Quality Improvement, CMS Measure

5 Tips for Chief Quality Officers to Prepare for CMS’s New Measures on Glycemic Management

Are you responsible for overseeing and improving the quality of care within your hospital or health system? Then you’ve probably heard about the two new quality measures involving glycemic management that CMS announced this summer. If you haven’t yet, we have plenty of resources available to help get you caught up, including a high-level overview and an on-demand CMS session from Glytec’s inaugural industry event, “Time to Target: Uniting Around Patient Safety.”

If you’re well-versed in the newly-announced electronic clinical quality measures (eCQMs) already, it’s time to take a deeper dive and start planning to ensure your organization stays ahead of the pack once CMS begins collecting – and more importantly – publishing performance data around glycemic rates. This is exactly why Dr. Danielle Scheurer and I recently connected during a recent webinar hosted by Becker’s Healthcare to discuss how to prepare for these measures.

Dr. Scheurer is a practicing Hospitalist Physician and the Chief Quality Officer for the Medical University of South Carolina hospital (MUSC). During our conversation, she shared how MUSC has used other eCQMs to drive practice change and provide a consistent metric of performance year over year. She also offered a template for institutions to implement or expand on glycemic management quality programs to strategically leverage the new eCQMs to improve patient safety and quality of care in the hospital.

Dr. Scheurer’s 5 tips for quality teams:

  1. Decide how you will report and get your data. This usually requires a combination of quality and support teams.  
  2. Balance hyperglycemic and hypoglycemic measurements. Reporting on just one won’t show a complete picture.  
  3. Form a glycemic management team if you don’t already have one. This typically consists of a multidisciplinary team representing nurses, pharmacists, diabetes educators, and physicians or advanced practice providers, at a minimum. A well-balanced team of experts will increase your chances of success.
  4. Complete a gap analysis to see what is missing in your reporting or data.  
  5. Review the processes and root causes that impact glycemic outcomes to see where improvement is needed.

While CMS hasn’t published an exact timeline for implementing these measures, people familiar with CMS’s previous eCQM roll-outs predict that data will start being collected in January 2023. As we know, quality improvement projects take time. Hospital leaders need to start taking action today to improve their data before the eCQMs are live.

The timeline below highlights key dates for the new rules:

  • October 2021 – January 2023: Hospitals will work with EHR vendors to implement reporting packages
    • Hospitals can also use this time to better understand and improve their glycemic management metrics before data collection begins
  • January – December 2023: first data collection period  
  • February 2024: Likely deadline to report data collected in 2023
  • October 2024: First datasets from 2023 published publicly
  • Fiscal Year 2025: Financial penalties will begin for those who don’t report eCQMs

In the end, collecting and publishing this data will set national benchmarks that will help everyone – payers, providers and the public – understand what good glycemic management looks like, and which hospitals we should learn from in order to set the new standard of care. By introducing transparency that can be used to compare hospitals on how they manage patient safety, this measure will also incentivize change and solutions for inpatient glycemia care. Hospitals can’t improve what they don’t measure, and CMS’s focus will help hospital leaders prioritize efforts to attain optimal glycemic management and implement solutions that will improve quality and decrease costs while personalizing care for patients.

It’s clear from Dr. Scheurer’s feedback that successful glycemic management programs are made up of great people, innovative technology and a streamlined process. These three ingredients will be essential for health systems as they embark on increasing their visibility into the new eCQM metrics and improving inpatient glycemic care.

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