How to Present Your Hospital CMS Star Rating to Your C Suite and Board


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This article is part of the Dexur Insight, which is focused on Hospital Quality and Safety topics and is read by CEOs, CMOs, CNOs, CQOs, Quality, Safety, Compliance, Analytics & Performance teams. Please email dexurqualitysights@dexur5.com to join this newsletter and receive updates (not more than once per week).

Dexur is a unified quality, safety, risk, and incident management platform. In 2023, Dexur had a 98% accuracy rate in predicting CMS Star Ratings. For 2024, based on Dexur customers' 2024 CMS Star Rating previews on May 3, 2024, Dexur’s accuracy is likely to maintain at least a 98% accuracy rate.

Once hospitals are aware of their CMS Star Ratings, Quality leads, CMOs, and CNOs need to start preparing for how to present these results to the C Suite and Board. The guide below outlines a path for optimal communication to the C Suite, Board, and other stakeholders.

Part 1: Analyze What Happened in the Past


  1. Identify What Domains and Measures Improved or Decreased the Most

  2. To effectively communicate with the C Suite and Board, it's crucial to identify and analyze the domains and measures that have shown the most significant changes. Understanding these variations will provide insight into the hospital's performance trajectory and areas needing attention.

    How Dexur Can Help

    Dexur provides AI-generated summaries that analyze the five major domains and the measures that increased or decreased the most. For instance, the screenshot example shows detailed predictions and highlights the specific areas of improvement or decline. This level of detail helps in understanding the broader picture and pinpointing exact measures for discussion.

    For example, in the provided Dexur AI Advisor Insights, the following key highlights are noted for 2024:

    1. CMS Star Rating: Predicted to be 1 star, a decrease from 2 stars in 2023.
    2. Summary Score: Predicted to fall to about -0.86 compared to 2023's score of -0.52.
    3. Mortality Group Score: Predicted to improve to about -1.61 compared to 2023's score of -1.4.
    4. Readmission Group Score: Predicted to decrease to about -0.6 compared to 2023's score of 0.21.
    5. Safety Group Score: Predicted to be about -0.32 compared to 2023's score of -0.51.
    6. Patient Experience Group Score: Predicted to decline to about 0.15 compared to 2023's score of 0.5.
    7. Timely & Effective Care Group Score: Predicted to be about -0.34 compared to 2023's score of -0.63.

    Analyzing these changes involves looking into specific measures within each domain. For instance, improvements in mortality rates might indicate better post-operative care or improved management of chronic conditions. Conversely, a decline in readmission scores could highlight issues in discharge planning or follow-up care.


  3. Go Deep Into Specific Measures

  4. Understanding the nuances of specific measures is essential for an in-depth analysis of hospital performance. This detailed scrutiny allows you to identify precise areas for improvement and implement targeted interventions. Here’s how to approach the analysis for key measures:

    Readmissions and Mortality
    • Gap Between Risk-Adjusted and Observed Rates: Examine the discrepancies between risk-adjusted rates and observed rates. Risk-adjusted rates account for patient demographics and comorbidities, providing a standardized way to compare outcomes across hospitals. Significant gaps may indicate areas where hospital protocols can be improved to better manage patient conditions post-discharge.

    • Subpopulations Analysis: Break down readmission and mortality rates by specific subpopulations (e.g., age groups, specific conditions) to identify which patient groups are most at risk and tailor interventions accordingly.

    HCAHPS (Patient Experience)
    • Top Box Scores vs. Linear Mean Scores: Analyze the differences between Top Box Scores (percentage of patients rating the highest category) and Linear Mean Scores (average scores). This analysis can uncover specific areas where patient experience is lacking. For example, a low Top Box Score but a high Linear Mean Score may indicate that most patients are somewhat satisfied, but very few are extremely satisfied.

    • Question-Level Insights: Delve into question-level data to understand which specific aspects of the patient experience are driving overall satisfaction scores. This could include communication with nurses, cleanliness of the hospital environment, or pain management.

