All hospitals are encouraged to review newly released hospital-specific reports for the Hospital-Acquired Condition (HAC) Reduction Program, accessed on QualityNet. These reports correct an error that previously excluded the first six months of 2014 data on Surgical Site Infections (SSIs). Omission of these data may have impacted possible payment adjustments for hospitals as well as results on the following:

  • SSI (colon and hysterectomy) measure standardized infection ratios (SIRs)
  • measure scores
  • domain 2 scores
  • total HAC scores

The Centers for Medicare & Medicaid Services (CMS) has also opened a second review and corrections period to focus on data elements directly impacted by the incomplete data. CMS encourages hospitals to submit corrections before Oct. 21. Hospitals may only submit corrections related to data elements directly impacted by the error – SIRs, domain 2, and total HAC scores. Hospitals cannot submit additional corrections related to other portions of the reports.

If you have questions or concerns, please contact Erin O’Malley, director of policy, at eomalley@essentialhospitals.org or 202.585.0127.