CMS SUCCESS STORY
TEMPLATE
NYSPFP recommends that hospitals submit a success story for initiatives in which they have attained a
Z-5 Engagement and Achievement Score of “4” and where they meet the board engagement criteria
provide by CMS (see page 3). A completed success story is required by hospitals wishing to obtain a
score of “5”.
Please check the following boxes, as appropriate:
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This success story may be posted on the NYSPFP Web site.
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This success story will be sent to CMS; and in turn CMS may post it on their Web site and/or
contact my hospital to potentially become a hospital mentor, or present on a national webinar, etc.
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I understand and accept that the document may be edited by NYSPFP’s communication team to
deem it compliant with Federal accessibility standards.
Signature: ________________________________________
Date: _________________________
Note: Take as much space as needed to complete the following information.
[Hospital Name] Success Story for [Initiative Name]
FACILITY:
SUBMITTED BY:
CONTACT INFORMATION :
Email:
Telephone #:
INITIATIVE NAME:
QUALITY IMPROVEMENT AIM or GOAL(S):
Revised 3.3.2014
NYS PARTNERSHIP FOR PATIENTS
[Hospital Name] Success Story for [Initiative Name]
RESULTS (Please embed or attach a run/control chart(s) that demonstrate the outcome achieved):
Describe innovations and interventions that spread improvement beyond the traditional evidence-based
practices, specifically how the hospital achieved the broad focus as outlined by CMS criteria (Please
embed or attach a run/control chart(s) that demonstrate this work):
LESSONS LEARNED:
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NYS PARTNERSHIP FOR PATIENTS
Level 5 Criteria as defined by CMS — To qualify for a “5” score, hospitals must demonstrate broad
engagement focus within the hospital-acquired condition (defined below).
ADE
A score of 5 in ADE indicates hospital improvement efforts in at least four of the
following areas: anticoagulant safety, glucose control, antimicrobial stewardship,
medication reconciliation, opiate safety, and/or a systematic application of human
factors principle using a tool similar to ISMP safety survey or a like method.
CAUTI
A score of 5 in CAUTI indicates hospital improvement efforts in working to
reduce CAUTI outside of the ICU.
CLABSI
A score of 5 in CLABSI indicates hospital improvement efforts in working to
reduce CLABSI outside the ICU and including dialysis patients, where appropriate.
Falls
A score of 5 in falls indicates hospital improvement efforts by participation in risk
assessment of falls, participation in other initiatives, and/or implementing policies
designed to reduce polypharmacy.
Obstetrical
A score of 5 in OB-EED indicates hospital has implemented an EED hard stop
Adverse
policy; or for OB Non-EED is engaged in additional improvement efforts, such as
Events
Pitocin protocols and fetal monitoring simulations.
Pressure
A score of 5 in Pressure Ulcers indicates hospital improvement efforts to include
Ulcers
multidisciplinary approach to pressure ulcer prevention, advanced staff and
leadership engagement, unit-based skin care program, or techniques that are above
and beyond traditional strategies for treatment and/or prevention.
Readmission A score of 5 in readmissions indicate hospital efforts to include community level as
well as hospital level initiatives to prevent readmissions.
SSI
A score of 5 in SSI indicates efforts and participation in a broader procedural harm
initiative (e.g., NQSIP, STS, or something equivalent).
VAE
A score of 5 in VAE indicates hospital efforts to improve ambulation or
implementation of delirium avoidance methods.
VTE
A score of 5 in VTE indicates hospital efforts containing improvement measures
including both medicine and surgery patients.
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