Hospital quality metrics are a set of standards developed by the Centers for Medicare & Medicaid Services (CMS) to quantify health care processes, patient outcomes, and organizational structures. You are likely familiar with some of these key metrics such as length of stay, 30-day readmission rates, or mortality rates which may be reviewed at a clinical service line, department, or hospital-wide level.

Hospital-acquired conditions such as central line-associated blood stream infections (CLABSI), catheter-associated urinary tract infection (CAUTI), or surgical site infections (SSIs) are also key quality metrics for a health care organization to track and monitor because preventing these from occurring in our patients is central to the goal of ensuring that every patient receives safe, effective, and high-quality care that is free of all preventable harm. 

CMS spearheads dozens of initiatives with publicly reported data aimed at reducing overall health care costs and improving care quality, including programs such as the Hospital Outpatient Quality Reporting Program, the Hospital Inpatient Quality Reporting Program, the Hospital Value-Based Purchasing Program, and the Hospital-Acquired Condition Reduction Program. 

Although the focus and metrics differ among these programs, the underlying premise of performance measurement and improvement is something that we can certainly all support. 

— Derek Zhorne, MD, Interim Chief Quality Officer

The Vizient Quality and Accountability scorecard is a tool that measures academic medical centers (AMCs) clinical performance year over year focusing on quality and safety in comparison with similar hospitals while targeting specific opportunities for improvement. The Q&A provides scoring and ranking across the cohort group of AMCs to identify structures and best practices across a variety of patient populations divided into six weighted domains. 

Vizient also provides a quarterly calculator reports with the same metrics within the six domains and allows quarterly ranking to track progress throughout the year. Within the calculator, a member can perform “what if” analyses to identify projected rankings and how scores with improved metrics will impact rankings.

CMS have developed a methodology to calculate and display overall hospital-level quality using a Star Rating system. An individual hospital is assigned a summary Star Rating of between 1 to 5 stars (more is better) based on the hospital’s performance across a variety of quality measures. The most recent CMS Star Rating included forty-nine individual quality measures among the five measure groups of mortality, readmission, safety of care, patient experience, and timely and effective care. The intent of the CMS Star Rating is to improve the usability and interpretability of information posted on Care Compare, which is a website designed for consumers to use along with their health care provider to make decisions on where to receive care. The CMS Star Rating is usually updated each year.

• What are these data sources?
  • Data sources for the Vizient Q&A scorecard is provided at the encounter level that we submit monthly to Vizient. It is based on our EPIC billing data.
  • CMS gets the data from two sources: 1) claims submitted to CMS for delivered care; and 2) information collected from patient medical records.

• How is the data for each collected?
  • UI Hospitals & Clinics submits encounter level data to Vizient monthly by using an extraction process from Clarity (EPICs data warehouse). The extraction process from Clarity begins as soon as the previous completed month reaches at least 90% “Coded Complete” in EPIC. We submit both Inpatient and Outpatient encounters in our Clinical data submission files. We utilize a rolling three-month period with every monthly submission to Vizient so we have the opportunity to pick up any late coded, changes, edits, etc. from a specific month, three different times. We also resubmit every fiscal year to catch any late changes prior to the deadline for the annual Q&A scorecard.
  • In general, the CMS rating is calculated through a complex process of grouping measures, calculating group scores, weighting summary scores, and dividing hospitals into appropriate peer groups for comparison purposes. The details of the methodology have changed over time.

• Where does the scorecard live?
  • Our Vizient Q&A data and scorecard lives within the Vizient Clinical Database. Vizient also offers an online query tool to run routine and ad hoc reports to track performance throughout the year. Our analytics team downloads encounter level data from the Clinical Database and stores the data both in HEDI Data warehouse as well as on Tableau Server for end users to easily access.
    
    
• Who manages the data?
  • Currently HCIS, and Hospital Decision Support manage the Vizient data. The CMO office manages the Q&A scorecard as well as providing analysis and presentation of the scorecard. The analysts in the CMO office are also responsible for validating and overseeing the entire cycle from data submission to extraction of the data.  
  • The Quality Improvement Program (QuIP) manages the evaluation and submission of the CMS quality measures. A team in Health Information Management collaborates with QuIP to abstract the data from the medical records according to measure specifications. Both teams leverage subject matter experts to improve performance on the measures and validate the data prior to submission.

• Why are these important in terms of quality work and how they directly affect the hospital?
  • The Q&A is important to see how well we are providing quality and patient safety to our patients. The metrics within the Q&A look at hospital acquired conditions as well as clinical metrics such as mortality, length of stay, and direct cost. When compared against other academic medical centers, we can identify where we have the largest opportunities to become better performers, whether it be in documentation, coding, or processes. It also is important as it gives us an idea on how satisfied our patients are with their care and where we can improve satisfaction across the institution.
  • The CMS Star Rating is publicly available on CMS’s Care Compare website along with UI Hospitals & Clinic’s performance on each quality measure. The quality measures within the CMS Star Rating are also included in CMS’s Pay-for-Performance Programs.

• What are the similarities and differences/variations in these data sources?
  • Similarities: Both use our hospital encounters to identify our performance across quality, safety, and patient satisfaction.
  • Differences: Vizient utilizes all inpatient and outpatient payors, including Medicare, Medicaid, and private insurances. Vizient also looks at all patients ages. CMS Star Rating only looks at Medicare Payors and patients 65 and older.

• How do they overlap?
  • Many of the metrics within the two reports are the same in regards to quality and safety.

• Why you might see that we are ranked high in one versus the other?
  • The Q&A only uses comprehensive academic medical centers. All patient ages and all insurance payors. The category/domains are weighted differently.

• What about the difference in time frames?
  • CMS Star Rating looks at older data when its calculating rankings, currently the Star Rating is based on fiscal year 2017 to fiscal year 2019 data. Vizient annual scorecard includes the previous fiscal year performance released in the fall of each year, currently July 2020 to June 2021.

• How do individuals access the data?
  • The Vizient Q&A is available to view and download directly from the Vizient Clinical Database site. Regarding our internal reports, the majority of the Vizient data and reports are available on Tableau Server.

• Who to work with to better understand the data:
  • Vizient Benchmarking:
    Kelly Noel-Roszell, Quality and Operational Improvement Engineer, Vizient Analyst, Vizient CDB Coordinator

• CMS Star Rating: Quality Improvement Program
  Phone: 319-356-4311
  Email: qip@healthcare.uiowa.edu

Kelly Noel-Roszell
Quality and Operational Improvement Engineer, Vizient Data Analyst, Vizient CDB Coordinator

Jennifer McDanel
Quality & Operations Improvement Engineer