Case Study

How to Evolve Your Quality Reporting Governance

20 Minute Read

Key Takeaways

The challenge

Many hospitals and health systems have a siloed approach to CMS quality reporting governance due to the constant evolution of reporting requirements. In addition, internal factors like multiple electronic health records (EHRs) and staff turnover make it challenging to coordinate quality reporting efforts across the Quality Payment Program (QPP), Promoting Interoperability (PI) program, and Alternative Payment Models (APM). We profiled four organizations that have made significant progress in addressing this challenge.

The organizations

  • Intermountain Healthcare is a 24-hospital health system based in Idaho, Nevada, and Utah. They participate in an Medicare Shared Savings Program (MSSP) Track 1+ Accountable Care Organization (ACO) and have one EHR.
  • Mass General Brigham is a 10-hospital health system in Massachusetts and New Hampshire. They participate in an MSSP Enhanced ACO and have one EHR.
  • West Willow Hospital (a pseudonym) is a 5-hospital health system based in the Southeastern United States. They have 2 inpatient EHRs and 18 outpatient EHRs.
  • Community Hospital Corporation (CHC) owns, manages, and consults with over 120 hospitals to guide, support, and enhance the mission of community hospitals and providers. Their hospitals operate on five EHRs.

The approach

All four organizations have evolved their governance structures over time to adapt to changing CMS requirements and take advantage of alignment between program requirements.

The result

Breaking down silos between QPP and PI program management enables the health systems to coordinate efficiently between departments, make decisions quickly, and reduce redundant efforts.



Breaking down silos for CMS reporting requires some degree of centralization and standardization of decision-making, resources, and processes. But the degree to which an organization centralizes and standardizes their QPP and PI program management depends on their size, investment in information technology (IT), participation in risk-based payment programs, and culture. These organizations each evolved their QPP and PI governance strategies to improve efficiency, while taking into account their resources and organizational structure. We recommend starting with the organization that best matches your current structure, size, and risk portfolio. However, it’s valuable to read each example to understand alternative approaches.


The models

  • Model

    Intermountain Healthcare: Leverage a culture of systemness

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  • Model

    Mass General Brigham: Capitalize on enterprise-wide EHR

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  • Model

    West Willow Health System: Convene an interdisciplinary workgroup

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  • Model

    Community Hospital Corporation: Deploy a centralized support team

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Compare profiled organizations

We recommend starting with the organization that best matches your current structure, size, and risk portfolio. Use this table to compare the characteristics of the hospitals below to your organization.

Comparison of profiled organizations


1. CHC Hospitals, CHC Consulting, and CHC ContinueCARE provide the resources and experience community hospitals need to improve quality outcomes, patient satisfaction, and financial performance. For more information on CHC, please visit :

2. Includes clinical quality, risk management, financial management, and legal.

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