Data Collection

PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program

The PCHQR program is comprised of multiple types of measures that are collected by participating PPS-Exempt Cancer Hospitals using a variety of tested data collection instruments. These measures have different sampling requirements, reporting methods, and data submission deadlines.

A facility can request an extension or waiver of various Quality Reporting Program requirements due to extraordinary circumstances beyond the control of the facility. To request an extension or waiver, complete and submit the Extraordinary Circumstances Exception form within 30 days of the disaster or extraordinary circumstance.

A facility may submit a Measure Exception Request Form due to no/low procedure volumes. Refer to listserve 2018-14-PCH for specifics.

Table 1: Safety and Healthcare-Associated Infection (HAI) Measures


NQF # PCH # Measure Name Specifications Manual & Measure Information Forms Data Collection Tool Acceptable Method of Transmission
0139 PCH-4 NHSN Central line-associated bloodstream infection (CLABSI) outcome CLABSI NHSN Resources CLABSI data collection tool National Healthcare Safety Network (NHSN)
0138 PCH-5 NHSN Catheter-associated urinary tract infection (CAUTI) outcome CAUTI NHSN Resources CAUTI data collection tool National Healthcare Safety Network (NHSN)
0753 PCH-6 and PCH-7 Harmonized procedure specific surgical site infection (SSI) outcome SSI NHSN Resources SSI data collection tool National Healthcare Safety Network (NHSN)
1717 PCH-26 CDC NHSN Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome CDI Resources CDI data collection tool National Healthcare Safety Network (NHSN)
1716 PCH-27

CDC NHSN Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylocccus aureus (MRSA) Bacteremia Outcome

MRSA NHSN Resources MRSA data collection tool National Healthcare Safety Network (NHSN)
0431 PCH-28 CDC NHSN Influenza Vaccination Coverage Among Healthcare Personnel (HCP) HCP NHSN Resources HCP data collection tool National Healthcare Safety Network (NHSN)

Table 2: Clinical Process/Cancer-Specific Treatment Measures


NQF # PCH # Measure Name Specifications Manual & Measure Information Forms Data Collection Tool Acceptable Method of Transmission
0223 PCH-1 Adjuvant chemotherapy is considered or administered within four months (120 days) of diagnosis to patients under the age of 80 with AJCC III (lymph node positive) colon cancer Colon measure specifications Data obtained from cancer registry Web-based data entry via QualityNet Secure Portal
0559 PCH-2 Combination chemotherapy is considered or administered within four months (120 days) of diagnosis for women under 70 with AJCC T1c, or stage II or III hormone receptor negative breast cancer Breast measure specifications Data obtained from cancer registry Web-based data entry via QualityNet Secure Portal
0220 PCH-3 Adjuvant hormonal therapy Hormonal therapy measure specifications Data obtained from cancer registry Web-based data entry via QualityNet Secure Portal

Table 3: Clinical Process/Oncology Care Measures (OCM)


NQF # PCH # Measure Name Specifications Manual & Measure Information Forms Data Collection Tool Acceptable Method of Transmission
0382 PCH-14 Oncology: Radiation dose limits to normal tissues Web-based data entry via QualityNet Secure Portal
0383 PCH-15 Oncology: Plan of care for pain Web-based data entry via QualityNet Secure Portal
0384 PCH-16 Oncology: Pain intensity quantified Web-based data entry via QualityNet Secure Portal
0389 PCH-18 Prostate cancer: Avoidance of overuse measure of bone scan for staging low risk prostate cancer patients Web-based data entry via QualityNet Secure Portal
0390 PCH-17 Prostate cancer: Combination androgen deprivation therapy for high risk or very high risk prostate cancer Web-based data entry via QualityNet Secure Portal
0210 PCH-32 Proportion of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life Measure information form under development None (This is a claims-based measure.) This data will be submitted by CMS contractor on behalf of the PCH.
0215 PCH-34 Proportion of Patients Who Died from Cancer Not Admitted to Hospice Measure information form under development None (This is a claims-based measure.) This data will be submitted by CMS contractor on behalf of the PCH.

Table 4: Intermediate Clinical Outcome Measures


NQF # PCH # Measure Name Specifications Manual & Measure Information Forms

Data Collection Tool

Acceptable Method of Transmission
213 PCH-33 Proportion of Patients Who Died from Cancer Admitted to the ICU in the Last 30 Days of Life Measure information form under development None (This is a claims-based measure.) This data will be submitted by CMS contractor on behalf of the PCH.
0216 PCH-35 Proportion of Patients Who Died from Cancer Admitted to Hospice for Less Than Three (3) Days Measure information form under development None (This is a claims-based measure.) This data will be submitted by CMS contractor on behalf of the PCH.

Table 5: Clinical Effectiveness Measure


NQF # PCH # Measure Name Specifications Manual & Measure Information Forms

Data Collection Tool

Acceptable Method of Transmission
N/A PCH-25 External beam radiotherapy for bone metastases (EBRT) Web-based data entry via QualityNet Secure Portal

Table 6: Patient Engagement/Experience of Care Measure


NQF # PCH # Measure Name Specifications Manual & Measure Information Forms

Data Collection Tool

Acceptable Method of Transmission
0166 PCH- 29 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Technical Specifications Survey instrument or approved survey vendor Submitted by vendor or upload via the QualityNet Secure Portal using the online data entry tool or in XML format

Table 7: Claims-Based Outcome Measure


NQF # PCH # Measure Name Specifications Manual & Measure Information Forms

Data Collection Tool

Acceptable Method of Transmission
N/A PCH- 30 and PCH-31 Admissions and Emergency Department (ED) Visits for Patients Receiving Outpatient Chemotherapy 2017 Admissions and Emergency Department (ED) Visits for Patients Receiving Outpatient Chemotherapy measure information form None. (This is a claims-based measure.) This data will be submitted by CMS contractor on behalf of the PCH.
3188 N/A 30-day Unplanned Readmissions for Cancer Patients Measure information form under development None. (This is a claims-based measure.) This data will be submitted by CMS contractor on behalf of the PCH.

QualityNet requires Internet Explorer with JavaScript enabled on it.

Steps to enable JavaScript in Internet Explorer
  1. Click on the Tools menu option at the top of the page.
  2. Select Internet Options from the drop-down menu.
  3. From the dialog box, choose the Security tab.
  4. Click on Custom Level.
  5. Set Active Scripting to Enable.
  6. Click OK to close the custom settings dialog.
  7. Click OK to close the Options dialog.