ Assessment
Example: Comprehensive assessment of symptom; includes assessment of patient
preferences/goals re: management of the symptom. Includes indicators tracking of bowel
movement frequency.
□ Interventions/treatment for patients on opioids
Example: Indicators tracking the initiation of treatment (e.g., interventions started within
certain timeframe of screening or assessment) or other aspects of treatment and interventions
to relieve symptom (e.g., bowel regimen initiated for patients receiving opioids).
□ Interventions/treatment for patients NOT on opioids
Example: Indicators tracking the initiation of treatment (e.g., interventions started within
certain timeframe of screening or assessment) or other aspects of treatment and interventions
to relieve symptom for patients NOT on opioids.
□ Symptom control/comfort
Example: Indicators of improvement in the symptom following intervention (e.g., indicators of
symptom control, comfort).
□ Management/control/comfort in last 1-2 weeks of life
Example: Indicators of level of symptoms and management in the last 1-2 weeks of life.
□ Patient/family education
Example: Indicators related to completing patient/family education related to symptom
management. Does not include patient/family ratings of education.
□ Patient/family experience/ratings of care
Example: Indicators of patient and/or family ratings of amount of care, quality of care, amount
of relief from symptoms, adequacy of education provided.
Subdomain 5: Physical Symptoms – Other
Topics:
□ Other
Example: Indicators related to screening, assessment, interventions/treatment and
management/control/comfort of other physical symptoms not covered elsewhere (for example,
wounds, dietary/nutrition/weight, fatigue).

Page 42 of 49

Appendix B: List of Quality Indicator Domains, Subdomains, and Topics with Examples

Domain 3: Care Coordination and Transitions
Topics:
□ Care coordination among hospice care professionals
Example: Communication/care coordination within the hospice, including interdisciplinary
team (IDT) members, etc.
□ Care coordination between hospice and other professional care providers or settings
Example: Communication/care coordination between hospice and NH staff, physicians,
pharmacy, labs and lab result, other. Does NOT include communication with family.
□ Transitions to other care settings
Example: Hospitalization, emergency room use.
□ Transitions from other care settings
Example: Timeliness from referral to admission/initiation of care.
□ Family ratings of care coordination/transitions
Example: Includes ratings of timeliness of equipment delivery, appropriateness of equipment,
etc.
□ Care coordination/transitions – other
Domain 4: Patient/Family Preferences
Topics:
□ Advance Directives/surrogate designation
Example: Indicators tracking discussions about or documentation of Physician Orders for LifeSustaining Treatment (POLST), Do Not Resuscitate (DNR)/ Do Not Intubate (DNI), living will,
preference for place of death, hospitalization, Cardiopulmonary Resuscitation (CPR), and
other advance directives. Does not include whether or not preferences were met.
□ Documenting patient/family preferences and goals of care
Example: Indicators tracking discussions about or documentation of clinically oriented
preferences, such as preferences for pain control vs. sedation, use of antibiotics in presence of
infection, etc.
□ Meeting patient/family preferences and goals of care
Example: Indicators tracking the extent to which stated preferences were met; includes whether
or not preferences for hospitalization, place of death, and goals of care were met.
Domain 5: Communication and Education
Includes communication with and education delivered to patient/family/caregivers.
Topics:
□ Communication with patient/family regarding hospice care broadly
Example: Indicators tracking communication about POC, patient's condition, Patient Bill of
Rights, who to contact, what to do afterhours. Also includes use of interpreter when needed.
□ Family ratings of communication
Example: Indicators of family ratings of how well the hospice communicated with them about
the patient and other aspects of hospice care.
□ Family education/communication about the dying process
Example: Indicators tracking whether hospice provided information and education about the
dying process, and how well prepared or confident the family/caregiver felt.
□ Family/caregiver confidence
Example: Family/caregiver confidence with providing care, about what to expect or do at the
time of death, or other aspects of caregiving.
□ Family education about managing symptoms
□ Family Education about equipment use

Page 43 of 49

Appendix B: List of Quality Indicator Domains, Subdomains, and Topics with Examples

□
□

Family Education about safety
Family education about Advance Directives/surrogate designation

