29796 Federal Register / Vol. 83, No. 123 / Tuesday, June 26, 2018 / Notices 

100. Kathleen Cooper-Loher, 

Marshfield, Wisconsin, Court of 

Federal Claims No: 18–0769V 

101. Kerstina Alexander on behalf of 

M.A., Deceased, Woodbridge, 

Illinois, Court of Federal Claims No: 

18–0770V 

102. Henry Milligan, Jr., Orlando, 

Florida, Court of Federal Claims No: 

18–0771V 

103. Cheryl Thompson, South Bend, 

Indiana, Court of Federal Claims 

No: 18–0772V 

104. Olivia Gallegos, Fresno, California, 

Court of Federal Claims No: 18– 

0773V 

105. Jacie Albanez and Mario Albanez 

on behalf of N.A., San Diego, 

California, Court of Federal Claims 

No: 18–0774V 

106. Scott Kelbick, Avondale, Arizona, 

Court of Federal Claims No: 18– 

0775V 

107. Elizabeth Phenneger, Spokane, 

Washington, Court of Federal 

Claims No: 18–0776V 

[FR Doc. 2018–13593 Filed 6–25–18; 8:45 am] 

BILLING CODE 4165–15–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Health Resources and Services 

Administration 

Proposed Standards for the Children’s 

Hospitals Graduate Medical Education 

Payment Program’s Quality Bonus 

System 

AGENCY: Health Resources and Services 

Administration (HRSA), Department of 

Health and Human Services. 

ACTION: Final response. 

SUMMARY: HRSA published a notice in 

the Federal Register on October 11, 

2017, soliciting feedback on the 

establishment of the Children’s 

Hospitals Graduate Medical Education 

Payment (CHGME) Program’s Quality 

Bonus System (QBS). In particular, 

HRSA requested feedback on the Fiscal 

Year (FY) 2019 and beyond multi-step 

implementation of the system, including 

demonstration of engagement in state or 

regional-level initiatives, 

documentation, and payment structure. 

This notice summarizes and responds to 

the comments received during the 60- 

day comment period. 

ADDRESSES: Additional information 

about the CHGME is available at https:// 

bhw.hrsa.gov/grants/medicine/chgme. 

FOR FURTHER INFORMATION CONTACT: 

Malena Crawford, Project Officer, 

Children’s Hospitals Graduate Medical 

Education Payment Program, Division of 

Medicine and Dentistry, HRSA at 

MCrawford@hrsa.gov or (301) 443–7334. 

SUPPLEMENTARY INFORMATION: The 

CHGME statute was amended in 2013. 

The amendments permit up to 25 

percent of the total amount appropriated 

annually in excess of $245 million, but 

not to exceed $7,000,000, to provide 

payments to newly qualified hospitals, 

as defined in section 340E(h) of the 

Public Health Service Act. The statute 

additionally states that the Secretary 

may establish a quality bonus system for 

CHGME hospitals using any remaining 

funds after payments are made to newly 

qualified hospitals. In FY 2018, 

Congress appropriated $315 million to 

the CHGME Program. Of this, 

approximately $4 million in payments 

were made to newly qualified hospitals. 

If funding levels and mechanisms 

remain constant in FY 2019, it is 

estimated that approximately $3 million 

may be available annually for the 

CHGME QBS. 

On October 16, 2017, through a 

Federal Register Notice (FRN), HRSA 

announced a 60-day public comment 

period to solicit input on the CHGME 

QBS proposed standards. HRSA 

proposed a multi-step implementation 

beginning in FY 2019 that initially will 

recognize high-level engagement of 

CHGME hospitals in state and regional 

health care transformation, as well as 

engagement of resident trainees in these 

activities. HRSA sought public comment 

on the timeline, eligibility, standards, 

documentation, and payment structure 

as described in the FRN. HRSA also 

requested comment on proposed QBS 

measures, potential data sources, and 

tiering of QBS payments for FY 2020 

and beyond. HRSA received feedback 

on the following program components 

in response to the FRN: 

• QBS Goals 

• Qualifying Initiatives for the FY 2019 

QBS 

• Measures and Metrics 

• Payment Structure 

• Documentation, Reporting 

Requirements and Reducing 

Reporting Burden 

• Implementation Timeline for FY 2020 

and Beyond 

HRSA carefully reviewed the 

comments received and used them to 

guide the development of the FY 2019 

CHGME QBS and to inform future 

iterations of the CHGME QBS. Final 

guidance for the FY 2019 CHGME QBS 

will be published in the FY 2019 

CHGME Notice of Funding Opportunity 

(NOFO). 

