Centers for Medicare and Medicaid Services
The Centers for Medicare & Medicaid Services, previously known as the Health Care Financing Administration, is a federal agency within the United States Department of Health and Human Services that administers the Medicare program and works in partnership with state government…
Full Answer
What are the quality initiatives of the Centers for Medicare?
CMS implements quality initiatives to assure quality health care for Medicare Beneficiaries through accountability and public disclosure. CMS uses quality measures in its various quality initiatives that include quality improvement, pay for reporting, and public reporting.
How do we measure quality of care at health care facilities?
Currently, there is no single entity that is responsible for measuring all aspects of quality of care at health care facilities. Most efforts have been focused on structural elements, such as tracking the availability of health care resources.
What are the quality measures used in a quality initiative?
CMS uses quality measures in its various quality initiatives that include quality improvement, pay for reporting, and public reporting. What are Quality Measures?
How can we improve the quality of health care?
Most efforts have been focused on structural elements, such as tracking the availability of health care resources. Over the years, several regulations have been enacted and authorities created at the state and national levels with the aim of protecting patients and improving quality of care.
What is Medicare doing to measure quality?
CMS implements quality initiatives to assure quality health care for Medicare Beneficiaries through accountability and public disclosure. CMS uses quality measures in its various quality initiatives that include quality improvement, pay for reporting, and public reporting.
What is the CMS strategy?
The CMS National Quality Strategy focuses on a person-centric approach from birth to death as individuals journey across the continuum of care, from home or community-based settings to hospital to post-acute care, and across payer types, including Traditional Medicare, Medicare Advantage, Medicaid and Children's Health ...
How can we improve quality measures in healthcare?
Principles Of Quality Improvement In HealthcarePrinciple 1: Promote hands-on improvement projects. ... Principle 2: Get buy-in on what “quality” means. ... Principle 3: Focus measures on improvement vs. ... Principle 4: Use an established quality improvement framework.More items...
How does CMS improve quality of care?
CMS manages quality programs that address many different areas of healthcare. These programs encourage improvement of quality through payment incentives, payment reductions, and reporting information on healthcare quality on government websites.
What is a quality strategy?
Quality strategy means an overarching system and/or process whereby quality assurance and quality improvement activities are incorporated and infused into all aspects of an organization's or system's operations.
How do you develop a quality strategy?
5 Key Elements in Building an Effective Quality StrategyManage expectations. ... Align to Objectives. ... Long Term Goals. ... Short Term Nurture. ... Metrics.
What makes a good quality measure?
Quality measures are typically evaluated on 4 criteria: importance, scientific soundness, usability, and feasibility. These 2 studies focus attention on scientific soundness, including both clinical soundness (the process-outcome relationship) and measurement soundness (reliability and validity).
What are the 3 types of measures for quality improvement?
Three Types of Measures Use a balanced set of measures for all improvement efforts: outcomes measures, process measures, and balancing measures.
How do you measure success in healthcare?
The seven groupings of outcome measures CMS uses to calculate hospital quality are some of the most common in healthcare:#1: Mortality. ... #2: Safety of Care. ... #3: Readmissions. ... #4: Patient Experience. ... #5: Effectiveness of Care. ... #6: Timeliness of Care. ... #7: Efficient Use of Medical Imaging. ... #1: Data Transparency.More items...•
What are the types of quality measures?
There are different types of quality measures, and they are usually categorized into four categories: process, outcome, structural, and balancing measures.
What are quality improvement models?
The Model for Improvement is split into two phases. The first phase involves setting aims, establishing measures, and selecting an intervention. The second phase involves testing the intervention in real world settings using the PDSA cycle.
What is national quality strategy?
The National Quality Strategy is a national effort to align public- and private-sector stakeholders to achieve better health and health care for all Americans.
What are the CMS goal?
Goal 1: Make Care Safer by Reducing Harm Caused in the Delivery of Care Strategic Result: Healthcare-related harms are reduced. Goal 2: Strengthen Person and Family Engagement as Partners in Their Care Strategic Result: Persons and families are engaged as informed, empowered partners in care.
How does the CMS influence nursing practice?
Thus, it simplifies nurses' work in that they have a solid base of medications to choose from for their patients. What concerns CMS, it helps nurses to arrange coordination within the healthcare facility, which leads to better patient outcomes (Salmond & Echevarria, 2017).
