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centers for medicare and medicaid services Medicare Promoting Interoperability Program
Reminder: CMS Releases Hospital-Specific Results for CMS Patient Safety Indicator (PSI) Measures and the Severe Obstetric Complications Electronic Clinical Quality Measure (eCQM) that will be Publicly Reported in October 2024

This is a reminder that the Centers for Medicare & Medicaid Services (CMS) released hospital-specific results via the Hospital Quality Reporting (HQR) system [ https://hqr.cms.gov/hqrng/login ] for the CMS Patient Safety Indicator (PSI) measures and the Severe Obstetric Complications (ePC-07) Electronic Clinical Quality Measure (eCQM) that will be publicly reported in October 2024.

The CMS PSI results come in a Hospital-Specific Report (HSR) with an accompanying user guide with information about the contents of the HSR. The following measures are included in the CMS PSI reports:


* CMS PSI 04 – Death Rate Among Surgical Inpatients with Serious Treatable Complications
* CMS PSI 90 – Patient Safety and Adverse Events Composite, calculated based on the following component CMS PSIs:
* PSI 03 – Pressure Ulcer Rate
* PSI 06 – Iatrogenic Pneumothorax Rate
* PSI 08 – In-Hospital Fall-Associated Fracture Rate
* PSI 09 – Postoperative Hemorrhage or Hematoma Rate
* PSI 10 – Postoperative Acute Kidney Injury Requiring Dialysis Rate
* PSI 11 – Postoperative Respiratory Failure Rate
* PSI 12 – Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate
* PSI 13 – Postoperative Sepsis Rate
* PSI 14 – Postoperative Wound Dehiscence Rate
* PSI 15 – Abdominopelvic Accidental Puncture or Laceration Rate

The ePC-07 results come with an accompanying discharge-level comma-separated values (CSV) file and a user guide with information about the contents of the discharge-level CSV file. The ePC-07 measure includes two outcomes:


* Severe obstetric complications
* Severe obstetric complications excluding delivery hospitalizations for which a blood transfusion was the only numerator event.

*Discharge Periods*

Your hospital’s results for the CMS PSI measures are calculated using data from eligible discharges occurring between July 1, 2021 through June 30, 2023.

Your hospital’s results and discharge-level CSV file for the ePC-07 measure use data from inpatient discharges occurring between January 1, 2023 to December 31, 2023.

*Accessing the Hospital-Specific Results *

You can now download the HSR for the CMS PSI measures that will be publicly reported in October 2024 and the discharge-level CSV file for ePC-07 for CY 2023 eCQM reporting from the HQR system.

The HQR system requires users to have a Health Care Quality Improvement System (HCQIS) Access Roles and Profile (HARP) account with access to Managed File Transfer (MFT) to log on. If you currently have a HARP account, visit the HQR login page [ https://hqr.cms.gov/hqrng/login ] and log in using your HARP user ID and password. If you do not have a HARP account, you may register for a HARP ID [ https://harp.cms.gov/register/profile-info ].

Log into the HQR system using your HARP ID credentials and navigate through the steps listed below to access your results.

For the CMS PSI measures:


* From the left-hand navigation menu, select “Program Reporting”
* Then select “Measure details”
* Here, you can view your hospital specific report (HSR)
* Select the release year (2024), followed by the program in which you are interested (IQR/PR). Under “Report,” you can see the list of files available for download (e.g., CMS PSI).
* To download a file, select “Export,” and the file will be downloaded through your browser. Once downloaded, open the ZIP file to view your site’s information.

For the ePC-07 measure:


* From the left-hand navigation menu, select “Program Reporting”
* Then select “Measure details”
* Click the “Measure details view” option
* Select the “IQR” option
* Select the “ePC-07a” or “ePC-07b” option depending on your need
* From the “Measure details view” page, click the “Export” dropdown on the top right of your screen
* Select “CSVs (discharge-level data)”

Only hospitals who self-selected and submitted ePC-07 patient-level data for CY 2023 inpatient discharges by the February 29, 2024 submission deadline will receive ePC-07 results. Hospitals participating in the Hospital Inpatient Quality Reporting (IQR) Program and/or the Medicare Promoting Interoperability Program could self-select to submit data for this measure beginning with the CY 2023 performance period. CMS will publicly report ePC-07 facility-level results for those hospitals in October 2024 on the data catalog on Data.cms.gov [ https://data.cms.gov/provider-data/ ].

If you have any issues accessing your HSR, please contact the Center for Clinical Standards and Quality (CCSQ) Service Center at QNetSupport@cms.hhs.gov, or by calling, toll-free, 866-288-8912 (TRS 711), weekdays from 8:00 a.m. to 8:00 p.m. ET. You can also view a brief instructional video [ https://youtu.be/Op5RLKjix9Y ] on how to download your report.

For questions related to HARP registration, please visit the HARP Help webpage or contact qnetsupport@cms.hhs.gov.

*Preview Period*

*The Preview Period for the CMS PSI measures and the ePC-07 measure began **July 31, 2024** and ends **August 29, 2024.* The Preview Period enables hospitals to review their hospital-specific results and submit questions about their calculations prior to the results being publicly reported in October 2024. Hospitals cannot request corrections to the underlying claims data or add new claims to the data extract during this period.

CMS encourages hospitals to review their results and submit questions about their calculations as soon as possible. Submit all requests for corrections using the QualityNet Question and Answer Tool [ https://cmsqualitysupport.servicenowservices.com/qnet_qa ] *no later than 11:59 p.m. PT on **August 29, 2024.*


* To submit a question using the QualityNet Question and Answer Tool, for the PSI measures select “Inpatient Claims-Based Measures” from the program list and “preview period request” as the subtopic under “Patient Safety Indicators (PSI).”
* For technical questions about the ePC-07 measure results and calculations, please send questions to the eCQM Jira Issue Tracker [ https://oncprojectracking.healthit.gov/support/login.jsp?os_destination=%2Fprojects%2FCQM%2Fissues%3Ffilter%3Dallissues ] (log in required).
* For questions regarding the preview period for the ePC-07 measure select “IQR- Inpatient Quality Reporting” as the program and “eCQMs” as the topic.

Hospitals should include “Preview Period Request” as the subject, describe each discrepancy and include the following:


* CMS Certification Number (CCN)
* Hospital name
* Hospital address
* Contact’s name, phone number, and email address
* Measure or component in question

*Hospitals should not include personally identifiable information (PII) or protected health information (PHI) in **emails.** When referring to the contents of the HSR, use the ID Number. *

*Additional information *

More information about the CMS PSI measures is available on the PSI pages on the QualityNet website. [ https://qualitynet.cms.gov/inpatient/measures/psi ] More information about the ePC-07 measure is available on the eCQI Resource Center. [ https://ecqi.healthit.gov/ecqm/eh/2023/cms1028v1 ]



Centers for Medicare & Medicaid Services




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