1
WGU D159: Evidence-Based Measures for Evaluating
Healthcare Improvements |Latest Update with
Complete Solution
Improving CMS Star Rating Scores: How Specialized Education and Cross -Training
Clinicians Improve OASIS Documentation
Peta-Jaye L. Richards
Western Governors University
Leavitt School of Health
Dr. Phillip Tarantino
March 14, 2025
D159: Evidence-Based Measures for Evaluating Healthcare Improvements
Project Reports
To evaluate the success of this documentation quality improvement initiative aimed
at improving CMS Quality of Care Star Rating scores by means of a specialized education
program and cross training clinicians, three essential data elements identified by the team
are clinician attendance rates, corridor intervention rates, Star Rating scores, and. Clinician
attendance rates for the two-part training is important to the evaluation process because
without participation, actively engaged clinicians cannot obtain the education required to
raise the quality of their care practices and documentation standards. Understanding of the
newly set standards and requirements to be in alignment with CMS comes not only with
being in attendance, but engaging in the discussions that bring clarification, as well as
participation in the tactile portion of the workshops. Lack of attendance will only result in a
perpetual state of misinformation coupled with subpar clinical care and documentation
, 2
practices that keep Star Rating scores low at Pathways Healthcare (PHC).
Corridor coding intervention rates are important to the evaluation process because it
allows the team to determine the number of patient entries that require intervention after
documentation is submitted. Pathways Healthcare has partnered with Corridor Group, the
nation’s leading provider in tech-enabled coding and clinical documentation review and
compliance. They work to help eliminate inaccuracies in coding and documentation. Ideally ,
PHC should see a decrease in corridor interventions after clinicians attend and participate in
the two-part class and workshop. Clinicians should thereafter have gained the knowledge
required to more accurately code functional scores on initial and subsequent assessments,
proving PHC’s contribution to patient improvements upon discharge.
The Quality of Care Star Rating scores themselves would also be important to the
evaluation process and be indicative of if the developed education course and workshop are
successful in raising scores. The purpose of this healthcare improvement project is to
determine if creating an OASIS specific education course will be beneficial in raising CMS
Star Rating scores. CMS posts quarterly updates in January, July, and October. Our timeline
of education provided for clinicians is from 12/2/24 to 1/28/25, with the duration between
1/29/25 and 3/28/25 as the period for clinicians to put their new training into practice. Rates
published from January 25’ and prior would be compared to the quarter published in April
25’. CMS also provides a 15-day preview during each quarter. For scores that will be
published in April 25’, the preview period will occur in February. Depending on the dates
CMS determines in February for the preview, that period may or may not be beneficial as an
accurate preview of projected improvements with limited OASIS submissions.
Data Management Plan
The first source for the first data element of clinician attendance rate is the actual
number of clinicians in attendance and participating that will be assessed through an
attendance roster sign-in sheet. The goal remains for 95% of clinicians to attend and
participate in the two-part specialized education program to improve CMS OASIS assessment
and documentation practices. Each manager for the four teams comprising M01 branch will
, 3
attend the class and workshop with their teams and then turn in their roster to the Project
Manager. The second and third source for the data element of Corridor Interventions rates
and Quality of Care Star Ratings will come from PHC’s QAPI Committee which already
monitors these data elements. At weekly meetings, the QA nurse presents data and trends
associated with corridor intervention prevalence and current Star Rating scores to track in
relation to the company’s goals. The Project Manager will attend each meeting to collect
presented data to measure the success of re-educating clinicians for improved OASIS
accuracy with the desired outcome of decreased corridor interventions and a higher Star
Rating score.
Process Key Performance Indicators
The first KPI will focus on training completion rates by 01/28/25. This will measure the
number of clinicians who receive the knowledge and skills that are necessary to perform
their jobs effectively and improve OASIS documentation. The KPI oversees tracking clinician
attendance and participation, with the PM working alongside the Clinical Educator and
Clinical Managers to reinforce its importance in improving the quality of patient care and
documentation.
