CMS STARs and Hospital Performance

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Transcript

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You're listening to Vital Signs, a podcast for Sentara providers. Welcome to the introduction to CMS Stars and Hospital Performance episode.

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In today's episode, we're joined by Paul Tesoriere MD, CME Sentara Martha Jefferson Hospital,

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and executive sponsor CMS Star's CPI goal. Before we turn things over,

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here are a few important CME announcements. This episode is accredited for AMAPRA Category one.

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Full accreditation, designation, and disclosure information, please refer to the show notes.

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And now here is Dr. Tesoriere.

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Hello. Welcome to the Sentara Physician and EPP podcast. I'm Doctor Paul Tesoriere,

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Chief Medical Officer of Centerra Martha Jefferson Hospital, and executive sponsor for Sentara's work on uh CMSar improvement.

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Whether you love them or hate them or ignore them, star ratings influence our reputation, our financial stability,

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and ultimately our ability to care for our patients.

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A question to think about If one of your family members were choosing a hospital today, would you want them to look at star ratings and evaluate that

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in their choice?

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Let's keep that in mind as we go forward.

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As you can see, this is where.

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Sentara stands from a 2025 star rating perspective with one five-star hospital.

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A good number of 4 stars and a handful of 3 star hospitals. Just remember that star ratings are on a bell curve,

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with about 10% of hospitals achieving 5-star and 10% achieving a 1-star rating with the rest falling in the middle.

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Let's start with some basics.

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CMS, the Centers for Medicare and Medicaid Services, again. Assigns this 1 to 5 star rating based on 45

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quality measures.

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And this is ultimately rolled up into one number. You could see the different domains with 4 domains.

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Uh, making up 88%, including mortality, safety of care, readmissions,

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patient experience, and ultimately, you have timely and effective care with 12% impact.

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As we look at this and think about.

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Some of the specific domains. Um,

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I'd like all the physicians and APPs to think about. Where, where can you influence these,

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uh, these ratings and uh.

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Potentially How can you help your facility improve their quality performance?

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So here's a quick summary of. What makes up CMS stars and how it potentially could impact our facilities.

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So it's a very complex methodology. And Given the fact that CMS uses A

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multi-year measurement window.

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means that

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What we're doing today in 2026 will actually impact our ratings in 2028 and beyond.

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So decisions and performance that we have right now will be impacting us two years from now.

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The reason for this multi-year measurement window is so CMS.

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can evaluate for stability, risk adjustment, adjustment, and fair national comparisons.

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And as we see

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The scores are extremely important because they directly affect our public reputation and patient choice.

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Value-based purchasing contracts and CMS penalties. Negotiation with commercial payers,

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market share and physician recruitment. And internal resources for staffing, technology, and programs can all be impacted.

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A single star change up or down can mean millions of dollars.

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So with the improvement in resources, think about how we can improve staffing, equipment and support within the hospital based on

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high quality performance.

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We also see that a lot of other regulatory and accreditation bodies utilize a lot of these same measures,

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including DNV, state quality reporting, and leapfrog.

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Let's take a closer look at the CMS stars by measuring domain. So in the 1st 22% segment of mortality,

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you can see the different areas um where we're measured and, you know, pretty

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Uh, pretty standard

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Diagnosis sets with COPD, heart failure, pneumonia, stroke.

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MIs in surgical patients. You can see the measuring periods somewhat vary from 3 years on most of them

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to 2 years for the surgical um.

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Uh, mortality rates, and also of interest, you could see the dates range from 2020

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to 2023 in the three-year measurement period for 2025 performance.

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In the safety of care, another 22%, you have pretty much all of our hospital acquired infections that we're closely looking

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at from us, from our CPI work within Sentara. And then also a specific look at patient safety and adverse

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composite or the PSI 90.

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You could see that there's a PSI uh in the mortality section uh for surgical patients and uh.

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In the next slide,

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You can see the PSI 90 is very procedurally and surgical oriented, um,

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with.

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Multiple post-op complications.

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On our elective surgeries.

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Uh, that range anywhere from. Hemorrhage to acute kidney injury to respiratory failure.

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PE DVT and post-op sepsis wounded hisscence.

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And these are our last two.

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22% domains, including readmissions. So you can see that have a lot of readmissions that are standard.

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High volume medical diagnoses like MI, heart failure, pneumonia, COPD.

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Surgical remissions with cabbage, hip and knees.

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As well as some outpatient measures with chemotherapy.

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Outpatient surgery and colonoscopy.

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These range from anywhere from one.

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To 3 years and the dates for the 2025 start period are on the right.

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Patient experience again, another major CPI work group.

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Breaks these Questions down

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To specifics, including communication with nurses and doctors, responsive to hospital staff.

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Communication about medicines and discharge information. As being

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Some of the top items that we are focusing on.

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And then you get a global rating of overall rating and willingness to recommend the hospital.

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You can see this is much more dynamic in the sense that all these measurement periods run just over one year.

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And can be heavily impacted in a short period of time, although again, there is delayed data.

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Last but not least, we have timely and effective care.

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As you can see, although this is a 12%.

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Contribution to the overall score. Again, this is mostly a 1 year measurement,

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obviously half year for. Uh, for vaccination against flu. But many of these are.

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Very hospital specific.

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And can be impacted and influenced in a short period of time with the appropriate work groups.

