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The Right Way to Use Clinical Analytics to Improve Patient Care

By Syed Raza, MD, CMO, Baylor St. Luke’s Medical Center

July 31, 2023 Posted in: Leadership
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When my residency ended in 1999, the medical world was just beginning to take note of the Centers for Medicare & Medicaid Services (CMS) core measures to evaluate how we treat patients and ensure we provide the right medication for heart failure, pneumonia and other conditions in a timely fashion. At the time, the numbers we reviewed were few and simple. CMS had only identified a few core measures, but these numbers were enough to begin comparing ourselves to other hospitals.

Since then, CMS requirements have become more stringent, and new metrics get added virtually every year. There are 100 metrics that CMS looks at now, and they use 47 of those to come up with hospital star ratings. It’s a lot to keep up with, but it’s also a treasure trove of analytical data. Used properly, this data can guide health leaders to make meaningful improvements. Clinical analytics help us judge how we’re doing presently, so we can make incremental progress toward the ultimate goal—caring for patients in the highest quality environment with maximum safety measures. 

A Case Study in Competition

In general, doctors are competitive. Most did well in high school and excelled while earning their undergraduate and medical degrees. They don’t want to provide the worst patient experience or have patients with the longest length of hospital stay or mortality. If you show them that their performance puts them at the bottom of the pile, they take action. 

At Baylor St. Luke’s Medical Center, approximately 25 percent of our inpatients present with sepsis. When CMS published sepsis metrics, our doctors were hesitant. They felt CMS’s definition of sepsis was too expansive. Hospital leadership reminded physicians that our goal as a hospital is to save tissue and lives, and we explained that we would follow CMS protocols to reach that goal. 

Initially, they weren’t convinced. Once we showed them the clinical analytics regarding our sepsis outcomes, everyone got on the same page. With this buy-in, we reviewed every aspect of our treatment protocol, including:

  • How long it takes to administer the first dose of antibiotic

  • Whether we administer the appropriate IV fluids

  • How quickly we check lactic acid levels


As we reviewed this data for every patient, we looked for areas of fallout. Then we developed processes to prevent such fallout from happening to any other patient moving forward. Thanks to these efforts, we made tremendous strides. Across the Texas Health Division of CommonSpirit, sepsis mortality rates have been halved over the past five years. 

Spreading Analytics Liberally but Cautiously

Since everything within medicine is judged by outcomes, all stakeholders should know what those outcomes are. As the example above shows, doing this can energize your team to take action that leads to substantial improvement.

But there’s more to do after sharing the data. Hospital leadership must work with physician and nurse leadership to determine a path forward to optimize future outcomes and statistics. Remind them repeatedly that the ultimate goal is not to score well on metrics. Rather, it is for patients to leave the hospital feeling better, with no harm done to them. If you ignore the information clinical analytics provides, then you risk not achieving this goal. At the same time, you also run the risk of getting left behind. Everyone uses clinical analytics to compare against competitors or sister facilities. If you don’t, you won’t keep up.

Patients also use available data to determine where to seek care. To have a great reputation in your community and beyond, you must have something to back your claims. Clinical analytics can give you that back-up proof. 

Use Clinical Analytics With Care 

Having data is crucial to making improvements, but if everything becomes metric-centric, you can wind up with a large group of health professionals with analysis paralysis: Give them too many things to work on at once, and you risk paralyzing them.

To avoid this, look at the big picture. Allow your analytics professionals to review the data and provide a summary statement. Then let their summary guide you, looking for overlap between the metrics. Once you find that overlap, institute processes that push multiple metrics forward at once. Otherwise, you’ll create a separate process for every metric. At some point, those processes will conflict and cause a stalemate.

Boosting Your Analytic Outcomes

As useful as CMS data points are, they’re at least a year behind. Therefore, hospital leadership should create their own internal rating system. Create a strong system, and you won’t be surprised with your CMS rating. You’ll know what your rating will be, and you’ll identify what areas need improvement before CMS points them out. This is vital because every other hospital is continually improving. Leaders must make continuous improvements to reduce mortality, readmissions and hospital infections. These efforts improve outcomes and patient satisfaction.

As you target patient satisfaction specifically, be willing to adjust any part of the health experience. Be particularly attentive to the measures that seem to drive CMS scores:

  • Bedside shift reports

  • Joint physician-nurse rounding

  • Post-discharge phone follow-up 

  • Responsiveness of staff to patient requests 


According to our analytics, these four areas drive how patients perceive their care. Pay attention to them and develop processes to improve other identified weaknesses, and your CMS scores will improve. 

Also, keep in mind that you can’t improve CMS numbers overnight. Give your updated processes time and they’ll benefit your hospital, your patients and your physicians, nurses and support staff alike.

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