The second KPI focuses on employee progression post training. Ultimately, this
project should improve the clinical documentation quality that is driving the low Star Rating
scores at PHC. Employee performance will be proven based on the documentation. More
accurate OASIS documentation will be submitted when clinicians have a better
understanding of CMS guidelines and standards, as well as assistance in honing skills
reflective of the training received. Clinicians who have attended and participated by
01/28/25, will then put it into practice, allowing documentation collected from 01/29/25 to
WGU D159: Evidence-Based Measures for Evaluating
Healthcare Improvements |Latest Update with
Complete Solution
Improving CMS Star Rating Scores: How Specialized Education and Cross -Training
Clinicians Improve OASIS Documentation
Peta-Jaye L. Richards
Western Governors University
Leavitt School of Health
Dr. Phillip Tarantino
March 14, 2025
D159: Evidence-Based Measures for Evaluating Healthcare Improvements
Project Reports
To evaluate the success of this documentation quality improvement initiative aimed
at improving CMS Quality of Care Star Rating scores by means of a specialized education
program and cross training clinicians, three essential data elements identified by the team
are clinician attendance rates, corridor intervention rates, Star Rating scores, and. Clinician
attendance rates for the two-part training is important to the evaluation process because
without participation, actively engaged clinicians cannot obtain the education required to
raise the quality of their care practices and documentation standards. Understanding of the
newly set standards and requirements to be in alignment with CMS comes not only with
being in attendance, but engaging in the discussions that bring clarification, as well as
participation in the tactile portion of the workshops. Lack of attendance will only result in a
perpetual state of misinformation coupled with subpar clinical care and documentation
, 2
practices that keep Star Rating scores low at Pathways Healthcare (PHC).
Corridor coding intervention rates are important to the evaluation process because it
allows the team to determine the number of patient entries that require intervention after
documentation is submitted. Pathways Healthcare has partnered with Corridor Group, the
nation’s leading provider in tech-enabled coding and clinical documentation review and
compliance. They work to help eliminate inaccuracies in coding and documentation. Ideally ,
PHC should see a decrease in corridor interventions after clinicians attend and participate in
the two-part class and workshop. Clinicians should thereafter have gained the knowledge
required to more accurately code functional scores on initial and subsequent assessments,
proving PHC’s contribution to patient improvements upon discharge.
The Quality of Care Star Rating scores themselves would also be important to the
evaluation process and be indicative of if the developed education course and workshop are
successful in raising scores. The purpose of this healthcare improvement project is to
determine if creating an OASIS specific education course will be beneficial in raising CMS
Star Rating scores. CMS posts quarterly updates in January, July, and October. Our timeline
of education provided for clinicians is from 12/2/24 to 1/28/25, with the duration between
1/29/25 and 3/28/25 as the period for clinicians to put their new training into practice. Rates
published from January 25’ and prior would be compared to the quarter published in April
25’. CMS also provides a 15-day preview during each quarter. For scores that will be
published in April 25’, the preview period will occur in February. Depending on the dates
CMS determines in February for the preview, that period may or may not be beneficial as an
accurate preview of projected improvements with limited OASIS submissions.
Data Management Plan
The first source for the first data element of clinician attendance rate is the actual
number of clinicians in attendance and participating that will be assessed through an
attendance roster sign-in sheet. The goal remains for 95% of clinicians to attend and
participate in the two-part specialized education program to improve CMS OASIS assessment
and documentation practices. Each manager for the four teams comprising M01 branch will
, 3
attend the class and workshop with their teams and then turn in their roster to the Project
Manager. The second and third source for the data element of Corridor Interventions rates
and Quality of Care Star Ratings will come from PHC’s QAPI Committee which already
monitors these data elements. At weekly meetings, the QA nurse presents data and trends
associated with corridor intervention prevalence and current Star Rating scores to track in
relation to the company’s goals. The Project Manager will attend each meeting to collect
presented data to measure the success of re-educating clinicians for improved OASIS
accuracy with the desired outcome of decreased corridor interventions and a higher Star
Rating score.
Process Key Performance Indicators
The first KPI will focus on training completion rates by 01/28/25. This will measure the
number of clinicians who receive the knowledge and skills that are necessary to perform
their jobs effectively and improve OASIS documentation. The KPI oversees tracking clinician
attendance and participation, with the PM working alongside the Clinical Educator and
Clinical Managers to reinforce its importance in improving the quality of patient care and
documentation.
The second KPI focuses on employee progression post training. Ultimately, this
project should improve the clinical documentation quality that is driving the low Star Rating
scores at PHC. Employee performance will be proven based on the documentation. More
accurate OASIS documentation will be submitted when clinicians have a better
understanding of CMS guidelines and standards, as well as assistance in honing skills
reflective of the training received. Clinicians who have attended and participated by
01/28/25, will then put it into practice, allowing documentation collected from 01/29/25 to