What is national quality strategy?
The National Quality Strategy is a national effort to align public- and private-sector stakeholders to achieve better health and health care for all Americans.
What are the National quality Strategy domains?
The National Quality Strategy (NQS) is a nationwide effort to provide direction for improving the quality of health and healthcare in the United States. It is guided by three aims: better care, healthy people and communities, and affordable care.
What is nursing home quality?
The nursing home quality measures come from resident assessment data that nursing homes routinely collect on the residents at specified intervals during their stay. These measures assess the resident's physical and clinical conditions and abilities, as well as preferences and life care wishes. These assessment data have been converted to develop quality measures that give consumers another source of information that shows how well nursing homes are caring for their resident's physical and clinical needs.
Why are quality measures important in nursing homes?
These quality measures were selected because they are important. They show ways in which nursing homes are different from one another.
How long do you stay in a nursing home?
The long stay resident quality measures show the average quality of care for certain care areas in a nursing home for those who stayed in a nursing home for 101 days or more.
How long is a short stay resident?
The short stay resident quality measures show the average quality of resident care in a nursing home for those who stayed in a nursing home for 100 days or less or are covered under the Medicare Part A Skilled Nursing Facility (SNF) benefit.
How much of the population will be covered by Medicare in 2028?
With Medicare Advantage penetration currently at about 36% of the total Medicare-eligible population, and projections showing this number will reach 42% by 2028, health systems need to find ways to profitably serve this population.
How many people age into Medicare per day?
Leaders have even stated that there is a potential to reach 50% penetration. Even though 10,000 people age into Medicare per day, most health systems still draw their entire operating margin from commercial business, whereas Medicare at best breaks even.
How does CMS adjust MA payments?
Optimize the MA payment process. CMS adjusts its MA payment—up or down—for each member based on anticipated clinical costs through a risk adjustment factor (RAF). The implication for providers is to focus on their hierarchal condition coding (HCC) strategies and align MA plans with those efforts for opportunities to receive payments that most accurately reflect the clinical complexity of every patient.
What is collaborative strategy in health care?
Through a collaborative strategy with MA plans, health systems can develop and fund foundational population health and clinical management competencies with senior populations. For example, in concert with clinical management improvements, health systems can work with MA plans to influence plan design, network design, and pharmacy benefits to align and enable a financial return on their population health management efforts.
How can health systems improve their performance?
The good news for health systems is they can improve performance by developing and deploying care models that integrate support services as well as disease prevention and healthy living strategies to delay progression to frailty and improve the lives of beneficiaries.
What is one co-branded model?
One is a co-branded model, where a system and plan create a joint-venture product that shares margin among two organizations. Care Partners of Connecticut, a JV between Tufts Health Plan and Hartford HealthCare, is one such example that launched for the 2019 plan year. This approach, which is beginning to draw more and more interest, creates more economic alignment between the health system and plan than pay for performance or shared savings arrangements.
When did Medicare start in 2019?
The 2019 Medicare Advantage (MA) plan year began on Jan. 1, and once again, more Americans are enrolling in MA plans than the year before. Fueled by an aging baby boomer population and attractive financial incentives to join, more than 22.3 million beneficiaries this year enrolled in an MA plan, an increase of 6.6% over 2018.
What is quality improvement?
Quality is defined by the National Academy of Medicine as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
How does CMS use quality measurement and improvement?
CMS uses quality improvement and quality measurement to achieve the goals and priorities of the Meaningful Measures Framework. The purpose of the Framework is to improve outcomes for patients, their families and providers while also reducing burden on clinicians and providers. CMS’ areas of focus are:
How does benchmarking help in healthcare?
Healthcare providers gain insights and improve outcomes through quality measure benchmarking. Benchmarking allows us to identify best practices in care. By analyzing variation in quality measures, we can identify research opportunities that advance professional knowledge, which informs the creation of future best practices.1 Similarly, quality measure benchmarks can be used to accurately track quality improvement progress.
Why do we use quality measures?
Patient and families use quality measures to select high-performing clinicians. Healthcare providers use quality measures to assess their own performance. Selection and choice decisions based on sound quality measures increase the likelihood of desired health outcomes.3.
Why is behavior made systematic?
