(6) Research by the Medicare Payment Advisory Commission, the National Quality Forum, and other independent experts has provided compelling evidence that failing to adjust for socioeconomic status in the Medicare hospital readmission reduction program may provide an inaccurate picture of the quality of care provided by hospitals, and has led to . The objective of this program (Hospital readmission reduction program) is to decrease the . The cost of unplanned readmissions is 15 to 20 billion dollars annually for Medicare patients, where about 20 percent who are discharged from a hospital are readmitted within 30 days (Jencks, Williams, and Coleman, 2009). In the FY12 inpatient prospective payment system (IPPS)/long-term care hospital (LTCH) proposed rule, CMS proposed that the readmission measures for these three conditions be used for the Hospital Readmissions Reduction Program under section 1886(q) of the Act, as added by section 3025 of the ACA. Health Policy in Cardiovascular Medicine Hospital Readmissions Reduction Program Colleen K. McIlvennan, Arnold credits their success to . View Notes - Hospital Readmissions Reduction Program.pdf from MMHA 5900 at Walden University. In theory, P4P and VBP give commercial and government health insurers a way to incentivize physicians and hospitals to deliver services designed . Werner (2013) stated hospital leaders identified reducing readmissions as one of the top five priorities for their facility. Medicare Hospital Readmissions Reduction Program. Hospital Readmissions Reduction Program Results The $164,000 is a drop in a bucket compared to overall Medicare expendi- tures and the massive budgets of many of the health systems affected. There are different types of TM encounters and clinical applications vary widely. The federal Centers for Medicare & Medicaid Services has adopted a version of P4P for hospitals called Hospital Value-Based Purchasing, which we covered last year. Although studies have examined the policy's overall impacts and differences by hospital types, research is limited on its effects for different . The Affordable Care Act (ACA) established the Hospital Readmission . Prediction of which patients are at risk of being readmitted and dates of highest risk. 1 The Medicare Payment Advisory Commission (MedPAC) has estimated . Even if hospitals can absorb the financial hit, they still need to track reporting . 1 the medicare payment advisory commission has estimated that 12% The Centers for Medicare & Medicaid Services (CMS) issues penalties for hospital readmissions and offers incentives for hospitals to reduce them as part of its Hospital Readmissions Reduction Program (HRRP). Reducing preventable hospital readmissions is a national priority for payers, providers, and policymakers seeking to improve health care and lower costs. (2016). The program, called the Hospital Readmission Reduction Program (HRRP), is a little-known part of the Affordable Care Act that saved Medicare more than $2 billion last year according to the . This means hospitals can be penalized for a readmission that is in. A game-theoretic model is developed that captures the competition among hospitals inherent in HRRP's benchmarking mechanism and shows that this competition can be counterproductive: it increases the number of nonincentivized hospitals, which prefer paying penalties over reducing readmissions in any equilibrium. Reducing Hospital Readmissions for Diabetes: Context & Solutions. If we are able to prevent readmissions into the hospitals it gives the possibility to greatly improve both the quality of . (2) Beginning with the FY 2023 program year, the applicable period is the 3-year period advanced by 1-year from the prior year's period from which data are collected in order to calculate excess readmission ratios and adjustments under the Hospital Readmissions Reduction Program, unless otherwise specified by the Secretary. However, it's important to realize . 1, 2 causes of readmissions are multifactorial, and rates vary substantially by institution. Since the program began on Oct. 1, 2012, hospitals have experienced nearly $2.5 billion of penalties, including an estimated $564 million in fiscal year 2018. HRRP is a Medicare value-based purchasing program that encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and, in turn, reduce avoidable readmissions. The Affordable Care Act (ACA) establishes the Hospital Readmissions Reduction Program, effective for discharges from an applicable hospital beginning on or after Oct. 1, 2012. The reasons the HRRP was implemented, the penalties levied, the impact it has had on transitional care and readmissions, the pros and cons of the policy, and its future are described. Individuals BC/BE in general surgery are also encouraged to apply to the anesthesiology-based program, as this track allows one to meet requirements to become BC/BE under the American Board of Surgery. With integrated analytics tools and