A $5.0 billion multi-hospital system faced a significant challenge when its CMS Star Rating dropped from three stars to two stars. This sudden decline posed both reputational and operational risks for the organization, especially in its highly competitive healthcare market.
The health system’s decline in CMS Star Rating was unexpected and alarming. Historically, a three-star system, the organization had invested considerable effort in quality improvement; yet the ratings did not reflect these initiatives. With their focus being on patient-centric care and aligning external quality scores with true quality outcomes, leadership engaged Impact Advisors to drive rapid improvement in quality ratings.
The primary challenges stemmed from the absence of proactive quality score forecasting and a lack of centralized infrastructure to manage quality outcomes and risk adjustment strategies. Leadership and frontline clinical teams were often reacting to issues as they arose, without a long-term plan to consistently improve metrics that influence external ratings.
Compounding these challenges was the siloed nature of teams responsible for Readmissions, Mortality, Safety, and Patient Experience. There was little collaboration or sharing of outcomes among these groups, resulting in fragmented efforts to drive improvement in CMS Stars. Meanwhile, Executive Leadership was looking for more visibility into the trajectory of external quality scores to avoid being surprised by a sudden drop in CMS Star metrics. From Impact Advisors’ initial assessment, it became clear that the quality ratings did not accurately reflect the true quality of patient care being delivered. Inaccuracies in clinical documentation and insufficient focus on capturing quality-focused comorbidities for risk adjustment contributed to the misrepresentation of patient population acuity. This gap presented both a challenge and an opportunity for improvement.
Unifying the Clinical Documentation Integrity, Quality, and Coding Teams
Impact Advisors’ quality improvement approach centered on building a strong and sustainable foundation for accurate documentation. The team deployed a two-pronged approach, focusing on improving both “Observed” and “Expected” measures by evaluating patient safety events and reviewing retrospective claims for historically undocumented patient risk factors.
At the heart of this work was a comprehensive quality documentation strategy that brought together the Clinical Documentation Integrity (CDI), Quality, and Coding teams under
one unified framework. Rather than tackling quality challenges in isolation, the team launched a series of concurrent initiatives. These included building strong governance and
accountability structures, automating inpatient CDI processes within Epic, educating teams on quality-specific documentation gaps, and improving data transparency for informed decision-making.
Over twelve months, targeted efforts such as a custom CMS Star Rating forecast tool, automated provider-facing Epic documentation queries, retrospective claim reviews, and
specialized committees—including a CMS Patient Safety Indicators (PSI90) subgroup and a system-wide Quality Improvement Committee—were launched to drive measurable
improvements in the organization’s external quality ratings. Provider education was also prioritized to ensure consistent, high-quality documentation that supports risk adjustment outcomes.
Impact Advisors implemented customized data models and Epic dashboards that provided real-time visibility into quality performance, empowering leadership to make
informed decisions and anticipate changes in ratings well before official results were published. The new infrastructure also fostered greater collaboration among previously siloed teams, breaking down barriers to information sharing and aligning efforts around shared goals.
Positive Impact
The Impact Advisors team brought a deep understanding of quality ranking calculations and the heavily weighted variables in the quality algorithm, enabling a key focus on the areas that mattered most. Coupled with the knowledge of EHR-enabled workflows and change management, several positive impacts were achieved.
The health system is on track to achieve 3 CMS Stars in 2028 based on current CMS regulations. Additionally, several other key results were achieved:
- Improved the PSI-90 composite score to better than national average.
- Successfully corrected ~470 CMS claims through updated accurate clinical documentation across 25 quality-specific comorbidities and 6 disease cohorts.
- Implemented an Epic CMS Star Documentation & Coding EHR Dashboard to monitor diagnosis rates of CMS cohorts and sustain accurate comorbidity documentation.
- Produced a comprehensive analytical model to forecast CMS Star ratings.
- Developed 25+ education resources for Quality and CDI teams to enhance their understanding of Quality documentation and CMS Star Score measures.