How to Improve Your CMS Quality Star Rating with a Language Access Plan

The Center for Medicare and Medicaid Services (CMS) created its Quality Star Rating program to help patients evaluate where they want to receive care.
This means your Star Rating impacts whether patients choose your organization for healthcare services.

So how can you improve your CMS Star Rating?

One way is to analyze which patients’ experiences may be the weakest.
As you may know, limited-English proficient (LEP) patients typically have a higher risk of not receiving the care they need due to language barriers.

Let’s review the evolution of CMS Star Ratings and identify language access opportunities
to help you improve LEP patient satisfaction, increase patient safety, and reduce readmission.

Overview Calculations Ratings Improvement

What is the CMS Overall Hospital Star Rating?

The Center for Medicare and Medicaid Services (CMS) released the Hospital Star Rating system in July 2016. The rating system was designed to increase transparency and empower patients to make an informed decision about which hospital to use for their healthcare services.

Why are CMS Star Ratings important?

CMS Hospital Star Ratings can be a crucial promotion tool for hospitals.

Patients looking for non-emergency care can use the CMS Hospital Compare website to help them understand the performance of local or national facilities. In addition to showing the Overall Hospital Quality Star Rating for each facility, site visitors can review the number of beds and specialties a hospital offers, the average time patients spend in the ER, and a star rating for Patient Experience.

Hospitals that wish to remain competitive and earn high ratings must understand how CMS calculates the ratings and how to use the ratings for practice improvement.

“Along with the overall hospital rating, Hospital Compare includes information on many important aspects of quality, such as rates of infection and complications and patients’ experiences, based on survey results.”

– Centers for Medicare & Medicaid Services

How are CMS Star Ratings calculated?

The Overall Hospital Quality Star Rating summarizes 47 comparable measures under five quality performance areas that have weighted scores that are used to calculate a hospital’s overall rating:

Performance Area or Measure Group	# of Measures	Star Rating Weight
Mortality	7	22%
Safety of Care	8	22%
Readmission	11	22%
Patient Experience	8	22%
Timely & Effective Care	13	12%

If a hospital has no measures in a particular measure group, the weighted percentage is redistributed proportionally to the other measure groups. For example, if a hospital had no measures in the Timely & Effective Care category, the 12% weight would be distributed evenly as 25% for each Mortality, Safety of Care, Readmission, and Patient Experience group.

How have calculations changed over time?

Since the Overall Hospital Star Ratings launched in 2016, CMS has updated calculations each year. For example, Efficient Use of Medical Imaging, Timeliness of Care, and Effectiveness of Care used to be separate categories but were later combined into the Timely & Effective Care measure group.

While there were no new measures included in the July 2022 calculations, two measures were eliminated:

OP-30: Colonoscopy interval for patients with a history of adenomatous polyps – avoidance of inappropriate use
ED-2b: Average time patients spent in the emergency department after the doctor decided to admit them as an inpatient before leaving the emergency department for their inpatient room

How can you improve your CMS Star Rating?

Improvement in any category – especially improvement that exceeds that of the average hospital – should result in a better overall score and an improved star rating.

LEP patients, on average, have worse outcomes and rate their providers lower than their English-speaking counterparts in the categories with the most significant impact on overall star ratings.

For hospitals with a high percentage of non-English speaking patients, improving these limited-English proficient (LEP) patient interactions may go a long way toward bettering CMS metrics.

Patient Experience

Evaluating a hospital’s patient experience begins with responses to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). The HCAHPS Patient Experience Questionnaire includes many questions on provider/patient communication, with a heavy focus on whether the patient felt listened to, understood, and respected; and whether the patient could understand their provider’s instructions.

What is HCAHPS? How does it impact CMS Star Ratings?

“As part of the initiative to add five-star quality ratings to its Compare Web sites, the Centers for Medicare & Medicaid Services (CMS) publishes HCAHPS Star Ratings to the Care Compare website. Star Ratings make it easier for consumers to use the information on the Compare Web sites and spotlight excellence in healthcare quality. Eleven HCAHPS Star Ratings will appear on Care Compare: one for each of the 10 publicly reported HCAHPS measures, plus an HCAHPS Summary Star Rating. CMS updates the HCAHPS Star Ratings each quarter.” – CAHPS® Hospital Survey

LEP patients represent an opportunity for hospitals to improve their HCAHPS questionnaire scores (and corresponding CMS Star Ratings) because they tend to rate hospitals worse than English-speaking patients. Negative experiences during treatment may contribute to LEP patients’ poor evaluations. Let’s review data to understand which factors are essential to delivering a positive patient experience:

Patient Understanding

The National Center for Biotechnology Information (NCBI) found that LEP patients are:

- 9x more likely to have trouble understanding a medical scenario
- 4x more likely to misunderstand medication labels
- 4x more likely to have a bad reaction to medication

NCBI concluded that patients who spoke a different language than their providers reported worse interpersonal care and were more likely to rate providers poorly when surveyed. Despite the presence of some level of language services in most hospitals, HCAHPS results for LEP patients indicate they don’t feel these standards are always being met.

