Hospital Quality Data (Chapter 270)

Each hospital or their agent must report data to the US CDC’s NHSN for specific healthcare associated infection (HAI) quality metrics, MRSA blood specimen Lab ID Event data for all facility-wide inpatients (FacWideIN), and data for Clostridium difficile Lab ID Events for all facility-wide inpatients (FacWideIN) in accordance with NHSN specifications.

Each hospital or their agent must report data to the MHDO for specific nursing-sensitive patient-centered (NSPC) health care quality data as defined by National Database for Nursing Quality Indicators (NDNQI) and the Joint commission.

See Rule Chapter 270 - Uniform Reporting System for Health Care Quality Data Sets on our rules page for a complete definition of which hospitals must submit which specific sets of data.

 

Note: Links to Resources can be found at the bottom of this page.

8/21/24 New Reporting Requirement Effective July 1, 2024

The reporting requirements, which are copied below and can be found in 90-590 CMR Chapter 270, Section 2. G., 2. I and 2. J (page 4) became effective July 1, 2024 (reporting to NHSN due by February 15, 2025).

2.G. Each hospital shall submit to the US CDC’s NHSN data a quarterly submission of data, separated by month, for Antimicrobial Use and Resistance (AUR) for all inpatient, emergency department, and 24-hour observation locations in accordance with NHSN specifications beginning July 1, 2024. (Measure steward – NHSN).

2.I. In lieu of reporting data directly to MHDO, each health care facility shall authorize Maine CDC to have access to the NHSN for facility-specific reports of data, including all patient identifiers, submitted for any measure under a state or federal mandate, and shall authorize the Maine CDC to use this data for data validation, public health surveillance and performance improvement purposes. Such data accessed and used by Maine CDC is not considered MHDO data but is protected by 22 M.R.S.A. §42(5) to the extent it is individually identifiable.

2.J. Each health care facility shall authorize the MHDO to have access to the NHSN for facility-specific reports of data, including all patient identifiers, submitted for any measure under a state or federal mandate. For the purpose of public reporting, all patient identifiers will be protected by MHDO and remain confidential.

Hospitals must grant MHDO access to their NHSN data specific to AUR and patient identifiers via conferring rights. This must be done by September 30, 2024.

Note: For detailed instructions on how to agree to confer rights, you can access the NHSN document titled, “Data Sharing in NHSN: Joining a Group and Accepting the Confer Rights Template”.

Data must be submitted to NHSN no later than the date of the 15th of the 5th month following the end of each calendar quarter in which the service occurred (although we do encourage reporting monthly). 1st Quarter January, February, March -due to NHSN by August 15th

Data Filig Periods

Quarter Months Date Due in NHSN
Q1 Jan, Feb, Mar August 15th
Q2 Apr, May, June November 15th
Q3 July, Aug, Sept February 15th
Q4 Oct, Nov Dec May 15th
1/30/24 Recording of the 1/24/24 Webinar is Available.

You will find the webinar recording on YouTube.

1/23/24 Webinar January 24th - Re: NEW Simplified Administrative Process for Hospital to Submit NSI data to MHDO

MHDO will hold a virtual webinar Wednesday, January 24, 1:00-2:00pm ET to review the new simplified administrative process for submitting your hospital’s NSI data to the Maine Health Data Organization. During the webinar we will review the improvements that have been made in the data submission process, demonstrate the new process, and discuss the timelines for the submission of the quarterly data that you are holding. (Note: Please continue to hold your Q2 and Q3 2023 NSI data until after the webinar. For those of you that have already submitted your Q2 and/or Q3 quarterly data to MHDO there is nothing more you need to do regarding this submission.
A recording of the webinar will be available for those who are unable to attend the session. Please return to this page for the link.

Connection information and the presentation deck are below.

7/5/23 Recording of June 29th Webinar is Available

The recording of the webinar held 6/29/23 can be found on YouTube here: https://youtu.be/rXTdcixR2K8

6/29/23 Webinar Regarding Three New HAI Measures Due with Q3 2023 Data

The webinar will be held virtually via Zoom from 1:00 - 2:00 pm. Connection information and presentation deck are below.

3/20/23 Communication sent to Hospitals About the Three Health Care Quality Reporting Requirements That Go Into Effect July 1, 2023.

