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User Guide for
Hospice Quality Reporting
Data Entry Site
User Guide for use in Voluntary Reporting cycle:
Data Collection from October 1, 2011 – December 31, 2011
Data Submission January 2012
This User Guide is considered a draft until OMB approval of the data submission
is received.
Table of Contents
I.
Introduction: Explanation of Data Collection ................................................................................................ 3
a. Purpose ......................................................................................................................................................... 3
b. Who, What, When & How ...................................................................................................................... 4
c. How to Access and use web Entry System ..................................................................................... 4
d. How to Submit Data for Non‐Web Users ......................................................................................... 5
II. Getting Started: How to Create Your Account ............................................................................................. 6
III. Completing the Web‐based Data Entry Form ............................................................................................... 9
a. Section 1: Facility Provider Information ......................................................................................... 9
b. Section 2: Contact Information ......................................................................................................... 10
c. Section 3: QAPI Program Information ........................................................................................... 12
Question 1: Do you have a QAPI program? .............................................................................. 12
Question 2: How many indicators are included in your QAPI program? .................... 13
Question 3: List the indicators in your QAPI program ....................................................... 14
Question 4: How much time did this take? .............................................................................. 18
IV. Frequently Asked Questions (FAQs) .............................................................................................................. 19
Help Desk:
A Help Desk will be staffed during regular EST business hours November 1, 2011 to January
31, 2012. Should you have any questions or technical difficulties, please contact the Help
Desk by calling 1‐800‐647‐9670 or sending an e‐mail to help.hospicequality@rti.org.
Quality Reporting Data Entry Website:
To access the Data Entry website for the Voluntary Reporting Period, please visit CMS’s
homepage for LTCH‐IRF‐Hospice Quality Reporting at https://www.cms.gov/LTCH‐IRF‐
Hospice‐Quality‐Reporting . From here, click on the “Hospice Quality Reporting” link located
on the left sidebar of the webpage. On the bottom of this next page under “Related Links
Outside CMS,” you will find the hyperlink to access the “Hospice Quality Reporting Data Entry
Site” homepage. Once on the Data Entry Site homepage, it might be helpful to bookmark this
page directly for easy future access.
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I.
Introduction: Explanation of Data Collection
a. Purpose:
CMS finalized a voluntary quality reporting period for hospices to precede the mandatory
quality reporting for the FY 2014 payment determination as set forth in Section 1814(i)(5) of the
Affordable Care Act for Hospice Programs. For the voluntary reporting, hospices may report one
structural measure collected from October 1, 2011 through December 31, 2011. The structural
measure hospices may report for the voluntary reporting cycle is: Participation in a Quality
Assessment and Performance Improvement (QAPI) Program that Includes at Least Three Quality
Indicators Related to Patient Care.
Data submitted during the voluntary reporting period will not affect any annual payment
updates. Submission of data collected during this timeframe will serve only to inform the future
development of the quality reporting program. Data submitted during this voluntary period will be
aggregated prior to being shared with CMS. Therefore, CMS will not have access to identifiable
hospice data. Voluntary data collected will permit CMS to understand the current state of QAPI
programs in hospices across the nation in order to enhance the quality reporting program for
subsequent years.
IMPORTANT INFORMATION – PLEASE TAKE NOTE:
There will be a lag between the data entry period and the data submission period for the
voluntary reporting cycle. The Quality Reporting website will be active for data entry
beginning November 2011. However, you will not be able to submit data until the
submission periods opens in January 2012. Should you wish to enter data before the
submission period opens, please use the
function that appears at
the bottom of the webpage containing Q1 – Q4. This function will allow you to save data for
changes/additions at a later date, and to access saved data for submission in January. If you enter
button,
data before the submission period opens and do not hit the
all data entered in your current session will be lost and you will have to reenter the
data upon your next login. All data must be completed and submitted to CMS no later
than 11:59 pm EST January 31, 2012. However, please note, if you begin entering data into the
system before the submission window opens in January, the ‘Submit Response’ button will be
disabled. This means before January 2012, you will only be able to use the ‘Save without
Submitting’ button to save data and you will have to return to submit your data once the
submission period opens. If you have created a User Name and password through the Quality
Reporting site, a reminder email will be sent to you when the submission window opens.
