1

A Guide to Assigning Program Management QualityNet Exchange Administrator Roles

September 2007

Minnesota’s Medicare Quality Improvement Organization (QIO)

This material was created by Stratis Health, the Medicare Quality Improvement Organization for Minnesota, under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S Department of Health and Human Services.

The contents do not necessarily reflect CMS policy. 8SOW-MN-GEN-07-35 09.2007

Assigning Program Management QualityNet Exchange Administrator Roles

2

What is Program Management? Program Management is a new category and function that has been added to QualityNet Exchange (www.qualitynet.org). The purpose of Program Management is for:

Measure Designation Provides online self-serve functionality for hospitals and vendors to select and maintain their measure designation for each quarter and each clinical topic for acute myocardial infarction (AMI), heart failure (HF), pneumonia (PN), and the Surgical Care Improvement Project (SCIP) submitted to the QIO Clinical Warehouse.

ICD Population & Sampling Allows self-reporting of sampling status and the number of discharges meeting topic eligibility for the four national clinical topics for each calendar quarter.

How do I find the Program Management function of QualityNet Exchange? QualityNet Exchange Administrators do not have access to view the Program Management function in the QualityNet Exchange Web site until they have been assigned Program Management roles. (Step-by-step instructions on how to assign roles are included on page 6 of this document.)

The Program Management roles are assigned within QualityNet Exchange. One QualityNet Administrator at a facility can assign the Program Management roles to the other QualityNet Administrator at the same facility. A QualityNet Administrator may not assign roles to him/herself. If a facility has only one QualityNet Administrator, Stratis Health has already assigned the roles for that facility.

Accessing the Program Management area of QualityNet Exchange and Performing Measure Designation:

1. Go to www.qualitynet.org 2. Click on the green QNet Exchange Login button. 3. Enter your QualityNet Exchange ID and password and click Login. 4. When the home page loads, you will see a heading called Provider Self-Serve on the left-

hand side on the bottom of the page. Click on the link called Program Management below that heading.

5. Another window will come up and you will then need to enter your QualityNet Exchange ID and password again, because this is a separate area.

6. On the next page, on the left-hand side, you will see an area with ICD Population & Sampling and Measures Designation. Click on Measures Designation to get to the Measures Designation page.

7. On the Measures Designation page, make sure your facility name and provider ID is showing in the pull-down menu next to Provider Name.

8. For Reporting Period, select the quarter that applies to the files you are preparing to submit. (For example, if you are getting ready to submit files for July-September 2007 discharges, you will need to select Quarter 3 for the Reporting Period.)

Assigning Program Management QualityNet Exchange Administrator Roles

3

9. Now click the Go button to be taken to the Measure Designation Summary Screen. Click on the Edit button for the Topic for which you need to edit the measures, and then select or deselect the measure(s) you need to update. When the box is white, you will be able to select or deselect measures. Prospective Payment System (PPS) providers will not be able to deselect the measures that have a red asterisk in front of them. Public reporting of these measures is required for Medicare annual payment update. If you are unsure whether or not the correct measures have been selected, please contact either Nancy Wolf at 952-853-8582, or the National HelpDesk at 1-866-288-8912.

10. Return to the Measures Designation Summary screen. Select Save if you wish to save the changes you made or select Cancel if changes do not need to be saved. You may now close out of the page if you are finished.

Does my hospital need to be concerned about assigning Program Management roles for my organization’s QualityNet Exchange Administrators? Yes. This document applies to all hospitals—both prospective payment system (PPS) hospitals and critical access hospitals (CAHs).

• PPS - The Centers for Medicare & Medicaid Services (CMS) Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) Fiscal Year 2008 Reference Checklist (found at www.qualitynet.org on the left navigation bar: Hospitals/RHQDAPU/How to Participate) identifies the need for PPS hospitals to submit aggregate population and sample size counts for Medicare and non-Medicare discharges for AMI, HF, PN, and SCIP on a quarterly basis to CMS via QualityNet Exchange. NOTE: This is not a requirement for fiscal year 2008 Annual Payment Update. However, it will be phased in over the coming year in preparation for fiscal year 2009 RHQDAPU requirements.

• CAHs - Although CAHs do not participate in the RHQDAPU program requirements, if you are submitting data to the QIO Clinical Warehouse you will need to participate in components of the Program Management process. Presently, your QualityNet Exchange Administrators will need to have Program Management roles assigned and will need to designate the measures you are submitting to the QIO Clinical Warehouse.