The original effective date for reporting these new measures under MHDO Rule Chapter 270 Uniform Reporting System for Health Care Quality Data Sets was January 1, 2020, however, to minimize administrative burden during the early years of the pandemic, the MHDO board made the decision to suspend the enforcement of Rule Chapter 270 Section 2. B. Now, over two years after the original effective date, the reporting requirement will become effective July 1, 2023.
Note: A webinar will be held in early May to review the new reporting requirements.

For all patients identified as eligible cases in the specific denominator and numerator categories specified by NHSN, each hospital, or their agent, shall submit to the US CDC’s National Healthcare Safety Network (NHSN), data for the following healthcare associated infection (HAI) quality metrics in accordance with NHSN specifications, beginning with all qualifying events on or after July 1, 2023.

Measure Definition Reporting Specifications
HAI-6 Catheter-associated urinary tract infection (CAUTI) rates for adult and pediatric patients in intensive care units, medical units, surgical units, medical/surgical units, mixed acuity units and rehabilitation units Data must be submitted through NHSN National Healthcare Safety Network (NHSN) Patient Safety Component Manual Chapter 7
HAI-7 Surgical Site Infection data for patients undergoing inpatient knee prosthesis (arthroplasty of the knee) surgical procedures (KPRO) Data must be submitted through NHSN National Healthcare Safety Network (NHSN) Patient Safety Component Manual Chapter 9
HAI-8 Surgical Site Infection data for patients undergoing inpatient hip prosthesis (arthroplasty of the hip) surgical procedures (HPRO) Data must be submitted through NHSN National Healthcare Safety Network (NHSN) Patient Safety Component Manual Chapter 9
11/07/22 New NSI Transmittal Workbook Available

You can download the most recent version of the NSI Transmittal Workbook (5.01) here, from the MHDO Hospital Data Submission Portal under "Guides", or from "How to submit data" lower on this page.

08/23/21 Counting Method 1 (Midnight Census) for NSI Data Submissions Will No Longer be an Option

On 7/28/21 NSI data submitters were notified that beginning with Q3 2021 data, counting Method 1 will no longer be an option. Below is a summation of the correspondence.

After reviewing recent NSI data submissions an issue has been identified regarding the patient days counting methods hospitals are using to report falls for NSI measures NSPC-2 Number of patient falls per patient days and NSPC-3 Number of patient falls with injuries. Several hospitals are utilizing Method 1 (Midnight Census) for patient days when counting and reporting the number of falls. As described and defined by the National Database for Nursing Quality Indicators (NDNQI), this method is restricted to hospital units that have only inpatient admissions. Method 1 is not appropriate for facilities with both inpatient and short stay patients since only inpatients are counted for total patient days (the denominator for these measures). As a result, hospitals using Method 1 that treat both inpatient and short stay patients may be undercounting patient days and thus artificially inflating Patient Falls and Falls with Injury rates. This will negatively impact comparisons over time and between hospitals.

In light of this, the Method 1 tab will be removed from MHDO’s NSI Transmittal Workbook starting with Q3 2021 submissions. Hospitals will need to use one of the following methods defined by NDNQI.

  • Method 2-Midnight Census + Patient Days from Actual Hours for Short Stay Patients,
  • Method 4-Patient Days from Actual Hours, or
  • Method 5-Patient Days from Multiple Census Reports to count Patient Falls and Falls with Injury.

Important Note and Next Steps: Beginning with Q3 2021 MHDO data submissions and for data submissions thereafter, you must download the most recent version of the NSI Transmittal Workbook (5.0) which will be found lower on this page under "How to submit data to MHDO" or in the MHDO hospital data submission portal under Guides. MHDO will no longer accept data submissions on outdated forms or if the transmittal form has been altered in any way.

04/23/20 Chapter 270 Quality Data Reporting Deadlines Extended

In light of the significant challenges that hospitals are facing during the COVID-19 pandemic, the MHDO has agreed to extend data reporting deadlines for the hospital data submission requirements defined in MHDO Rule Chapter 270, Uniform Reporting System for Health Care Quality Data Sets.