    Infections
    • Raw Infection Counts vs. Standardized Infection Ratios (SIRs): Differentiate between raw infection counts and SIRs. While raw counts provide a direct measure of infections, SIRs offer a comparative measure that adjusts for patient risk factors. High SIRs may point to procedural or environmental factors contributing to higher infection rates.

    • Type of Infections: Categorize infections by type (e.g., surgical site infections, catheter-associated infections) to identify which procedures or areas within the hospital are most prone to infections and require stricter protocols or interventions.

    How Dexur Can Help

    Dexur can assist in these areas by providing comprehensive tools and analyses:

    • Observed vs. Risk-Adjusted Rates: Dexur provides detailed comparisons of observed rates against risk-adjusted rates, highlighting discrepancies that may require attention.

    • Top Box to Linear Mean Scores Conversion: Dexur’s advanced algorithms convert Top Box Scores to Linear Mean Scores and Star Ratings, helping hospitals understand the impact of patient feedback on their overall ratings.

    • Infection Analysis: Dexur analyzes both SIRs and raw infection counts, offering insights into infection trends and areas needing improvement.

    By diving deep into specific measures, hospitals can gain a clearer understanding of their performance, pinpoint precise areas for improvement, and implement effective strategies to enhance patient outcomes and overall ratings.


  5. Analyze and Illustrate How Small Changes Can Have Big Impacts on Final Scores

  6. Understanding the significance of small changes in performance metrics is crucial for hospitals aiming to improve their CMS Star Ratings. Even minor adjustments can have substantial effects due to the narrow margins that differentiate performance percentiles.

    The Impact of Small Changes

    The difference between the bottom 10th and top 90th performance percentiles is often minimal. For instance, a slight improvement in readmission or mortality rates can elevate a hospital's ranking significantly. This is because CMS Star Ratings are highly sensitive to changes in these critical measures, and even minor progress can lead to a notable increase in the overall score.

    • Readmissions: A small reduction in readmission rates can result in a significant percentile rank improvement. For example, decreasing readmission rates by 0.1% could shift a hospital from the 25th percentile to the 50th percentile, significantly impacting the hospital’s Readmission Group Score.

    • Mortality: Similarly, reducing mortality rates by a small margin can lead to substantial percentile rank changes. This improvement can positively influence the hospital's overall Mortality Group Score, thereby enhancing the hospital’s CMS Star Rating.

    Illustrating the Impact

    To effectively convey the impact of small changes to the C Suite and Board, it’s important to use clear, data-driven illustrations:

    • Numerator and Denominator Counts: Highlight how changes in numerator (e.g., number of readmissions or deaths) and denominator (e.g., total discharges or patients) counts affect the overall rates and scores. Show how a small change in these counts can result in a significant shift in the percentile rankings.

    • Percentile Mapping: Use percentile maps to demonstrate how the hospital's performance compares to peers. This visual representation can illustrate the potential impact of small improvements on the hospital's relative standing and overall CMS Star Rating.

    How Dexur Can Help

    Dexur provides robust tools to help hospitals understand and leverage these small changes:

    • Automatic Calculation of Numerator and Denominator Counts: Dexur automatically calculates and updates these counts, providing real-time insights into how small changes impact overall scores and rankings.

    • Percentile Analysis and Mapping: Dexur’s advanced analytics tools map the hospital's performance to percentile ranks, showing the potential gains from minor improvements. This helps in strategizing targeted interventions that can yield significant benefits.

    By emphasizing the importance of small changes and illustrating their potential impact with concrete data, hospitals can better communicate the value of continuous improvement efforts to their C Suite and Board. This approach not only highlights areas for targeted interventions but also underscores the strategic importance of seemingly minor adjustments in achieving better outcomes and higher CMS Star Ratings.


