Director’s Corner: Hitting the Mark

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Steps to take help improve performance of care at your department.

Dear Director,


Our department quality review program hasn’t changed in 20 years and feels stale.  What can I do to freshen it up and make a meaningful impact for our hospital and our patients?

Managing an emergency department has become more complex over time. We are under increasing pressure to meet patient expectations related to the quality of their care assessed through patient surveys.

Additionally, various metrics have been developed that attempt to quantify certain components of the quality of care we deliver. Our quality assurance and performance improvement plans should be impactful, practical, meaningful to our docs and aligned with the hospital’s goals.  With increasing malpractice premiums, publicly reported measures and hospitals focused on mortality rates, we should have plenty of opportunity to create a program that hits our goals.


The Basics

What the hospital cares about

CMS defines hospital quality though 50+ specific quality measures that are revised or updated annually.  However, the list of CMS measures largely or entirely determined by ED performance is actually relatively short at this time.  There are ED throughput metrics (OP-18, OP-22), sepsis metrics (SEP-1), acute MI transfer metrics (OP-2, OP-3b) and stroke transfer metrics (OP-23).

There are other CMS measures that the ED influences — such as those metrics related to readmission, mortality and hospital acquired conditions (e.g. CAUTIs, CLABSIs).   CMS metrics are important to your hospital because they are reportedly publicly and therefore impact your hospital’s reputation.


Some of the CMS measures are used to determine your hospital’s CMS quality star ranking or are used by other organizations such as Leapfrog, Watson Health, Healthgrades or US News and World Report that rank hospital quality.  Individual CMS metrics impact a hospital’s reimbursement if they are included in one of the CMS “pay-for-performance” programs, such as the value-based purchasing program, readmissions reduction program or hospital-acquired conditions program.

Given the importance of CMS measure performance to the hospital, ED physicians should be aware of how the department is performing on the measures that the ED largely or entirely controls. You may also choose to share CMS metric performance on some of the other measures that the ED influences (e.g. mortality, readmissions), especially if your hospital is pursuing an improvement initiative related to one of these metrics.

Beyond CMS quality measures, your hospital tracks additional metrics if it is (or intends on becoming) a STEMI center, stroke center, or trauma center.  These metrics, with specific case details, should also be regularly shared with your providers.

Almost all hospitals have a director of quality — typically a nurse — and a team of quality analysts who work with the clinical committees and various departments to collect the data, make sure that everyone understands the quality measure definitions and assist in quality improvement activities.

In my hospital, the quality team provides SEP-1 data for my department and per individual ED physician, which periodically I share at our department meetings.  They are also our experts regarding the SEP-1 “rules.”  The hospital quality team co-leads ongoing sepsis quality improvement meetings along with our ED physician sepsis champion.  This has resulted in sepsis antibiotics order sets, automatic orders to repeat elevated lactates and a sepsis screening tool for triage, among other quality improvement actions.

What your group cares about

Quality performance impacts your group’s financial performance. One way this occurs is through the cost of obtaining malpractice insurance.  You should present and discuss the care of conditions or specific cases that result in either frequent and/or high value malpractice claims.  Addressing these issues can benefit your patients and reduce your group’s malpractice premiums.  Reviewing “closed claims” is one way to integrate risk management and quality improvement.

More recently, your group’s reimbursement can be impacted by quality performance though the Medicare Access and CHIP Reauthorization Act (MACRA).   This legislation established the CMS Quality Payment Program that ties provider (not hospital) reimbursement to quality performance.

Unless your group participates in an Advanced Alternative Payment Model (rare for EM physician groups), then your group is required to participate in the Merit Based Incentive Payment System (MIPS).   This program started in 2017 and is revenue neutral in that it is required to redistribute funds between lower and higher performing groups.  There is also a special pot of money that is available to groups that meet “exceptional performance.”

Initially, CMS made it relatively easy to avoid a penalty.  Starting in 2022, the score required to avoid a penalty has been raised significantly (from 60 to 75) with up to nine percent of a group’s CMS reimbursement at risk depending on MIPS performance.

Given the increased risk of penalty (or conversely, the increased possibility of a bonus), now is the time to get a handle on your group’s MIPS strategy.   For EM groups in 2022, your MIPS score will be determined by three domains – quality measures (55%), quality improvement activities (15%) and cost (30%).

In the quality domain, MIPS requires a group to be scored on six quality measures.  If your group does not participate in a qualified clinical data registry (such as ACEP’s CEDR), then it is limited to being scored on six measures derived by CMS.

If your group participates in a qualified clinical data registry (QCDR), there will be other measures (which are typically more relevant to ED quality performance) than the CMS measures.

Your group is allowed to submit performance on the six measures that have the best performance compared to benchmark.  It also has the freedom to submit any of the measures in the QCDR (if your group participates in a QCDR) or any of the CMS measures approved for use in the ED.  Either way, you should consider focused education and metric performance feedback on those measures that your group believes will end up determining your MIPS quality domain score.

