Is a quality reporting program the first step toward P4P?

Proposed Wage Index sets dates for required reports

[Editor's note: This is the first of a two-part series that looks at quality improvement programs in hospice. This month, the proposed requirements for hospice quality reporting are examined along with advice about how to prepare and examples of clinical quality indicators some hospices are using. Next month, non-clinical quality indicators and their importance to the overall quality program will be discussed.]

Although Quality Assessment and Performance Improvement (QAPI) programs have been part of the Hospice Conditions of Participation since 2008, hospice managers should review their programs now to see if they are ready to handle quality reporting requirements in the future.

The Proposed Hospice Wage Index for FY2012 addresses a number of items including the hospice cap calculation, face-to-face requirements, and a new requirement for quality reporting.

"Hospice is on the track toward linking reimbursement to performance," says Melanie Merriman, PhD, MBA, a hospice consultant in North Bay Village, FL. The good news is that the Centers for Medicare and Medicaid Services (CMS) recognizes the need for a multi-year implementation, she points out.

The initial measures, according to the proposed rule, are limited to a National Quality Forum (NQF)-endorsed measure on pain management [NQF #0209: The percentage of patients who were uncomfortable because of pain on admission to hospice whose pain was brought under control within 48 hours] and one structural measure related to participation in a Quality Assessment and Performance Improvement (QAPI) Program that includes at least three quality indicators related to patient care. CMS proposes that hospices report the structural measure, using a template provided by CMS, says Merriman.

According to the proposed rule, hospices that do not report the required quality data by January 2013 will see a 2% reduction in their market basket update for FY2014. "Although 2014 seems like a long time away, hospice managers must evaluate their programs now to ensure they can collect and report the data that may be required," says Merriman. Key dates to report data are:

• Jan. 31, 2013 — Report structural measures related to the QAPI program that is in place from October 2012 through December 2012.

• April 1, 2013 — Report data on pain management measure for patients seen between October 2012 through December 2012.

There is also a proposed option to voluntarily report the structural measure by Jan. 31, 2012. The data submitted on this date will not be used for public reporting or for payment determination. "I think it is important that hospices submit information about their QAPI program early because it will give CMS more information to use as plans for inclusion of other measures are made," says Liz Silva, vice president of hospice for Deyta, a quality improvement and satisfaction measurement company based in Louisville, KY. Information from the voluntary submissions will provide CMS with an overview of the type of data hospices are already collecting and will identify trends of the most common quality measures implemented throughout the industry. "Hospices have an opportunity to share their experience with CMS early in the program's development so it makes sense to voluntarily report."

Because hospice does not have a standardized data collection tool such as the OASIS form used in home health, most hospices are conducting retrospective benchmark or quality studies by reviewing medical records, points out Merriman. Even with electronic records, the data are not always collected consistently, or located in the same place in each chart, she says. "Hospice managers should begin now to ensure their data collection tools are designed well so the information can be easily retrieved."

"We don't know what additional measures will be added to the quality reporting program, but if the inconsistencies in documentation can be addressed now with revised forms to improve collection of data overall, the hospice should be able to adjust to whatever measures are added," says Merriman. "I think the pain management measure will be included, even if this is just the proposed rule," she adds.

The pain management measure will not be difficult for the staff at Visiting Nurse Services of New York (VNSNY) Hospice Care in New York, NY. "We've participated in the AIM Project and the pain management measure is one that we have focused upon," explains Patricia Vigilante, RN, CHPCA, MPA, director of quality management services for the hospice. "We've also used the NHPCO [National Hospice and Palliative Care Organization] performance measures, which also include pain management," she adds.

Staff education critical

The key to successfully capturing data is to develop and train staff members on the use of a consistent assessment or evaluation tool, suggests Vigilante. "For pain management we identified processes and tools that standardize the way we assess and document pain," she says. "We use the Edmonton Symptom Assessment Scale for evaluation of pain management and all staff members were trained on its use," she says.

Developing a QAPI program that can be implemented in about 50 hospices of all different sizes and locations is more complicated than focusing on one hospice, but it can be done, admits Karen Mikula, RN, BSN, CPHQ, senior director of quality initiatives at VITAS Innovative Hospice Care, Miami, FL. "We have a QAPI Dashboard that serves as our quality framework," she says. By identifying specific measures that all hospices will monitor, VITAS can not only provide each hospice with information about individual performance, but also can provide benchmark information so managers can evaluate their performance against others, she explains.

