The Weekly Quality Brief
The Weekly Quality Brief is a short, practical podcast for healthcare quality professionals who need clear answers in a constantly changing regulatory landscape.
Each week, Medisolv experts break down real questions submitted by hospitals and health systems — covering quality reporting, CMS programs, Joint Commission requirements, eCQMs, Star Ratings, and more. Episodes are based on the Quality Academy Weekly Q&A and focus on what matters most right now, without unnecessary jargon or theory.
Whether you’re new to quality or deep in the details, The Weekly Quality Brief helps you understand what’s changing, why it matters, and what to do next — in...
Show more
All Episodes
The Weekly Quality Brief: Hybrid Measure Reports, ISCM-R Reporting Timelines, and CJRX Model Questions (6/4/24)
This episode covers questions related to newly released CMS reports, measure reporting timelines, the ISCM-R measure, and the proposed CMS Innovation Center's Comprehensive Joint Replacement (CJRX) model. CMS Reports & Public Reporting Availability of spring Hybrid Hospital-Specific Reports through the HQR portal Release of readmission, mortality, EDAC, THA/TKA complication, and THA/TKA PRO-PM reports Access to preoperative patient-reported outcome (PRO) data for THA/TKA participants Timing of Care Compare refreshes and preview periods Discussion of upcoming claims-based measure releases and reporting schedules Information Transfer PRO-PM Minimum survey completion requirements for the Information Transfer PRO-PM CMS guidance regarding administration of the survey to all eligible patients Definition of a completed survey Random sampling requirements and submission expectations when the minimum survey threshold is not met Mortality & EDAC Measure Modifications Review of CMS proposals to add Medicare Advantage patients to mortality and EDAC measures Timeline for implementation across the Hospital IQR and Hospital Value-Based Purchasing programs Expected measurement periods, preview reports, and public reporting dates Introduction of the proposed Diabetes EDAC measure Explanation of how measure modifications flow from public reporting into payment programs Hospital Value-Based Purchasing Updates Timeline for incorporating modified mortality and EDAC measures into Hospital Value-Based Purchasing Future inclusion of HCAHPS Care Transition and Responsiveness of Hospital Staff measures Updates to HAI baselines and future program scoring changes Review of preview reports, baseline reports, and payment adjustment timelines ISCM-R (Formerly Failure to Rescue) Clarification of the transition from PSI-4 to Failure to Rescue and now ISCM-R CMS documentation and specification naming inconsistencies Expected timing for Hospital-Specific Reports (HSRs) Public reporting timelines and measurement periods Programs impacted by ISCM-R, including Hospital IQR, Hospital Star Ratings, and Leapfrog Safety Grades Measure Prioritization & Program Alignment Discussion of approaches for evaluating measures across multiple quality programs Examples of measures that affect public reporting, Star Ratings, Leapfrog, HAC Reduction Program, and Hospital Value-Based Purchasing Considerations for prioritizing improvement efforts based on program overlap CJRX Proposed Model Questions regarding hospital points of contact and distribution of model files CMS listserv enrollment and future communication processes Explanation of CJRX target price methodology, including: Regional benchmark pricing Prospective trend factors Risk adjustment multipliers Normalization factors Discount factors Relationship between CJRX episodes and THA/TKA PRO-PM quality measure populations Discussion of patients receiving multiple joint replacements within a 90-day episode window Collaboration agreements with post-acute care providers and gainsharing arrangements Availability of beneficiary-level claims data, including post-acute care services Eligibility considerations for hospitals participating in the Rural Community Hospital Demonstration, Critical Access Hospital program, and Rural Emergency Hospital program Explanation of how quality scores affect CJRX reconciliation payments for both underspending and overspending scenarios Upcoming Topics Planned discussion of ECAT measures and Leapfrog’s Emergency Department measures Review of Jira tickets and submission processes during a future sessionThe Weekly Quality Brief: ECAT Measure Clarifications, Hospital Harm eCQM Guidance, and HCAHPS Reporting Changes (5/28/26)
