American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

PPS-Exempt Hospitals Quality Reporting Program (PCHQR)

The Centers for Medicare & Medicaid Services (CMS) has contracted with the American College of Surgeons to plan and implement the reporting of cancer care measures to CMS on behalf of the 11 PPS-exempt cancer hospitals (PCH) through its Rapid Quality Reporting System (RQRS). The requirement for public reporting by the PCHs is defined in Section 3005 of the Patient Protection and Affordable Care Act (ACA), and must begin effective Fiscal Year 2014. CMS has identified the following three National Quality Forum–endorsed quality of cancer care measures that will be reported on the Hospital Compare website:

  • Combination chemotherapy is considered or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1cN0M0, or Stage II or III hormone receptor negative breast cancer.
  • Tamoxifen or third generation aromatase inhibitor is considered or administered within 1 year (365 days) of diagnosis for women with AJCC T1cN0M0, or Stage II or III hormone receptor positive breast cancer.
  • Adjuvant chemotherapy is considered or administered within 4 months (120 days) of diagnosis for patients under the age of 80 with AJCC Stage III (lymph node positive) colon cancer.

PPS-Exempt Cancer Hospitals

Dana-Farber Cancer Institute

Boston, MA

Fox Chase Cancer Center

Philadelphia, PA

Memorial Sloan-Kettering Cancer Center

New York, NY

Roswell Park Cancer Institute

Buffalo, NY

James Cancer Hospital

Columbus, OH

Sylvester Comprehensive Cancer Center

Miami, FL

Moffitt Cancer Center

Tampa, FL

MD Anderson Cancer Center

Houston, TX

USC Norris Comprehensive Cancer Center

Los Angeles, CA

City of Hope

Duarte, CA

Fred Hutchinson Cancer Research Center

Seattle, WA

The following documents are posted for the reference and use of the 11 PPS-exempt cancer hospitals:

Cancer Hospital Workgroup

Twelve health care professionals from across the country have been nominated to participate in the PPS-Exempt Cancer Hospital Workgroup (CHW). The workgroup will serve in an advisory role to the Centers for Medicare & Medicaid Services to help identify operational opportunities and challenges that arise from participating in the quality reporting program for cancer-specific care measures.

Charge 11/06/12
Workgroup Membership

Recording and Materials for Past CHW Meetings

2014 PCH Activities
February 2014 CHW Meeting
April 2014 CHW Meeting
May 2014 CHW Meeting
June 2014 CHW Meeting

PCHQR Project Specification Documentation

Information documenting the PCHQR reporting project—including: participating hospitals, the development of the cancer measures reported in this project, the technical specifications of the three measures, and the manner in which case-level data are collected abstracted, reported, and verified is summarized in a two-page manual. Hyperlinks are provided to direct users to appropriate source documentation.

The data items, selection criteria used to identify cases in the denominator of each measure, and the logic applied to distinguish concordant from non-concordant cases are documented for each of the three cancer measures adopted for use in the PCHQR reporting project. These specifications provide greater clarity and improve the transparency with which measure rates are calculated in the RQRS, and do not constitute a change in the methodology used in the implementation of the NQF-endorsed measures reported through either the RQRS or CP3R.

PCHQR Project Specifications
Cancer Measure Specifications
Cancer Measure Submission Timeline
HAI Measure Submission Timeline
RQRS Data Validation