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b. Who, What, When & How:
Each hospice may voluntarily complete the Hospice Quality Data Submission Form. If you
choose to participate in the voluntary reporting, you should:
•
•
•
•
•
Read the instructions carefully before completing each data field.
Visit the data collection form online to enter your responses:
https://www.cms.gov/LTCH‐IRF‐Hospice‐Quality‐Reporting .From this link, click the
“Hospice Quality Reporting” link, located on the left sidebar of the webpage. The link to
the data entry site (“Hospice Quality Reporting Data Entry Site”) is located under
“Related Links Outside CMS” at the bottom of the webpage.
Report whether or not during the timeframe from October 1, 2011 through December
31, 2011, you had a QAPI program that included at least three quality indicators related
to patient care for the voluntary reporting period.
List the patient care related quality indicators used in your hospice’s QAPI program
from October 1, 2011 through December 31, 2011.
You may enter your QAPI program information on the Hospice Quality Reporting Data
Entry Site beginning in November 2011. Enter and submit your data no later than
January 31, 2012.
c. How to access and use the web entry system:
The Hospice Quality Reporting data entry form can be found online by visiting CMS’s
homepage for LTCH‐IRF‐Hospice Quality Reporting at https://www.cms.gov/LTCH‐IRF‐Hospice‐
Quality‐Reporting . From here, click on the “Hospice Quality Reporting” link located in left sidebar.
On the bottom of this next page under “Related Links Outside CMS,” you will find the hyperlink to
access the “Hospice Quality Reporting Data Entry Site” homepage. Once on the Data Entry Site
homepage, it might be helpful to bookmark this page directly for quick and easy future access. You
are required to create a user account before entering any information about your hospice and QAPI
Program. Although you are able to save data entered on the site and return to it at a later date,
please remember your username and password if you wish to revisit the site to complete your
responses in multiple sessions. Also note, the window for data submission will not open until
January 2012. This means that if you complete your data entry in one sitting before the
window for data submission opens, you will still need to make note of your username and
password to log back into the site and submit your data. If you have created an account
through the quality reporting website, you will receive a reminder email notifying you that
the data submission window has opened and to log back into your account to submit your
saved data.
No specific browser is required to access the site, however you must have the cookies
feature enabled in order to visit the quality reporting website. If you try to access the site, a
message will pop up in your browser window if cookies are not enabled. Your browser should
prompt you with further instructions to enable cookies and access the quality reporting site.
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d. How to submit data for nonweb users:
If you are not able to access the web data submission form, please contact our Help Desk to
request an alternative method for data submission. You can reach the Help Desk by calling 1‐800‐
647‐9670 or sending an e‐mail to help.hospicequality@rti.org
Before you begin:
Before you begin the data entry process, please familiarize yourself with the kind of information
you will be asked to submit by reviewing this User Guide (screen shots provided in‐text will give
you specific details for each question). Outside of the general overview this manual can provide,
there are a few key pieces of information you will need to know before you begin your data
entry. If you do not know it already, it might be helpful to find this information beforehand and
have it written down for reference while entering your data on the Quality Reporting site. The
necessa
ry pieces of information are:
9 NPI Number
9 CMS Certification Number (CCN)
9 Details of your hospice’s QAPI program and the patient care‐related indicators you track.
You may cut and paste from a Word or Excel file if your hospice has an indicator list
prepared.
What to do if you Have Questions:
A Help Desk will be staffed during normal EST business hours November 1, 2011‐January 31,
2012. Should you have any questions or technical difficulties, please contact the Help Desk by
calling 1‐800‐647‐9670 or sending an e‐mail to help.hospicequality@rti.org. A hyperlink to both
the Help Desk and the User Guide also appears at the top left corner of each page on the Quality
Reporting Website.
