NCHICA Forum on Quality Reporting

NCHICA Thought Leader Forum
Quality Reporting

June 22, 2016, 9:30-11:30 am
Research Triangle Foundation Headquarters



June 22, 2016, 9:30-11:30 am (registration and networking at 9:00 am)


Research Triangle Foundation of NC, 12 Davis Drive, Research Triangle Park, NC. Click here for directions.


The registration fee is $50 NCHICA members/$75 non-members/$25 students.

Click here to register.


Session Descriptions

Leveraging Transparent Reporting for Quality Improvement

Transparent reporting of quality data is one way to drive improvement, and public reporting of hospital data, in particular, has blossomed over the past decade.  CMS recently transformed the reporting landscape by releasing overall star ratings of hospitals in April 2015.   However, many third-party entities also engage in public ranking and rating of hospitals, such as Leapfrog, US News and World Report, and various state hospital associations.

This session will:

  • Describe the history of public reporting of hospital quality data
  • Compare the approaches of various organizations who engage in transparent, public reporting of quality data, highlighting some of the technical and political challenges of working in this space, and
  • Describe the efforts of our own organization, the North Carolina Quality Center (NCQC), in our year-long redesign and relaunch of our public reporting efforts.

Health care providers struggle to determine which measures and reports are reliable and meaningful to quality improvement. NCHA member hospitals and other stakeholders collaborated to redesign our reporting website, The NCQC team implemented new ideas using Agile Scrum iterative and incremental development practices. The redesign of the site maintains the Quality Center’s focus on transparent reporting while identifying specific areas in North Carolina where there are opportunities for improvement. In addition, relevant information on the site such as hospital-level trends and state-specific benchmarks provides opportunities for hospitals and health systems to track their individual quality improvement progress, as well as to demonstrate the collective progress of NC hospitals towards better care.  Going forward, the site is better aligned with NCQC’s offerings of improvement resources in areas such as infections, readmissions, culture of safety, IHI’s Triple Aim, and patient and family engagement.

Session Objectives:

  • Describe the current state of transparent data reporting in hospital quality improvement and why it is important.
  • Explain the benefits of the Agile Scrum development process.
  • Give an example of how quality data can be used to improve patient outcomes.

Elizabeth Mizelle, MPH, Healthcare Data Analyst, NC Quality Center, North Carolina Hospital Association


Transitioning to Electronic Clinical Quality Measures – How Are You Positioned?

Until now, electronic clinical quality measures (eCQMs) have been optional or a “check the box” activity.  For 2016, the Centers for Medicare and Medicaid (CMS) requires providers to calculate and submit select eCQMs electronically. This will also mark the first year that eCQMs impact reimbursement.  If hospitals do not electronically submit the required eCQMs, their Medicare reimbursement will be negatively impacted. Provider quality departments have submitted abstracted CQMs for many years, and these have also been publically reported.  Abstracted CQMs are typically high-performing. These two quality reporting efforts, abstracted CQMs and eCQMs, are converging. This shift puts more emphasis on eCQMs and their dependence on the underlying data elements in the certified health information technology (CHIT). When providers shift to eCQMs, abstractors can no longer review and interpret both structured and unstructured data to improve measure performance. As a result, eCQM performance is often dramatically different, in a negative way, from that of similar abstracted measures. Although there are no threshold or public reporting requirements for eCQM performance in 2016, organizations need to prepare for those eventualities.

CMS has proposed a four-fold increase in the number of eCQMs that will be required for the Inpatient Quality (IQR) Reporting Program in 2017. Developing a strategy for eCQM reporting and understanding the current state of eCQM performance is a first step in preparing for this transition. Given the increasing role that eCQMs will play in both quality and reimbursement for governmental and commercial payers, organizations must understand their current state and prepare for both public reporting and measure thresholds.

Session Objectives:

  • Review why Electronic Clinical Quality Measures (eCQMs) are increasingly important
  • Describe an eCQM assessment, sample findings and recommendations
  • Discuss what additional efforts may be required by providers beyond what their vendors will provide

Liz Richard, MBA/MHS, Managing Director, Value Realization Solutions, Encore, A Quintiles Company


Overview of MACRA: Moving Providers through Transformation from Fee-for-Service to Outcomes-Based Reimbursement

This session will provide an overview of the proposed Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) reform for Medicare payment. The MACRA makes three important changes to how Medicare pays those who give care to Medicare beneficiaries. These changes create a Quality Payment Program (QPP):

  • Ending the Sustainable Growth Rate (SGR) formula for determining Medicare payments for health care providers’ services.
  • Making a new framework for rewarding health care providers for giving better care not more just more care.
  • Combining our existing quality reporting programs into one new system.

Session Objectives:

  • Provide an overview of the proposed change, including timeline
  • Discuss strategies that can be deployed to prepare for the changes

Karen Southard, MHA, RN, State Program Director, SC-AQIN/QIO, The Carolinas Center for Medical Excellence

NCHICA has created a collaborative organization that no other State has achieved. It includes vendors, providers, payers, physicians, nurses, clinicians, attorneys, information technologists and other professionals, working together to improve healthcare within North Carolina in every way, from the use of technology, to public policy considerations, to patient privacy, and more. Belonging to, and participating in, this organization helps you to not only keep up with the changing healthcare environment, but to have some influence on those changes.

— David B. Dillehunt
VP, CIO, FirstHealth of the Carolinas Inc.,
Pinehurst, NC

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