Code of Vermont Rules › Agency 21 - DEPARTMENT OF FINANCIAL REGULATION › Sub-Agency 040 - DIVISION OF HEALTH CARE ADMINISTRATION › Chapter 026 - HOSPITAL REPORTING RULE › Section 21 040 026 - HOSPITAL REPORTING RULE

Current through June, 2024
Section 1.0 Authority
This rule is adopted pursuant to
				  18 V.S.A.
				  §§
											9405a,
				  9405b,
				  and 18 V.S.A. § 1919.
Section
				2.0 Purpose
The purpose of this rule is to establish the process and time
				  line for data submission and reporting for the generation of a statewide
				  hospital quality report and reporting on the community health needs
				  assessments.
Section 3.0
				Definitions
3.1 "Annual Reporting Manual"
				means the document published annually by the Department and the Green Mountain
				Care Board (GMCB) that describes in detail the necessary data specifications
				and guidelines for submission and publication for hospitals and the development
				of Community Health Needs Assessments (CHNA). The reporting manual shall
				contain, at a minimum, a list of quantitative measures; the methodology for
				collecting and analyzing data; and parameters for presenting quantitative and
				qualitative information. It is maintained on the Department website.
3.2 "Benchmark" means an attribute or
				achievement that serves as a standard for other providers or institutions to
				emulate. Benchmarks differ from other standard of care goals in that they
				derive from empiric data - specifically, performance or outcomes
				data.
3.3 "Charge" means the
				amount, in U.S. dollars, that a hospital invoices a purchaser or patient for a
				particular service or combination of services performed by the hospital prior
				to the application of any discounts, reductions or mark-downs that may
				ultimately affect the amount the purchaser or patient is obligated to pay for
				the performance of such service(s).
3.4 "Community Health Needs Assessment" means
				a written report made widely available to the public by the hospital that,
				using qualitative and quantitative data:
3.4.1 Identifies significant health needs of
				the community it serves;
3.4.2
				Prioritizes those health needs; and
3.4.3 Identifies resources (such as
				organizations, facilities, and programs in the community, including those of
				the hospital) potentially available to address those health needs.
3.4.4 For these purposes, the health needs of
				a community include requisites for the improvement or maintenance of health
				status both in the community at large and in particular parts of the community
				(such as particular neighborhoods or populations experiencing health
				disparities).
3.4.4.1 These needs may
				include, for example, the need to address financial and other barriers to
				accessing care, to prevent illness, to ensure adequate nutrition, or to address
				social, behavioral, and environmental factors that influence health in the
				community.
3.5
				"Commissioner" means the Commissioner of the Vermont Department of
				Health.
3.6 "Department" means the
				Vermont Department of Health.
3.7
				"Hospital" or "Community Hospital" means a place licensed under Chapter 43 of
				Title 18 devoted primarily to the maintenance and operation of diagnostic and
				therapeutic facilities for in-patient medical or surgical care of individuals
				who have an illness, disease, injury, or physical disability, or for
				obstetrics.
3.8 "Hospital Report
				Card" means a compilation of standardized quality and financial information for
				statewide comparisons by hospital.
3.9 "Implementation Plan" means the specific
				plan to address the results of the Community Health Needs Assessment developed
				by a hospital. This plan includes a description of identified health needs,
				strategic initiatives developed to address the identified needs, annual
				progress on implementation of the proposed initiatives, and opportunities for
				public participation.
3.10
				"Psychiatric Hospital" means a hospital for the diagnosis and treatment of
				mental illness, as defined in
				18 V.S.A. §
											1902.
3.11 "Reliability" means the consistency of a
				measure. A reliable measure of quality should produce consistent results when
				repeated in the same population and setting, even when assessed by different
				people at different times. Any variation in a quality measure should reflect a
				true change in quality and not errors produced by the measurement itself. Such
				inconsistencies and errors occur when trying to measure quality in rare events
				(e.g., mortality), a small number of events (e.g., small hospitals may conduct
				very few of a specific procedure), or restricted samples of events (e.g.,
				counting occurrence of an event over a relatively short period of time).
				Quality measures should be repeated periodically, and any changes in the
				measures should reflect a true change in quality.
3.12 "Validity" means the accuracy of a
				measure, so that a specific quality indicator measures what it is intended to
				measure. Reliability is a prerequisite to validity, but does not guarantee a
				valid measure. The validity of a quality measure is assessed by whether it
				makes sense logically and clinically, correlates well with other measures of
				the same aspects of quality, and captures the meaningful aspects of quality.
				Quality measures should be linked to significant processes or outcomes of care
				as demonstrated by established scientific studies.