Assess whether CMS reporting can be certified this quarter (6c498b)

Situation

An academic medical center reviewing a mortality series cannot treat three weekend deaths that look similar on first read as color commentary on length-of-stay outliers versus DRG peers. Sepsis-alert program lead must close CMS reporting can be from that extract under Healthcare / Outcomes Review.

Decision

Sepsis-alert program lead in an academic medical center reviewing a mortality series must choose Proceed under protocol / Pause the pathway / Escalate safety review / Hold using length-of-stay outliers versus DRG peers after three weekend deaths that look similar on first read.

Hypotheses to test

• Three weekend deaths that look similar on first read is noise around an already-controlled Outcomes Review process in an academic medical center reviewing a mortality series, given length-of-stay outliers versus DRG peers.
• Three weekend deaths that look similar on first read is the event in length-of-stay outliers versus DRG peers that forces Proceed under protocol for sepsis-alert program lead under Healthcare.
• Length-of-stay outliers versus DRG peers shows a one-file miss after three weekend deaths that look similar on first read, not a Outcomes Review program failure.
• Length-of-stay outliers versus DRG peers cannot decide CMS reporting can be yet after three weekend deaths that look similar on first read; hold is the only Healthcare close an academic medical center reviewing a mortality series can defend.

Analysis required

• Assess patient-safety and HIPAA / minimum-necessary implications of CMS reporting can be.
• Quantify who is harmed if length-of-stay outliers versus DRG peers is wrong.
• Separate a documented exception from an OCR-relevant gap in an academic medical center reviewing a mortality series.
• For this Healthcare Outcomes Review file, read length-of-stay outliers versus DRG peers against three weekend deaths that look similar on first read and write the one fact that would move CMS reporting can be for sepsis-alert program lead.

Recommendation

Choose Proceed under protocol / Pause the pathway / Escalate safety review / Hold on this Healthcare / Outcomes Review packet (length-of-stay outliers versus DRG peers after three weekend deaths that look similar on first read). Lead with the Healthcare option length-of-stay outliers versus DRG peers can support after three weekend deaths that look similar on first read, then the two facts that force it, then the Monday action for sepsis-alert program lead in an academic medical center reviewing a mortality series.