Regarding the quality improvement domain, you need to be aware of which quality improvement activities your group plans to submit to CMS to maximize the score in this domain.  You’ll need to make sure you incorporate these improvement activities into your department’s quality program for the year.

What your docs care about

Your department’s quality performance efforts should not be limited to those issues or topics for which CMS or another organization has provided defined metrics or those issues that impact your group’s reimbursement.  Your site physicians should have the opportunity to participate in efforts to improve care for the issues and topics for which they are passionate, and which may be especially relevant to your ED.

This might be quality improvement related to airway preparedness, treatment of opioid use disorder, or one of a myriad of other issues.  Allow some bandwidth to address issues that especially matter to your team and to your patients.

Another great way to keep your providers engaged in quality improvement is to regularly present challenging cases from your ED for discussion.  Most of us are very familiar with the concept of M+M from our residency training although not all EDs outside academic centers regularly discuss individual cases.  If done right, this is a good way to boost the collegiality of your group, educate around interesting topics or changes in practice standards and identify new opportunities for quality improvement.

My group does regular reviews of sepsis and stroke fallouts so we can make sure everyone understands the metric, understand the issues behind the misses and review some of the documentation techniques to help us explain our medical decision making while maintaining compliance with the rules of the measure.

As a group, we’re responsible for achieving a certain level of performance regardless of the metric. Over the past year, we’ve tried to provide case specific feedback to the docs on all cases that are formally reviewed. I’m pretty transparent with data, so intermittently throughout the year, I’ll share individual doc performance for metric success at a staff meeting.  I’ve yet to meet a doc who doesn’t want to be successful, so this allows for some comparison.

Regardless of the measure, the N is typically not huge for any individual doc and it’s rare for anyone to be perfect.  And while I may not worry about an individual miss each doc may have, I do worry about the doc who is significantly below the group.  While my job is to help improve the system and the process, I do need each individual to do their part as well.

Lastly, it’s always interesting to your providers to see a list of patients they discharged but were readmitted within the next 72 hours.  Many of these patients will not be surprises (e.g. some psych complaints, threatened miscarriage patients) although in other cases, there may be opportunities to improve either the diagnosis or treatment provided.

My approach

I originally got into ED administration because I wanted to improve patient care more than one patient at a time.  Developing and maintaining an effective quality improvement process is an essential tool. As a first step, you need to be in contact with your director of quality so you can make sure your plan aligns with the hospital goals.

I’m a fan of the M+M presentation and reviewing individual cases, which make for great opportunities to teach the key components of the metric. If I have a provider who is a serious outlier on the metrics, I’ll coach them on understanding the metric and reviewing fallouts.  On the hospital side, we need to be represented in the key quality committees and understand how we impact the key metrics.  All of us want to save lives, so covering mortality data is important. Highlighting system and process improvements that have contributed to performance success is important as well.

The Ongoing Professional Practice Evaluation (OPPE) is the semiannual review required by Joint Commission where chairs confirm that docs are performing appropriately for each credentialing aspect. I use RSI and sedation audits to help meet OPPE criteria.

I also like looking at ICU upgrades and 72 hour returns for admission as additional PI opportunities.  It’s important to look for trends such as whether ICU docs are consulted and turned down a patient or not consulted at all.  While some cases are clearly unanticipated progression of disease, other patients will show opportunities for docs to rethink their decision making.

For any potential QI project, you don’t need to review every single case though I think it’s helpful to do about 25-30 cases a month per category if the volume exists. If there’s 90 on the spreadsheet, reviewing every third case should work.  Over the course of six or 12 months, every doc should have a representative number of cases reviewed. Obviously, if you’re a STEMI/stroke/trauma center, those cases will typically be reviewed by committees outside the ED as well.

Try to get your team involved.  Having more champions will increase the available content experts, perform QA reviews, participate in QI activities, and ultimately improve performance.  Create your plan, let your docs know what will be reviewed and what the expectations are, and then provide feedback on a regular basis. Ultimately, improved care is good for the patients and that’s why we’re here.


EXECUTIVE EDITOR Dr. Silverman is Chairman of Emergency Medicine at the Virginia Hospital Center. He also serves as the Director of the Alteon-Mid Atlantic Leadership Academy. Dr. Silverman’s practical wisdom is available in an easy-to-use reference guide, available on Amazon. Follow on Twitter @drmikesilverman

Dr. Sverha is the Vice Chair of Emergency Medicine at the Virginia Hospital Center in Arlington, VA.  He also serves as the Chair of the Alteon Mid-Atlantic Clinical Operations Council.  He is a recipient of the Choosing Wisely Champion Award presented by ACEP’s Quality and Patient Safety Committee.

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