Quality Advisor

So Much to Celebrate in May

May is Mental Health Awareness Month: WHA Expands Programs to Support Substance Use Treatment

 WHA partners with Program for Research, Outreach, Therapeutics, and Education in the Addictions (PROTEA) on one key initiative, Rural Health & Substance Use Support (RHeSUS), which aims to expand access to treatment by increasing the number of health care providers who prescribe for substance use disorders. By training more providers across care settings, WHA is working to improve timely and effective access to care. Offerings include: an upcoming Substance Use Disorders Management Boot Camp: May 15 - 16, 2025, and the RHeSUS Program Lunch and Learn Series which occurs the third Monday of each month from 12:15 – 1:15 p.m.

WHA is also partnering with the Wisconsin Society of Addiction Medicine (WISAM) on an emergency department initiative, Overdose Response Protocol, to identify patients at risk for opioid misuse. Those identified are offered a HOPE Kit—containing Narcan and other harm reduction supplies—and may begin buprenorphine treatment directly in the ED. Patients are connected with peer recovery support and follow-up care to ensure a compassionate, patient-centered approach.

Looking ahead, WHA is excited to launch a new initiative, Caring for Caregivers: Advancing Health Workforce Well-Being in Wisconsin, starting June 1.

Together, these efforts reflect WHA’s continued commitment to mental health and substance use support across Wisconsin communities.

Happy National Nurses Week! We're so grateful for the compassion, dedication and exceptional care nurses provide every day across Wisconsin. Thank you to all the amazing nurses making a difference in their communities. To access more information, see American Nurses Enterprise toolkit.

National Hospital Week, May 11-17, is an opportunity to celebrate Wisconsin hospitals and health systems and recognize the many ways they are more than health care. Over the last year, our hospitals and health systems:

• Contributed over $2.3 billion in community benefits and charity care
• Employed over 110,000 Wisconsinites
• Ranked among the top states in patient satisfaction

Next week, WHA will concentrate its social media content on the many ways our hospitals and health systems are impacting their communities beyond the bedside. Follow our social media channels:

• Facebook
• LinkedIn
• Instagram
• X

For more information on hospital week, including templates for you to create your own posts celebrating the many ways your hospital or health system is more than health care, visit: www.wha.org/hospital-week.

Zimpel Earns Certified Professional in Healthcare Quality

Casey Zimpel, WHA clinical quality improvement manager, passed the Certified Professional in Healthcare Quality (CPHQ) certification exam. Passing the CPHQ exam demonstrates a quality professional's mastery of seven health care quality domains: quality leadership and integration, performance and process improvement, population health and care transitions, health data analytics, patient safety, regulatory and accreditation, and quality review and accountability. Congratulations Casey!

As a clinical quality improvement manager at WHA, Zimpel will continue to leverage her knowledge to implement evidence-based practices, streamline processes and foster a culture of continuous improvement by leading quality initiatives. As a part of this effort, Zimpel collaborates with Wisconsin hospitals to enhance patient outcomes, reduce errors and ensure compliance with regulatory standards, ultimately elevating the overall quality of care.

Wisconsin Leads the Nation in Hospital Cleanliness Ratings

April 2025 — In a time when healthcare quality and patient satisfaction are more critical than ever, Wisconsin has emerged as a national leader in hospital cleanliness, according to newly released federal data.

Becker’s Hospital Review recently published findings based on the Centers for Medicare & Medicaid Services' (CMS) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. These surveys, conducted between April 1, 2023, and March 31, 2024, assess patients' experiences during recent inpatient hospital stays, including their impressions of cleanliness, communication, responsiveness, and more. High marks in this category reflect strong environmental services practices, staff diligence, and hospital-wide commitments to infection control.

Cleanliness in hospitals goes far beyond appearances — it directly impacts patient safety and health outcomes. A clean hospital environment helps prevent the spread of infections, reduces the risk of healthcare-associated complications, and contributes to a more comfortable, trustworthy patient experience.

The data, last updated on January 8, reveals that Wisconsin tops the nation with 30 hospitals earning a prestigious 5-star rating for cleanliness — the highest possible rating from CMS. These 30 hospitals represent a significant share of the 374 total 5-star cleanliness ratings awarded nationwide.

Even more impressive, 59 of Wisconsin's 96 hospitals received either a 5-star or 4-star rating, showcasing the state's consistent excellence in maintaining high cleanliness standards across a wide range of healthcare facilities.

This recognition comes on the heels of another national accolade earlier this year, when Wisconsin hospitals were spotlighted for their top-tier patient experience scores. Read more about that recognition here.

Wisconsin Medicaid Program Ranks Among Top 10 for Mental Health Services

Wisconsin’s Medicaid program has been ranked 10th best in the nation for mental health services, based on a recent analysis of performance data.

The state earned a Behavioral Health Performance Index score of 56.81, with especially strong marks in evidence-based medication use (68.93) and care continuity and follow-up (60.87). Metrics included timely treatment initiation for substance use disorders, adherence to prescribed medications for mental health conditions, and follow-up care after emergency or hospital visits.

The state’s overall performance highlights meaningful progress in delivering timely, effective behavioral health care through its Medicaid program. See full article here.