MHDO will suspend the enforcement of the current deadlines described in Rule Chapter 270 with the following revised submission dates:

  • All Q4 2019, Q1 2020 and Q2 2020 quality data reporting for HAI-1, 2, 6, and NSPC-1, 2 and 3 must be submitted to the MHDO by January 30, 2021
  • The new requirement for the reporting of HAI-7 and 8 (surgical site infection rates for patients undergoing inpatient knee and hip prosthesis) is extended by one year; the revised start date is January 2021. MHDO will send an update later this year on the details specific to this new requirement

Please do not hesitate to contact Kimberly Bonsant with any questions.

Submission of Data to MHDO

Submissions Deadlines:

Quarter Months Deadline
Q1 Jan, Feb, Mar August 15th
Q2 Apr, May, June November 15th
Q3 July, Aug, Sept February 15th
Q4 Oct, Nov Dec May 15th

How to submit data to MHDO:

Go to the Hospital Data Portal at https://mhdo.maine.gov/hospital_portal to download the form you need, and once complete simply upload.

If you prefer, the Nursing Sensitive Indicators Transmittal Workbook (Version 5.01) can be downloaded here for completion prior to submitting to the portal.

Many find the NSI Microspecifications Manual (Version 4.1) helpful as it contains information regarding technical issues.

Note: For assistance with the new portal, see the Chapter 270 User Manual under the "Help" section in the Hospital Data Portal or download the Chapter 270 User Manual here if you prefer.

Questions and Assistance:

The MHDO Help Desk is available for any technical/system issue you may encounter. Support is available during regular business hours (8 a.m. – 5 p.m. EDT, Monday – Friday). You will receive a phone call or an e-mail within two hours of your request. Toll-free Phone: (866) 451-5876 or Email: mhdohelp@hsri.org.

Questions regarding completion of the forms, deadlines or requests for extensions can be directed to Kimberly Bonsant, Hospital Compliance Officer, MHDO at kimberly.bonsant@maine.gov or (207) 287-2296.

Important Announcements

12/6/19 Information Regarding Changes to MHDO Rule Chapter 270, Uniform Reporting System for Health Care Quality Data Sets

The MHDO board of directors adopted an updated version of Rule Chapter 270, which replaced the current version of the Rule as of June 22, 2019. You can access a copy of the updated Rule on our Statute and Rules page. Below is a summary of several key changes to this rule.

  • All HAI-1 data collected on-or-after July 1, 2019 must be submitted via the NHSN. (Note: HAI-1 data collected for any reporting period ending prior to July 1, 2019 may be submitted directly to the MHDO Hospital Data Portal.)
  • No longer require the collection of data for the HAI bundle compliance measures, HAI-3, HAI-4, and HAI-5. The last required submission of this data is for the fourth quarter of 2018. However, as of 6/12/19 seven hospitals submitted their first quarter 2019 bundle compliance measures to the MHDO; therefore, hospitals had the option to submit their first quarter 2019 data to the MHDO prior to August 15, 2019. This was a completely optional data submission.
  • Section 2(c) is revised to change “MRSA LabID Event data” to “MRSA blood specimen LabID Event data”, to conform with the current NHSN measure specifications already in use by Maine hospitals.
  • There are three new HAI measures. The collection period begins January 1, 2020; the timeline for the first data submission is described below. Data must be submitted via NHSN.
    1. HAI-6 for the reporting of, “Catheter-associated urinary tract infection rates for adult and pediatric patients in intensive care units, medical units, surgical units, medical/surgical units, mixed acuity units and rehabilitation units, with first reporting due on August 15, 2020 (this includes Critical Access Hospitals);
    2. HAI-7 for the reporting of Surgical Site Infection data for patients undergoing inpatient knee prosthesis (arthroplasty of the knee) surgical procedures (KPRO) with the first reporting due on November 15, 2020 for all hospitals; and
    3. HAI-8 for the reporting of Surgical Site Infection data for patients undergoing inpatient hip prosthesis (arthroplasty of the hip) surgical procedures (HPRO) with the first reporting due on November 15, 2020 for all hospitals.
  • Section 2(G) has been replaced with new language that requires each health care facility to, “authorize Maine CDC to have access to the NHSN for facility-specific reports of data submitted for any healthcare associated infection measure under a state or federal mandate, and shall authorize the Maine CDC to use this data for data validation, public health surveillance and performance improvement purposes. Such data accessed and used by Maine CDC is not considered MHDO data but is protected by 22 M.R.S.A. §42(5) to the extent it is individually identifiable.”
  • Section 2(H) requires, “Each health care facility shall also authorize the MHDO to have access to the NHSN for facility-specific reports of data submitted for any healthcare associated infection measure under a state or federal mandate, for the purpose of public reporting.”
  • Sections 2(I) and 2(J):
    • Instruct the Maine Quality Forum (MQF) and Maine CDC to, “develop and implement an external validation process” for HAI data submitted to the NHSN;
    • Requires each hospital selected for an external validation study to cooperate with the State’s third-party validation contractor; and
    • Exempts any hospital that had been selected, in the same year, for a federal validation study, on the condition that an exempted hospital, “submit a copy of the federal validation report summary to the MQF within 14 days of their receipt of the final federal report,” and authorizes MQF to use information from the federal summary, “for the purpose of public reporting.”
8/15/17 Recording of the 8/3/17 Webinar is Now Available - The 8/3/17 webinar can be found on YouTube.