Because each of the hospices in her organization is accustomed to collecting data in a specific way, Mikula does not see a problem for them to submit information for a quality reporting program. For hospices that may not have developed their QAPI programs to the point that will be needed, she offers the following tips:

Make sure your QAPI program is solidly in place and that you are measuring quality indicators that are likely to be included in a quality reporting program.

At first, focus on indicators that reflect the hospice mission, such as pain management, patient safety issues such as falls, or family satisfaction, she suggests. Use AIM measures as well as NHPCO core measures as a guideline for indicators that are likely to be used by CMS.

Educate and involve your staff members in your QAPI program.

"Complying with the COP requirements related to QAPI doesn't mean just paper compliance," points out Mikula. "To be effective, QAPI has to be put into practice by every employee as they perform their jobs."

Develop a consistent method of data collection.

"This can be a challenge for a small program," admits Mikula. "If you are pulling your data manually, be sure your forms allow staff members to use the same language, in the same place, to perform the assessment." Knowing that the data are located in the same location in all records will speed up collection, she points out.

Assign responsibilities for performance improvement to one person.

"One person overseeing the day-to-day collection of information and reporting is ideal," says Mikula. While the general manager has the ultimate responsibility, VITAS does have a dedicated performance improvement position in almost all hospices, she says. "At some of our smaller sites, we have people serving dual roles of performance improvement and seeing some patients," she says.

While the majority of hospices are pulling data manually, regardless of whether they use paper or electronic records, Merriman anticipates a change. Once the measures are identified by CMS, hospices will need to revise their forms to collect the correct data, she suggests. Hospices that use electronic records with the capability to pull data for reports need to work with their vendors to make sure the data collected match CMS requirements, she adds.

At this point vendors don't have a way to capture real-time data for quality reports, admits Silva. "So many hospices customize their forms and the data they collect that we can't easily develop a way to generate reports," she says. Once CMS standardizes requirements, all vendors will be able to create the capability, she adds.

Overall, quality reporting can be a good thing for hospice, says Merriman. "It is all about improving patient care. This will be a tool that hospices can use to improve their services and learn best practices from others."


For more information about quality reporting, contact:

Martha Lasseter, MBA, CNPCA, Vice President of Compliance, Treasure Coast Hospice, 1201 SE Indian St., Stuart, FL 34997. Tel: (772) 403-4525; e-mail:

Melanie P. Merriman, PhD, MBA, Touchstone Consulting, 7511 Beachview Drive, North Bay Village, FL 33141. Tel: (305) 762-7966; fax: (305) 762-7191; e-mail:

Karen Mikula, RN, BSN, CPHQ, Senior Director of Quality Initiatives, VITAS Innovative Hospice Care, 100 South Biscayne Blvd., Suite 1300, Miami, FL 33131. Tel: (786) 318-5330; fax: (708) 478-5819; e-mail:

Liz Silva, Vice President of Hospice, Deyta, 7400 New LaGrange Road, Suite 200, Louisville, KY 40222. Tel: (781) 640-3767; fax: (502) 896-0718; e-mail:

Patricia Vigilante, RN, CHPCA, MPA, Director of Quality Management Services, VNSNY Hospice Care, 1250 Broadway, New York, NY 10001. Tel: (212) 609-1913; e-mail:


To see a copy of the Proposed Hospice Wage Index for FY2012, go to and select "Browse this and other dates," then select "May 9, 2011" and scroll down to "Centers for Medicare and Medicaid Services," and click on "Hospice Wage Index for FY2012."

The following resources can help a hospice manager or quality improvement director identify quality indicators that are appropriate for the agency, collect data, calculate measures, and develop interventions to improve quality of care.

Hospice AIM Toolkit. Go to and under the heading "Healthcare Providers," select "Hospice Provider Toolkit." Resources are free.

PEACE Project. Go to and select "Who we serve," then choose "Hospice" and click on "Hospice PEACE Project." Forms and tools are free.

National Hospice and Palliative Care Organization. Go to, select "Professional Resources" and choose "Hospice Statistics and Research." Select "End Result Outcomes Measure" to access data collection sheets for measurement of relief of pain within 48 hours of admission.

Florida Department of Elder Affairs. Go to, access a copy of the state's annual report of hospice outcomes, the data collection form, and information on the reporting program.