Comments on the Proposed Standards 

of the Quality Bonus System 

HRSA received 17 responses to the 

request for comments. Thirteen 

commenters are current CHGME 

hospitals and four are state/national 

associations. Comments are summarized 

below. 

QBS Goals 

Summary of Comments 

Nearly all commenters supported 

establishing the CHGME QBS to 

recognize and reward quality training 

programs for residents supported by the 

CHGME program and agreed with the 

approach to recognize engagement in 

initiatives geared towards transforming 

pediatric health care to improve access, 

quality, and cost effectiveness. 

However, many commenters questioned 

whether there was enough information 

about these initiatives to establish a 

baseline, draw comparisons between 

children’s hospitals, and make 

judgements about relative performance. 

Several suggested the proposed 

approach could be enhanced by starting 

with documentation of transformation 

activities in which residents are 

involved. Specifically, one commenter 

recommended ‘‘that HRSA work to 

identify current residents’ engagement 

in quality initiatives and how residents 

can further engage on broader based 

initiatives before transitioning the 

Quality Bonus Program to other criteria 

in FY 2020 and beyond.’’ A few 

commenters also requested that HRSA 

offer more clear and specific goals for 

the multi-step implementation of the 

QBS. 

Response 

After considering feedback from 

stakeholders, the revised goal of the 

QBS will be to recognize hospitals for 

quality improvement & GME 

transformation efforts in high priority 

focus areas and build standards to 

increase engagement and involvement 

of residents in broader initiatives. HRSA 

will implement a baseline phase for 

CHGME QBS in FY 2019. Information 

collected during this baseline phase will 

be used to establish QBS standards for 

implementation in FY 2021. In order to 

qualify for the QBS payment, CHGME 

awardees must submit documentation 

in the FY 2019 reconciliation 

application describing the hospital’s 

initiatives, resident curriculum, and 

direct resident involvement in the 

following areas: Integrated care models, 

telehealth/HIT, population health, 

social determinants of health, and 

additional initiatives to improve access 


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Federal Register / Vol. 83, No. 123 / Tuesday, June 26, 2018 / Notices 29797 

and quality of care to rural/underserved 

communities. 

Qualifying Initiatives for the FY 2019 

QBS 

Summary of Comments 

Many commenters recommended 

expanding the list of initiatives that 

would qualify for the QBS and 

mentioned a number of other initiatives 

that children’s hospitals are currently 

involved in, which included national 

and regional non-federal collaboratives. 

One commenter recommended 

recognizing initiatives that address 

pediatric health disparities (e.g., 

childhood obesity, immunizations, 

access to care, poverty, food insecurity, 

population health, child abuse, opioid 

overuse) at the local and regional levels, 

initiatives that positively impact the 

health of surrounding communities, 

hospital quality improvement projects, 

and other quality-related programs that 

meet the goals of the Healthy People 

2020. Another commenter 

recommended recognizing resident 

participation in medical homes and 

clinically integrated networks. 

Several commenters recommended 

that HRSA start by compiling a list of 

the quality improvement and 

transformation efforts that residents 

currently engage in to identify focus 

areas for increased engagement and 

involvement. A few commenters 

expressed concerns that resident 

engagement in these initiatives may be 

limited due to training requirements 

that require rotating to a variety of 

clinical sites and normal resident 

turnover in training programs that 

typically last between 3–5 years. 

Response 

HRSA considered the commenters’ 

recommendations for qualifying 

initiatives for FY 2019 and has revised 

the FY 2019 QBS qualification 

requirements taking into consideration 

the comments received. As mentioned 

above, in order to qualify for the FY 

2019 QBS payment, CHGME awardees 

must submit documentation in the FY 

2019 reconciliation application 

describing the hospital’s initiatives, 

resident curriculum, and direct resident 

involvement in the following areas: 

integrated care models, telehealth/HIT, 

population health, social determinants 

of health, and additional initiatives to 

improve access and quality of care to 

rural/underserved communities. In all 

areas, CHGME awardees will be 

required to highlight initiatives aimed at 

improving access and quality of care to 

rural and/or underserved communities. 

More details will be included in the FY 

2019 CHGME NOFO. 

Measures and Metrics 

Summary of Comments 

Several commenters recommended 

focusing the QBS measures and metrics 

on the CHGME program and its goals, 

including measures regarding the 

quality of resident training. Commenters 

offered a number of potential measures 

and metrics that ranged from residency 

training characteristics, graduate 

outcomes, clinical learning environment 

outcomes, and health care 

transformation activities. One 

commenter recommended developing 

measures and metrics to evaluate how 

well training programs prepare 

graduates to improve the quality of care 

provided to local communities and 

integrate quality improvement into their 

clinical practice. They also 

recommended that quality measures 

could evaluate the quality of training 

settings, including commitment to 

caring for underserved populations, and 

impact on addressing healthcare 

problems in the community. 