8/3/17 Webinar for New Online Submission Portal

A webinar was held from 2:00 - 2:30 to discuss requirements and steps involved with the new MHDO submission system for HAI and NSI data. A demonstration of logging in, submitting a file, and verifying its receipt was provided. You may download the PowerPoint Deck now, and check back in a few weeks for the recorded webinar.

New 7/26/17 Online Quality Data Submissions Portal Now Available for the Submission of HAI and NSI data

Hospitals can now submit their HAI and NSI data transmittal workbooks via the online portal at https://mhdo.maine.gov/hospital_portal. Simply register, login and upload your reports.

9/6/16 Message from the MHDO Executive Director Re: Rule Chapter 270

Earlier this spring the Maine Legislature approved changes to Rule Chapter 270 - the rule that governs the submission of healthcare quality data to the Maine Health Data Organization (MHDO). Many of the changes to Chapter 270 align with changes at the federal level. As a reminder the changes to Chapter 270 went into effect as of June 1, 2016. This means the changes in the rule take effect beginning with data collected on and after July 1, 2016 (2016-Q3). A more detailed overview of these changes can be found on our rules page.

The following is a list of the key provisions that were deleted from Chapter 270:

  • all 8 Surgical Care Improvement Project (SCIP) measures which, due to their success, had been retired by CMS and already suspended by MHDO;
  • all 3 Care Transition Measures (CTM) now included in the CMS HCAHPS survey and publicly available on the CMS website;
  • 9 out of 12 Nursing Sensitive Indicators (NSI) including
    • prevalence of vest or limb restraints;
    • RN care hours, LVN/LPN care hours, UAP care hours, and contract nursing care hours as a percentage of total care hours;
    • RN care hours and total nursing care hours per patient day;
    • staff turnover rates for RNs and LVN/LPNs.

Hospitals are still required to collect NSI data for the following three measures:

  • NSPC-1 Hospital-acquired pressure ulcers;
  • NSPC-2 Number of falls per patient day;
  • NSPC-3 Number of falls with injury per patient day

NSI Data Submittal Workbook:

  • Hospitals should continue to use the NSI Data Submittal Workbook Version 2.0 for NSI data collected through the 2016-Q2 reporting period;
  • Hospitals should use the new NSI Data Submittal Workbook Version 3.0 for NSI data collected for the 2016-Q3 reporting period and thereafter.

Note: Both versions of the NSI Data Submittal Workbook and the new version of the NSI Microspecifications Manual are available on this page under How to submit data.

Other Key Changes to Chapter 270 include:

  • The range of hospital (ALL hospitals) units reporting data for HAI-1, central-line catheter-associated blood stream infection (CLABSI) rates, was expanded to include medical, surgical and medical/surgical units, and thus bring Maine’s measure in line with changes made by NHSN and CMS.
  • The MRSA and C.difficile LabID reporting requirements have been amended. Hospitals will now submit their MRSA and CDI data to NHSN using the facility-wide inpatient (FacWideIN) option. Hospitals may voluntarily continue to report data by unit location, however, Chapter 270 no longer requires it.
  • Data reporting deadlines for all Chapter 270 measures are now 4-1/2 months after the close of the reporting quarter in order to harmonize with federal reporting deadlines.