First, behavior is made systematic so that the same inputs result in the same outputs within the bounds of uncertainty (randomness). Second, behavior is aligned with evidence on sound practices (e.g., guidelines and systematic reviews).
What are the mechanisms of quality measurement?
The mechanisms of quality measurement are selection and choice. A quality measure is a tool for making “good decisions” defined as decisions that make it more likely to experience a good result and less likely to experience an adverse result that was not foreseen or was not understood. Patient and families use quality measures to select ...
What is the priority of the President?
Quality health care for people with Medicare is a high priority for the President, the Department of Health and Human Services (HHS), and the Centers for Medicare & Medicaid Services (CMS). HHS and CMS began launching Quality Initiatives in 2001 to assure quality health care for all Americans through accountability and public disclosure.
What is CCSQ in healthcare?
CMS' Center for Clinical Standards & Quality (CCSQ), led by the CMS Chief Medical Officer and the CCSQ Leadership Team, is a cadre of professionals with diverse backgrounds in clinical, scientific, public health, legal, IT, project management, academic, and business management fields. We serve CMS, HHS, and the public as a trusted partner with a steadfast focus on improving outcomes, beneficiaries' experience of care, and population health, while also aiming to reduce healthcare costs through improvement.
What is CMS quality management system?
Known as the Measures Management System (MMS), this system is composed of a set of business processes and decision criteria that CMS funded measure developers follow in the development, implementation, and maintenance of quality measures. The steps in the measure development process are summarized in the document " Quality Measures Development Overview, " which is available as a downloadable file in the " Downloads " section, below.
What is Section 101 MACRA?
In addition, Section 101 of the MACRA promotes the development of APMs by providing incentive payments for certain EPs who participate in APMs and by encouraging the creation of additional Physician-Focused Payment Models (PFPM s).
What is the CMS quality strategy?
The CMS Quality Strategy pursues and aligns with the three broad aims of the National Quality Strategy and its six priorities. Each of these priorities has become a goal in the CMS Quality Strategy. To learn more about the CMS Quality Strategy, and to provide feedback and public comment, please click on the following link: CMS Quality Strategy
What is a physician quality reporting program?
The Physician Quality Reporting Programs Strategic Vision (or “Strategic Vision”) describes a long-term vision for CMS quality measurement for physicians and other health care professionals and public reporting programs, and how they can be optimized and aligned to support better decision-making from doctors, consumers, and every part of the health care system . This Strategic Vision articulates how we will build upon our successful physician quality reporting programs to help achieve the CMS Quality Strategy’s goals and objectives, and therefore contribute to improved healthcare quality across the nation. Access the Strategic Vision by clicking this link: Physician Quality Reporting Programs Strategic Vision (PDF)
What is CMS practice transformation?
Practice Transformation is a process that results in observable and measurable changes to practice behavior.
What is the core quality measure?
Today, the Core Quality Measures Collaborative (CQMC) released four updated core measure sets covering specific clinical areas as part of its mission to provide useful quality metrics as the nation’s health care system moves from one that pays based on volume of services to one that pays for value. These updated core sets are a result of months of consensus-based review and deliberation among the group’s 75+ multi-stakeholder member organizations, evaluating hundreds of existing quality measures against the CQMC’s rigorous criteria. CQMC will release four additional updated core measure sets and two new core measure sets over the coming months. The CQMC is a diverse coalition of health care leaders representing over 75 consumer groups, medical associations, health insurance providers, purchasers and other quality stakeholders, all working together to develop and recommend core sets of measures by clinical area to assess and improve the quality of health care in America. The coalition was convened in 2015 by America’s Health Insurance Providers (AHIP) and the Centers for Medicare & Medicaid Services (CMS) and is housed at the National Quality Forum (NQF). Please see http://www.qualityforum.org/CQMC_Core_Sets.aspx for more information.
What is core measure set?
These core measure sets are a major step forward for alignment of quality measures between public and private payers and provides a framework upon which future efforts can be based.
What is ongoing monitoring?
Ongoing monitoring by the Collaborative of the use of these measures will enable modifications of measure sets, as needed and based on lessons learned, including minimizing unintended consequences and selection of new measures as better measures become available.
How does CMS improve quality of care?
CMS believes that by reducing burden on providers and focusing quality improvement on key areas across payers, quality of care can be improved for patients more effectively and efficiently.