  7. Understand and Show the Gap Between Internal Hospital Data and Final Published Values

  8. Hospitals often rely heavily on internal data to track readmissions and mortality rates. However, this data is typically limited to events occurring within the same hospital, missing a significant portion of patient outcomes that happen outside the hospital’s direct oversight (See Dexur’s article series on Out of Hospital Impact). Understanding and addressing this gap is critical for a comprehensive assessment of hospital performance and quality of care.

    Internal Hospital Data Limitations
    1. Readmissions: Internal data usually captures only readmissions to the same hospital. This creates a blind spot for readmissions occurring at different hospitals, which can be a substantial percentage of total readmissions. As a result, hospitals might underestimate their true readmission rates.

    2. Mortality: In-hospital mortality data only accounts for deaths occurring within the hospital. This excludes out-of-hospital deaths, such as those happening at home or in other care facilities, leading to incomplete mortality statistics.

    3. Data Errors: Internal data may contain errors or inconsistencies due to algorithm coding issues, patient cohorts and other reasons (see this article on Why Internal Hospital Quality tracking may be wrong). This can lead to discrepancies between internal performance assessments and the final CMS-published values.

    Out-of-Hospital Impact & Quality Measure Calculation Accuracy

    To bridge this gap, it’s essential to consider out-of-hospital data, which provides a more comprehensive view of patient outcomes. This includes:

    1. Readmissions to Other Hospitals: By including readmissions to other hospitals, a more accurate readmission rate can be determined. This helps identify broader trends and potential issues in the discharge process and post-hospital care coordination.

    2. Out-of-Hospital Mortality: Including data on out-of-hospital deaths offers a fuller picture of mortality rates. This can highlight areas for improvement in post-discharge care, follow-up processes, and patient education on managing their conditions outside the hospital setting.

    3. Complete Patient Journey: Understanding the complete patient journey from admission to discharge and beyond provides insights into the overall quality of care and patient outcomes. This holistic view is crucial for identifying systemic issues and improving care transitions.

    How Dexur Can Help

    Dexur addresses these gaps by providing access to comprehensive Medicare claims data, sourced directly from CMS. This data encompasses the full patient journey, including out-of-hospital events, offering a complete picture of patient outcomes.

    1. Full Patient Journey Data: Dexur leverages Medicare claims data to track patients across different care settings. This includes readmissions to other hospitals and out-of-hospital mortality, ensuring a thorough assessment of readmission and mortality rates.

    2. Accurate and Complete Data: By using claims data, Dexur minimizes errors and inconsistencies that are often present in internal hospital data. This ensures more accurate performance metrics and better alignment with CMS-published values.

    3. Holistic Performance Analysis: Dexur’s platform enables hospitals to analyze the full spectrum of patient outcomes, providing insights into both in-hospital and out-of-hospital impacts. This comprehensive analysis supports targeted interventions and strategic planning to improve overall care quality and patient outcomes.

By understanding and addressing the gap between internal hospital data and out-of-hospital impact, hospitals can ensure a more accurate assessment of their performance. This comprehensive approach allows for better-informed decisions, improved care coordination, and ultimately, enhanced patient outcomes and CMS Star Ratings.

Part 2: Present a Plan for Improvement


  1. Impress Upon the C Suite and Board that CMS Star Ratings and Quality Programs Are a Multi-Year Effort and May Take a Few Years to Start Seeing Initial Results

  2. The Complexity of Rolling Three-Year Data

    Improvements in CMS Star Ratings are a multi-year effort, and the rolling three-year data period adds significant complexity to performance tracking as it shifts annually to include the most recent data while excluding the oldest. This shifting timeframe makes it challenging for Quality teams, as tracking three years of data and running analyses with incomplete or continuously changing data sets is particularly arduous and prone to errors.

    Recognizing the Overlap and Time Lag

    CMS ensures hospital quality is consistently maintained over the years, not just in the present. This rolling three-year data period necessitates ongoing vigilance and proactive management from Quality teams, as their efforts influence future evaluations. Additionally, there is a time lag in CMS calculations, meaning improvements may not be reflected immediately in the ratings. This requires patience and sustained effort from hospitals to see the impact of their quality improvement initiatives. Dexur previously wrote an article on managing the rolling three-year data period for CMS Quality Programs and its impact on hospital performance metrics.

