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<chapter num="04" heading="Hospital Quality and Performance Evaluation System" title_num="10" subtitle_num="25">
  <regulation prefix="Regulation" num=".01" heading="Definitions.">
    <paragraph num="A.">
      <text>In this chapter, the following terms have the meanings indicated.</text>
    </paragraph>
    <paragraph num="B.">
      <text>Terms Defined.</text>
      <paragraph num="(1)">
        <text>“Commission” means the Maryland Health Care Commission.</text>
      </paragraph>
      <paragraph num="(2)">
        <text>“Hospital” has the meaning stated in Health-General Article, §19-301, Annotated Code of Maryland.</text>
      </paragraph>
    </paragraph>
  </regulation>
  <regulation prefix="Regulation" num=".02" 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>
  <regulation prefix="Regulation" num=".03" heading="Summary Studies, Reports, and Compilations.">
    <paragraph num="A.">
      <text>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.</text>
    </paragraph>
    <paragraph num="B.">
      <text>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.</text>
    </paragraph>
    <paragraph num="C.">
      <text>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.</text>
    </paragraph>
  </regulation>
  <regulation prefix="Regulation" num=".04" heading="Extension of Time.">
    <paragraph num="A.">
      <text>A hospital may request an extension of time of up to 30 days for submission of data required in Regulation .02 of this chapter.</text>
    </paragraph>
    <paragraph num="B.">
      <text>The hospital shall:</text>
      <paragraph num="(1)">
        <text>Submit the request to the Executive Director of the Commission not later than 30 days before the data are due;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Explain the reason for the extension request; and</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Propose a reasonable specific date for submission of the report.</text>
      </paragraph>
    </paragraph>
    <paragraph num="C.">
      <text>A hospital may file a written petition with the Commission for review of a denial of an extension of time request.</text>
    </paragraph>
    <paragraph num="D.">
      <text>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.</text>
    </paragraph>
  </regulation>
  <regulation prefix="Regulation" num=".05" heading="Penalty for Failure to File Reports.">
    <text>A hospital that does not timely file data may be subject to penalties described in COMAR 10.25.12.</text>
  </regulation>
  <annotations>
    <annotation type="Authority">Health-General Article, §§19-109(a)(1) and (7) and 19-134(e), Annotated Code of Maryland</annotation>
    <annotation type="History" subtype="Administrative History">Effective date: October 15, 2001 (28:20 Md. R. 1783)</annotation>
    <annotation type="History" subtype="Administrative History">Regulation .04 amended effective December 23, 2002 (29:25 Md. R. 1982)</annotation>
    <annotation type="History" subtype="Administrative History">Chapter revised effective June 16, 2008 (35:12 Md. R. 1120)</annotation>
  </annotations>
</chapter>