Why is it so difficult to have actionable and useful information?
It is difficult to have actionable and useful information because physicians and other clinicians must currently report multiple quality measures to different entities. Measure requirements are often not aligned among payers, which has resulted in confusion and complexity for reporting providers.
Why is it important to have accurate information on health care quality?
There is a great demand today for accurate, useful information on health care quality that can inform the decisions of consumers, employers, physicians and other clinicians, and policymakers. This is increasingly important as the health care system moves towards value-based reimbursement models.
Is CMS using core measures?
CMS is already using measures from the each of the core sets. Using the notice and public comment rule-making process, CMS also intends to implement new core measures across applicable Medicare quality programs as appropriate, while eliminating redundant measures that are not part of the core set. Commercial health plans are rolling out ...
What is the purpose of PDSA?
The purpose of PDSA quality improvement efforts is to establish a functional or causal relationship between changes in processes (specifically behaviors and capabilities) and outcomes. Langley and colleagues51proposed three questions before using the PDSA cycles: (1) What is the goal of the project? (2) How will it be known whether the goal was reached? and (3) What will be done to reach the goal? The PDSA cycle starts with determining the nature and scope of the problem, what changes can and should be made, a plan for a specific change, who should be involved, what should be measured to understand the impact of change, and where the strategy will be targeted. Change is then implemented and data and information are collected. Results from the implementation study are assessed and interpreted by reviewing several key measurements that indicate success or failure. Lastly, action is taken on the results by implementing the change or beginning the process again.51
What is the importance of quality improvement?
Quality improvement requires five essential elements for success: fostering and sustaining a culture of change and safety, developing and clarifying an understanding of the problem, involving key stakeholders, testing change strategies, and continuous monitoring of performance and reporting of findings to sustain the change.
What is failure mode and effects analysis?
Failure modes and effects analysis (FMEA) is an evaluation technique used to identify and eliminate known and/or potential failures, problems, and errors from a system, design, process, and/or service before they actually occur .74–76FMEA was developed for use by the U.S. military and has been used by the National Aeronautics and Space Administration (NASA) to predict and evaluate potential failures and unrecognized hazards (e.g., probabilistic occurrences) and to proactively identify steps in a process that could reduce or eliminate future failures.77The goal of FMEA is to prevent errors by attempting to identifying all the ways a process could fail, estimate the probability and consequences of each failure, and then take action to prevent the potential failures from occurring. In health care, FMEA focuses on the system of care and uses a multidisciplinary team to evaluate a process from a quality improvement perspective.
Why are people hesitant to participate in quality improvement efforts?
Even with strong and committed leadership, some people within the organization may be hesitant to participate in quality improvement efforts because previous attempts to create change were hindered by various system factors,93a lack of organization-wide commitment,94poor organizational relationships, and ineffective communication.89However the impact of these barriers were found to be lessened if the organization embraced the need for change,95changed the culture to enable change,90and actively pursued institutionalizing a culture of safety and quality improvement. Yet adopting a nonpunitive culture of change took time,61, 90even to the extent that the legal department in one hospital was engaged in the process to turn the focus to systems, not individual-specific issues.96Also, those staff members involved in the process felt more at ease with improving processes, particularly when cost savings were realized and when no layoff policies were put in place to protect job security even when efficiencies were realized.84
How is quality measured in health care?
More than 40 years ago, Donabedian27proposed measuring the quality of health care by observing its structure, processes, and outcomes. Structure measures assess the accessibility, availability, and quality of resources, such as health insurance, bed capacity of a hospital, and number of nurses with advanced training. Process measures assess the delivery of health care services by clinicians and providers, such as using guidelines for care of diabetic patients. Outcome measures indicate the final result of health care and can be influenced by environmental and behavioral factors. Examples include mortality, patient satisfaction, and improved health status.
Why is it important to adopt process improvement techniques?
Because errors are caused by system or process failures,5 it is important to adopt various process-improvement techniques to identify inefficiencies, ineffective care, and preventable errors to then influence changes associated with systems.
What is RCA technique?
RCA is a technique used to identify trends and assess risk that can be used whenever human error is suspected65with the understanding that system, rather than individual factors, are likely the root cause of most problems.2 , 4A similar procedure is critical incident technique, where after an event occurs, information is collected on the causes and actions that led to the event.63
What is the Australian healthcare agreement?