    How Dexur Can Help

    Dexur provides detailed tracking on the start and end dates of each performance period, how much time is left, and the performance forecast for each measure. This aligns frontline staff with leadership by ensuring everyone is aware of the current status and future projections.

    For example, the provided image illustrates how Dexur tracks and forecasts mortality rates for conditions like pneumonia and stroke, as well as death rates among surgical inpatients with serious treatable complications. By offering this level of detail, Dexur helps hospitals maintain a clear understanding of their performance trends and necessary improvements over time.

    • Start and End Dates: Dexur identifies the specific start and end dates of each performance period, providing clarity on the exact timeframe under review.

    • Time Remaining: Dexur calculates the remaining time in each performance period, helping hospitals understand how much time they have to influence their scores before the period closes.

    • Performance and Forecasts: Dexur offers performance data and forecasts for each measure, allowing hospitals to anticipate future ratings and align their improvement strategies accordingly.

    Using this information, Quality teams can effectively manage their efforts, ensuring that interventions are timely and targeted to yield the best possible outcomes in future CMS evaluations. This approach fosters a proactive quality improvement culture, driving sustained improvements in patient care and hospital performance.


  3. Come Up With A Plan to Improve

  4. Understanding the Need for Simulation-Based Improvements

    Hospitals need to carefully analyze and manage all 47 measures in the CMS Star Ratings. Each measure requires careful attention and fine-tuning to maintain its integrity and achieve better percentile scores. For the quality team, this involves significant time and resources, making it both a costly and intricate task.

    Challenges in Manual Simulations

    Performing simulations manually is impractical due to the vast amount of data and countless scenarios that need to be processed and analyzed. Additionally, analyzing these measures against the ever-changing methodologies adds to the complexity. Performing all these calculations and adjustments, and managing measure exclusions manually are complex and unattainable tasks for hospitals.

    How Dexur Can Help

    Dexur has developed AI-powered and manual simulations that analyze hundreds of millions of combinations, creating scenarios to enhance readmission, mortality, safety, and patient experience measures. These simulations can also be aligned to other Quality programs such as Leapfrog, VBP, HACRP so as to maximize the impact of improvements across all programs.

    • AI-Powered Simulations: The AI simulator analyzes all possible combinations of measure changes to identify the shortest path to improving a hospital’s Star Rating. This saves hospitals the effort of manually exploring numerous scenarios and allows them to focus on implementing targeted interventions.

    • Manual Simulations: Dexur’s manual simulator can be used to help build intuition on where to improve scores. Users can manually adjust the scenarios by changing measure scores to check the improvements against those simulated scenarios.

    Hospitals can set specific goals and interventions based on AI and manual simulations to reach their benchmarked targets, improving their performance metrics and overall Star Ratings. This approach ensures that hospitals can strategically plan and execute quality improvement initiatives, making the process more efficient and effective.


  5. Establish SMART Goals to Match the Improvement Plan

  6. Why SMART Goals Are Necessary

    Setting SMART (Specific, Measurable, Achievable, Relevant, Time-bound) goals is essential for aligning hospital improvement efforts with simulation-driven plans. SMART goals provide a clear framework that guides quality improvement initiatives, ensuring that they are focused, trackable, and attainable within a given timeframe. This structured approach helps hospitals to:

    1. Specific: Define clear, specific targets for each measure, ensuring that every team member understands the exact goals.

    2. Measurable: Establish criteria for measuring progress, allowing for objective evaluation of improvements.

    3. Achievable: Set realistic goals that are attainable, considering the hospital's resources and capabilities.

    4. Relevant: Ensure that goals are aligned with broader hospital objectives and patient care priorities.

    5. Time-bound: Set deadlines for achieving each goal, fostering a sense of urgency and accountability.

    How Dexur Can Help

    Dexur's AI Advisor extends its capabilities to goal setting by identifying specific measures needing improvement and providing measurable criteria by comparing observed rates with risk-adjusted rates. The AI Advisor helps hospitals establish SMART goals (see this article by Dexur) that are informed by comprehensive data analysis and simulation results.

