Hospice Voluntary Quality Data Reporting Form

CMS Voluntary Quality Reporting Program Related to
Section 3004 of the Affordable Care Act for Hospice Programs

Instructions for Completing the CMS
Voluntary Quality Reporting Program
Hospice Quality Data Submission Form
Background:
CMS is proposing a voluntary quality reporting cycle for hospices that precedes the
required quality reporting requirements mandated for the FY 2014 payment
determination as set forth in Section 1814(i)(5) of the Act. For the proposed voluntary
reporting, hospices shall report one structural measure collected for the period October
1, 2011 through December 31, 2011. The structural measure hospices shall report for
the voluntary reporting cycle is: Participation in a Quality Assessment and
Performance Improvement (QAPI) Program that Includes at Least Three Quality
Indicators Related to Patient Care.
Submission of data collected during this timeframe will permit CMS to analyze the
data and learn what the important patient care quality issues are for hospices as we
enhance the quality reporting program design to require more standardized and specific
quality measures to be reported by hospices in subsequent years.
Who, What, When, and How:
Each hospice may voluntarily complete the Hospice Quality Data Submission Form.
■ If you choose to participate in the voluntary reporting, you should:
○ Read the instructions for completing each data field carefully.
○ Report whether or not (yes/no) you have a QAPI program that includes at
least three quality indicators related to patient care for the voluntary reporting
period October 1, 2011 through December 31, 2011.

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○ List the patient care-related quality indicators included in your hospice’s QAPI
program during the voluntary reporting period October 1, 2011 through
December 31, 2011.
○ Submit your Hospice Quality Data Submission Form for the voluntary time
period of October 1, 2011 through December 31, 2011 no later than January
31, 2012.
Data Field Instructions for the Hospice Quality Data Submission Form
1. Hospice Provider’s Business Name—Enter the legal name of your hospice
organization.
2. Hospice Provider’s Mailing Address—Enter the mailing address of your hospice
organization.
3. Hospice Provider’s Physical Address—Enter the physical address of your
hospice organization if it is different than the mailing address.
4. Hospice Provider’s Business Phone Number—Enter the phone number to reach
your hospice organization during weekdays 8:30 a.m. to 4:30 p.m. Use numerals
only, no dashes or other characters.
5. CMS Certification Number (CCN)—Enter six numerals only, no dashes or other
characters.
6. National Provider Identification (NPI)—Enter ten numerals only, no dashes or
other characters.
7. Hospice Contact—Enter name, phone number, and e-mail of a contact for
questions about this form.
8. Q1—Answer Yes IF your hospice organization’s QAPI program includes three or
more patient care-related quality indicators.
a. Patient care-related quality indicators include indicators that address
topics such as:
i. Symptom management such as pain, dyspnea, nausea, anxiety,
depression;
ii. Care coordination such as management of transitions and
communication among staff and with other providers;
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iii. Patient safety such as falls, medication errors, infections; and
iv. Care provision in accordance with documented patient/family
preferences such as presence of documentation of advance
directives and surrogate decision makers.
9. Q2—Indicate the number of patient care-related indicators your QAPI program
includes. If you select “0” as your response for Question 2, skip Question 3 and
go directly to Question 4.
10. Q3—ALL hospices with a QAPI program that includes at least one patient carerelated indicator should list up to 20 indicators using the form. See the examples
in the first two rows of the spreadsheet. Enter one indicator on each line, starting
below the examples.
a. Indicator Topic—To enter information about your first indicator, click on
cell B4. A small arrow appears to the right of the cell. Click on the arrow to
view the dropdown menu. Select the topic area the indicator addresses by
highlighting it with your cursor and clicking. Note that if none of the topics
apply, you can choose “Other.”
b. Indicator Name—Write in the full name of the indicator. You may cut and
paste from a Word or Excel file if you already have an indicator list
prepared.
c. Brief Description—Describe the indicator more completely. Include any
information that will help us understand what the indicator measures.
d. Data Source—Click on cell E4. A small arrow appears to the right of the
cell. Click on the arrow to view the dropdown menu. Select the data
source for the indicator from the choices provided. Note that if none of the
choices apply, you can choose “Other.”
e. To begin entering information on your next indicator (if applicable), click on
cell B5, and follow the instructions for steps a through d above.
11. Q4—Indicate the number of minutes it took you to complete the data collection
form.

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How Your Hospice Program Will Be Evaluated:
■ Your hospice will not be evaluated for compliance with hospice quality reporting
requirements during the voluntary reporting period, October 1, 2011 through
December 31, 2011. Responses received from hospices reporting the structural
measure data with specific patient care-related quality indicators will allow CMS
to learn what hospices consider to be important patient care-related quality
indicators.
■ A mandatory reporting period will begin October 1, 2012. Further details
regarding the mandatory hospice quality reporting program will be available on
the CMS Web site.
We will announce operational details with respect to the data submission methods
for the voluntary reporting cycle using this CMS Web site http://www.cms.gov/LTCHIRF-Hospice-Quality-Reporting by no later than December 31, 2011 should these
measures be finalized.

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond
to a collection of information unless it displays a valid OMB control number. The valid
OMB control number for this information collection is 0938-XXXX. The time required to
complete this information collection is estimated to average 15 minutes per response,
including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form,
please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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