CMS Releases 2023 Voluntary Hybrid Hospital-Wide Readmission Measure HSRs

This announcement serves to notify hospitals that Hospital-Specific Reports (HSRs) for the 2023 voluntary reporting of the Hybrid Hospital-Wide Readmission (HWR) measure under the Hospital Inpatient Quality Reporting Program are now available via the Hospital Quality Reporting (HQR) System to hospitals that participated in voluntary reporting.
 
The HSRs are designed to provide these hospitals with their detailed measure results and discharge-level data. Information provided in the HSR for voluntary reporting of the Hybrid HWR measure include

1. Your hospital’s performance on the Hybrid HWR measure
2. National and State Performance Categories for the Hybrid HWR Measure
3. A summary of your hospital’s submission of core clinical data elements from the electronic health record for the Hybrid HWR measure
4. Discharge-level information for the Hybrid HWR measure
5. Distribution of patient risk factors for the Hybrid HWR measure.

To view your hospital’s HSR for the Hybrid HWR measure, hospital staff with a registered HCQIS Access Roles and Profile (HARP) account and an approved HQR User Role from the designated Security Administrator/Official (SA/SO) at their organization will need to log into the HQR system with a HARP email address and password. Once in the HQR System, hospital staff should follow the instructions in the video to access their Hybrid HWR HSR.
 
NOTE: The HSRs contain personally identifiable information and protected health information. The HSRs also contain discharge-level data and hospital-specific results. Emailing these data is a security violation.

If your hospital cannot access it’s HSR via the HQR system, it could be because your hospital

1. Did not successfully submit data during the voluntary data submission period.
2. Did not appear as open during the time period in which the measure was calculated.
3. Did not have any eligible cases for the calculation of the methods during the applicable hospital discharge timeframe.
4. Was not registered on the Hospital Quality Reporting system.

If any of the above applies to your hospital, you may not be able to view an HSR.
If you think your hospital should have received an HSR but did not, or if you have questions on transmitting data, please contact qnetsupport@cms.hhs.gov and provide the name of your hospital and your hospital’s CMS Certification Number (CCN).
 
Do you want to learn more about using your HSR?
 
The Hybrid HWR HSR User Guide (HUG) provides instruction on navigating and understanding each field of the HSR and will help hospital staff understand the evaluated measure, track its outcome, and further their quality improvement efforts. For more information on your Hybrid HWR HSR, please see the Hybrid HWR HSR HUG on the QualityNet website at Hospitals – Inpatient > Measures > Hybrid Measure> Reports.

For more information on the Hybrid HWR measure, please see the Hybrid Measure Frequently Asked Questions (FAQ), Hybrid Measure Fact Sheet, and other resources on QualityNet website at Hospitals – Inpatient > Measures > Hybrid Measure > Resources.
 
Support Resources
 
Hospitals can report any discrepancies or concerns regarding claims data and calculations to the QualityNet Service Center at qnetsupport@cms.hhs.gov.
 
Please submit questions about the Hybrid HWR measure methodology, implementation, and specifications (e.g., cohort inclusion and exclusion criteria, risk adjustment, outcome, planned readmission algorithm) and previous measure testing and development to the QualityNet Question and Answer Site. Select "IQR - Inpatient Quality Reporting" under Program and "Hybrid Measures" under Topic.
 
For questions about the electronic measure specifications, value sets and appropriateness of mapping, please submit questions via the Hybrid Measures Issue Tracker JIRA page.