N.J. Admin. Code § 8:43G-27.6

Current through Register Vol. 56, No. 9, May 6, 2024

Section 8:43G-27.6 - Performance measurement and assessment system

(a) The Department shall establish a Quality Improvement Advisory Committee (QIAC), including provider, consumer and individuals with quality of care research expertise representation, to advise the Department in developing a hospital performance measurement and assessment system. The data collected through this system shall be used by the Department to:

1. Promote the standardized reporting of data by hospitals;

2. Provide the Department with information on the performance of hospitals to support the Department's oversight role;

3. Assist general hospitals to measure and improve the quality of care provided within their facilities;

4. Support efforts to inform consumers about performance of individual hospitals and the industry as a whole; and/or

5. Any other purpose consistent with this chapter, particularly N.J.A.C. 8:43G-17.

(b) The Quality Improvement Advisory Committee shall advise the Department on the development of a uniform data reporting system to obtain reliable, standardized and comparable information from all hospitals. This quality performance measurement reporting system may include measures of:

1. Processes of care demonstrated to significantly enhance patient outcomes;

2. Patient outcomes, risk-adjusted where feasible and appropriate;

3. Patient satisfaction with the care provided; and

4. Other indicators of care as recommended by the QIAC.

(c) To minimize costs to hospitals and the Department, performance measures shall incorporate, when possible, data routinely collected by hospitals or available to the Department from other sources. Data for this quality performance measurement system may be derived from, but not limited to, the following:

1. Medical record chart review;

2. Patient satisfaction surveys;

3. Computerized health care encounter data; and

4. Administrative data systems including billing data.

(d) Where applicable, the Department shall use nationally recognized performance measurements/indicators to promote cost-effective collection and reporting of data.

(e) Hospitals shall submit quality performance measurement data as the Department shall request from time to time directly from each hospital.

(f) The Department may conduct audits of each hospital's performance measurement indicator data including on-site audits, where applicable.

(g) During the development and implementation of the uniform data reporting system, the QIAC shall address the following:

1. The relevance, validity and reliability of each measure selected to be an indicator of performance;

2. Methods for improving the quality of care in hospitals;

3. Protection of confidentiality of patient-specific information;

4. Cost and difficulty of data collection;

5. Measures to reduce duplicative reporting of information;

6. Public release of data in formats useful to purchasers and/or consumers; and

7. Methods for efficient utilization of resources.

(h) The QIAC shall meet on an ongoing basis to evaluate data as it is received by the Department, and shall advise the Department on processes for disseminating analyses of data collected in order to promote improved performance.

N.J. Admin. Code § 8:43G-27.6

New Rule, R.1999 d.436, effective 12/20/1999.
See: 31 New Jersey Register 367(a), 31 New Jersey Register 614(a), 31 New Jersey Register 4293(c).
Public Notice: Postponement of effective date for hospitals to report indicators of care.
See: 33 New Jersey Register 2348(a).
Amended by R.2003 d.308, effective 8/4/2003.
See: 34 New Jersey Register 3944(a), 35 New Jersey Register 3556(b).
Rewrote the section.