<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".02" citation="COMAR 10.25.04.02" title_num="10" subtitle_num="25" chapter_num="04" heading="Hospital Evaluation — Data Collection and Reporting Requirements.">
  <paragraph num="A.">
    <text>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:</text>
    <paragraph num="(1)">
      <text>National Quality Forum;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Hospital Quality Alliance;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Quality Indicator Project of the Maryland Hospital Association;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Agency for Healthcare Research and Quality;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Hospital Quality Initiative of the Centers for Medicare and Medicaid Services;</text>
    </paragraph>
    <paragraph num="(6)">
      <text>Centers for Disease Control and Prevention's National Healthcare Safety Network;</text>
    </paragraph>
    <paragraph num="(7)">
      <text>Joint Commission's ORYXR initiative; or</text>
    </paragraph>
    <paragraph num="(8)">
      <text>Work of academic, professional, healthcare research, and patient safety organizations.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>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:</text>
    <paragraph num="(1)">
      <text>Acute myocardial infarction;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Cardiac surgery and angioplasty;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Emergency department care;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Healthcare-associated infections;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Heart failure;</text>
    </paragraph>
    <paragraph num="(6)">
      <text>Maternity and newborn care;</text>
    </paragraph>
    <paragraph num="(7)">
      <text>Patient experience;</text>
    </paragraph>
    <paragraph num="(8)">
      <text>Patient safety;</text>
    </paragraph>
    <paragraph num="(9)">
      <text>Pediatric care;</text>
    </paragraph>
    <paragraph num="(10)">
      <text>Pneumonia;</text>
    </paragraph>
    <paragraph num="(11)">
      <text>Health information technology; and</text>
    </paragraph>
    <paragraph num="(12)">
      <text>Intensivist staffing.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>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.</text>
  </paragraph>
</regulation>