    For example, consider the provided table:

    Target Readmission Rate Percentile Index Hospitalizations over 3 Years Target Readmission Over 3 Years Number of Readmission Reductions per year
    22.03% (Hospital Current Score) 10th Percentile 227 50 NA
    18.2% 10th Percentile 227 41 NA (Already above target percentile)
    17.4% 30th Percentile 227 39 4 Readmission /Year
    17% 50th Percentile 227 39 4 Readmission/Year
    16.6% 70th Percentile 227 38 4 Readmission/Year
    16% 90th Percentile 227 36 5 Readmission/Year
    • Target Readmission Rate: The image shows various target readmission rates and their corresponding percentiles. For a hospital with a current readmission rate of 22.03% (10th percentile), setting a goal to reduce this rate to 18.2% (still within the 10th percentile but lower) is a SMART goal that is specific and measurable.

    • Index Hospitalizations Over 3 Years: The image indicates 227 index hospitalizations over three years, providing a baseline for measuring readmission reductions.

    • Target Readmission Over 3 Years: To reach the 18.2% target, the hospital needs to aim for 41 readmissions over three years.

    • Number of Readmission Reductions per Year: The image outlines the annual readmission reductions required to achieve the target rates. For instance, reducing readmissions by 4 per year to reach a 17.4% rate (30th percentile) or by 5 per year to achieve a 16% rate (90th percentile).

    Using this data, hospitals can establish SMART goals such as:

    • Specific: Reduce the readmission rate from 22.03% to 18.2% over three years.

    • Measurable: Achieve 41 readmissions over three years.

    • Achievable: Implement strategies to reduce readmissions by 4 per year.

    • Relevant: Focus on reducing readmissions as a key driver of overall hospital performance improvement.

    • Time-bound: Achieve these reductions within the next three years.

    By leveraging Dexur's AI Advisor, hospitals can ensure that their goals are well-defined and aligned with their overall improvement plan. This approach facilitates effective monitoring and management of progress towards achieving higher CMS Star Ratings and better patient outcomes.


  7. Develop Intervention Plans and Track Impact of Interventions Against These Measures

  8. Show the C Suite and Board How the Team Plans to Implement Interventions and Track Their Impact

    To effectively communicate with the Board, it's essential to demonstrate a structured plan for implementing interventions and tracking their impact on performance measures. This involves setting up evidence-based intervention strategies and utilizing robust tracking mechanisms to ensure continuous improvement.

    Need for Evidence-Based Intervention Tracking

    Ineffective Traditional Approaches and Why Manual Interventions Fail:

    Hospitals often set improvement goals based on deteriorating measures, relying on manual or traditional interventions that frequently prove ineffective. These methods struggle due to a lack of real-time tracking and feedback mechanisms, making it difficult to accurately gauge their impact on quality measures.

    Understanding the Challenges:

    Manual tracking and interventions can be time-consuming and prone to errors, leading to inconsistent results and missed targets. This lack of precision and real-time feedback makes it difficult for hospitals to achieve significant improvements in patient outcomes and overall performance. Without accurate tracking and data-driven insights, it is challenging to identify which interventions are working and which need adjustment.

    How Dexur Can Help

    Dexur's AI Advisor extends beyond data analysis to include goal setting and intervention tracking, enabling hospitals to establish specific, data-driven objectives and evaluate the effectiveness of their interventions.

    • AI-Driven Analysis: Dexur analyzes historical data to identify high-impact areas for intervention, ensuring that efforts are focused on measures most likely to improve overall performance.

    • Real-Time Tracking: Hospitals can load intervention data into Dexur’s platform, allowing for real-time monitoring and assessment of their impact. This continuous feedback loop ensures that interventions are adjusted promptly based on their effectiveness.