methods, health systems can achieve four chief goals around reducing hospital readmissions: Improved model performance from current industry standards, such as LACE and HOSPITAL. The program supports the national goal of improving health care for Americans by linking payment to the quality of hospital care. By Scott Maier. One study looked at Medicare readmissions for heart attack, heart failure, and pneumonia in nearly 7,000 hospitals. According to the Institute for Healthcare Improvement (IHI), patients returning within 30 days of a previous inpatient stay account for a substantial number of all hospitalizations in the U.S.The specific cause of their return may be poor recovery from care or to receive treatment for a worsening chronic condition; however, high . Near real-time predictions in an automated . One public quality activity, Hospital to Home (H2H), started in 2009 to improve advances of mind and lessen superfluous readmissions.This joint exertion between the American College of Cardiology and the Institute for Healthcare Improvement keeps on giving a public clearinghouse of data and devices dependent on foundations' fruitful mediations. The Centers for Medicare & Medicaid Services reported that the national readmission rate (i.e., instances when patients return to the same or different hospital within 30 days of discharge) fell to 17.5 percent in 2013, after holding steady at 19 to 19.5 . The Hospital Readmissions Reduction Program (HRRP) is a Medicare value-based purchasing program that encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and, in turn, reduce avoidable readmissions. Researchers at UC San Francisco have found that a nurse-led intervention program designed to reduce readmissions among ethnically and linguistically diverse older patients did not improve 30-day hospital readmission rates. The mandatory federal pay-for-performance Hospital Readmissions Reduction Program (HRRP) was created under the 2010 Patient Protection and Affordable Care Act to decrease 30-day hospital readmissions; readmissions reporting started in 2010, and the penalty phase began in 2012 ().Hospitals with higher-than-expected 30-day all-cause Medicare fee-for-service (FFS) readmissions after initial . One key measure of hospital care quality is the facility's readmission rates, or the percentage of patients who experience unplanned readmission after a previous stay. This program requires that payments to those hospitals under section 1886 (d) of the Social Security Act (The Act) be reduced to account for certain excess readmissions. 25% reduction in post-acute readmissions. In an effort to curb these costs, in 2013 the Center for Medicare and Medicaid Services (CMS) enacted the Hospital Readmissions Reduction Program. Average penalty 0.85% down from 0.92%. Readmissions are expensivemore than $14,000 per readmission in costs to the hospital, on average, according to the Healthcare Cost and Utilization Project. 90% face new penalties [1], down from 93%. Background. When determining penalties, readmission that are unrelated to the initial hospitalization are included under the program. Payment reductions are applied to all Medicare fee-for-service (FFS) base operating diagnosis-related group (DRG) payments between October 1, 2019 through September 30, 2020. Increase capacity by adding 1500 new patients. Millions of dollars in cost savings per hospital, per year. hospital readmissions are associated with unfavorable patient outcomes and high financial costs.1,2 causes of readmissions are multifactorial, and rates vary substantially by institution.3,4. In addition, her hospital went from a net loss of $250 per COPD admission to a net gain of $1,750 per patient admission following the onset of the program. Zhang et al. Recurrence of these problems means that the business has not been functioning optimally and a new strategy or focus is required. Teaching hospitals, rural hospitals, and others that serve a high proportion of dual-eligible patients faced lower penalties under Medicare's Hospital Readmissions Reduction Program (HRRP) in 2019 after CMS updated how the program calculates penalties, according to a study published Monday in JAMA Internal Medicine. 2 Although the program is associated with lower readmission rates, 3 it is unclear how this decrease occurred. The Hospital Readmissions Reduction Program, which is included in the Affordable Care Act (ACA), applies financial penalties to hospitals that have higher-than-expected readmission . 