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Hospital Performance Measure Reporting Guidance

Ohio Revised Code section 3727.33 requires each hospital to submit information semi-annually (April 1 and October 1) showing its performance in meeting inpatient and outpatient performance measures to the Ohio Department of Health. The performance measures that must be reported are specified in Ohio Administrative Code rule 3701-14, Reporting of Hospital Performance Measures.

All Ohio hospitals meeting this definition are required to report to ODH regardless of what is required to be reported to the Centers for Medicare and Medicaid Services (CMS) or the Joint Commission (JC). "Hospital" means an institution located as a single site engaged primarily in providing to inpatients, by or under the supervision of an organized medical staff of physicians licensed under Chapter 4731. of the Revised Code, diagnostic services and therapeutic services for medical diagnosis and treatment or rehabilitation of injured, disabled, or sick persons. "Hospital" does not mean an institution that is operated by the United States government or by the Ohio Department of Mental Health.

The Hospital Performance Measures Instruction Manual should be used to assist hospitals in collecting and reporting the required performance measures.  The instruction manual includes details about who is required to report, collection time frames, reporting deadlines and how to use the data collection system located at Also included in the instruction manual are detailed definitions for most measures. This instruction manual is updated before each reporting period to reflect the most recent changes in reporting.

In addition to the Performance Measures Instruction Manual the Data Submission User Manual and training video should be used to assist hospitals in entering data into the data collection system.

The reporting guidelines and specifications for CMS, JC, Agency for Healthcare Research and Quality (AHRQ) and Centers for Disease Control and Prevention (CDC/NHSN) measures can be found at the following websites:

Centers for Medicare & Medicaid Services  
Joint Commission
Agency for Healthcare Research and Quality
Centers for Disease Control and Prevention
National Quality Forum

It is important to note that all data reported through this mandate is publically reported on the Ohio Hospital Compare website.  The site will be updated each January 1 and July 1 with the most recent twelve months of data provided by hospitals. The Common Name file was created to provide a crosswalk between the technical measure being reported to ODH and the user friendly name being displayed on the Ohio Hospital Compare website.

Links to Other Consumer Hospital Sites
Centers for Medicare & Medicaid Services Hospital Compare
Joint Commission's Patient Safety and Quality Standards
Agency for Healthcare Research and Quality State Snapshots


Mailing Address:
Ohio Department of Health
Division of Quality Assurance
Bureau of Information and Operational Support
246 North High Street
Columbus, OH 43215

Telephone: (614) 466-2702
Fax: (614) 564-2476

Last Updated: 12/28/11