A few commenters recommended that 

HRSA more critically evaluate future 

QBS measures and metrics. Specifically, 

one commenter stated that they were 

‘‘particularly concerned about the 

proposed plans for FY 2020. Currently, 

there are no ‘‘off the shelf’’ measures 

that can be used to determine the 

quality of training programs. We 

recommend a thorough stakeholder 

process be convened with pediatric 

experts and CHGME hospitals to outline 

the best path forward.’’ 

A number of commenters cautioned 

that it is hard to tie patient outcomes to 

resident training. A few other 

commenters discouraged using graduate 

outcomes as a QBS measure, suggesting 

that hospitals are unable to control the 

specialty choices and future practice 

locations of residents. Several 

commenters also cautioned against 

using metrics relating to hospital 

outcomes which could not be directly 

tied to training. They recommended 

only using measures that were within a 

hospital’s control. The following chart 

highlights other suggested measures and 

metrics from commenters: 

ADDITIONAL QBS MEASURES AND

METRICS RECOMMENDED BY COMMENTERS

Residency Training 

Quality of resident training. 

Volume of trainee-led initiatives and participation in larger hospital initiatives. 

ADDITIONAL QBS MEASURES AND

METRICS RECOMMENDED BY COMMENTERS—Continued 

Percentage of training time spent in rural 

and underserved locations. 

Graduate Outcomes 

Percentage of graduates practicing in underserved areas. 

Practice patterns and competency levels of 

graduates. 

Clinical Learning Environment Outcomes 

Value of clinical care. 

Number of unnecessary medical tests, 

treatments, and procedures. 

Rates of medical complications (hospital-acquired infections, unplanned extubations). 

Rates of surgical complications (surgical 

site infections). 

Hospital readmission rates. 

Chronic disease management (treatment 

compliance and percentage at goal). 

Health Care Transformation Activities 

Number of faculty and resident publications. 

Number of health care transformation initiatives. 

Commenters also identified existing 

sets of measure that could be reviewed 

to identify potential candidates for use 

in the QBS such as the American Board 

of Family Medicine’s (ABFM) 

Certification Survey Questionnaire, the 

ABFM’s National Family Medicine 

Residency Graduate Follow-up Survey, 

the Children’s Hospital Association 

approved activities such as Solutions for 

Patient Safety, the American College of 

Surgeons’ Pediatric National Surgical 

Quality Improvement Program, and the 

Accreditation Council for Graduate 

Medical Education’s (ACGME) 

milestones and measures. 

Response 

HRSA appreciates the 

recommendations for potential QBS 

measures and metrics and recognizes 

the concerns regarding appropriate 

measures and metrics expressed by the 

commenters. HRSA will be reviewing 

all the sets of measures that were 

identified, as well as individual 

measure that were suggested for 

potential incorporation into the next 

phase of the QBS. Following the initial 

baseline phase of the QBS as detailed 

above in Qualifying Initiatives for the 

FY 2019 QBS response section, HRSA 

plans to conduct an environmental scan 

of GME quality measures, analyze the 

data collected during the baseline year, 

develop quality measures for GME 

programs in the above areas, and 

manage an organized stakeholder 

engagement process on potential QBS 


sradovich on DSK3GMQ082PROD with NOTICES
29798 Federal Register / Vol. 83, No. 123 / Tuesday, June 26, 2018 / Notices 

standards and measures for future 

iterations. 

Payment Structure 

Summary of Comments 

Most commenters agreed with the 

tiered payment method but highlighted 

the importance of clearly messaging that 

funding tiers are not indicative of 

different levels of quality or engagement 

for the first phase of the CHGME QBS. 

One commenter offered, ‘‘the bonus 

payments would have a more significant 

effect in transforming the quality of 

CHGME programs if the payments were 

funded at a level larger than $3 million 

and were in excess of current program 

funding.’’ 

Response 

HRSA will continue to message 

clearly that the FY 2019 CHGME QBS 

payment tiers are not reflective of the 

quality of the initiatives. The payment 

tiers were developed taking into account 

the size of the training programs and 

CHGME payments typically awarded. In 

future years, once the data sources were 

better developed HRSA would work to 

develop a payment structure that takes 

into account both the size of the 

program and quality. As noted earlier, 

the amount of funding available for the 

QBS is provided for in statute and the 

$3 million funding amount is an 

estimation, assuming funding levels and 

mechanisms remain constant. 

For FY 2019, QBS payments will be 

disbursed with the CHGME FY 2019 

reconciliation payments. CHGME 

hospitals that submit the required 

documentation with the FY 2019 

reconciliation application will receive a 

portion of the available funds for the 

CHGME QBS payment. Amounts will be 

distributed according to a three-tiered 

payment structure detailed in the 

Federal Register, 82 FR 48102. 