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II. Getting Started: How to Create Your Account
1) Access the Quality Reporting homepage by typing or pasting https://www.cms.gov/LTCH‐
IRF‐Hospice‐Quality‐Reporting in your web browser’s address bar. Click on the “Hospice
Quality Reporting” link, located on the left sidebar of the webpage. The link to the Hospice
Quality Reporting Data Entry site is located under “Related Links Outside CMS” at the
bottom of the webpage. Once on the Data Entry site, it might be helpful to bookmark this
page directly for quick and easy future access.
2) If you are a new user, click on the ‘Register’ button, located above the Account Information
box on the Hospice Quality Reporting webpage. If you are a returning user, log in using the
user name and password you created in your initial session.
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3) Enter the information requested on the ‘Create A New Account’ page:
•
User Name – Create your own user name. Your username can be any length and any
combination of letters, numbers, or symbols. Usernames are not case‐sensitive.
•
Password – Create your own password. Passwords must be a minimum of 6
characters, but can be any combination of letters, numbers, or symbols. Passwords
are case‐sensitive.
•
Confirm Password – Re‐enter the password that you created.
•
Email – Please provide a valid e‐mail address where you currently receive e‐mail
messages. The Quality Reporting Team will use this email account to send updates
on data submission windows and data submission confirmations.
•
Security Question ‐ Create your own security question to be used if you forget your
password. Make sure it is something you can answer correctly in the future.
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•
Security Answer – Create an answer to your Security Question. Make sure it is
something that you will remember in the future if you forget your password. The
answer to your security question is not case‐sensitive.
4) Click ‘Register’ to create your account.
5) You will be taken to a screen that confirms your account was created. To proceed to the
data collection page, click the button that says ‘Continue.’
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III. Completing the WebBased Data Entry Form:
a. Section 1: Facility Provider Information
1) Enter the National Provider Identification number (NPI) and CMS Certification Number
(CCN) for your hospice in the first screen that appears after you log in. The NPI is a unique,
10‐digit number assigned to each health care provider. The CCN is a 6‐digit number,
formerly known as the Medicare Provider Number.
•
National Provider Identification (NPI) – Enter ten numerals only; no dashes, spaces,
or other characters.
•
CMS Certification Number (CCN) – Enter six numerals only; no dashes, spaces or other
characters.
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b. Section 2: Contact Information
¾ Enter the business contact information for your hospice. Also, please enter the personal
contact information of someone at your hospice that can, if necessary, answer questions the
Hospice Quality Reporting Team might have regarding data submitted by your hospice.
•
Hospice Provider’s Business Name – Enter the legal name of your hospice
organization.
•
Hospice Provider’s Mailing Address – Enter the mailing address of your hospice
organization.
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•
Hospice Provider’s Physical Address – Enter the physical address of your hospice
organization if this is different than the mailing address.
•
Hospice Provider’s Business Phone Number – Enter the phone number to reach your
hospice organization during weekdays 8:30 to 4:30. Numerals only, no dashes, spaces,
or other characters.
•
Contact Name – Enter the name of a contact person who will be able to answer
questions about data entered on this form. This may or may not be the individual who
completes the data entry form
•
Contact Phone – Enter the phone number of a contact for questions about this form.
Numerals only, no dashes, spaces, or other characters.
•
Contact Email – Enter the email address of a contact for questions about this form.
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c. Section 3: QAPI Program Information
Q1: Does your hospice have a QAPI program that includes three or more quality
indicators related to patient care?
