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Type:
Logic/Intent/Data Elements
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Resolution: Unresolved
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Priority:
Moderate
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None
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Dalana Ostlie
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5093892719
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Grace Surgical Hospital, Lubbock, Texas
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Yes
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Possibly remove lab timing constraints for 2025/2026 reporting period by allowing all pre-admission labs to be included to accommodate for this issue.
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CMS0529v6, CMS0844v6
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CMS0529v5, CMS0844v5
The above surgical hospital has voluntarily reported for the 2024/2025 voluntary reporting period on the HWR and HWM hybrid measures.
The HSR received in May of 2025 shows that the hospital failed the lab category with a performance score of 0.00% although labs appear for individual patients, they are outside of the 24-hour parameters around an inpatient admission.
Upon further investigation, the hospital does pre-admission lab work on their patients, from a few days up to 10 days before a patient’s scheduled procedure. This workflow does not meet the current lab requirements for these measures, and it appears they are in danger of failing the IQR during the mandatory reporting for the 2025/2026 reporting period. In the next reporting period for 2026/2027, the lab time constraints appear to have been removed so it appears this will no longer be a problem, but it remains so for the current reporting period.
We respectfully submit this issue to be reviewed by the measure stewards and look forward to any consideration that will appreciate the huge burden it would put on a hospital to change their practice to meet the hybrid measure requirements.