Lastly, in an effort to align Rule Chapter 270 with the appropriate measure steward the following clarification is being made to section 2(C).

Each hospital shall submit to the US CDC’s National Healthcare Safety Network (NHSN) MRSA data for blood only Lab ID Event, for all inpatients (facility-wide) in accordance with NHSN specifications no later than January 1, 2014. (Measure steward - NHSN).

If you have any questions please contact Kim Wing at kimberly.wing@maine.gov. Thank you. Karynlee

2/08/16 Message from the MHDO Executive Director Re: Our New NSI Microspecifications Manual & NSI Data Transmittal Workbook

I am pleased to announce that we have finalized our 2016 version of our new NSI Microspecifications Manual with two important clarifications regarding the counting of patient days. We are also releasing a new version (2.0) of our NSI Data Transmittal Workbook in Excel. Thanks to those of you that provided feedback on the workbook-we hope this version is easier to use.

Overview of Changes in the Manual

  • "Patient Days" refers to all patients, not just inpatients: The new edition of the NSI Manual clarifies some confusion that may have been caused by the titles of the two falls measures (NSPC-2 and NSPC-3) and the two nursing-care-hours-per-patient-day measures (NSSC-5 and NSSC-6) as they appeared in earlier editions of the NSI Microspecifications Manual and the Excel-based NSI Data Transmittal Workbook. Although the instructions appearing in the manual and on the form make clear that you should count the number of patient days for all patients, including outpatients or other short stay patients, the measure titles mistakenly referred to “Inpatient Days”. Short stay days are the equivalent of taking the number of short stay hours and dividing by 24. The American Nurses Association (ANA), the measure steward for all four measures, offers several options for counting short stay days.
  • The ANA has discontinued the use of one of the five options for counting patient days: The ANA has discontinued their patient day counting Method 3, "Midnight Census plus Patient Days from Average Short Stay Hours". Beginning with the 2016-Q2 data reporting period, hospitals may still use Method 1, 2, 4 or 5. You can locate more information about each method by referring to the NSI Microspecifications Manual. Note: Beginning with the 2016-Q2 reporting period, all hospitals must include short stay days in their patient day calculations, and include outpatient falls in the falls and falls with injury measures. Hospitals that have already submitted or collected NSI data based on inpatient days only for any reporting period prior to 2016-Q2 do not need to re-submit.

Improvements to the NSI Data Transmittal Workbook

  • No more redundant data entry: We have greatly reduced redundant data entry when utilizing the “Data Submittal Worksheet”. For example the spreadsheet automatically copies the number of Patient Days for NSPC-2 (Falls with Injury) to the three other cells where it appears. Also when you enter the number of RN care hours for NSSC-1, LPN hours for NSSC-2 and UAP care hours for NSSC-3, the spreadsheet automatically calculates Total Nursing Care Hours and enters it in each of the five locations where it belongs.
  • Locked cells and easier navigation: All calculated cells have been highlighted in green and locked to prevent users from accidently overwriting their contents. In fact, every cell has been locked except for data entry cells. This means you can now navigate each spreadsheet tab by using the TAB key.
  • You can now hide unused rows with one click: We’ve also added a new HIDE UNUSED ROWS button, which when clicked, will check each row to see if you have entered your hospital’s internal name (in Column B) for that row’s hospital unit. If the internal unit name is blank the row gets hidden. By displaying only the rows that you’re using, we hope to make it easier and faster to navigate the form. What if the button hides a row that you discover you need to use? It’s easy, just click the UNHIDE ALL ROWS button to make all the rows reappear. Enter your hospital’s internal name for the missing unit and then click the HIDE UNUSED ROWS button again to return to data entry.
  • When you enter the internal unit name on the “NSPC-1 Pressure Ulcer – Required” tab, Excel will copy that unit name to all the other data entry tabs in the Workbook.

Other Changes

All hospitals are now required to indicate their patient day counting method by choosing from the new pull-down menu near the top of the “Data Submittal Worksheet” summary tab.

Lastly, please save your worksheet by using the SAVE TO DESKTOP pink button on the “Data Submittal Worksheet” tab. This will automatically save a correctly named copy of your NSI data file to your Windows Desktop.

