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Improving from a Two-Star to a Five-Star CMS Quality Measure Rating

Jun 6, 2023 | Resources

The Challenge

CMS quality measure star ratings (now know as Care Compare) are one key element in a Skilled Nursing Facility (SNF) performance, along with DOH surveys.  The Granite GRC team was engaged to help a SNF improve their two-star rating. The SNF wanted to get a better rating in a short period of time, and wanted training on how to maintain a great rating after Granite GRC’s engagement was complete.

The Solution

Granite GRC’s team created a master action plan after conducting a thorough analysis of the SNF’s nursing and medical operations.  Quality measures were used to identify focused areas for clinical outcome improvements.  Clinical staff were placed into subject specific teams and assigned performance measures/metrics to address through the facility Quality Assurance/Performance Improvement (QAPI) Committee. Progress of team assignments was reported on during nursing and medical department meetings, and to the QAPI Committee.  Staff were educated and competency tested in areas of new clinical practice or a simple policy change. Communication best practices were put into place and staff members were educated and held accountable for communication excellence. Administration provided resources, direction and support as needed for team assignments.

The Results

In approximately 6 months, the facility achieved their five-star rating, which they still sustain. The annual Department of Health survey followed the five-star rating achievement with a deficiency free survey. The QAPI system remains the facility bedrock for performance outcome monitoring and sustained improvements.