How to Integrate CMS QAPI Goal Setting Frameworks for CMS Star Rating, VBP & HRRP


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CMS QAPI (Centers for Medicare & Medicaid Services Quality Assurance and Performance Improvement) encourages healthcare organizations to establish and monitor quality improvement goals. These goals can align with the metrics and measures used in CMS quality programs, including Star Ratings, VBP and HRRP. By setting specific goals to improve performance on quality measures that impact Star Ratings VBP and HRRP, healthcare organizations can directly link their compliance efforts to the desired outcomes in CMS quality programs.

CMS QAPI recommends using the SMART goal-setting framework, which stands for Specific, Measurable, Achievable, Relevant, and Time-bound. Here's how SMART goal setting can be linked to CMS quality programs such as Star Rating improvements in Dexur’s platform.

Specific: When setting goals within the CMS QAPI framework, it's important to be specific about the desired outcome. In the context of Star Rating improvements, healthcare organizations can identify specific areas or quality measures that directly impact their ratings and implement targeted interventions and quality improvement initiatives.

How Dexur Helps in Setting Specific Goals for CMS Star Rating, HRRP & VBP:

Dexur’s AI and Manual Simulations identifies the specific measure and how much it has to be improved to achieve this desired outcome, by crunching through hundreds of millions of combinations. For example, Dexur’s AI Simulator can identify one specific goal for a sample Hospital (Acme Hospital), which is to reduce COPD mortality rate from 8.6% to 7.1%. This goal is aligned with the objective of achieving a 5-star rating, which signifies excellent performance for hospitals.

Measurable: SMART goals should include measurable criteria to track progress. CMS quality programs provide specific metrics and measures that contribute to Star Ratings. Healthcare organizations can link their SMART goals to these metrics and establish quantifiable targets.

How Dexur Helps in Measurable Goals for CMS Star Rating, HRRP & VBP:

Dexur’s platform allows multiple measurable data points for the same measure. For e.g. Observed Rates Vs Risk Adjusted Rates or Internal Hospital Data Vs Dexur Medicare claims Analytics. All these various data elements can be measured at varying frequency.

Attainable: Goals within the SMART framework should be realistic and attainable. When linking SMART goal setting to Star Rating improvements, healthcare organizations should consider their current performance levels, available resources, and the time required for improvement. Setting overly ambitious goals may lead to frustration and potential resource constraints. Therefore, it is crucial to establish goals that are challenging yet achievable based on the organization's circumstances.

How Dexur Helps in Setting Attainable Goals for CMS Star Rating, HRRP & VBP:

Dexur’s platform tracks all Hospitals’ measure-wise data, which enables hospitals to compare thier performance against benchmark data from similar healthcare facilities to determine if they can reach the 10th, 30th, 50th, 70th or 90th percentile. Dexur's AI simulation software automatically ranks goals based on the likelihood of attainment (e.g. going from 10% to 30% percentile rather than from 70th to 90th percentile)

Relevant: SMART goals should be relevant to the overall objectives of the healthcare organization and align with CMS quality programs. By linking goal setting to Star Rating improvements, healthcare organizations prioritize quality measures that have a direct impact on their ratings.

How Dexur Helps in Relevant Goals for CMS Star Rating, HRRP & VBP:

Dexur’s platform tracks the relevance of all quality measures that impact the CMS quality programs including Star Ratings. For example, Acme hospital’s improvement efforts to reduce COPD mortality rate ensures that it is relevant to the organizations’s goal of improving the CMS Star Ratings. Each goal is mapped to a measure which is mapped to quality programs and organizational strategy.

Time-bound: SMART goals need to have a specific timeframe for completion. In the context of CMS quality programs and Star Rating improvements, healthcare organizations should set deadlines for achieving their goals. This time-bound aspect helps create a sense of urgency, establishes accountability, and facilitates progress tracking.

How Dexur Helps in Time Bound Goals for CMS Star Rating, HRRP & VBP:

Dexur’s platform sets the deadline for the goals and facilitates Hospitals to set timeframes to achieve this goal. For example, a time bound goal for Acme Hospital could be to decrease the COPD mortality rate from 8.6% to 7.1% within 12 months for the FY 2026, representing a decrease of 1.5%. It means reducing the overall mortality rate by 0.13% per month for a total reduction of 1.5% within 12 months.

An Illustrative Example from Dexur on how QAPI SMART Framework for Goals

By incorporating the SMART goal-setting principles into their QAPI processes, healthcare organizations can establish clear, measurable, and time-bound objectives that align with CMS quality programs and directly impact their Star Ratings, HRRP and VBP. SMART goals implemented within Dexur provides a structured framework for improvement efforts and enable organizations to track progress, make necessary adjustments, and achieve desired outcomes in a systematic manner.

Specific Measurable Attainable Relevant Time bound
Measure Priority Status What do we want to accomplish? Who will be involved/affected? Where will it take place? What is the current data figure for that measure? What do you want to increase/decrease that number to? Did you base the measure or figure you want to attain on a particular best practice/average score/ benchmark? Briefly describe how the goal will address the business problem stated above. What is the target date for achieving this goal?
COPD Mortality High Active

FY 2026 Goal COPD -

7.1% (90th %ile)

Mark Inpatient 8.60% Decrease

7.1%

(90th %ile)

Improve CMS Star Rating from 4 to 5 Start:2023-07-01 to End:2024-06-30