Domain 6: Patient/Family Experience/Ratings of Care and/or Services
Topics:
□ Overall ratings/willingness to recommend
Example: Indicators tracking overall ratings/satisfaction with hospice care and/or services
(e.g., G1 and G3 from Family Evaluation of Hospice Care (FEHC), FEHC Composite, other
overall ratings obtained from family surveys).
□ Patient personal care needs met
Example: Indicators tracking whether personal care needs were met (e.g., C1 from FEHC or
other similar).
□ Respectful treatment
Example: Indicators tracking family perception of hospice care being respectful and/or
culturally sensitive (e.g., C2 from FEHC , and other indicators related to respectful and
culturally sensitive care).
□ Improved comfort/wellbeing/quality of life
Example: Indicators tracking family perception of hospice care with respect to improving
overall wellbeing, comfort, quality of life.
□ Evening/weekend on-call service
Example: Indicators tracking family ratings of evening/weekend/on-call service availability,
quality, responsiveness (e.g., G2 from FEHC and other indicators about evening/weekend/oncall service or care).
□ Volunteer Services
Example: Family ratings about amount and quality of volunteer services.
□ Family ratings of disciplines providing care
Example: Family ratings of quality or satisfaction with care or services provided by any and all
disciplines (e.g., nursing care, aide care, social work care).
Domain 7: Spiritual
Topics:
□ Screening/assessment/management of spiritual needs/issues
Example: Indicators tracking assessment and management of spiritual needs/issues. Includes
indicators related to timely assessment, appropriate interventions.
□ Patient/family experience/ratings of spiritual care
Example: Indicators tracking patient/family ratings of quality and/or quantity of spiritual care
(e.g., percent who had as much spiritual or religious contact as they wanted E2 on the FEHC
survey and other similar indicators).
□ Spiritual care – other
Domain 8: Psychosocial
Subdomain 1: Depression
Topics
□ Depression screening
Example: Screening for presence/absence and/or severity of symptom.
□ Depression assessment
Example: comprehensive assessment of symptom; includes assessment of patient
preferences/goals re: management of the symptom.

Page 44 of 49

Appendix B: List of Quality Indicator Domains, Subdomains, and Topics with Examples

□
□
□
□
□

Depression interventions/treatment
Example: Indicators tracking the initiation of treatment (e.g., interventions started within
certain timeframe of screening or assessment) or other aspects of treatment and interventions
to relieve symptom.
Symptom control/comfort
Example: Indicators of improvement in the symptom following intervention (e.g., indicators of
symptom control, comfort).
Depression management/control/comfort in last 1-2 weeks of life
Example: Indicators of level of symptoms and management in the last 1-2 weeks of life.
Patient/family education
Example: Indicators related to completing patient/family education related to symptom
management. Does not include patient/family ratings of education.
Patient/family experience/ratings of care
Example: Indicators of patient and/or family ratings of amount of care, quality of care, amount
of relief from symptoms, and adequacy of education provided.

Subdomain 2: Anxiety
Topics:
□ Anxiety screening
Example: Screening for presence/absence and/or severity of symptom.
□ Anxiety assessment
Example: Comprehensive assessment of symptom. Includes assessment of patient
preferences/goals re: management of the symptom.
□ Anxiety treatment/intervention
Example: Indicators tracking the initiation of treatment (e.g., interventions started within
certain timeframe of screening or assessment) or other aspects of treatment and interventions
to relieve symptom.
□ Symptom control/comfort
Example: Indicators of improvement in the symptom following intervention (e.g., indicators of
symptom control, comfort).
□ Anxiety management/control/comfort in last 1-2 weeks of life
Example: Indicators of level of symptoms and management in the last 1-2 weeks of life.
□ Patient/family education
Example: Indicators related to completing patient/family education related to symptom
management. Does not include patient/family ratings of education.
□ Anxiety patient/family experience/ratings of care
Example: Indicators of patient and/or family ratings of amount of care, quality of care, amount
of relief from symptoms.
Subdomain 3: Assessment and management of social support
Topics:
□ Assessment and management of social support
Example: Assessment and management of caregiver and other social supports.
Subdomain 4: Assessment and management of psychosocial distress
Topics:
□ Assessment and management of psychosocial distress
Example: Assessment and management of psychosocial distress.
Subdomain 5: Other psychosocial
Topics:
□ Other psychosocial

