The CMS, however, says it will gather data specifically on patients who are unable to self-report their pain level at the 48-hour follow-up mark.
“The good thing is that CMS is saying to us, 'Don't do the math,' ” Simon says. “They just want us to give them all of the numbers. Hopefully, they'll take out the people who, for whatever reason, could not respond.”
The second measure for 2013's quality reporting program was conceived as a way for the CMS to collect data about how hospices are currently measuring quality in their organizations, says Dowell of the CMS.
“The ACA requires that we use endorsed measures in reporting programs unless there are none available and at the time, there were only two,” Dowell says, referring to two NQF measures, the pain management indicator and another that measures patient experience.
In February, the NQF endorsed 14 measures for palliative and end-of-life care, addressing topics such as pain, shortness of breath and care-preference documentation, which the CMS has indicated it will likely choose among for future versions of the hospice reporting program.
In order to fulfill the requirements of the structural measure, hospices will simply have to confirm that they have a quality assessment and performance improvement, or QAPI, program that includes at least three quality indicators related to patient care. Then they will indicate what areas their measures cover by checking boxes next to various quality domains and sub-domains.
“The structural measure gathers information on what hospices are already collecting and what they think are important indicators,” Dowell says.
To help hospices prepare for quality reporting, the CMS arranged a three-month voluntary reporting period when hospices could submit data about their QAPIs. During the voluntary reporting period, which ran from Oct. 1, 2011, until Dec. 31, the CMS received responses from 911 hospices, according to a report from RTI International, a CMS contractor. Of those respondents, more than 95% said they had a QAPI program in place that included more than three indicators.
The results of that report revealed just how widely varied hospices' internal quality programs are and how complex efforts to standardize them may prove to be.
In total, participating hospices submitted 6,712 quality indicators during voluntary reporting. Pain assessment and management accounted for more than 1,200 of those measures, while another 812 addressed communication with patients and their families. Other common measurement areas included anxiety, shortness of breath, care coordination, nausea, fall prevention and medication management.
“This is an industry that has for years collected information that is discrete to the hospice and to the region, and that data is not necessarily transferrable,” says O'Maley-Lanphear, who emphasized the need for common metrics. “CMS' first bite—the voluntary reporting cycle—produced thousands of measures.”
Not all measures are created equal, of course. According to RTI International's report, some hospices are using high-quality indicators that measured “important and actionable areas of quality related to patient care, with appropriate specifications and precise descriptions of the numerator and the denominator.”
On the other end of the spectrum, many hospices' measures lacked precision, according to the report. Some even submitted indicators that were more like quality-related goals—such as “All patients will be free of pain”—which lacked numerators and denominators altogether.