Code of Vermont Rules
Agency 21 - DEPARTMENT OF FINANCIAL REGULATION
Sub-Agency 040 - DIVISION OF HEALTH CARE ADMINISTRATION
Chapter 026 - HOSPITAL REPORTING RULE
Section 21 040 026 - HOSPITAL REPORTING RULE
Universal Citation: VT Code of Rules 21 040 026
Current through February, 2024
Section 1.0 Authority
This rule is adopted pursuant to 18 V.S.A. §§ 9405a, 9405b, and 18 V.S.A. § 1919.
Section 2.0 Purpose
The purpose of this rule is to establish the process and time line for data submission and reporting for the generation of a statewide hospital quality report and reporting on the community health needs assessments.
Section 3.0 Definitions
3.1 "Annual Reporting Manual"
means the document published annually by the Department and the Green Mountain
Care Board (GMCB) that describes in detail the necessary data specifications
and guidelines for submission and publication for hospitals and the development
of Community Health Needs Assessments (CHNA). The reporting manual shall
contain, at a minimum, a list of quantitative measures; the methodology for
collecting and analyzing data; and parameters for presenting quantitative and
qualitative information. It is maintained on the Department website.
3.2 "Benchmark" means an attribute or
achievement that serves as a standard for other providers or institutions to
emulate. Benchmarks differ from other standard of care goals in that they
derive from empiric data - specifically, performance or outcomes
data.
3.3 "Charge" means the
amount, in U.S. dollars, that a hospital invoices a purchaser or patient for a
particular service or combination of services performed by the hospital prior
to the application of any discounts, reductions or mark-downs that may
ultimately affect the amount the purchaser or patient is obligated to pay for
the performance of such service(s).
3.4 "Community Health Needs Assessment" means
a written report made widely available to the public by the hospital that,
using qualitative and quantitative data:
3.4.1 Identifies significant health needs of
the community it serves;
3.4.2
Prioritizes those health needs; and
3.4.3 Identifies resources (such as
organizations, facilities, and programs in the community, including those of
the hospital) potentially available to address those health needs.
3.4.4 For these purposes, the health needs of
a community include requisites for the improvement or maintenance of health
status both in the community at large and in particular parts of the community
(such as particular neighborhoods or populations experiencing health
disparities).
3.4.4.1 These needs may
include, for example, the need to address financial and other barriers to
accessing care, to prevent illness, to ensure adequate nutrition, or to address
social, behavioral, and environmental factors that influence health in the
community.
3.5
"Commissioner" means the Commissioner of the Vermont Department of
Health.
3.6 "Department" means the
Vermont Department of Health.
3.7
"Hospital" or "Community Hospital" means a place licensed under Chapter 43 of
Title 18 devoted primarily to the maintenance and operation of diagnostic and
therapeutic facilities for in-patient medical or surgical care of individuals
who have an illness, disease, injury, or physical disability, or for
obstetrics.
3.8 "Hospital Report
Card" means a compilation of standardized quality and financial information for
statewide comparisons by hospital.
3.9 "Implementation Plan" means the specific
plan to address the results of the Community Health Needs Assessment developed
by a hospital. This plan includes a description of identified health needs,
strategic initiatives developed to address the identified needs, annual
progress on implementation of the proposed initiatives, and opportunities for
public participation.
3.10
"Psychiatric Hospital" means a hospital for the diagnosis and treatment of
mental illness, as defined in
18 V.S.A. §
1902.
3.11 "Reliability" means the consistency of a
measure. A reliable measure of quality should produce consistent results when
repeated in the same population and setting, even when assessed by different
people at different times. Any variation in a quality measure should reflect a
true change in quality and not errors produced by the measurement itself. Such
inconsistencies and errors occur when trying to measure quality in rare events
(e.g., mortality), a small number of events (e.g., small hospitals may conduct
very few of a specific procedure), or restricted samples of events (e.g.,
counting occurrence of an event over a relatively short period of time).
Quality measures should be repeated periodically, and any changes in the
measures should reflect a true change in quality.
3.12 "Validity" means the accuracy of a
measure, so that a specific quality indicator measures what it is intended to
measure. Reliability is a prerequisite to validity, but does not guarantee a
valid measure. The validity of a quality measure is assessed by whether it
makes sense logically and clinically, correlates well with other measures of
the same aspects of quality, and captures the meaningful aspects of quality.
Quality measures should be linked to significant processes or outcomes of care
as demonstrated by established scientific studies.