Page 45 of 49

Appendix B: List of Quality Indicator Domains, Subdomains, and Topics with Examples

Domain 9: Structure and Process of Care
Includes indicators tracking structures and processes of care, such as availability of certain services or
professionals and meeting internal or external policies or requirements.
Topics:
□ Visit frequency
Example: indicators tracking frequency of visits, variances in frequency versus predicted
frequency for example.
□ Volunteer services
Example: Indicators tracking utilization of/number of care hours provided by volunteers.
Excludes ratings of volunteer services.
□ Other structures and processes of care
Example: Indicators of meeting internal or external policies or requirements. Includes
indicators such as PEACE measure: comprehensive assessment in 5 days, IDT POC completed,
physical and psychological symptoms screening on initial assessment, supervision of aides.
Domain 10: Grief, Bereavement, and Emotional Support
Topics:
□ Grief and bereavement assessment and care
Example: Indicators tracking completion of bereavement assessment, anticipatory grief
assessment, grief assessment, family ratings of grief and bereavement care.
□ Emotional care for patient/family before and/or at time of death
Example: Indicators tracking provision of emotional care for the patient and/or family before
and/or at the time of death. Includes family ratings of the quality and quantity of emotional
care.
□ Emotional care for family after the death
Example: Indicators tracking provision of emotional care for the patient and/or family after the
time of death. Includes family ratings of the quality and quantity of emotional care.
□ Culturally sensitive caregiving
Example: Family ratings of the degree to which bereavement, grief, and emotional care was
culturally sensitive.

Page 46 of 49

Appendix C: NQF #0209 Measure Worksheet

Appendix C: NQF #0209 Measure Worksheet
This worksheet contains the seven data elements as they will appear on the CMS data entry website. For
further instructions on filling in answers to the seven data elements listed below, please see section NQF
#0209 Measure Reporting in this User Guide.
In order to allow providers the full window to ask the follow-up comfort question by then end of the data
collection period (11:59 PM on December 31, 2012), a patient must be admitted no later than 11:59 PM
on December 26, 2012 to be included in NQF #0209 Measure Reporting for this reporting period.
Data Element 1.
Enter the number of admissions during the data collection period (October 1, 2012 through
December 26, 2012). Providers should answer Data Elements 2-7 based on the patients included in
the total number of admissions for Data Element 1.
____________________________________
Data Element 2.
Pain Measure Denominator: Enter the number of patients who answered YES to the question
“Are you uncomfortable because of pain?” at the initial assessment (after admission to hospice
services) during the data collection period.
______________________________________
Data Element 3.
Enter the number of patients who answered NO to the question “Are you uncomfortable
because of pain?” at initial assessment (after admission to hospice services) during the data
collection period .
___________________________________________

Data Element 4.
Enter the number of patients excluded.
_______________________________________
Data Element 5.
Pain Measure Numerator: Enter the number of patients who answered YES to the follow-up
question “Was your pain brought to a comfortable level within 48 hours of the start of hospice
care?” during the data collection period.
________________________________________
Data Element 6.
Enter the number of patients who answered NO to the follow-up question “Was your pain
brought to a comfortable level within 48 hours of the start of hospice care?” during the data
collection period.
_____________________________________________

Data Element 7.
Enter the number of patients unable to self-report at follow-up.
_____________________________________________

Page 47 of 49

Appendix D: Glossary

Appendix D: Glossary
Term

CCN
Denominator
Electronic Medical
Record
Family survey/
questionnaire

Incident report/log

Look-back period
(data collection
period)
NQF #0209
Measure
Numerator
Paper Medical
Record
Patient care-related
Quality Indicator