¾ Answer ‘Yes’ if your hospice organization’s QAPI program includes 3 or more patient care‐
related quality indicators during the reporting period October 1, 2011 – December 31,
2011. Patient care‐related quality indicators include indicators that address topics such as:
o symptom management such as pain, dyspnea, nausea, anxiety, depression;
o care coordination such as management of transitions and communication between
staff and with other providers ;
o patient safety such as falls, medication errors, infections;
o care provision in accordance with documented patient/family preferences such as
presence of documentation of advance directives and surrogate decision makers
¾ Answer ‘No’ if your hospice organization’s QAPI program includes fewer than 3 patient care‐
related quality indicators during the reporting period October 1, 2011 – December 31, 2011.
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Q2: How many patient carerelated indicators are included in your hospice’s QAPI
program?
¾ Indicate the number of patient care‐related indicators your QAPI program includes. If you
select “0” as your response for Question 2, skip Question 3 and go directly to Question 4.
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Q3: List the indicators in your QAPI program
¾ All hospices with a QAPI program that includes at least one patient care‐related indicator
should list their indicators (up to 20) for Question 3.
¾ To begin listing the patient care‐related indicators in your QAPI program click the ‘Add New
Indicator’ button.
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¾ After you click the ‘Add New Indicator’ button, a new screen will appear with drop down
menus and text boxes to fill in information for the selected patient care‐related Indicator
Topic, Indicator Name, Indicator Description, Numerator, Denominator, and Data Source.
¾ Indicator Topic – Select from the drop‐down list the topic that best describes the QAPI
indicator.
¾ Indicator Name – Write in the full name of the indicator. You may cut and paste from a
Word or Excel file if you already have an indicator list prepared.
¾ Brief Description – Describe the indicator more completely. Include any information that
will help us understand what the indicator measures. This description should include the
type of score (e.g., percentage, proportion, number) and the target population and focus of
measurement.
¾ Numerator – The variable that is on the top part of the fraction that describes the process,
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condition, event, or outcome that satisfies the measure focus or intent.
¾ Denominator – The variable that is on the bottom part of the fraction that describes the
population evaluated by the individual measure. Please also specify any denominator
exclusions.
¾ Data Source – Select the data source for the indicator for the choices provided. Note that if
none of the choices apply, you can choose “Other”.
¾ After you have filled in each information field, click the ‘Save’ button. After you click ‘Save’, the
information just entered will be saved and converted into a table format on your web browser.
¾ From here, you can click ‘Add New Indicator’ to continue adding additional QAPI indicators or
you can edit/delete previously added indicators using the edit/delete buttons that now appear in
the table. After you enter your last QAPI indicator and add it to the table by clicking ‘Save,’
continue to Question 4.
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PLEASE NOTE:
¾ If you are entering data BEFORE the submission period opens in January 2012: Please note, at
this point in time you will only be able to enter and save data; you cannot submit any data
during this time. During this time frame, the ‘Submit Response’ button will be deactivated. Thus,
to save work you will only be able to use the ‘Save without Submitting’ button. You must click this
button before closing or logging out of your session or all data will be lost and you will have to
reenter data upon your next login. Even if you complete all information in all fields and save your
work, you will have to login again in January to submit your saved work to the Quality Reporting
database. Data entries will not be considered complete until you click ‘Submit Response’ in January.
If you have created a login through the data reporting website, you will receive an email in January
reminding you to submit any saved data to the Quality Reporting database.
¾ If you are entering data AFTER submission period opens in January 2012: Please note, you
have 2 options. You can complete all data entry in one session and click ‘Submit Response’ when
you are done. This will send your data to the database and your participation will be considered
complete. Alternatively, you can enter data in multiple sessions. To do this, you will use the ‘Save
without Submitting’ button. Return to the site as many times as you would like to edit existing data
or add new data. Until you are ready to submit, use the ‘Save without Submitting’ button before
each logout or your data will be lost. When you feel your data entry is complete, click the ‘Submit
Response’ button to send your data to the Quality Reporting database.
¾ If you use the ‘Save without submitting function’ please make sure to carefully review all data
you had entered in previous sessions before submitting your final data entry to the Quality
Reporting database. You will want to verify that no information has been lost or compromised
before submitting your data entry.
