Improving your Hospital’s CMS Star Rating Virtual Learning Cohort
Learning Sessions and Rapid Cycle Improvement Project

Program Overview

This 8-part learning cohort will be led by a multidisciplinary team from various hospitals and organizations. The cohort will support hospitals to understand the CMS Star Rating Program and assist with creating improvement projects to enhance internal programs. Participants will learn techniques to improve, sustain, or adopt processes that may enhance an organization’s quality program and result in improved CMS Star Rating.

Target Audience - Quality Leaders/Staff, Nursing Leaders/Staff, Clinic Staff, HIM and Coding Specialists, C-Suite

Cost - No cost is associated with this program for member hospitals.

Session #1 – CMS Star Rating Overview
February 28, 2023, 11:00 AM - 12:00 PM CT
Objectives:
Understand the CMS Star Rating Methodology
Understanding your Data
Risk Adjustment Measures
Improvement Opportunities in your Facility

Speakers: Caitlyn Gillooley and Akin Demehin | American Hospital Association

Session #2 – 5 Star Data Review
March 22, 2023, 12:00 - 1:00 PM CT
Objectives:
Demystifying and understanding your CMS 5 Star Reports
Identifying Opportunities for Improvement within your Organization
Engaging your Management Team on Quality Initiatives Surrounding the CMS Star Rating
Team Accountability Approaches for Improving Metrics
Creating Data Tools to Assist with Quality Improvement Projects

Speakers: Barb Peterson, APRN, MSN, CPHQ | Great Plains Health

Session #3 – A CAH’s Journey to a 5-Star Rating
April 11, 2023, 12:00 - 1:00 PM CT
Objectives:
Partnering with your ACO and Payors to Close Patient Care Gaps
Utilizing CCM to Prevent Readmissions
Continuing Improvement Opportunities in the Post-Acute Care Setting
Breaking down the CMS Star Rating Program
Timely and Effective Care Measures
Utilizing your Electronic Health Record

Speakers: April Benson, MSN, RN, Beverly Nelson, RN | Boone County Health Center

Session #4 – Improving the Patient Care Experience
April 25, 2023, 12:00 - 1:00 PM CT
Objectives:
Demonstrate Organizational Strengths and Barriers to Quality Star Ratings Within a Large Health System
Explore the Future of Using and Improving HCAHPS Quality Star Ratings for Continued Quality Patient Experience and Improvement
Identify Key Initiatives Within the Health System to Cultivate an Environment that Encourages and Sustains Future Quality Star Ratings
Articulate Initiatives on How Improving Quality Star Ratings Relates to Successes Within the System

Speakers: Lauren Robins, OTD, OTR/L, CLT, SSBB, Adrianne Carson | Methodist Health System

Session #5 – Preventing Readmissions and Improving Quality of Care
May 11, 2023, 12:00 - 1:00 PM CT
Objectives:
Define Tactics in Each Stage of Interaction: Pre-Hospital, Intra-Hospital and Post-Hospital to Support a Successful Discharge
Discuss the Importance of “Hand Off” in all Aspects of Discharge
Identify Processes that Support Coordination of Care: Patient Transport, Family Engagement, and Interdisciplinary Collaboration
Identify Community Resources that can Impact a Safe Discharge

Speakers: Nicole Blaser, MSN, RN | Columbus Community Hospital

Session #6 – Patient Safety Measures and Preventing Incidents from Occurring in your Hospital
May 31, 2023, 12:00 - 1:00 PM CT
Objectives:
Identify and explain the 8 Standards for the “Safety of Care” Measure Group and How they are Weighted Within the Overall Star Rating
Describe Common Complications Related to Hip and Knee Replacement Patients
Compare Best Practices for Hip and Knee Replacements to Existing Organizational Orthopedic Clinical Pathways
Evaluate Organizational Falls Prevention Protocols in Relation to Hip and Knee Replacement Patients

Speakers: Emily Barr and Carla Snyder | Nebraska Coalition of Patient Safety

Session #7 – Accountable Care Organizations (ACO)
June 6, 2023, 12:00 - 1:00 PM CT
Objectives:
Understanding of the Purpose of an ACO
Understanding the Operations of an ACO Related to Quality Improvement Efforts and Performance Management
Understand How Data and Quality Performance in an ACO Contributes to CMS Star Rating

Speakers: Tera Heidtbrink, MSN, RN | Bryan Health Connect

Session #8 – Recap and the Future of CMS Star Rating Program
June 20, 2023, 12:00 - 1:00 PM CT
Objectives:
Discussion of Learnings Throughout the Cohort
Future of CMS Star Rating Program
How Nebraska can have a Voice on a National Level
Q&A

Speakers: Caitlyn Gillooley and Akin Demehin | American Hospital Association

Contacts
For more information, please contact Dana Steiner – dsteiner@nebraskahospitals.org or Amber Kavan – akavan@nebraskahospitals.org

Links to the webinars will be sent out a couple days prior to each session.