This episode covers questions from a Quality Academy Q&A session focused on quality reporting programs, hospital harm eCQMs, HCAHPS reporting, and CMS payment models. Quality Reporting Programs Clarification of Emergency Care Access and Timeliness (ECAT) measure terminology across CMS rulemaking and reporting programs Discussion of ECAT’s adoption in the OQR and REHQR programs Review of CMS considerations for future inclusion of ECAT-related measures in Hospital Value-Based Purchasing Explanation of the relationship between the Hospital IQR, OQR, IPPS, and OPPS programs Requirements for measures to be publicly reported in IQR before inclusion in Hospital Value-Based Purchasing Hospital Harm eCQMs Clarification of the 30-day timeframe used in the Postoperative Respiratory Failure Hospital Harm measure Discussion of encounter-based logic versus post-discharge events and readmissions Review of hospitalization period requirements within numerator logic Examples illustrating how prolonged hospital stays are evaluated under the measure Pressure Injury Documentation & Present on Admission Review of ONC Jira guidance regarding present-on-admission (POA) documentation Timing requirements for pressure injury assessments and skin examinations Differences between timing requirements for skin findings and POA indicators Clarification that POA exclusion logic is based on hospitalization data regardless of when the POA indicator is updated Discussion of stage II, III, IV, unstageable, and deep tissue pressure injury timing windows TEAM Model Explanation of how TEAM episodes are triggered using qualifying MS-DRGs and HCPCS codes Distinction between assigned MS-DRGs and diagnosis or procedure code positions Review of episode eligibility criteria and anchor hospitalization requirements Discussion of CMS TEAM participant data files and episode identification HCAHPS Updates Explanation of why Responsiveness of Hospital Staff and Care Transition measures do not appear in July 2026 preview reports Review of HCAHPS survey changes beginning with 2025 discharges Discussion of transitional public reporting periods for HCAHPS submeasures Introduction of new HCAHPS concepts including Care Coordination, Restfulness of Hospital Environment, and Information About Symptoms Timeline for public reporting of updated HCAHPS submeasures Star Ratings Demonstration of Medisolv’s Hospital Star Rating Analyzer Discussion of projecting future star ratings using publicly reported performance data Overview of measure-level modeling and scenario planning functionality Review of available consulting services related to star rating improvement CMS Reporting & Preview Reports Discussion of the availability of July 2026 Hospital Compare preview reports Question regarding the release timing of hybrid measure HSR reports Status of inquiries submitted to QualityNet regarding hybrid reporting availability Quality Academy Updates Results of the survey regarding future Weekly Q&A scheduling Discussion of potential changes to session timing Request for feedback on the upcoming HHER (Healthcare Reporting) ConferenceThe Weekly Quality Brief: Hospital Value-Based Purchasing Mortality Measure Updates and Care Compare Reporting Timelines (5/21/26)
Episode Description Hospital Value-Based Purchasing Program Review of proposed updates to mortality measures in the Hospital Value-Based Purchasing (HVBP) Program Discussion of the transition from three-year to two-year mortality measure performance periods Proposed inclusion of Medicare Advantage patients in mortality measures beginning in FY 2032 Timeline of when updated mortality measure results will first appear in the Hospital IQR Program and later affect HVBP payment adjustments Expected reporting overlap between IQR and HVBP mortality measure results Review of HVBP measurement periods, baseline reports, performance reports, and payment adjustment timelines Discussion of future inclusion of Medicare Advantage patients in the Complication Hip and Knee measure beginning in FY 2033 Overview of HCAHPS measure updates and scoring timelines within HVBP Review of HAI baseline updates from 2015 national data to 2022 national data Care Compare & Star Ratings Reporting Review of updates to the Care Compare Measure Timeline Dashboard Discussion of April 2026 Care Compare public reporting data and performance periods Clarification and correction of an outpatient hospital visits measure timeline within the public reputation toolkit Verification of current Hospital Star Ratings performance periods used for 2026 ratings Discussion of upcoming Leapfrog timeline updates Quality Academy Community Resources Guidance on using the Quality Academy Community forums for peer-to-peer operational questions Overview of community groups available by EHR and topic