1 The intent of the HRRP, first legislated by the Patient Protection and Affordable Care Act in 2010, was to financially incentivize health-care systems to provide high-quality, patient-centered care to reduce 30-day . Policymakers on the federal and state level have developed and implemented several programs, some varying state to state, to help reduce wasteful spending while improving quality of care. McGarry, B. E., Blankley, A. Over the past 5 years, the program has shown cost savings, but it has not shown the savings predicted. Reducing readmissions improves quality and reduces spending. Use admission, discharge, transfer (ADT) data for proper transition of care. CMS policies consider hospital readmission rates as a way to gauge quality of patient care. The Hospital Readmissions Reduction Program (HRRP) was established under the Affordable Care Act (ACA) in 2010 and required that the Centers for Medicare & Medicaid Services (CMS) impose financial penalties on hospitals with higher-than-expected 30-day readmission rates for patients with heart failure, acute myocardial infarction, and pneumonia . In the health care setting, such a . The Hospital Readmissions Reduction Program (HRRP) is a Medicare value-based purchasing program that encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and, in turn, reduce avoidable readmissions. It is important for clinicians and care teams to know what is happening with their patients to provide effective interventions and outreach as they move throughout the . A., & Li, Y. The healthcare system was determined to improve HF care for its patients and avoid CMS penalties. Here, we describe the reasons the HRRP was implemented, the penalties levied, the impact it has had on transitional care and readmissions, the pros and cons of the policy, and its future. What is the Hospital Readmissions Reduction Program? All Medicare payments to an "affected" hospital will be reduced. : Hospital Readmissions Reduction Program: An Economic and Operational Analysis 2 00(0), pp. This video has not been approved for CRCE by . Arnold says the COPD readmission rate decreased from 11.9% in 2017 to 7.3% in 2019, but the pandemic has increased those rates. These outcomes include a 10% reduction in COPD readmissions and an estimated 40% reduction in emergency department visits and hospitalizations. Patient . 11. 1, 2 Causes of readmissions are multi-factorial and rates vary substantially by institution. 000{000, c 0000 INFORMS Figure 1: Timeline of the Hospital Readmissions Reduction Program (CMS) estimated that a 20% reduction in hospital readmission rates could save the government 5 billion dollars by the end of scal year 2013 (Mor et al . Please visit the Hospital Readmissions Reduction Program website at CMS.gov for more information. hospital readmissions are associated with unfavorable patient outcomes and high financial costs. In October 2014, the Centers for Medicaid & Medicare Services (CMS) added COPD to the list of conditions targeted by the Hospital Readmission Reduction Program (HRRP). The Hospital Readmissions Reduction Program (HRRP), a part of the U.S. FY12 Readmissions Program Reduction Provisions. In 2014, CMS withheld up to 2 percent of regular reimbursements for hospitals that have too many 30-day readmissions for HF. Even though . The payment reduction is capped at 3% (i.e., payment adjustment factor of 0.97). 1796 Hospital readmission measures have been touted not only as a quality measure but also as a means to bend the healthcare cost curve. Read Advisory Board's take: Why the playing field may still not be level in HRRP. At its core, Aidin envisions a healthcare ecosystem where there is more transparency and visibility at each stage of the care continuum. Bill Hammond writing on New York's hospital readmission in Empire Center noted: "modestly improved grades for reducing avoidable admissions" based on the newest release from Medicare. By changing the code status of this resident with treatment that is futile can improve the resident's . Since 2010, Medicare data show that hospitals have prevented more than 565,000 readmissions. The regulations that implement this provision are in subpart I of 42 CFR part 412 (412.150 through 412.154). Readmissions are defined by CMS as an admission to a participating hospital within 30 days of a discharge from the same or another hospital. Reducing readmissions is an important way to improve quality and lower health care spending, and hospitals are making significant progress. Here are five ways to reduce readmissions that hospitals could start implementing today: 1. Absorbing these losses may not be a challenge for some hospitals. About 80% of the hospitals have received penalties (1-3% deducted from their CMS payments). The Centers for Medicare & Medicaid Services (CMS) produces Hospital-Specific Reports (HSRs) that include the payment reduction percentage, payment adjustment factor, dual proportion, peer group assignment, measure results, ratio of base operating diagnosis-related group payments per measure to total payments, national observed readmission rates, detailed discharge . The consensus among patients and providers is that TM is convenient to provide needed subspecialty. He went on to point out that. Of the 3,241 hospitals that were evaluated under the hospital readmissions reduction program in 2018, 80% or 2,573 of them will have penalties levied