What is Measures Designation? All hospitals (PPS and CAH) will need to enter their measure designations (the clinical measures your organization is currently submitting to the QIO Clinical Warehouse) and then update only when additional measures are added or a hospital wishes to discontinue collection of a measure(s). Measure designations will be carried forward to subsequent quarters. Measures that have been deselected will remain deselected (check mark removal) until they are reselected (check mark added). The measure designation fields in the Program Management area of QualityNet Exchange are defaulted to all measures, excluding test measures, for all hospitals.

Assigning Program Management QualityNet Exchange Administrator Roles

4

• PPS - You will not need to change your measure designation unless: Your organization submits the two AMI test measures (these measures have not been

automatically selected) or You do not wish to submit SCIP-Inf 4, 6, 7, and Card 2 (these measures have been

selected). • CAH -You will need to review the automatic measure selections and de-select measures

you are currently not submitting to the Warehouse. For many CAH this may include the AMI and SCIP measures.

What happens if I do not deselect measures? If you do not deselect the measures (remove the check mark from the box) you are currently not submitting to the Warehouse, cases may be rejected if all the elements needed to calculate the measure are not submitted. Measure designation in QualityNet Exchange should accurately reflect the measures you submit to the QIO Clinical Warehouse each quarter. What if I need to change my measures but I have already submitted my cases? If measure changes are needed and files have already been submitted, the files for the measures requiring the change will need to be deleted from the QIO Clinical Warehouse. Contact the National HelpDesk to assist you (1-866-288-8912). You may then edit your measure designation (see above topic - How do I find the Program Management function of QualityNet Exchange) and the files will need to be resubmitted to the QIO Clinical Warehouse. What is the deadline for completing Measures Designation? All hospitals need to complete the measures designation process prior to submitting data to the QIO Clinical Warehouse for 2Q 2007 (April-May-June). The deadline for data submission for this quarter is November 15, 2007. Be aware that if your QualityNet Administrator account has been made inactive due to disuse, it could take as long as five business days for it to be reactivated by the National HelpDesk Security team so that these roles can be assigned for your facility. Also, close to the submission deadline, the QualityNet Web site can be extremely slow and wait times on the National HelpDesk phone lines can be long. Please plan accordingly so that you are able to submit your data in time. Vendor users - Many vendors submit data to the QIO Clinical Warehouse well in advance of the submission deadline. You should complete measures designation as soon as possible. Authorized contracted vendors can also designate the measures they will be submitting for a reporting discharge period. Consult with your vendor to determine who will complete the initial measures designation process. CART users - If you are using CART for data collection and submission, you need to complete measures designation prior to exporting and uploading your data for 2Q 2007 submission.

Assigning Program Management QualityNet Exchange Administrator Roles

5

What is ICD population & sampling? The ICD population and sampling function in Program Management allows hospitals or their vendors to enter the Medicare and non-Medicare population and the sample size for each quarter of a reporting period. The sample size requirements are based on the Specifications Manual for National Hospital Quality Measures found on the QualityNet Exchange Web site.

This function is proposed to begin with 4Q 2007 data submission (May 15, 2008) and will need to be completed prior to the data submission deadline. For the May 15, 2008, deadline, population and sampling data for each clinical topic will need to be completed by May 1, 2008, and quarterly thereafter.

NOTE: Neither PPS or CAH hospitals are required to complete the ICD Population and Sampling at this time. Additional information will be forthcoming from CMS regarding the ICD Population & Sampling function and start date. What are my next steps? QualityNet Exchange Administrators at each hospital will need to assign the new Program Management roles within their own organization.

Identify who at your hospital is the QualityNet Exchange Administrator. Contact Mary Montury at Stratis Health (www.mmontury@mnqio.sdps.org) or

952-853-8541 or the QualityNet Help desk if you do not know your QualityNet Exchange Administrator.

If you are the QualityNet Exchange Administrator and require the Program Management role(s), please contact your back-up QualityNet Exchange Administrator within your organization and request the role(s). You cannot grant role(s) to yourself. Most hospitals have two QualityNet Exchange Administrators.