Please contact Kim Wing at Kimberly.Wing@maine.gov with any questions or concerns.

- Karynlee

12/30/15 To: All Maine Hospital Association Quality and IP Contacts Re: Healthcare Associated Infection (HAI) Data

The Maine Health Data Organization (MHDO) has released a new version of the MHDO HAI Data Transmittal Workbook and the HAI Microspecifications Manual, both of which can be found under Healthcare Associated Infection (HAI) Data below.

The data transmittal workbook and the manual have been revised to conform with the current CMS Inpatient Quality Data reporting requirements for the HAI-1 (CLABSI infection rate) measure which went into effect on January 1, 2015.

MHDO's requirements for HAI-1 data reporting were previously limited to patients in ICUs for hospitals that had an ICU and to patients in Mixed Acuity Units for hospitals that did not have an ICU.

Beginning with the 2016-QTR1 reporting period on January 1, 2016, MHDO will require HAI-1 data reporting for patients in all adult and pediatric ICUs, Medical Units, Surgical Units and Medical/Surgical Units.

Hospitals that do not have an ICU, Medical Unit, Surgical Unit or Medical/Surgical Unit should substitute all adult and pediatric patients in their Mixed Acuity Unit(s), including patients in swing beds.

Please note that the denominator criteria for the four other Chapter 270 HAI measures (HAI-2 through HAI-5) have not changed.

Lastly per request, MHDO removed the two questions at the top of the HAI data transmittal workbook that asked for the total number of central line days and ventilator days over the prior 12 months. These questions have been replaced by a reminder that the 12-month number of central line days and 12-month number of ventilator days each determine which sampling method your hospital should use for collecting central line bundle compliance data and ventilator bundle compliance data in the upcoming quarter.

For more information, please refer to the HAI Data Microspecifications Manual or contact the MHDO at 207-287-9900 or 287-6722.

Surgical Care Improvement Program (SCIP) Measures -

SCIP Submission Form

1/13/15 MHDO Announcement in Response to CMS' Suspension of SCIP Inf-4 Measure Collection:

Consistent with the recent announcement by CMS, the MHDO will suspend the collection of SCIP–Inf-4 as of Quarter 3 (Q3) 2014. Meaning, hospitals will not need to report SCIP-Inf-4 for Q3 2014 and Q4 2014 reporting periods. Consistent with our earlier notification regarding the other SCIP measures, hospitals will need to report for Q3 2014 and Q4 2014 reporting period. Bottom line:

  1. Effective with July 1, 2014 discharges, we are no longer enforcing the collection of SCIP-Inf-4
  2. As of January 1, 2015 we are no longer enforcing the collection of the other SCIP measures defined in Chapter 270.

Please do not hesitate to contact Karynlee Harrington at Karynlee.harrington@maine.gov or Kim Wing at Kimberly.Wing@maine.gov with any questions.

12/24/14 MHDO Announcement in Response to CMS' Suspension of the Majority of SCIP Measures

The MHDO Board of Directors voted at the December 18th board meeting to align with the decision made by CMS regarding the Surgical Care Improvement Project (SCIP) measures. Effective January 1, 2015 many of the measures will become voluntary reporting measures with CMS; therefore MHDO will suspend the enforcement of data collection effective January 1, 2015 for the following SCIP measures consistent with the action of the measure steward (CMS):

  • SCIP-Card-2, SCIP-Inf-1a-h, SCIP-Inf-2a-h,SCIP-Inf-3a-h, SCIP-Inf-09 and SCIP-VTE-2

Important: The MHDO will continue to enforce the collection of SCIP-Inf-4 (again, consistent with the measure steward).

10/10/14 MHDO Announcement: Suspension of data collection for SCIP-Inf-10

Pursuant to Sections 2 and 11 Rule Chapter 270, and CMS' decision, announced in the Revisions to Version 4.3 of the CMS Specifications Manual for National Hospital Quality Measures, to retire the SCIP-Inf-10 (perioperative temperature management) the Maine Health Data Organization (MHDO) will suspend collection of SCIP-Inf-10 numerator and denominator data for the 2014-Q1 reporting period forward.

As always, we welcome your questions and suggestions. Please send them to Kimberly.Bonsant@maine.gov.

Links to Other Quality Data Resources