Annual Quality Rule Update
Minnesota Statutes, section 62U.02 requires the Commissioner of Health to establish a standardized set of quality measures for health care providers across the state. To implement the collection of quality measurement data, the Minnesota Department of Health (MDH) has developed the Minnesota Statewide Quality Reporting and Measurement System (Quality Reporting System), created through Minnesota Rules, chapter 4654. This rule compels physician clinics and hospitals to submit data on a set of quality measures to be publicly reported and also establishes a broader standardized set of quality measures for health care providers across the state. MDH collects quality measure data, while health plans may only require providers to submit data on those measures that are part of the standardized set.
The Commissioner of Health is required to evaluate the measures included in the standardized set of quality measures every year. MDH updates the Quality Reporting System measure set annually through a process that includes seeking public comment and recommendations from the community, and concludes by issuing an updated administrative Rule. The Rule and appendices describe specific data elements that providers are required to submit to MDH for each measure.
Please subscribe to the Department's Statewide Quality Reporting and Measurement System Updates to stay informed of our rulemaking activities and opportunities to provide input.
Proposed Rule Amendments Published, Comments Requested
Minnesota Rules, Chapter 4654, Proposed Expedited Amendments to Rules Governing Health Care Quality Measures, was published in the October 23, 2017 edition of the State Register. This publication only includes the proposed changes to the rule.
MDH invites public comment on the proposed rule, appendices, and measure specifications during the 30-day public comment period. Written comments are due by 4:30 p.m. on Wednesday, November 22, 2017. Interested persons or groups must submit comments or questions to: Denise McCabe, Minnesota Department of Health, P.O. Box 64882, St. Paul, MN 55164-0882, (651) 201-3550, fax (651) 201-5179, and email@example.com.
MDH summarized key proposed changes for quality measurement and reporting during 2018 in the memo posted below.
The proposed rule amendments and appendices are available for download below.
- Minnesota Statewide Quality Reporting and Measurement System, Proposed Rule Amendments (PDF)
- Minnesota Statewide Quality Reporting and Measurement System: Appendices to Minnesota Administrative Rules, Chapter 4654, October 2017 (PDF)
Physician Clinic Measure Specifications Referenced in Appendix A
- Optimal Diabetes Care Composite (PDF)
- Optimal Vascular Care Composite (PDF)
- Depression Remission at Six Months (PDF)
- Optimal Asthma Control Composite (PDF)
- Asthma Education & Self-Management (PDF)
- Colorectal Cancer Screening (PDF)
- Pediatric Preventive Care: Adolescent Mental Health and/or Depression Screening (PDF)
- Total Knee Replacement Outcome (PDF)
- Spinal Surgery: Lumbar Fusion Outcome (PDF)
- Spinal Surgery: Lumbar Discectomy Laminotomy Outcome (PDF)
- Health Information Technology Survey for Physician Clinics (PDF)
Hospital Measure Specifications Referenced in Appendix B
- Hospital Readmissions Reduction Program Excess Readmission Score (PDF)
- Emergency Department Stroke Registry Door-to-Imaging Performed Time Indicator (PDF)
- Emergency Department Stroke Registry Time to Intravenous Thrombolytic Therapy Indicator (PDF)
Other Measure Specifications
- Additional Information about Minnesota Department of Human Services Quality Measures as Referenced in Minnesota Rules, Chapter 4654.0200, Subp. 19C (PDF)
Preliminary Comments - Closed
From June 16 through July 17, 2017, MDH invited interested stakeholders to:
- Provide input on physician clinic measurement priorities and opportunities for alignment;
- Review and comment on the Hospital Quality Reporting Steering Committee’s hospital measure recommendations; and
- Submit recommendations on the addition, removal, or modification of standardized quality measures for physician clinics and hospitals.
Preliminary comment materials:
- Invitation to Comment on Standard Set of Quality Measures (PDF)
- Physician Clinic Measure Considerations (PDF)
- Hospital Measure Recommendations (PDF)
On June 22, MDH, MN Community Measurement, and Stratis Health held a public forum to present quality measure recommendations and other related information in connection with the annual update of the Quality Reporting System for the 2018 reporting year. The public forum provided an opportunity for interested stakeholders to comment on the recommendations and to ask questions.
Rulemaking Key Milestones and Timeline
- MDH invites interested stakeholders to submit recommendations for standardized measures. Recommendations to add, remove, or modify measures must relate to one or more of the criteria outlined below.
- MDH receives hospital quality measure recommendations from the Hospital Quality Reporting Steering Committee and invites public comment on them.
- Mid-year, MDH convenes a public forum with Stratis Health and MN Community Measurement to present and discuss measure recommendations, and changes to measure specifications.
- During October, MDH publishes a proposed rule in the State Register and opens a 30-day public comment period on the proposed rule and appendices.
- MDH adopts the final rule and publishes it in the State Register by the end of the year.
Standardized Measure Recommendations Criteria
The standardized set of quality measures includes the measures for which the Department directly collects data, as well as a broader set for which health plans may require providers to submit data. The Commissioner of Health established these measures in Minnesota Rules, chapter 4654, and is required to review them on an annual basis.
Recommendations must address how addition, removal, or modification of a quality measure relates to one or more of the following criteria:
- the magnitude of the individual and societal burden imposed by the clinical condition being measured by the quality measure, including disability, mortality and economic costs;
- the extent of the gap between current practices and evidence-based practices for the clinical condition being measured by the quality measure, and the likelihood that the gap can be closed and conditions improved through changes in clinical processes;
- the relevance of the quality measure to a broad range of individuals with regard to (1) age, gender, socioeconomic status, and race/ethnicity (2) the ability to generalize quality improvement strategies across the spectrum of health care conditions, and (3) the capacity for change across a range of health care settings and providers;
- the extent to which the quality measure has either been developed or accepted, or approved through a national consensus effort;
- the extent to which the results of the quality measure are likely to demonstrate a wide degree of variation across providers; and
- the extent to which the quality measure is valid and reliable.