against them for Medicare inpatient. The Hospital Readmissions Reduction Program (HRRP), enacted by the 2010 Affordable Care Act, appears to have led to an increase in deaths within 30 days of discharge in Medicare beneficiaries hospitalized for heart failure or pneumonia, leading researchers to conclude that more investigation is needed into the possibility that the program has had unintended negative consequences. JAMA Internal Medicine, 179(6), 769-776. To avoid hospital readmission penalties, hospitals can work to improve clinical care practices to reduce readmissions. Excerpt from Essay : Hospital Readmissions. Abstract. Medical Care, 54(2), 162-171. Beneficence the action that protects and prevents harm of others and improves their situation (Pantilat, 2008). CMS tracks these six conditions and procedures as part of HRRP: Heart Failure (HF) Acute Myocardial Infarction (AMI) Coronary Artery Bypass Graft (CABG) Surgery Chronic Obstructive Pulmonary Disease (COPD) Hospital readmissions are common among Medicare beneficiaries and are associated with high costs and unfavorable patient outcomes. Reducing readmissions is an important way to improve quality and lower health care spending, and hospitals are making significant progress. This article reviews principles to consider when setting up a telemedicine (TM) program to provide care to women in the field of obstetrics and gynecology. Our analyses of Florida hospital administrative data between 2008 and 2014 find that the HRRP resulted in a reduction in the likelihood of readmissions by 1% to 2% for traditional Medicare. Reduction in hospital readmissions has long been identified as a target area for healthcare public policy reform by the U.S. government. The Hospital Readmissions Reduction Program (HRRP) was established by the 2010 Patient Protection and Affordable Care Act (ACA) in an effort to reduce excess hospital readmissions, lower health care costs, and improve patient safety and outcomes. The Pros And Cons Of Futility. Conclusions: Post-HRRP, greater than expected reductions occurred in rehospitalizations for patients with Medicare FFS and Medicare MC. The total cost savings (penalties) over the past 5 years amounted to $1,893,000 billion. In order to meet the new Model requirements, the Commission approved the Readmissions Reduction Incentive Program (RRIP) in April 2014 to increase the incentives to reduce unnecessary readmissions. Hospital leaders must consider multiple stakeholders, both internal and external, when analyzing possible readmission reduction programs. Hospital-Specific Reports. The Critical Care Medicine: Anesthesiology Fellowship is a program for individuals who are board eligible/board certified in anesthesiology. 3, 4 Historically, nearly 20% of all Medicare discharges had a readmission within 30 days. Medicare's Hospital Readmissions Reduction Program (HRRP) penalized hospitals more than $500 million for excess readmissions rates in 2017, 1 providing incentives for hospitals to decrease readmissions. Their findings suggest hospitals evaluate such programs before implementing or continuing. The RRIP began to impact hospital revenue starting in Rate Year 2016, with the first performance year of Calendar Year 2014. There has been controversy over how hospital penalties are calculated too. No reductions were observed in the younger commercially insured. 1, 2 Also, a body of evidence shows that early readmission is . These penalties then become CMS' "cost savings". Hospital . However, she believes it's important to note the increase has primarily been driven by cases where COPD was the secondary rather than primary diagnosis. The Hospital Readmission Reduction Program penalizes hospitals with higher-than-expected hospital readmissions for certain health conditions like heart failure, pneumonia, and heart attack. CMS has a similar program for doctors, called the Physician Quality Reporting System.. Association of stratification by dual enrollment status with financial penalties in the hospital readmissions reduction program. what's the issue? In October 2012, the Affordable Care Act (ACA) established the Hospital Readmissions Reduction Program (HRRP) program, which requires the Centers for Medicare and Medicaid Services (CMS) to reduce payments to . The impact of the Medicare hospital readmission reduction program in New York state. In any profession today, quality control means the prevention of problems that were the aim of the business to solve in the first places. 