Timely & effective care
Process of care measures reported under the Hospital Inpatient Quality Reporting (IQR) and Outpatient Quality Reporting (OQR) programs
The measures of timely and effective care (also known as “process of care” measures) show
- The percentage of hospital patients who got treatments known to get the best results for certain common, serious medical conditions or surgical procedures.
- How quickly hospitals treat patients who come to the hospital with certain medical emergencies, and
- How well hospitals provide preventive services.
Where the information comes from
Most of the measures of timely and effective care come from the data that hospitals get from medical records of their eligible patients, following standards for abstracting and reporting the information. Data submissions include auditing procedures and edit checks to assess whether data submitted are consistent with CMS’s defined specifications. In addition, CMS validates the data submitted to provide assurance that the hospital, or its designated agent, can accurately abstract patient medical records and accurately submit data. Please refer to QualityNet for more information on the validation process for data submitted through the IQR- Opens in a new windowExit Disclaimer - Opens in a new window and OQR- Opens in a new windowExit Disclaimer - Opens in a new window programs, please refer to QualityNet.- Opens in a new windowExit Disclaimer - Opens in a new window
The Centers for Disease Control and Prevention (CDC)- Opens in a new window developed the measure for healthcare worker influenza vaccination. Hospitals submit healthcare worker vaccination data—based on employee health records and self-reported vaccination records—to CDC’s National Healthcare Safety Network- Opens in a new window.
Veterans Health Administration (VHA) data is abstracted using the External Peer Review Program (EPRP). Validation of VHA data is performed within the EPRP process, by VHA staff, and by The Joint Commission.
Department of Defense (DoD) data is collected from military hospitals. Clinical Quality Measures are reviewed and monitored through special clinical studies, Joint Commission facility reviews, and Health Plan performance oversight.
Who the measures apply to
Most of the measures of timely and effective care apply to any adult patients treated at hospitals participating in the IQR and OQR programs for whom the recommended treatments would be appropriate, including Medicare patients, Medicare managed care patients, and non-Medicare patients. Hospitals with a large number of discharges may provide data from a sample of eligible Medicare and non-Medicare patients, based on CMS sampling rules. For VHA hospitals, the measures apply to eligible adult patients treated at VHA hospitals in accordance with The Joint Commission guidelines.
The healthcare worker influenza vaccination measure tracks the number of healthcare workers who have received the flu vaccine each flu season. This measure applies to all facility employees, licensed independent practitioners, adult student/trainees and adult volunteers, and includes those employees who work in a hospital outpatient department.
For VA hospitals, healthcare worker influenza vaccination data is collected internally by the VA from employee health records. Facility level data is validated centrally by VHA’s program office.
The measures of timely and effective care and the healthcare worker influenza vaccination measure don't require risk adjustment, because patients and healthcare workers for whom the recommended treatment would not be appropriate aren't included in the calculations.
CMS doesn't perform tests of statistical significance in reporting the measures of timely and effective care. However, the information provided on the site enables the user to calculate confidence intervals for each reported measure, based on sample size. The smaller the sample size, the greater the difference in rates must be in order for that difference to be statistically meaningful. Large differences between individual hospitals’ rates may be significant, but small differences between hospitals are usually not significant.
Significance testing is not performed on the healthcare worker influenza vaccination measure because it's not appropriate to do so.