    • Evidence-Based Recommendations: Dexur provides evidence-based recommendations for interventions, ensuring that hospitals are implementing strategies proven to work in similar contexts.

    For example, the provided image illustrates the tracking of heart failure (HF) 30-day mortality rates. The graph shows the projected impact of specific interventions, such as:

    • High-Risk Patient and Support Protocol: Initiated in October 2023, this intervention aims to reduce mortality by providing targeted support to high-risk patients.

    • Medication Adherence Compliance: Starting in April 2024, this intervention focuses on ensuring patients adhere to their prescribed medications, further reducing mortality rates.

    • 3-Day Post Discharge Check-In: Implemented in July 2024, this intervention involves checking in with patients three days post-discharge to address any immediate concerns and prevent complications.

    By setting clear goals, such as reducing the HF 30-day mortality rate to 10.4% by FY 2025 (70th percentile) and to 9.2% by FY 2026 (90th percentile), and tracking the impact of these interventions, hospitals can demonstrate a data-driven approach to quality improvement.

    Using Dexur’s AI Advisor and evidence-based intervention tracking, hospitals can ensure their improvement plans are strategic, measurable, and adaptable. This approach not only enhances the precision and effectiveness of interventions but also provides the Board with clear, actionable insights into how quality goals will be achieved.


  9. Develop A Monthly Cadence to Align With C Suite on Progress

  10. Importance of a Monthly Cadence

    Establishing a monthly cadence for presenting progress to the C Suite is crucial for several reasons:

    1. Alignment: Regular updates ensure that the entire leadership team remains aligned on the hospital's quality improvement goals and progress. It fosters a unified approach towards achieving the CMS Star Ratings and other quality benchmarks.

    2. No Surprises: Consistent reporting minimizes the risk of unexpected issues arising at critical moments. By maintaining transparency and providing regular updates, the C Suite can anticipate challenges and address them proactively.

    3. Accountability: A monthly cadence reinforces accountability among teams responsible for various quality measures. Regular check-ins highlight areas needing attention and ensure that interventions are being implemented as planned.

    4. Timely Adjustments: Frequent reviews allow for timely adjustments to strategies and interventions. If certain measures are not improving as expected, the hospital can quickly pivot and implement new tactics.

    5. Stakeholder Engagement: Regular updates keep all stakeholders informed and engaged, fostering a culture of continuous improvement and shared responsibility for patient outcomes.

    How Dexur Can Help

    Dexur offers several tools and resources to support hospitals in establishing and maintaining a monthly reporting cadence:

    1. Monthly Guidance Reports: Dexur publishes monthly guidance on CMS Star Ratings and other quality programs such as Leapfrog, VBP, HCAHPS, etc. These publications provide the latest updates, best practices, and insights to help hospitals stay on track with their quality improvement efforts.

    2. Early Warning Alerts: Dexur’s platform can provide early warning alerts for potential issues. By detecting trend changes early, hospitals can take preemptive actions to mitigate negative impacts on their quality measures.

    3. Trend Change Detection: Dexur’s advanced analytics detect significant changes in trends, helping hospitals understand the root causes and adjust their strategies accordingly.

    4. Impact of Interventions: Dexur evaluates the effectiveness of interventions in real-time, allowing hospitals to see the direct impact of their efforts and make necessary adjustments.

    For example, using Dexur’s monthly guidance and alert system, a hospital can track its progress on key measures such as readmission rates and mortality rates. If an early warning alert indicates an unexpected increase in readmissions, the hospital can investigate the cause and implement corrective actions promptly. Additionally, by reviewing the impact of interventions monthly, the hospital can ensure that its strategies are effective and aligned with its overall quality improvement goals.

    Implementing a monthly reporting cadence with the support of Dexur’s tools ensures that hospitals maintain alignment, transparency, and accountability in their quality improvement efforts. This structured approach not only enhances the hospital’s ability to meet and exceed quality benchmarks but also fosters a culture of continuous improvement and proactive management.