¾ All data must be submitted no later than 11:59 pm EST January 31, 2012. No late submissions
will be accepted. Once you submit your data, you will receive a confirmation email from the Quality
Reporting Team. Please keep a copy of this email for your records.
¾ You can make edits and revisions to already submitted data before 11:59 pm January 31,
2012. To make edits to your data, log back in to the system, and make any changes necessary. If
you are editing your QAPI indicators in Question 3, please make sure to click the ‘Update’
button that will appear beneath the text boxes to save your updated QAPI information. When
you are done with all your revisions, click the ‘Submit Response’ button. You will receive another
confirmation email to confirm your second data submission. Any and all changes must be made
before the deadline for submission on January 31, 2012. After this date you will be locked out of the
data entry system and will not be able to make changes/edits to your data.
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Q4: How much time did this take?
¾ Indicate the number of minutes it took you to complete the data collection form.
¾ At this point, please use either the ‘Save without Submitting’ button or the ‘Submit
Response’ button to either save your work and return to it at a later date or, if you feel your
data entry is complete, to submit your response. If you logout or close your browser
without first clicking one of these buttons, all data you have entered will be lost and you
will have to reenter your responses upon your next login.
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IV. Frequently Asked Questions (FAQs)
I.
Technical HowTo’s:
1) Q: Does it matter which web browser I use to access the data entry system?
A: No. While no specific browser is required to access the site, you must have the cookies
feature enabled in order to visit the quality reporting website. See the last paragraph of
page 4 for additional information about cookies. However, if the page is not loading
correctly, please try an alternate browser. Should the page still not load correctly, please
contact the Help Desk.
2) Q: Can I save my work if I want to come back to it another day or must I complete the
entire form at once?
A: Yes, you can save your work and return for another session to enter more information or
make changes. Use the ‘Save without Submitting’ button to save entered data and return to
it at a later date. This is the only button that will save your data for editing/additions in a
future session. Should you log out without clicking this button, data will be lost and you will
have to re‐enter data.
3) What’s the difference between ‘Save without Submitting’ and ‘Submit Response’?
A: You can ‘Save without Submitting’ if you’d like to return to the data entry site to add
more information later. You can click ‘Submit Response’ if you feel the information you
have entered is complete. This will send your data to the Quality Reporting database and
your participation will be considered complete. However, please note, if you begin entering
data into the system before the submission window opens in January, the ‘Submit Response’
button will be disabled. This means before January 2012, you will only be able to use the
‘Save without Submitting’ button to save data and you will have to return at a later date to
submit your data.
4) Q: Do I have to login from the same computer each time to access my hospice’s data?
A: No, you can log in to the web system from any computer and use the same account login
information.
5) Q: What if I forget my username/password?
A: You can click the ‘Forgot password?’ link next to the Log In button on the main page of
the web system. The system will then ask you your security question that was created upon
registration. If you answer your security question correctly, your password will be emailed
to the email address that was specified on registration. There is no ‘Forgot Username?’
function, so please make note of your username upon registering with the site. If you do
forget your username, please call the HelpDesk for assistance.
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6) Who can I contact if I need additional help/support or if I cannot access the website?
A: Contact the Help Desk at 1‐800‐647‐9670 or help.hospicequality@rti.org.
Alternatively, links to the User Guide will be placed throughout the web‐based form. These
links might prove especially useful should you be completing the data entry form during
non‐business hours.
II.
Data Entry Fields:
7) Q: What if I don’t have a CCN or NPI?
A: Please contact the Help Desk for further information if you do not have a CCN and/or NPI.
8) Q: Who should I list as the ‘Contact Name’ under ‘Facility Provider Information’?
A: The contact person should be someone who can answer questions about the responses
provided in the voluntary data collection. This may or may not be the individual who
completes the data entry form.
9) Q: What if I have fewer than 3 patientcare related QAPI indicators?
