Planning views for Age-Friendly, PSSM, Maternal Morbidity + DACA. Confirm every date on QualityNet, NHSN, and your accreditor. Not legal or compliance advice.
Apiary Labs builds AuditCare: hospital attestation and survey-readiness evidence (Age-Friendly, PSSM, Maternal + DACA first).
Illustrative U.S. hospital cadence. HQRP publishes firm open/close dates each payment year. Use this to lock the spring evidence file in the fall; do not treat it as “submit this week.”
| When | What | Confirm on |
|---|---|---|
| January | Joint Commission standards update (National Performance Goals since Jan 2026). Policies, education, tracer prep. | TJC E-dition, National Performance Goals |
| February | NHSN housekeeping: OrgID, roles, annual surveys. | CDC NHSN |
| March | HQR dry-run: CCN routing, structural selections, attestor accounts. | QualityNet / HQR |
| April – May | IQR structural attestation window: Age-Friendly, Maternal Morbidity, DACA in HQR. PSSM in NHSN on CDC deadlines. | QualityNet Important Dates; NHSN |
| April – June | HVBP / VBP performance report reconciliation. | QualityNet HVBP |
| Aug 17, 2026 | IQR Q1 quarterly (Jan–Mar 2026 discharges). Weekend deadlines move to the next business day. | QualityNet Important Dates |
| Nov 15, 2026 | IQR Q2 quarterly (Apr–Jun 2026 discharges). | QualityNet Important Dates |
| Mid-year | Evidence refresh: policies, extracts, committee minutes behind affirmations. | Your binder |
| September – November | Fall budget: fund structural gaps that span more than one department. | Board / Quality calendar |
| December | Year-end binder for surveys and the next cycle. | Your binder |
| Rolling | NHSN HAI + PSSM live on CDC deadlines (separate login from HQR). | CDC NHSN |
Source: QualityNet Important Dates and Deadlines, CDC NHSN, and the current IQR structural set after FY 2026 IPPS (HCHE removed). Print this page to share.
Submitted in CMS HQR as part of IQR structural / Structural MSR. Same HQR window as Maternal Morbidity and DACA. Not the same portal as PSSM.
| 4Ms / domain | What CMS is asking | Typical evidence | Typical owner |
|---|---|---|---|
| What Matters · Domain 1 | Protocol to elicit, document, and update goals, preferences, advance directives, and proxies at admission, pre-procedure, and status change. | Named written protocol; EHR fields; training roster | CMO / Care Management |
| Medication · Domain 2 | Named framework (Beers, STOPP/START, or equivalent). Reviews on admission, before major procedures, and on status change. | Protocol naming the criteria; pharmacy workflow; PIM metric | Pharmacy + Quality |
| Mentation + Mobility · Domain 3 | Validated cognitive, mobility, and malnutrition screens plus structured intervention. Malnutrition added August 2025. | Named tools (4AT/MoCA, TUG/SPPB, MNA-SF/MUST); intervention pathway | Nursing + Nutrition |
| Beyond the 4Ms · Domain 4 | Social isolation, caregiver stress, elder abuse: screen and respond. | Protocol; social-work pathway; referral log | Social Work / Case Management |
| Leadership · Domain 5 | Named champion or interprofessional committee with a written charge. | CMO/CNO designation letter; minutes; board report | CNO / Quality Director |
To attest yes, practices must be in place for the majority of older patients. A single admission note does not satisfy the update cadence.
Patient Safety Structural Measure is per-facility NHSN, not HQR. Confirm OrgID and the active reporting year in NHSN.
Source: CMS PSSM structural statements as implemented in NHSN. Multi-facility CCNs use the lowest facility score where applicable.
One official two-part question in HQR. Both parts must be true to attest Yes. Hospitals that do not provide inpatient labor/delivery still submit N/A — the IPPS Measure Exception form cannot be used instead. A prior Yes is how CMS awards the Birthing-Friendly designation on Care Compare.
| Part | What CMS is asking | Typical evidence | Typical owner |
|---|---|---|---|
| Official question | Participate in a statewide or national perinatal QI collaborative and implement maternal safety practices/bundles from that collaborative (hemorrhage, severe hypertension/preeclampsia, or sepsis are examples). | HQR response (Yes / No / N/A) plus the file below | Quality + Obstetric Medical Director |
| Part 1 · Collaborative | Named AIM or state perinatal quality collaborative, covering the reporting calendar year. | Membership letter, invoice, or collaborative roster | Quality Director |
| Part 2 · Bundles | Implemented practices from that collaborative, not a plan to implement after December 31. | Bundle protocol, drills, audit, committee minutes for the reporting year | Obstetrics + CNO |
| N/A file | No inpatient labor, delivery, and postpartum care. | One-line service-scope note. Still submit N/A in HQR. | Quality + CMO |
Source: CMS Maternal Morbidity Structural Measure specifications and QualityNet IQR measures page. Confirm the active reporting year on QualityNet.
DACA is not a clinical measure. It is the annual HQR acknowledgement that Hospital IQR Program data for the reporting year are accurate and complete to the best of the authorized user’s knowledge. Same typical window as Age-Friendly and Maternal Morbidity: April 1–May 15. Confirm dates on QualityNet.
Source: QualityNet IQR Program measures page and FY 2028 Hospital IQR Program Guide (DACA + web-based structural measures).
A one-pager Quality can forward. If you cannot produce the artifact in the room, do not attest yes.
Self-reported answers in a scan are intake. The working file is dated evidence with owners.
We will co-brand a free scan or white-label the gap summary for members or clients. We do not sell an unbuilt multi-facility heat map. Hospitals buy Professional at $5,000 per facility per year.
The scan is free. Professional is the survey readiness binder: dated evidence, named owners, and the export. $5,000 per facility per year.