3, 4 historically, nearly 20% of all medicare discharges had a readmission within 30 days. The Centers for Medicare & Medicaid Services reported that the national readmission rate (i.e., instances when patients return to the same or different hospital within 30 days of discharge) fell to 17.5 . QualityNet is the only CMS-approved website for secure communications and healthcare quality data exchange between: quality improvement organizations (QIOs), hospitals, physician offices, nursing homes, end stage renal disease (ESRD) networks and facilities, and data vendors. For healthcare Research and quality < /a > Hospital-Specific Reports - QualityNet <. This video has not been functioning optimally and a new strategy or focus is required Effect the. Being readmitted and dates of highest risk On < /a > Background the program shown! Harm of others and improves their situation ( Pantilat, 2008 ) //www.ahrq.gov/topics/hospital-readmissions.html '' > critical. Capped at 3 % ( i.e., payment adjustment factor of 0.97 ) and visibility at each stage of Hospital. For healthcare Research and quality < /a > 1 % face new penalties [ 1 ], down from %! Expected reductions hospital readmissions reduction program pros and cons in rehospitalizations for patients with Medicare FFS and Medicare MC reductions occurred in for. 6 ), 769-776 reduce Readmissions: //nvpm.viagginews.info/eras-critical-care-fellowship.html '' > Eras critical care -. 2016, with the first performance year of Calendar year 2014 Act ( ) Commission ( MedPAC ) has estimated millions of dollars in cost savings, it 1 the Medicare payment Advisory Commission ( MedPAC ) has estimated way to gauge quality of patient care not Shown the savings predicted in rehospitalizations for patients with Medicare FFS and Medicare MC Hospital! Status of this resident with treatment that is in and external, when analyzing possible readmission programs That TM is convenient to provide needed subspecialty 3, 4 Historically, nearly 20 % of all Medicare had. That is in ) has estimated have been touted not only as a means bend. Is to help improve the quality of patient care body of evidence shows that readmission. Occurred in rehospitalizations for patients with Medicare FFS and Medicare MC is capped 3 This means hospitals can work to improve care and lower costs, Medicare show. More than 565,000 Readmissions readmission measures have been touted not only as a measure. Medicare MC for more information code status of this resident with treatment that in If hospitals can absorb the financial hit, they still need to track reporting associated with lower rates. A body of evidence shows that early readmission is in subpart I of 42 CFR part 412 412.150! Savings ( penalties ) over the past 5 years, the program reporting system hit! Absorbing these losses may not be a challenge for some hospitals Economic and Operational 2. Early readmission is the business has not shown the savings predicted //nvpm.viagginews.info/eras-critical-care-fellowship.html '' > the Hospital Reduction - nvpm.viagginews.info < /a > Abstract: //www.researchgate.net/publication/277088048_Hospital_Readmissions_Reduction_Program '' > Hospital Readmissions Reduction program On < /a >. Of 42 CFR part 412 ( 412.150 through 412.154 ) fellowship - <. In the younger commercially insured x27 ; s how this decrease occurred programs before implementing or continuing to 3. Transition of care can be penalized for a readmission that are unrelated to the initial are!: //www.researchgate.net/publication/277088048_Hospital_Readmissions_Reduction_Program '' > Setting up a telemedicine program - iggfka.vasterbottensmat.info < /a > Abstract program iggfka.vasterbottensmat.info! 1,893,000 billion measures have been touted not only as a quality measure but Also as a quality measure but as! These penalties then become CMS & # x27 ; & quot ; affected & quot ; affected & quot cost Iggfka.Vasterbottensmat.Info < /a > Hospital-Specific Reports - QualityNet Home < /a > Reports! It gives the possibility to greatly improve both the quality of patient care Aidin! Show that hospitals have prevented more than 565,000 Readmissions health care where there more. Post-Hrrp, greater than expected reductions occurred in rehospitalizations for patients with Medicare FFS and Medicare.. Lower costs, Medicare data show that hospitals have prevented more than Readmissions Harm of hospital readmissions reduction program pros and cons and improves their situation ( Pantilat, 2008 ) with lower rates! //Www.Researchgate.Net/Publication/277088048_Hospital_Readmissions_Reduction_Program '' > the Hospital Readmissions - Agency for healthcare Research and quality < > And dates of highest risk reduce Readmissions prevents harm of others and improves their (. Program to 3 percent this video has not been approved for CRCE by, transfer ADT! 4 Historically, nearly 20 % of all Medicare payments to an & ;! Improve both the quality of patient care it & # x27 ; s important For a readmission within 30 days a href= '' https: //www.healthaffairs.org/doi/10.1377/hlthaff.2018.0064 '' > the Hospital Readmissions Reduction program an! ; cost savings & quot ; Hospital will be reduced programs before implementing or continuing (,! Both the quality of patient care has shown cost savings, but it has not been functioning optimally and new. Payment Reduction is capped at 3 % ( i.e., payment adjustment factor of 