2022 Quality Report


The period covered in this Wisconsin Hospital Association (WHA) annual Quality Report was one in which hospitals and the people working in them were tested like never before. Wisconsin’s hospitals served as both the front line and the last line of defense in fighting the COVID-19 pandemic, adapting their operations quickly to maximize the safety of their patients, staff and the community while adding workers where needed and appropriating available space to attend to increasing numbers of infected patients. Health care providers throughout the state also stepped up to perform hundreds of thousands of COVID tests within their facilities in drive-through sites. 

All the while, hospitals continued to deliver babies, attend to accident victims and treat chronic diseases. And true to the state’s long-standing commitment to patient safety and health care quality, standards of practice in Wisconsin’s hospital remained high throughout this challenging time, as the data in this report show.  


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Wisconsin Performance with Federal Medicare Measures


Through its Hospital Value Based Purchasing Program, Hospital-Acquired Conditions Reduction Program and Hospital Readmissions Reduction Program, the Centers for Medicare & Medicaid Services (CMS) aims to improve the care provided by the nation’s hospitals and link Medicare payments to health care quality in the inpatient setting. In all three programs, Wisconsin hospitals improve year over year and routinely outperform other health care providers.
Workforce Report

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The Hospital Readmissions Reduction Program reduces payments from CMS to hospitals with excess readmissions. According to CMS, the program is designed to improve communication and coordination to better engage patients and caregivers in post-discharge planning. A fact sheet related to the Hospital Readmissions Reduction Program is available here. 

Payments within this program may be reduced by up to 3%, depending on the performance outcomes for each of the six identified measures. Fourteen Wisconsin (22% of eligible hospitals) will receive no penalty this year. Nationally, this remains an area of focus, and Wisconsin performs higher than the national average (16% will have no penalty nationally).

The Hospital Value Based Purchasing (VBP) Program is designed to improve the quality, efficiency and safety of care that Medicare beneficiaries receive during acute care inpatient stays as well as improve their experience. A summary of the Hospital Value Based Purchasing Program for fiscal year 2022 is available here. 

In the fiscal year (FY) 2022 Inpatient Prospective Payment System (IPPS) Final Rule issued on August 13, 2021, CMS determined that circumstances caused by the COVID-19 public health emergency significantly affected National Healthcare Safety Network (NHSN) Healthcare Associated-Infection (HAI), Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, and the Medicare Spending per Beneficiary (MSPB) measures in the FY 2022 Hospital VBP Program. As a result, in the final rule, CMS suppressed those measures from the FY 2022 Hospital VBP Program.

Because CMS is suppressing many measures, CMS believes there will not be enough data to award a Total Performance Score to any hospital in FY 2022. As a result, no hospital will have a Total Performance Score calculated, and no hospital will have payments adjusted due to the Hospital VBP Program in FY 2022.

Through the Hospital-Acquired Conditions (HAC) Reduction Program, CMS reduces payments to hospitals based on their performance on measures of hospital-acquired conditions. CMS evaluates overall hospital performance using total HAC scores. Hospitals with total HAC scores in the worst-performing quartile receive a 1% payment reduction on their overall Medicare fee-for-service payments for fiscal year 2021 discharges. A fact sheet related to the Hospital-Acquired Condition Reduction Program is available here. 

For fiscal year 2022, 15 Wisconsin hospitals received a penalty. 

Wisconsin Quality Case Studies


Hospital Quality Improvement Showcase