Share Your Hospital's Quality Improvement Stories

The WHA quality team is gathering stories for our annual 2025 Wisconsin Health Care Quality Report, promoting quality stories within Wisconsin hospitals. If your hospital has a quality improvement project highlighting projects in 2024, we would like to hear from you. Stories included in last year’s report can be viewed here.

Email your story and attach any photographs or images of your work to Marcia Egle by May 23.

Photos, graphs or images should be sent as separate attachments for inclusion in the report. Photos should be sent as .jpg or .png files; graphs should be sent as .jpg, .png, PowerPoint slide, Excel file or PDF.

WHA Foundation Offers Simulation Training Scholarships

The WHA Foundation is once again proud to offer Clinical Simulation Training scholarships to Wisconsin member hospitals. These scholarships allow member hospitals to send interdisciplinary teams to participate in clinical simulation training focused on stroke, severe sepsis/septic shock, or high-risk OB delivery. Over the years, hundreds of hospital members from across the state have taken advantage of this unique opportunity. Please see below for more information, including the 2025 application. 

Scholarship Application Deadline:  Friday, May 30, 2025.

Application Materials

For complete information on scholarship eligibility and criteria, please click here: 2025 WHA Foundation Simulation Lab Scholarships - Eligibility and Criteria.

To complete the 2025 Clinical Simulation Training application, please click here.

CMS Notification of Delay in the Release of the Overall Hospital Quality Star Rating

The Centers for Medicare & Medicaid Services (CMS) is announcing a delay in the scheduled update of the Overall Hospital Quality Star Ratings on Medicare.gov. The ratings, which were originally planned for public release in April 2025, will not be updated on schedule because CMS is working to validate related data after recent systems updates. Instead, we anticipate that the next update will occur in July 2025.

As a result, the information included in the April 2025 Preview Report—specifically the Star Rating tab and the Overall Star Rating Hospital-Specific Report, which were made available to hospitals at the beginning of the Preview Period on February 13, 2025—will not be publicly reported as initially scheduled.

CMS remains committed to providing accurate, meaningful, and transparent information to support patients, families, and caregivers in making informed healthcare decisions. We will provide hospitals with new Hospital-Specific Reports for a full 30-day preview period prior to the future public release later this year. CMS is requesting that hospitals do not release or publicize the Star Rating results from the April 2025 Preview until the results are released publicly.

CMS Issues FY 2026 IPPS/LTCH PPS Proposed Rule

On April 11, 2025, CMS released the FFY 2026 proposed rule for the Medicare Inpatient Prospective Payment System (IPPS). The proposed rule reflects the annual updates to the Medicare FFS inpatient payment rates and policies. In addition to the regular updates to wage indexes and market basket, the following policies are being proposed in this rule:

• Utilizing FFY 2024 MedPAR and FFY 2023 HCRIS data for standard calculations;
• Updates to the Medicare DSH payment policies, including hospital eligibility for DSH UCC payments in FFY 2026 being based on audited FFYs 2020–2022 S-10 data;
• Rebasing and revising the operating market basket and capital input price index (CIPI), including updating the labor-related share, using FFY 2023 Medicare cost report data;
• Discontinuing the low wage index policy and implementing a budget neutral transitional wage index value for providers who were eligible for the low wage index policy in FFY 2024;
• Changes to reclassification policies;
• Updates to the Transforming Episode Accountability Model (TEAM);
• Updates to the Medicare Promoting Interoperability Program;
• Updates to the VBP Program, RRP, HAC Reduction Program, and Hospital IQR Program;
• Removal of the VBP Health Equity Adjustment (HEA) beginning with the FFY 2026 VBP program; and
• Updates to the payment penalties for non-compliance with the Hospital IQR and EHR incentive programs.

Proposed program changes would be effective for discharges on or after October 1, 2025, unless otherwise noted.

The proposed rule was published on April 30 and can be viewed on the Federal Register. Additionally, DataGen has provided a Payment Brief.

Association for Professionals in Infection Control and Epidemiology (APIC) Sponsors Complimentary Symposium

Join APIC Friday May 16, 2025, for an exclusive virtual symposium sponsored by Metrex, a trusted leader in infection prevention and disinfection solutions. This session is designed for health care professionals committed to improving environmental hygiene and patient safety through smarter, evidence-based disinfection practices.

For more information and to register click here.

Agency For Healthcare Research and Quality (AHRQ) Safety Program for Healthcare Associated Infection (HAI) Prevention Recruitment Is Open

AHRQ is recruiting adult intensive care units (ICUs) and non-ICUs to participate in a free 9-month program to reduce central line-associated bloodstream infection (CLABSI) rates in acute care hospitals with a minimum of 50 beds. Participants of the AHRQ Safety Program for HAI Prevention: CLABSI will gain free expert consultation to promote infection prevention procedures and patient safety culture, learn tools to enhance teamwork and communication and receive regular benchmarking reports comparing progress with similar units. Participants will also receive continuing education (CEU/CME) credits. Recruitment for the CLABSI cohort is open through June 2025. Visit their website for more information about the program and to sign up for free informational webinars.