# COMAR Title 10 — Maryland Department of Health

## Subtitle 25 — Maryland Health Care Commission

### Chapter 04 — Hospital Quality and Performance Evaluation System

**Authority:** Health-General Article, §§19-109(a)(1) and (7) and 19-134(e), Annotated Code of Maryland

**Administrative History:** Effective date: October 15, 2001 (28:20 Md. R. 1783)

**Administrative History:** Regulation .04 amended effective December 23, 2002 (29:25 Md. R. 1982)

**Administrative History:** Chapter revised effective June 16, 2008 (35:12 Md. R. 1120)

#### Regulation .01 Definitions.

*COMAR 10.25.04.01*

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

  (1) “Commission” means the Maryland Health Care Commission.

  (2) “Hospital” has the meaning stated in Health-General Article, §19-301, Annotated Code of Maryland.

#### Regulation .02 Hospital Evaluation — Data Collection and Reporting Requirements.

*COMAR 10.25.04.02*

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 ORYXR 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.

#### Regulation .03 Summary Studies, Reports, and Compilations.

*COMAR 10.25.04.03*

A. Subject to §B of this regulation, summary studies, reports, or other compilations of data developed by the Commission from the data submitted in accordance with this chapter are public information.

B. Disclosure under §A of this regulation may not be made in such a way that the data furnished for a specific patient can be identified.

C. The Commission shall publish annually, on a comparative basis, the results of the quality and performance evaluation system through one or more reports. The reports may also compare hospital performance to public health goals established by the Secretary of Health or the United States Public Health Service, United States Department of Health and Human Services.

#### Regulation .04 Extension of Time.

*COMAR 10.25.04.04*

A. A hospital may request an extension of time of up to 30 days for submission of data required in Regulation .02 of this chapter.

B. The hospital shall:

  (1) Submit the request to the Executive Director of the Commission not later than 30 days before the data are due;

  (2) Explain the reason for the extension request; and

  (3) Propose a reasonable specific date for submission of the report.

C. A hospital may file a written petition with the Commission for review of a denial of an extension of time request.

D. The Commission shall review the decision of the Executive Director. The Commission may affirm, reverse, or modify the decision of the Executive Director after providing the hospital with an opportunity to present its position to the Commission.

#### Regulation .05 Penalty for Failure to File Reports.

*COMAR 10.25.04.05*

A hospital that does not timely file data may be subject to penalties described in COMAR 10.25.12.