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Although somewhat of an eye shark, please take a look at these domains.

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And you can see that there's a lot of crossover. With our mortality,

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safety of care, readmissions, with a lot of other.

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Quality programs that we participate in.

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You could see that

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Top 100 hospitals.

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Health grades

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Value-based purchasing

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have a lot of overlap in what we're doing. So by addressing a lot of these core measures in our CMS stars.

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We are impacting

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Really a tremendous amount.

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Of other quality programs. And driving

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Our perception, our patient delivery.

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To the top.

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Where it belongs. And where Santera wants to be.

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Again, to close out the other two components, again, you can see with leapfrog health grades.

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In the top 100 hospitals obviously values patient experience very heavily as well as they should.

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Timely and effective care.

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Is mostly a sea mess.

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So here we have a

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April 2026 preview of what we think our final star ratings might look like for the year.

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And you could see we are trending. With multiple hospitals moving towards a 5 star.

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Several maintaining 4 star performance and a few 3 stars.

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I think the most important thing to point out is we have no 1 or 2 star hospitals, and we continue to see our

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Sentara curve move to the left with more 4 and 5 star hospitals.

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And again, if you're thinking, if you think about the bell curve.

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Where most hospitals are 3 stars, 10% sit at 5 and 1 star. I think this speaks very well for Sentara,

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but.

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We have more work to do and ultimately. Uh, if we can get all our hospitals to 4 and 5 stars,

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I think that'd be a tremendous accomplishment for the system.

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In the table on the right shows historical performance over the past 10 years, and the errors are indicating improvement or decrease in performance.

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And, uh, one thing we can note is Sentara. Has had a slow and gradual

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improvement. As a whole over time.

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This table further breaks down each of our domains, and you can kind of see where your hospital is performing.

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Year over year In each one of our 5. CMS domains.

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The system has maintained strong performance and patient experience and mortality measures. In 2026 is showing one of the strongest system-wide

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performances to date.

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So really every domain matters. mortality, safety, pre-admissions, patient experience, and timely care all contribute meaningfully to the final rating.

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And small improvements add up.

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A single measure moving from below average to average can shift an entire domain score.

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And with our data lags, we have to be very proactive because the things that we do today will influence our star ratings,

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again, as I mentioned, down the line starting in 2028.

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And as mentioned before, these are more than a score, they shape public trust, financial stability,

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and competitive positioning.

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I think when we take a step back and look at what we've accomplished so far, we should be very proud,

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but there's always more work to be done.

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As you can see, we're well on our way to our initial work in 2026.

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Each of the markets and then hospitals chose their areas of focus in the first month of the year.

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We're now deep into our PDCA workshops, where we're Evaluating our opportunities.

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We're creating action plans, and then we're measuring our results.

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Because of the amount of projects we're starting this in. Two phases with the first set very active

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and the second set to start momentarily in the month of April. We're also refreshing our MBI

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boards or managing for Gail Improvement.

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And we think this will allow teams to.

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Manage and keep visibility around their areas of improvement.

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Keep safety and quality center of mind.

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In all of our team meetings.

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As we go forward

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You see an initial breakdown of all the projects uh by hospital.

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With a range of projects at each hospital from 2 to 6. And you could see that there's a lot of overlap

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in some of these domains and some of these specific projects. Ultimately, hopefully we'll provide a roadmap for

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success. In each one of these areas that other hospitals can then utilize potential solution sets that make sense for their

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organization. So I think that We could actually magnify this work and we spread it across the system.

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So with over 40 targeted improvement opportunities.

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Addressed in the PDCA cycles as mentioned.

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The the raw number just required a breaking up into two phases, as mentioned, and you can see which projects are.

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Being approached now and then which ones will start later this month.

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Again, this is not a one size fits all solution. It's very hospital specific, data-driven,

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and clinically grounded.

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As you think about your workflow and your day, and evaluating some of these areas of opportunities.

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One thing I would like to have you think about is what area could you impact the most and where can you be the most helpful for

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your institution to really improve their quality of care.

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Here's a quick reference slide with points of contact for each hospital and each of the areas of opportunity that teams

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are um

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Embarking on a PDA cycle at their individual hospitals. Again, please reach out to each other,

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share ideas.

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Even if it may not be something. Your hospital is working on, you could still learn from a solution set from a different hospital.

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And ultimately will be Keeping a repository of all our different solution sets.

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I think I've addressed most of these questions and answers within the presentation.

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Uh, but feel free to peruse these, um, on your own time.

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And I want to leave you with some takeaways. We have to realize that every domain matters.

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And that each one of us has an impact to touch many of them.

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Small improvements are compounding. And these can turn to meaningful star changes.

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And again, today's care shapes tomorrow's reputation and resources.

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CMS stars is more than a score. It reflects on how safely we practice, how clearly we communicate,

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and how reliably we treat our patients.

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So thank you for everything that you do for our patients.

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Thank you for Listening and hopefully learning from this presentation.

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And At Sentara, we got to keep striving for excellence in every patient interaction.

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Thank you very much.

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Thank you for joining us. You've been listening to Sentara Vital Signs, a podcast created for Sentara providers.

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As a reminder, please check today's show notes for details on how to claim your continuing education credits.

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That's it for now, but we'll be back soon with another episode of Vital Signs, the podcast that delivers evidence-based education for physicians

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and healthcare providers on the go.