This is a good time for all QualityNet Exchange Administrators to log into the secure QualityNet Exchange Web site. If a QualityNet Administrator has not logged in for over 120 days, CMS deactivates that person’s QualityNet Account. The account may be reinstated at the request of any QualityNet Administrators at the facility by calling the National HelpDesk at 1-866-288-8912, which can take up to five business days.

If you are the only QualityNet Exchange Administrator at your hospital, Stratis Health has already given you the Program Management role(s).

Why can’t the QIO (Stratis Health) or CMS assign these roles? Why do I need to assign the roles? CMS has implemented a new policy that assigns responsibility to the hospital QualityNet Exchange Administrators to grant additional roles. CMS will not allow automatic assignment of new roles. Stratis Health may only assign roles for hospitals with just one QualityNet Exchange Administrator. If you have questions regarding the Program Management function or the implementation timeline, contact Nancy Wolf, Program Manager, at nwolf@stratishealth.org or 952-853-8582.

Assigning Program Management QualityNet Exchange Administrator Roles

6

Step-by-Step Instructions: Please complete in the following sequence: Assigning Program Management Roles to QualityNet Exchange Administrators NOTE: You must complete all steps in the following process or the person whose QualityNet Exchange account your are modifying will not be able to log in. If you are interrupted during the process for long enough that the edit is not completed, simply start again at the beginning and proceed all the way through to the end. Step 1: Using Internet Explorer, go to QualityNet Exchange (www.qualitynet.org)

Click on the green QualityNet Exchange Login button. On the next page that loads (pictured below), enter your QualityNet Exchange ID and password, and click the Log-In button.

Step 1

Assigning Program Management QualityNet Exchange Administrator Roles

7

Step 2: Scroll down to the User Administration heading on the left hand side of the screen Click on the Edit User link.

Step 2

Assigning Program Management QualityNet Exchange Administrator Roles

8

Step 3: In the Select User to Edit screen, on the left hand side, you will see a folder with your Provider Name and ID next to it. Click on the plus sign on the left side of the folder to expand the folder. Step 4: Click where it says View all users in (Your Hospital Name and Provider ID), and on

the right hand side you will see a list of people at your facility who have been given QualityNet user accounts.

Step 5: Click on the name of the QualityNet Administrator whose account you wish to edit.

When it highlights in blue, click the Add selected user button, and the person’s name should appear in the Selected User box below.

Step 6: Click on the Edit Selected User link (shown in purple below the Selected User box).

Steps 3 & 4:

Step 5:

Step 6:

Assigning Program Management QualityNet Exchange Administrator Roles

9

Step 7: You will now come to the User Information screen next. Unless you have edits to do for the person’s basic information, just click on Continue on the bottom of the screen.

Step 7

Assigning Program Management QualityNet Exchange Administrator Roles

10

Step 8: Now you will come to the User System Permission screen. Make sure User Registration and QualityNet Exchange are selected and then click on Continue on the bottom of the screen.

User Role Permission Screen appears Under Program Management section, check the two boxes:

ICD Population Sampling Measure Designation

Add a screen shot Step 6:

Step 8

Assigning Program Management QualityNet Exchange Administrator Roles

11

Step 9: The next screen is the User Role/Detail Items screen. This is where the actual role assignment is made. There should already be a number of roles selected if you are granting Program Management roles to a QualityNet Administrator.

Under the Program Management heading, click into the boxes next to ICD Population Sampling Update and Measure Designation Update. You may now click Continue to go on to the next screen.

Step 9

Assigning Program Management QualityNet Exchange Administrator Roles

12

Step 10: The next screen is the User Role/Detail Items screen that provides confirmation that the changes you made have been saved.

Click on Continue on the bottom of the screen.

Step 10

Assigning Program Management QualityNet Exchange Administrator Roles

13

Step 11: Confirming the change The next screen is the User Role/Detail Items screen that provides confirmation that the changes you made have been saved.

Confirm that the Program Management role(s) is/are listed in the Requested Application and System Permissions list.

Enter the password you use to log into QualityNet in where it says Enter your password. Click Submit.

The assignment of Program Management roles is now complete. NOTE: Each Administrator should complete the role assignment process for the other facility Administrator, logging in using their own password to assign the Program Management roles. If you have questions about assigning Program Management roles in QualityNet Exchange, contact Mija Valdez, Helpdesk Support Specialist, at mvaldez@stratishealth.org or 952-853-8554.

Step 11