Sec. 10.25.04.02. Hospital Evaluation — Data Collection and Reporting Requirements

A. Each hospital shall file with the Commission data on measures to be included in the Commission's comparative quality and performance evaluation system and the Health Services Cost Review Commission's quality-based reimbursement initiative. The measures may be drawn from, but are not limited to, the:

(1) National Quality Forum;

(2) Hospital Quality Alliance;

(3) Quality Indicator Project of the Maryland Hospital Association;

(4) Agency for Healthcare Research and Quality;

(5) Hospital Quality Initiative of the Centers for Medicare and Medicaid Services;

(6) Centers for Disease Control and Prevention's National Healthcare Safety Network;

(7) Joint Commission's ORYX^R initiative; or

(8) Work of academic, professional, healthcare research, and patient safety organizations.

B. The measures shall relate to the outcomes of healthcare services and the process through which those services are delivered for the hospital as a whole as well as specific clinical areas and may include, but are not limited to, the following:

(1) Acute myocardial infarction;

(2) Cardiac surgery and angioplasty;

(3) Emergency department care;

(4) Healthcare-associated infections;

(5) Heart failure;

(6) Maternity and newborn care;

(7) Patient experience;

(8) Patient safety;

(9) Pediatric care;

(10) Pneumonia;

(11) Health information technology; and

(12) Intensivist staffing.

C. The Commission shall provide notice in the Maryland Register and on its website of the form, format, and schedule for submission of data on measures to be reported to the Commission under this regulation.