The overarching strategy for ensuring quality of care is captured in the National Healthcare Agreement of the COAG (2012) . The agreement sets out the common objective of Australian governments in providing health care — a sustainable system with improved outcomes for all — and the performance indicators and benchmarks on which progress is assessed. It also sets out national-priority policy directions, programs, and areas for reform, such as addressing major chronic diseases and their risk factors. Indicators and benchmarks in the agreement address issues of quality from primary to tertiary care and include disease-specific targets of high priority, as well as general benchmarks.
What is the SUS performance index?
In 2012, the Ministry of Health launched SUS Performance Index, which tracks indicators related to access, effectiveness, equity, and other improvement goals. However, political and policy changes have hampered the use of these evaluations for improving quality of care.
What is the Danish Institute for Quality and Accreditation in Healthcare?
The Danish Institute for Quality and Accreditation in Healthcare (IKAS) was instrumental in implementing accreditation in hospitals and in primary and municipal health care through the Danish Healthcare Quality Program.
What is the quality of care?
Quality of care is addressed through a range of measures broadly defined by law and in more detail by the Federal Joint Committee. The Institute for Quality Assurance and Transparency (IQTiG) is responsible for measuring and reporting on quality of care and provider performance on behalf of the Federal Joint Committee. In addition, the institute develops criteria for evaluating certificates and quality targets and ensures that the published results are comprehensible to the public. All hospitals are required to publish findings on selected indicators, as defined by the IQTiG, to enable hospital comparisons. There is a mandatory quality reporting system for the roughly 1,600 acute-care hospitals, in which data of 290 publicized process and outcome indicators across 30 treatment areas are collected. Based on these data, sickness funds and the White List ( Weisse Liste ), a nonpartisan online tool, report outcomes to help patients choose hospitals. Indicators for quality-related hospital accreditation and payment are currently being developed.
What are the visions of a prefecture?
These delivery visions also include plans for developing pediatric care, home care, emergency care, prenatal care, rural care, and disaster medicine. Structural, process, and outcome indicators are identified, as well as strategies for effective and high-quality delivery. Prefectures promote collaboration among providers to achieve these plans, with or without subsidies as financial incentives.
What is the Canadian Institute for Health Information?
In addition, the Canadian Institute for Health Information produces regular public reports on health system performance, including indicators of hospital and long-term care facility performance. To date, there is no information publicly available on doctors’ performance across the country. Most provinces post summary inspection reports online.
How often is the National Health Service Survey conducted?
The National Health Service Survey for patients and providers is conducted every five years (the latest was in 2018), and a report is published after each survey highlighting data on selected quality indicators.
What does it mean when a hospital has a high referral rate?
If referrals are high, it may indicate patient needs aren’t being met, or it could simply serve to track the volume of patients being sent to more specialized facilities.
What does it mean when a hospital has a high percentage of patients leaving?
A high percentage may mean the facility isn’t adequately serving patients who need treatment, a situation that can lead to high readmission rates or public safety issues.
What is the patient to staff ratio?
Patient-To-Staff Ratio: The number of hospital staff divided by the number of patients for a specific time period. This indicates whether the facility—or even a certain division—is under- or overstaffed. Typically, understaffing leads to a decline in quality.
How do hospitals collect feedback?
Typically, hospitals collect feedback by mailing and emailing surveys to previous patients . Low satisfaction can signal a problem with hospital operations or care quality, but high scores are often used as marketing tools to promote the hospital and attract donors.
What is the difference between effectiveness and efficiency?
Effectiveness measures relate to services based on established medical treatments or knowledge (care that’s been proven to work), efficiency measures focus on avoiding waste (waste of time, resources, or equipment), and timeliness measures evaluate the promptness of services (reducing wait times, eliminating discharge delays, etc.). Many of these are commonly included in larger quality improvement programs, too.
What does a high readmission rate mean?
A high percentage could indicate care is low quality and ineffective.
What is the definition of a high rate of complications?
Complication Rate: The percentage of patients who develop complications (typ ically surgical complications) as a result of care. It can be tracked by a specific timeframe or division. A high rate of complications is common for hospitals that regularly perform high-risk procedures; or it can indicate a low quality of care.