Section 4.0 Reporting Requirements to the Department
The Department may require hospitals to report measures by payer, race, gender, socioeconomic status, or other variables indicative of equity in treatment or access. In addition, the Department may require hospitals to report only on measures for which there are enough cases to make reporting reliable. The Department, in consultation with experts in quality measurement, will determine what constitutes adequate case numbers for public reporting. Measures reported to the Health Department may include:
4.1 Quality, patient safety and infection
rate measures
4.1.1 Hospitals shall submit
valid, reliable, and useful information per the Annual Reporting
Manual.
4.2 Nurse
Staffing Information
4.2.1 Hospitals shall
submit valid, reliable, and useful information on nurse staffing, in accordance
with the Annual Reporting Manual.
4.2.2 This information may include
system-centered measures such as skill mix, nursing care hours per patient day,
and other system-centered measures for which reliable industry benchmarks
become available.
4.3
Information on Hospital Pricing
4.3.1
Community hospitals shall submit information on hospital pricing to the
Department using a template, and following a deadline established in the Annual
Reporting Manual. Community hospitals shall also respond to the Department's
comments and questions after the initial submission, and validate the data the
Department produces prior to the publication of the Report, as specified in the
Annual Reporting Manual.
4.3.2 This
information shall include:
4.3.2.1 A
comparison of cost for higher volume health care services; and
4.3.2.2 Any other services to be determined
by the Commissioner and to include an array of hospital and/or physician
services.
Section 5.0 Requirements for Publication on Community Hospital Websites
Community hospitals shall post the following on their website:
5.1 Community Health Needs
Assessment in accordance with the Internal Revenue Service, Annual Reporting
Manual, and any other Green Mountain Care Board reporting requirements. This
shall include the following:
5.1.1 A
description of where and how consumers may obtain detailed, information about,
or a copy, of the hospital's Community Health Needs Assessment and strategic
plan.
5.1.2 Contact information
including, but not limited to, the telephone numbers, email addresses, fax
numbers and postal addresses of the person in charge of the Community Health
Needs Assessment at the hospital.
5.2 Implementation Plan which shall include a
description of initiatives that the hospital is undertaking or plans to
undertake to meet community health needs identified through the hospital's
Community Health Needs Assessment.
5.3 An Annual Progress Report of the
Implementation Plan, as described in the Annual Reporting Manual, of the
proposed initiatives;
5.4 A summary
description of the hospital's process for achieving openness, inclusiveness and
meaningful public participation in its Community Health Needs Assessment,
strategic planning, decision-making and identification of community health
needs. Such description shall include:
5.4.1.1 The manner in which the hospital has
incorporated meaningful public participation into its strategic planning,
decision-making and identification of health care needs in its service
area;
5.4.1.2 A listing of the
activities that are available for public participation (e.g., volunteer
opportunities, regional or community partnerships, public meetings, community
events, interviews with key community leaders, surveys, and/or focus groups);
and
5.4.1.3 Contact information,
including but not limited to the department(s), telephone numbers, e-mail
addresses, fax numbers and postal addresses at the hospital for consumers to
use if interested in learning about public participation events; website
references may also be included;
5.5 Hospital governance information including
the following:
5.5.1 Means of obtaining a
schedule of meetings of the hospital's governing body, including times
scheduled for public participation; and
5.5.2 A listing of current governing body
members and their qualifications, as required in
18 V.S.A. §
9405b(b) (3), including each
member's:
5.5.2.1 Name;
5.5.2.2 Town of residence;
5.5.2.3 Occupation;
5.5.2.4 Employers and job title;
and
5.5.2.5 The amount of
compensation, if any, for serving on the governing body.
5.5.2.6 Contact information including, but
not limited to, the telephone numbers, e-mail addresses, fax numbers and postal
addresses of the person responsible for public participation at the
hospital.
5.5.3 The
hospital's affiliation and membership with other hospital, Accountable Care
Organizations (ACOs), and/or other managing entities described in the Annual
Reporting Manual.
5.6
Summary of the hospital's consumer complaint resolution process, including but
not limited to:
5.6.1 A description of the
complaint resolution process, including how to register a complaint;
5.6.2 Contact information, including but not
limited to telephone numbers, e-mail addresses, fax numbers and postal
addresses for the hospital employee(s) responsible for the implementation of
the complaint resolution process;
5.6.3 Contact information, including but not
limited to telephone numbers, email addresses, fax numbers and postal addresses
for Department of Disability, Aging, and Independent Living, Licensing and
Protection Division in order to register a complaint against the hospital;
and
5.6.4 Contact information for
other relevant organizations as described in the Annual Reporting
Manual.
5.7 Financial
Assistance Policies as required by the Internal Revenue Service
(IRS).