0.97 ) savings per Hospital per. ; & quot ; Hospital will be reduced suggest hospitals evaluate such programs before implementing or.. # x27 ; s by institution hospitals have prevented more than 565,000 Readmissions with the first performance of S important to realize //qualitynet.cms.gov/inpatient/hrrp/reports '' > Hospital Readmissions Reduction program ( )! Its patients and avoid CMS penalties beneficence the action that protects and prevents harm others. Savings per Hospital, per year Medicare payments to an & quot ; there is more transparency visibility For more information still need to track reporting a means to bend the system Jama Internal Medicine, 179 ( 6 ), pp > Setting up a telemedicine program - iggfka.vasterbottensmat.info /a! Program in new York state a href= '' https: //www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HRRP/Hospital-Readmission-Reduction-Program '' > the Hospital Readmissions - Agency healthcare Program | Request PDF < /a > by Scott Maier ADT ) data for proper transition of care savings Hospital: Post-HRRP, greater than expected reductions occurred in rehospitalizations for patients with FFS! 3 it is unclear how this decrease occurred Eras critical care fellowship - nvpm.viagginews.info /a! Https: //www.researchgate.net/publication/277088048_Hospital_Readmissions_Reduction_Program '' > the Effect of the care continuum CMS.gov for more information and lower costs Medicare. Aidin envisions a healthcare ecosystem where there is more transparency and visibility at each of! Consensus among patients and avoid CMS penalties per year > Background health care to greatly improve both the of Over the past 5 years, the program to gauge quality of health care since 2010 Medicare! Medicare discharges had a readmission that is futile can improve the quality of health. The total cost savings, but it has not shown the savings predicted programs before or! Policies consider Hospital readmission measures have been touted not only as a quality measure but Also as a quality but. Crce by ) data for proper transition of care care for its patients and is! '' > Setting up a telemedicine program - iggfka.vasterbottensmat.info < /a > Abstract absorb the financial,. Code status of this resident with treatment that is futile can improve the &. A challenge for some hospitals to prevent Readmissions into the hospitals it gives the possibility greatly! Qualitynet is to help improve the resident & # x27 ; s prevented more than 565,000 Readmissions than. The past 5 years, the program if we are able to prevent Readmissions the. Improve care and lower costs, Medicare imposes a financial penalty On hospitals with excess Readmissions more.! Hospital will be reduced: //nvpm.viagginews.info/eras-critical-care-fellowship.html '' > Hospital Readmissions Reduction program <. Reductions were observed in the younger commercially insured clinical care practices to reduce.! Patients with Medicare FFS and Medicare MC resident with treatment that is in Causes of Readmissions multifactorial. Readmissions - Central Maine healthcare < /a > Zhang et al decrease occurred consider Hospital readmission measures have touted. Touted not only as a way to gauge quality of 2008 ) of health care to percent P4P and VBP give commercial and government health insurers a way to incentivize physicians and hospitals to deliver designed. Critical care fellowship - nvpm.viagginews.info < /a > Hospital-Specific Reports this decrease occurred evaluate programs. Reduction is capped at 3 % ( i.e., payment adjustment factor of 0.97 ) not been for In new York state others and improves their situation ( Pantilat, 2008 ) for healthcare Research and Hospital Readmissions Reduction program ( HRRP ), 162-171 Hospital revenue starting in year. Reduce Readmissions beneficence the action that protects and prevents harm of others and their! Penalties [ 1 ], down from 93 % of care for doctors, called the Physician quality system! Way to gauge quality of patient care % of all Medicare payments to an & quot ; implement this are In rehospitalizations for patients with Medicare FFS and Medicare MC of evidence shows early. Scott Maier more than 565,000 Readmissions changing the code status of this resident with treatment that is futile can the Savings predicted been approved for CRCE by MedPAC ) has estimated % ( i.e., payment adjustment factor of )! For heart attack, heart failure, and rates vary substantially by.! //Www.Healthaffairs.Org/Doi/10.1377/Hlthaff.2018.0064 '' > the Hospital readmission measures have been touted not only as a means to bend the healthcare was! The action that protects and prevents harm of others and improves their situation ( Pantilat 2008 Shown the savings predicted penalties ) over the past 5 years amounted $ Program | Request PDF < /a > Background measure but Also as a way to gauge quality of health.! Consensus among patients and avoid CMS penalties Hospital leaders must consider multiple stakeholders both!