A: We want to hear from all hospices. As long as you have at least 1 QAPI indicator, you can
still complete all questions (Question 1 – Question 4) of the voluntary reporting data entry
form.
10) Q: What if I have no patientcare related QAPI indicators? Can I still participate in the
voluntary reporting period?
A: Yes, you can still submit data and participate in the voluntary reporting period. If you
have no QAPI indicators, you should respond and submit data for Questions 1, 2, and 4,
leaving question 3 blank.
11) Q: What is a patient carerelated indicator?
A: Patient care related quality indicators include indicators that address topics such as:
i. symptom management such as pain, dyspnea, nausea, anxiety, depression;
ii. care coordination such as management of transitions and communication
between staff and with other providers ;
iii. patient safety such as falls, medication errors, infections;
iv. care provision in accordance with documented patient/family preferences
such as presence of documentation of advance directives and surrogate
decision makers
12) Q: What if I have patient carerelated indicators but I don’t know the
numerator/denominator?
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A: The numerator and denominator can be left blank and the web system will still allow you
to submit your information.
13) Q: How many indicators can I list?
A: Although we expect most organizations will have 20 or fewer patient‐care related QAPI
indicators, you may add more than 20 if you wish. Alternatively, if you have more than 20
QAPI indicators, you could list only the 20 you feel best capture patient care‐related data for
your organization.
14) Q: What if the topic of my indicator is not listed in the drop down menu or fits under
more than 1 category in the drop down menu?
A: If the topic is not listed, please select ‘Other’ from the drop down menu. If the topic fits
more than one category, please select the option you think best reflects the indicator.
15) Q: What if data for calculation of my indicator is obtained from more than 1 source?
A: The drop down menu for data source under Question 3 will only allow you to choose one
data source. If data for the calculation of your indicator is obtained from more than 1
source, please choose the source that the majority of data is pulled from.
Submission Questions:
16) Q: Can I enter/save information before the submission period opens in January?
A: Yes, the system will save the data you have previously entered. You will receive a
reminder email once the submission period opens in January. At that point, you will be able
to submit your saved data.
17) Q: When should I submit my data?
A: You can enter data into the form and save it beginning in November 2011. You can
submit data once CMS indicates the data submission period is open, sometime in January
2012. CMS will post an announcement on their website informing hospices that the data
submission function is now available. Please check https://www.cms.gov/LTCH‐IRF‐
Hospice‐Quality‐Reporting for updates and announcements. If you have already created a
username/password through the quality reporting website, you will also receive a reminder
email once the period has opened.
18) Q: How will I know if my data has been received once submitted?
A: You will see a confirmation screen once your data has been submitted. You will also
receive a confirmation email. Please keep a copy of this email for your records.
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19) Q: Once I submit data, can I go back and make changes to what has been submitted?
A: If you submit your data before the submission window closes on January 31, 2012 you
will be able to login again to the system and make changes to your submission. See page 17
for instructions. However, once the window closes on January 31, 2012, you will no longer
have access to the system and, at this point, can no longer amend submitted data. Should you
need to change your submission after January 31, please contact the Help Desk for more
information.
20) Q: Who will read this/what will be done with my data?
A: Data submitted during the voluntary reporting period will not affect any annual payment
updates. Data submitted during this voluntary period will be aggregated prior to being
shared with CMS. Therefore, CMS will not have access to identifiable hospice data. Data
submitted during the voluntary reporting period will not affect any annual payment
updates. Submission of data collected during this timeframe will serve only to inform the
future development of the quality reporting program.
21) Q: Are there any consequences for not submitting data?
A: Submission of the data is voluntary. There are no consequences for not submitting data,
but we hope you will participate in this opportunity to help shape the future of Hospice
Quality Reporting.
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| File Type | application/pdf |
| File Title | User Guide for Hospice Quality Reporting Data Entry Site |
| Subject | User Guide for Hospice Quality Reporting Data Entry Site |
| Author | CMS |
| File Modified | 2011-10-27 |
| File Created | 2011-10-27 |