Section 6.0 Requirements for Publication on Psychiatric Hospital Websites
Psychiatric hospitals shall post the following on their website:
6.1 Quality of Care measures
as described in the Annual Reporting Manual;
6.2 Hospital financial and budget information
as described in the Annual Reporting Manual;
6.3 Hospital pricing information following
the template established in the Annual Reporting Manual and described in
section 4.3 of this rule;
6.4
Information of hospital-acquired infections;
6.5 A description of the hospital's strategic
plan, identified areas of need, and strategic initiatives aimed at addressing
those needs.
6.6 Hospital
governance information as described in section 5.4 of this rule;
6.7 Summary of the hospital's consumers
complaint resolution process as described in section 5.5 of this rule;
and
6.8 Financial Assistance
Policies as described in the Annual Reporting Manual.
Section 7.0 Paper copies of reports
Should an individual or member of the public need a paper copy of any item listed in sections 4.0 - 7.0 of this rule, the hospital will make a paper copy available.
Section 8.0 Reporting by Green Mountain Care Board
The Green Mountain Care Board shall publish reports, based on information provided by hospitals during the budget review process, which shall include:
8.1 Finances: Summaries of
the hospitals' finances, including but not limited to ratios, statistics and
indicators relating to liquidity, cash flow, productivity, surplus, charges and
payer mix. Such ratios, statistics and indicators shall represent two years of
actual results and current budget year.
8.2 Budgets: Summaries of the hospitals'
budgets which represent two years of actual results and current budget
year.
8.3 Cost Shift:
Quantification of cost shifting from public payers to private payers for one
year of actual results and current budget year.
8.4 Key Performance Indicators: Summaries of
the hospitals' capital key performance indicators for two years of actual
results and current budget year.
8.5 Capital Investments: Summaries of capital
expenditures and plans for one to four years.
Section 9.0 Process for Adding Reporting Measures
9.1 The Department will consider
relevant criteria in evaluation of potential measures for inclusion in the
reporting manual, including but not limited to:
9.1.1 Reliability;
9.1.2 Validity;
9.1.3 Basis in scientific evidence; 9.1.4
National consensus;
9.1.4 National
consensus;
9.1.5 Availability of
relevant, reliable and valid external benchmarks;
9.1.6 Well-developed
specifications;
9.1.7 Importance to
consumers;
9.1.8 Adequacy of case
numbers;
9.1.9 Cost of data
collection; and
9.1.10 Importance to
public health protection.
9.2 Measures requiring new data collection by
the hospitals:
When the Department wishes to add measures to reporting requirements that require new data collection not currently required by state or federal requirements, the Department will:
9.2.1 Solicit input from patient safety
experts, hospitals, health care professionals, consumer advocates and members
of the public.
9.2.1.1 The Department will
convene a meeting with at least one member from each group listed in 9.2.1 of
this rule.
9.2.1.2 The Department
will send a detailed list of the proposed measures with their specifications
and the reason the measure is being proposed to the group no later than 2 weeks
prior to the first meeting.
9.2.1.3
If a stakeholder is unable to attend the meeting the Department will accept
written comments until the close of business on the scheduled meeting day.
9.2.1.4 After the conclusion of
the meeting, the Department will compile the feedback from the group and
respond in writing to the feedback and make any changes deemed reasonable prior
to notifying hospitals of the new measures per 9.2.2 of this rule.
9.2.2 Notify hospitals of the new
measures 180 days prior to the inception date for data collection with respect
to such measures.
9.3 The
Department will, whenever possible, use measures that are required by other
measure stewards. Measures adopted by the Department from external sources are
the same specifications as those of the original measures steward unless
specified otherwise.
9.3.1 Hospitals must
adhere to reporting and submission requirements and deadlines set by the
measure stewards. Specifications will be provided in the Annual Reporting
Manual.
9.3.2 Examples of measure
stewards are: Centers for Medicare and Medicaid Services (CMS), Vermont Program
for Quality in Health Care (VPQHC), National Healthcare Safety Network (NHSN),
Green Mountain Care Board (GMCB), Internal Revenue Service (IRS), and Vermont
Association of Hospitals and Health Systems (VAHHS).
9.4 Measures included in existing federal or
state reporting:
9.4.1 When the Department
adds measures to the reporting requirements that do not require new data
collection processes, the Department will notify hospitals by December 1 of the
year prior to the scheduled June 1 publication date.
9.4.2 The timeline for reporting the new
measures will be dependent on the type of measure and will be specified in the
Annual Reporting Manual.
STATUTORY AUTHORITY:
R.I.G.L. 18 V.S.A. §§ 1919, 9405a, 9405b
Disclaimer: These regulations may not be the most recent version. Vermont may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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