Cultural Competence

Focusing on cultural competence along with high-quality language access may succeed at improving HCAHPS scores where basic compliance has failed.

What is Cultural Competence?

Cultural competence refers to how healthcare providers can meet the social, cultural, and linguistic needs of patients to help eliminate racial and ethnic health disparities. Language and culture are closely woven together, and these language barriers and cultural misunderstandings are two common issues that contribute to poor health outcomes and readmission rates. A culturally competent healthcare system can help improve the quality of care and patient experience. For example:

Interpreters should be sensitive and consider participants’ cultures throughout each session. They need to pay close attention to when a cultural misunderstanding may cause miscommunication. CyraCom’s interpreters are taught to listen for “untranslatables,” which are concepts that have no absolute interpretation from one language to another. The interpreter will also alert the providers should the LEP person seem to have little to no experience in a Western medical environment.

Professional translators have the cultural knowledge and nuanced understanding of language that allows them to translate text while incorporating proper context, tone, and style. Unlike machine translation, human translators are uniquely able to retain the intent and meaning of the source text while allowing the translated text to be accessible to a specific audience.

Learn More About Cultural Competence

NCBI analyzed over 19,000 HCAHPS surveys from 66 California hospitals and learned that:

“Hospitals with greater cultural competency have better HCAHPS scores for doctor communication, hospital rating, and hospital recommendation. Furthermore, HCAHPS scores for minorities were higher at hospitals with greater cultural competency on four other dimensions: nurse communication, staff responsiveness, quiet room, and pain control.”

Patient Satisfaction

NCBI also found that “quality of interpretation correlates with patient understanding and satisfaction with the encounter.” In contrast, relying on bilingual staff and/or patient family and friends “appears to have many negative clinical consequences including reduced trust in physicians [and] lower patient satisfaction.”

Defining high-quality interpretation

How do you know if your organization’s interpretation services meet “high-quality” standards? Just like CyraCom showcases our quality standards by maintaining ISO accreditations, many hospitals participate in Joint Commission surveys or DNV Healthcare accreditation processes to evaluate their services. These third-party institutions use set criteria or standards to determine how well the facility responds to patient needs. Here are a few standards the Joint Commission uses to assess language access:

Joint Commission Standards Related To Language Access

Standards	Elements of Performance (EP)
RI.01.01.03 The hospital respects the patient’s right to receive information in a manner the patient understands.	EP 1. The hospital provides information in a manner tailored to the patient’s age, language, and ability to understand. EP 2. The hospital provides language interpreting and translation services. EP 3. The hospital provides information to the patient who has vision, speech, hearing, or cognitive impairments in a manner that meets the patient’s needs. Note: The hospital determines which translated documents and languages are needed based on its patient population. Note: Language interpreting options may include hospital-employed language interpreters, contract-interpreting services, or trained bilingual staff. These options may be provided in person or via telephone or video
HR.01.01.01 The hospital defines and verifies staff qualifications.	EP 1. The hospital defines staff qualifications specific to their job responsibilities. Note: Qualifications for language interpreters and translators may be met through language proficiency assessment, education, training, and experience. The use of qualified interpreters and translators is supported by the Americans with Disabilities Act, Section 504 of the Rehabilitation Act of 1973, and Title VI of the Civil Rights Act of 1964.
RC.02.01.01 The medical record contains information that reflects the patient’s care, treatment, and services.	EP 1. The medical record contains the following demographic information: The patient’s name, address, date of birth, and the name of any legally authorized representative The patient’s sex The legal status of any patient receiving behavioral health care services The patient’s communication needs, including preferred language for discussing healthcare EP 25. The medical record contains the patient’s race and ethnicity.
RI.01.01.01 The hospital respects, protects, and promotes patient rights.	EP 1. The hospital has written policies on patient rights. EP 2. The hospital informs the patient of the patient’s rights. EP 5. The hospital respects the patient’s right to and needs for effective communication. EP 6. The hospital respects the patient’s cultural and personal values, beliefs, and preferences. EP 9. The hospital accommodates the patient’s right to religious and other spiritual services. EP 29. The hospital prohibits discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.
PC.02.01.21 The hospital effectively communicates with patients when providing care, treatment, and services.	EP 2. The hospital communicates with the patient during the provision of care, treatment, and services in a manner that meets the patient’s oral and written communication needs.
RI.01.03.01 The hospital honors the patient’s right to give or withhold informed consent.	EP 13. Informed consent is obtained in accordance with the hospital’s policy and processes and, except in emergencies, prior to surgery.

Learn How Meet Joint Commission Language Access Standards

NCBI’s findings for hospitals mirror those of another industry with a heavy focus on satisfaction scores: the customer service industry. The International Customer Management Institute (ICMI) studied the impact of businesses adding language services support to their customer service channels. A majority of contact center managers told ICMI that providing language services:

- Improved satisfaction with customer support
- Positively impacted customers that prefer a language other than English
- Increased customer loyalty

Mortality/Safety of Care

Section 1557 of the Affordable Care Act requires healthcare organizations to provide interpretation services and translated documents for LEP patients.