HRSA expects that future quality 

measures will likely be a combination of 

both quantitative and qualitative 

measures, where payment will be 

directly linked to the level of 

achievement of an individual hospital. 

We will continue to seek additional 

input from stakeholders and experts on 

the appropriate measures and metrics 

for future iterations of the CHGME QBS. 

Documentation, Reporting 

Requirements and Reducing Reporting 

Burden 

Summary of Comments 

Several commenters indicated that 

HRSA already collects quite a bit of 

information through the annual report 

and recommended that HRSA build on 

its existing reporting requirements to 

minimize reporting burden. These 

commenters suggested that new 

reporting requirements would add an 

administrative burden and deter 

maximum participation in the QBS. One 

commenter questioned whether HRSA 

would publicly share the QBS data. 

Response 

HRSA agrees that participation in the 

QBS should not be overly burdensome 

and will work to create reasonable 

documentation requirements. HRSA 

acknowledges that it is already 

collecting some quality-related data in 

the annual CHGME performance 

measures and is developing ways to 

improve these fields. In addition, as part 

of the further development of the QBS, 

HRSA will be reviewing the different 

sets of data that children’s hospitals 

already report to identify if any of the 

measures could be used as part of the 

QBS. A long-term goal would be to have 

transparency regarding the QBS data 

and HRSA will make sure to include 

that topic in stakeholder discussions. 

Any new data collection form(s) that are 

developed will require Office and 

Management and Budget (OMB) 

approval. Stakeholders will be able to 

provide public comments on any new 

data collection form(s) developed. 

Implementation Timeline for FY 2020 

and Beyond 

Summary of Comments 

Half of commenters recommended a 

longer timeline to phase in the full FY 

2020 and beyond QBS proposed 

framework, in order to ensure a 

thorough stakeholder engagement 

process in which pediatric experts are 

adequately involved in establishing 

metrics and measures, identifying 

quality outcomes, and evaluating QBS 

standards. 

Response 

HRSA recognizes concerns about the 

QBS implementation timeline. We 

understand that there are many 

important factors that must be taken 

into account when implementing the 

QBS, and each requires thorough and 

well-informed consideration. In 

addition, QBS-related data collection 

must align with existing reporting and 

payment schedules for the CHGME 

Payment Program. The first phase of the 

CHGME QBS is planned to start in FY 

2019, and we have taken into 

consideration feedback collected 

through this FRN. The data collected 

during the FY 2019 QBS will give HRSA 

an indication of the current experiences 

across our children’s hospitals so that 

we can establish reasonable parameters 

and measures moving forward. In 

addition, HRSA is examining using 

existing reporting requirements to 

establish components of the QBS for FY 

2020 and beyond. HRSA will continue 

collaborating with stakeholders and 

experts to inform future phases and 

measures for the CHGME QBS. As new 

QBS measures will affect a fiscal year 

payment, any updates or changes will 

be included in that year’s NOFO. 

Conclusion 

HRSA appreciates the comments and 

recommendations received and has used 

them to guide the development of the 

FY 2019 CHGME QBS and inform future 

iterations of the CHGME QBS. Final 

guidance for the FY 2019 CHGME QBS 

will be published in the FY 2019 

CHGME NOFO. If you have questions or 

concerns about comments that were not 

addressed in this notice, please contact 

MCrawford@hrsa.gov. 

Dated: June 19, 2018. 

George Sigounas, 

Administrator. 

[FR Doc. 2018–13592 Filed 6–25–18; 8:45 am] 

BILLING CODE 4165–15–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Health Resources and Services 

Administration 

Agency Information Collection 

Activities: Submission to OMB for 

Review and Approval; Public Comment 

Request; National Survey of Organ 

Donation Attitudes and Practices, OMB 

No. 0915–0290—Reinstatement With 

Change 

AGENCY: Health Resources and Services 

Administration (HRSA), Department of 

Health and Human Services. 

ACTION: Notice. 

SUMMARY: In compliance with the 

Paperwork Reduction Act of 1995, 

HRSA has submitted an Information 

Collection Request (ICR) to the Office of 

Management and Budget (OMB) for 

review and approval. The ICR is for 

reinstatement with change of a 

previously approved information 

collection, assigned OMB control 

number 0915–0290, which expired on 

March 31, 2015. Comments submitted 

during the first public review of this ICR 

will be provided to OMB. OMB will 

accept further comments from the 

public during the review and approval 

period. 

DATES: Comments on this ICR should be 

received no later than July 26, 2018. 


sradovich on DSK3GMQ082PROD with NOTICES