Patient survey/
questionnaire

QAPI program

Quality Indicator
(QI)
Structural Measure

Definition
CMS Certification Number, also known as the Medicare provider number. This is a 6-digit
number, usually in the format: xx-xxxx.
The number in the bottom part of a fraction; represents the total population in terms of which
statistical values are expressed.
Any computer-based system used to manage a patient’s medical record. Systems may be
purchased from EMR vendors or internally developed by hospice providers.
Any survey or questionnaire (phone-, paper-, or electronic-based) where the family or
caregiver is asked about the hospice care process including family/caregiver report of the
patient’s experience of care. Examples of family survey/questionnaires include the Family
Evaluation of Hospice Care (FEHC) or other FEHC-like surveys. Family surveys are usually
taken after patient discharge.
Any log or report that tracks incidents or occurrences in a hospice organization, including, but
not limited to, falls, injury, medication errors/adverse events, infections, hospitalizations, and
pressure ulcers/wounds. Incident reports/logs can track events involving hospice patients or
hospice employees.
The timeframe in which data for a quality measure is collected. For both the Structural
Measure and the NQF #0209 Pain Measure, the look-back period is October 1, 2012 –
December 31, 2012.
The NQF #0209 Pain Measure reflects the number of patients who report being
uncomfortable because of pain at the initial assessment (after admission to hospice services)
who report that pain was brought to a comfortable level within 48 hours.
The number in the top portion of a fraction; represents a subset of the entire population in
terms of which statistical values are expressed.
A paper-based system used to manage a patient’s medical record.

Quality Indicators that include patient care domains such as management of physical or
physiological symptoms. They might also address care coordination, transitions,
communication with the patient and family, or patient safety issues like falls and medication
errors. Patient care-related indicators do NOT address organizational or business goals.
Any survey/questionnaire (phone-, paper-, or electronic-based) where the patient is asked
about his or her experience with the process of care. A requirement for patient surveys is that
the patient is asked to self-report on his/her experience with the care process; any survey or
questionnaire given after patient discharge is likely a family/caregiver survey, not a patient
survey/questionnaire.
A CMS Condition of Participation (CoP) that requires hospice providers to develop,
implement, and maintain an effective, ongoing, hospice-wide data-driven quality assessment
and performance improvement (QAPI) program. The hospice organization's governing body
must ensure that the program reflects the complexity of its organization and services; involves
all hospice services (including those services furnished under contract or arrangement);
focuses on indicators related to improved palliative outcomes; and takes actions to
demonstrate improvement in hospice performance. The hospice provider must maintain
documentary evidence of its quality assessment and performance improvement program and
be able to demonstrate its operation to CMS. For more details about the QAPI program CoP
please see: http://www.ecfr.gpoaccess.gov/cgi/t/text/textidx?c=ecfr&sid=818258235647b14d2961ad30fa3e68e6&rgn=div5&view=text&node=42:3.0.
1.1.5&idno=42#42:3.0.1.1.5.3.3.4.
A metric used to track quality of care. It should be clearly defined and measureable. Data for
quality indicators may come from a variety of data sources including paper or electronic
medical records, patient or family surveys/questionnaires, and/or incident reports/logs.
The Structural Measure provides CMS with details about the number and types of patient care
quality indicators currently being used by hospice providers in their QAPI programs.

Page 48 of 49

Appendix E: Quality Reporting Timeline

Appendix E: Quality Reporting Timeline
2012:
October 2012

November 2012

December 2012

• Data collection and recording
for NQF #0209 Pain Measure
begins 10/1/12.
• “Data collection” for structural
measure begins 10/1/12 – for
structural measure data
collection, providers should
complete Appendix A
worksheet.

• Data collection and recording
for NQF #0209 Pain Measure
• Complete structural measure
“data collection” by
completing the Appendix A
worksheet.

• Data collection and recording
for NQF #0209 Pain measure
ends 12/31/12.
• Complete structural measure
“data collection” by
completing the Appendix A
worksheet.

February 2013

March 2013

2013:
January 2013
• 1/1/13 – data entry site opens
for provider use/data
submission.
• Measure submission for
structural measure due to CMS
no later than 1/31/12.
• NQF #0209 Pain Measure
aggregation and data
submission.

• NQF #0209 Pain Measure
aggregation and data
submission.

• NQF #0209 Pain Measure
aggregation and final data
submission to CMS no later
than April 1, 2013.

Page 49 of 49