ACA Section 1557 Requirements

Post a Notice of Nondiscrimination and Taglines

Statutes and regulations mandate entities to provide a notice of nondiscrimination. Covered entities such as healthcare providers must continue to provide taglines (short statements advising language services are available) whenever necessary to ensure meaningful access by LEP individuals to a covered program or activity.

Eliminate Unqualified Interpreters

Section 1557 requires qualified interpreters and prohibits the use of:

A patient’s minor children (except in emergencies to prevent imminent patient harm)
Adult family and friends (unless the patient refuses an interpreter – the provider may still utilize an interpreter if they determine the family member/friend cannot interpret adequately)
Bilingual staff, unless interpreting is part of “the individual’s current, assigned job responsibilities” and the staff member “has demonstrated* that he/she is
- Proficient in speaking and understanding both spoken English and at least one other spoken language, including any necessary specialized vocabulary, terminology, and phraseology, and;
- Is able to effectively, accurately, and impartially communicate directly with individuals with limited English proficiency in their primary languages.”

*Demonstrating these skills will likely require some form of interpreter training/certification

Provide Qualified Interpreters to Patients / Family Members / Spouses / Partners

Section 1557 mandates that providers “take reasonable steps to provide meaningful access to each individual with limited English proficiency eligible to be served or likely to be encountered in its health programs and activities.” It also bans discrimination based on association, meaning providers must supply interpreters as needed to their patients’ families, spouses, or partners as needed.

Confirm that Remote Interpretation Options are Fully Functional

Section 1557 supports the use of qualified phone and video interpreters to help providers deliver timely language access to their LEP patients – with the caveat that video interpretation must meet the quality standards set for ASL interpretation by the Americans with Disabilities Act:

“Real-time, full-motion video and audio over a dedicated high-speed, wide-bandwidth video connection or wireless connection that delivers high-quality video images that do not produce lags, choppy, blurry, grainy images, or irregular pauses in communication.
A sharply delineated image that is large enough to display the interpreter’s face, arms, hands, and fingers, and the participating individual’s face, arms, hands, and fingers, regardless of his or her body position.
Clear, audible transmission of voices.

Adequate training to users of the technology and other involved individuals so that they may quickly and efficiently set up and operate the VRI.”

Train Staff to Understand the Importance and Consequences of 1557

HHS has concluded that its enforcement of Section 1557 should conform to the Department of Justice’s Title VI Manual. The manual states that, under applicable Federal case law, compensatory damages are generally unavailable for claims based solely on a Federal agency’s disparate impact regulations.

Read a Lawyer’s Analysis of Section 1557 Litigation

CyraCom roadmap to improve patient safety with CMS Quality Rating program

Despite the legal requirements of Section 1557, studies show that communication barriers in healthcare lead to a greater chance of extended-stay hospitalizations, misdiagnosis, and grave medical errors for LEP patients. As recently as 2016, 1-in-3 hospitals failed to offer interpreters to LEP patients.

Hospitals can improve patient safety by enhancing communication strategies and implementing language services. Developing or improving your hospital’s Language Access Plan creates a roadmap to better care for LEP patients. You need to inform staff about available language resources and provide regular, effective staff training.

Your language access plan, training, and resources need to clearly explain when staff should utilize in-house interpreters and when to activate remote interpreters. Partnering with a trusted language services provider (LSP) like CyraCom helps your staff access qualified interpreters whenever they need them.

When selecting an LSP, recognize the needs of your staff. Consider how your chosen provider could help you improve staff adoption in these areas:

Convenience: Interpreter resources like phones and video carts should be kept close and accessible to staff.

Support: LSPs should provide quality training and implementation, as well as ongoing client support services.

Simplicity: Connecting to an interpreter should be easy, with few steps.

Speed: Staff should wait seconds, not minutes, on average, for a remote interpreter.

Effectiveness: Quality of interpretation provided should be consistently high.

Learn More About Ongoing Changes To Section 1557

Readmissions

affordable care act

Readmissions rates factor significantly into a hospital’s CMS star rating, comprising nearly a quarter of the overall score.

In addition, the Affordable Care Act mandated that hospitals cut unnecessary patient readmissions, and failure to do so carries significant consequences. More than 2,600 hospitals nationwide faced $420 million in Medicare reimbursement cuts based on their 2015 readmission rates.

Statistically, non-English speakers, particularly in Latino and Chinese populations, readmit at a significantly higher rate than the general population.

Why the difference? A review of 10.7 million Medicare patient records revealed that avoidable readmissions cost Medicare $17 billion a year because patients do not:

- Understand their diagnosis
- Know which medications to take and when
- Comprehend important information or test results
- Schedule a follow-up appointment with their doctor
- Receive adequate care at home

For LEP patients, a reliable language services program may prevent these misunderstandings. Hospitals committed to reducing readmissions among their LEP patient populations are making interpreters part of their continuum of care, active in each stage of the treatment process:

Admissions: Interpretation at check-in expedites the process and puts LEP patients at ease.