SUCCESS STORY

Accelerating Quality Performance

A critical access hospital partnered with Impact Advisors to improve quality performance by deploying an educational and technology-enabled approach to optimize provider workflows and strengthen clinical documentation accuracy. The clinical documentation gaps that the organization was facing limited its ability to receive credit for true quality of care. Impact Advisors was engaged to build a quality program that would improve documentation accuracy, optimize its Epic electronic health record, and provide real-time visibility into quality performance measures.
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A non-profit, community healthcare system on the East Coast, preparing to become an Academic Medical Center, partnered with Impact Advisors to accelerate its quality
improvement journey to reflect the true acuity of its patient population. 

Impact Advisors partnered with the hospital to implement a targeted quality improvement program focused on strengthening clinical risk documentation accuracy, enhancing Epic-enabled provider workflows, and improving performance transparency.

Elevating Quality Performance Targets

In early 2025, leadership recognized that quality ratings were not reflecting the true level of care being delivered. Clinical documentation gaps, risk adjustment knowledge capture, and lack of real-time quality forecasting contributed to external quality scores that understated patient acuity and performance.

Impact Advisors’ initial assessment identified two major opportunity areas:

  1. Clinical documentation accuracy
  2. System-wide external quality education and operational alignment

These challenges required focused intervention to accelerate improvement and support long-term sustainability.

Unifying Quality, Documentation, and Analytics Efforts

Impact Advisors executed a comprehensive quality improvement program designed to strengthen CMS Stars performance through improved documentation workflows, Epic-native automation, retrospective claim accuracy review, and multidisciplinary education.

The program was organized around four integrated focus areas: 

  • Automated Provider Risk-Adjustment Documentation Tools
  • Quality Documentation Reporting and Real-Time Epic Dashboard Capabilities
  • Quality Education and Training Program
  • Retrospective CMS Claims Reviews 

Across all workstreams, Impact Advisors applied a consistent methodology of baseline assessment, performance gap analysis, Epic solution design, phased rollout, provider-informed optimization, and transition to operational ownership.

Epic-Enabled Provider Documentation Tools

To improve risk-adjusted documentation capture and ensure credit is received for true patient acuity, Impact Advisors implemented and optimized Epic automation to support provider workflows:

  • Five new Epic OPA alerts (and one existing alert optimized), with an adoption rate >70%
  • Eight SmartPhrases to support complete provider documentation
  • Coding enhancements to strengthen comorbidity capture

Quality Dashboards, Forecasting, and Performance Visibility

In partnership with hospital Quality and Business Intelligence teams, Impact Advisors designed and launched two new Epic dashboards:

  • CMS Star Quality Dashboard, enabling real-time visibility to performance across key measures critical to the CMS Star Summary Score; delivered 15+ Epic dashboard demos across multidisciplinary teams to establish operational ownership
  • CMS Star Documentation Trends Dashboard, enabling Quality, CDI, and Coding teams to track comorbidity documentation claim rates (connecting the dots to the Retrospective Claim Accuracy Workgroup) in real-time and providing focus on Epic quality provider documentation OPA alert metrics (provider agreement rates and counts of ICD-10 codes added to patients’ problem lists by providers)
 
A CMS Star Forecasting Model was also developed and transitioned to internal ownership, enabling proactive quality performance management.

Provider Education and Quality Training

Impact Advisors delivered targeted training to embed sustainable change:

  • Provider roadshow sessions for hospitalists and clinical service line leaders
  • CMS Star education and reporting for CDI and Coding teams
  • Tip sheets and workflow guidance to support ongoing adoption for the quality team

Claim Accuracy Workgroup and Retrospective Reviews

A multidisciplinary Claim Accuracy Initiative was launched to improve CMS documentation compliance and ensure accurate ICD-10 sequencing. Impact Advisors supported:

  • One-year retrospective claims review
  • Standardized chart validation workflows
  • Weekly governance across CDI, Coding, and Billing teams

Keys to Success

The engagement’s success was driven by strong executive sponsorship, clear ownership across multidisciplinary teams, and close collaboration with hospital leadership. Impact Advisors’ deep understanding of CMS Star ratings and quality documentation enabled rapid trust-building with director-level staff. In addition, the weekly Claim Accuracy Initiative Workgroup and strong partnership with the Business Intelligence team supported consistent execution, high adoption, and sustained improvements in quality performance.

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