Instructions for Updating the Model Quality Dashboard Using the QTD Report in HQIP
There is no requirement or expectation for hospitals to use the Model Quality Dashboard. Although the measures on the Model Quality Dashboard are recommended for reporting by HQI, the goal of the QTD effort is to encourage hospitals to be more transparent with the public about their quality of care using whatever quality measures they choose to publicly report.
Nonetheless, for hospitals interested in updating the measures presented on the Model Quality Dashboard, the following steps are provided to help accomplish this task using the information presented in HQIP:
Navigate to the Patient Safety Metrics Dashboard section and select CMS Hospital Compare Measures over Time (Quality Transparency Dashboard).
On the right, under the Measure Group filter, find the “Healthcare-Associated Infections (HAI SIRs)” option.
Select the Recordstab.
Find the rows with Measure Name “HAI-1: CLABSI: Central Line-Associated Bloodstream Infections (ICUs and Select Wards)”.
Find the HAI-1 row with the latest End Date. (The file should be pre-sorted, but you can filter the End Date column by descending if needed. Additionally, you can change what columns to view via the blue box highlighted in the screenshot below.)
Copy the Measure Start & End Dates,Score, California Score, and National Score into the appropriate spaces on the QTD Template.
Select Report Liston the left pane.
Navigate to the Patient Safety Metrics Dashboard section and select CMS Hospital Compare Measures over Time (Quality Transparency Dashboard).
On the right, under the Measure Group filter, find the “Healthcare-Associated Infections (HAI SIRs)” option.
Select the Recordstab.
Find the rows with Measure Name “HAI-3: SSI COLO: Surgical Site Infections from Colon Surgeries”.
Find the HAI-3 row with the latest End Date. (The file should be pre-sorted, but you can filter the End Date column by descending if needed. Additionally, you can change what columns to view via the blue box highlighted in the screenshot below.)
Copy the Measure Start & End Dates,Facility Score, California Score, and National Score into the appropriate spaces on the QTD Template.
Select Report List on the left pane.
Navigate to the California Maternal Quality Care Collaborative (CMQCC) Measures section and select CMQCC Maternal Quality Measures Rates, Trends, & Benchmarks.
Ensure the Nullipararous, Term, Singleton, Vertex (NTSV) Cesarean Birth Rate is selected in the tables.
Select the Recordstab.
Find the NTSV row with the latest Measure Start Date.
Copy the Measure Start & End Dates,Score, and California Score into the appropriate spaces on the QTD Template.
The National Level is available from Centers for Disease Control and Prevention, National Center for Health Statistics, Vital Statistics Rapid Release, Births: Provisional Data Year report as the measure called “low-risk cesarean delivery rate” (e.g., Births: Provisional Data for 2024 was 26.6%).
Select Report List on the left pane.
Navigate to the Sepsis 1-2-3 Rates, Trends, Benchmarks, Readmissions, & Missed Opportunities section and select Sepsis Mortality for Inpatient Encounters.
Under Filters, change From Discharge Date and To Discharge Date to reflect the latest 12-month period of inpatient discharges available for your hospitals (e.g., “01/01/2023 – 12/31/2023” for CY2023) and click the Apply Filter button.
Use the group “SEP-3 Sepsis“.
Copy the Date Range (Monthly),Hospital Rate, and All California Hospital Rate into the appropriate spaces on the QTD Template.
Note: You can search for a national score (e.g., 15%) or type ‘N/A’ for National Level. Make sure to click Reset To Default Filters before moving to the next measure.
Select Report Liston the left pane.
Navigate to the Patient Safety Metrics Dashboard section and select CMS Hospital Compare Measures over Time (Quality Transparency Dashboard).
On the right, under the Measure Group filter, find the “Readmission Measures (HRRP)” option.
Select the Recordstab.
Find the rows with Measure Name “READM-30-HOSP-WIDE: 30-Day Hospital-Wide All-Cause Unplanned Readmission (HWR)”.
Find the READM-30-HOSP-WIDE row with the latest Start Date.
Copy the Measure Start & End Dates,Score, California Score, and US Score into the appropriate spaces on the QTD Template.