area Discussion of how members can submit questions, start conversations, and participate in group discussions Weekly Q&A Resources & Knowledge Library Overview of how Weekly Q&A recordings, transcripts, show notes, and question responses are archived within Quality Academy Review of article organization by measure and program categories Demonstration of the Academy’s search functionality and AI-assisted content search Discussion of how submitted questions are converted into written reference articles ONC Jira Tickets Discussion of how to access publicly available ONC Jira tickets referenced during prior Q&A sessions Preview of an upcoming walkthrough covering ticket submission and search processes Guidance on locating Jira ticket links within Quality Academy articles Care Compare Preview Reports Discussion of July Care Compare preview report availability Review of the HQR preview process and correction period prior to public reporting Guidance on reviewing claims-based measure results before publicationThe Weekly Quality Brief: 2027 eCQM Specifications, Hospital Harm Requirements, and CJRX Quality Scoring (5/14/26)
This episode covers updates from CMS quality reporting programs, proposed rule changes, hospital harm measure requirements, FHIR-based data submission, and the proposed CJRX payment model. CMS & Quality Reporting Updates CMS Care Compare April refresh and publication of 2026 Star Ratings Updates to quarterly public reporting data, including HAIs and HCAHPS Release of 2027 hospital and clinician eCQM specifications and updated value sets Planned updates to Quality Academy playbooks and value set comparison resources Discussion of the CMS Measures Under Consideration (MUC) list and how proposed measures may move into future IQR, OQR, and ASCQR programs eCQM & Future Measure Discussions Potential expansion of Advanced Care Planning eCQM into ASCQR Discussion of substantive measure changes within the IQR program Review of future measure tracking and proposed reporting changes FHIR API & Psychiatric Reporting Explanation of FHIR APIs and standardized healthcare data exchange Overview of CMS plans to use FHIR API submission for the psychiatric Patient Assessment Instrument (PAI) Discussion of USCDI-aligned data element updates and implications for EHR vendors and reporting systems Hospital Harm Measures & NHSN Reporting Confirmation that Hospital Harm Falls with Injury and Hospital Harm Acute Kidney Injury measures are mandatory beginning in 2028 Clarification of oncology CAUTI and CLABSI exception reporting requirements for hospitals without oncology units NHSN submission deadlines and CMS exception form timelines Information Transfer & AI Abstraction Tools Medisolv plans to support the Information Transfer PRO-PM measure Availability of the measure within Encore chart-abstracted applications Discussion of Medisolv’s partnership with Lilac for automated survey workflows Overview of Health Elements AI abstraction capabilities and future integration plans for registry abstraction workflows Maternal Morbidity Structural Measure Clarification of proposed updates to the maternal morbidity structural measure requirements Discussion of proposed reporting requirements for Perinatal Quality Improvement Collaborative participation beginning with 2026 reporting periods Mortality Measures & Value-Based Purchasing Explanation of why mortality measures are being reintroduced into IQR before updates to the Hospital Value-Based Purchasing Program Review of proposed mortality measure specification updates, including: Medicare Advantage patient inclusion Two-year performance periods ICD-10-based risk adjustment methodology Timeline for public reporting and future inclusion within HVBP CJRX Payment Model & Quality Scoring Overview of the proposed CJRX mandatory payment model for short-term acute care hospitals Explanation of HCAHPS linear mean roll-up scoring methodology Review of THA/TKA PRO-PM scoring and substantial clinical benefit calculations Discussion of risk adjustment, inverse probability weighting, and reliability adjustments Breakdown of CJRX composite quality score calculations, including: Inpatient and outpatient measure weighting Complication measures HCAHPS and OAS CAHPS scoring Patient-reported outcome weighting National percentile ranking methodology Discussion of inpatient versus outpatient LEJR weighting within composite quality scores Operational & Platform Notes Guidance for workflow- and EHR-specific questions within Quality Academy community groups Planned fixes for the Future Measures Tracker PDF export issue Reminder regarding Quality Academy scheduling survey participation