Open Accessibility Menu

Sign up for Live Healthy eNewsletter here.

CMS star rating helps consumers

  • Category: Announcement
  • Posted On:
  • Written By: Deb Sutton, Sweetwater Memorial Marketing Director
CMS star rating helps consumers

MHSC gets overall 2-star rating, 3-star patient experience rating

The Centers for Medicare & Medicaid Services Care Compare website refreshed its star ratings. Star ratings are meant to help consumers understand the quality of care provided by hospitals.

The Centers for Medicare & Medicaid Services methodology for calculating the star rating has been updated, affecting the ratings of healthcare centers nationwide. Memorial Hospital of Sweetwater County is no exception.

The 5-year-old CMS star rating system summarizes a variety of measures into a single star rating for each hospital. CMS simplified and revised its methodology after receiving stakeholder feedback on the method of calculation.

Under the previous methodology, CMS targeted up to 65 measures categorized within seven measure groups. The CMS Star Rating Refresh used 48 of those 65 measures in five measure groups: mortality, safety of care, readmission, patient experience, and timely and effective care. CMS simplified its methodology to calculate an average and compares similar hospitals using peer grouping methods. It’s now easier for hospitals to predict star ratings over time.

For the past two years, Sweetwater Memorial earned an overall four-star rating out of five. Under CMS’s April 2021 Star Rating Refresh, Sweetwater Memorial has an overall two-star rating. This refresh is calculated and based primarily on 2019 data.

CMS displays the patient experience measure group, listing it as “patient survey ratings” on its website. Sweetwater Memorial continues to maintain a three-star patient survey rating.

“My goal is to get back to a four-star rating by the end of this year,” said Sweetwater Memorial CEO Irene Richardson. “We believe this is not a reflection of the quality of care we provide our patients. We’re taking an even closer look at improvement opportunities.”


To receive a star rating, hospitals must report three measures in three measure groups, one of which must be mortality or safety of care. This reduced the number of hospitals eligible for a star rating. Hospitals are then peer grouped based on the number of measure groups for which they reported. MHSC reported at least three measures in four of the five measure groups.

Under the new methodology, 455 (13.6%) hospitals received a five-star rating; 988 (29.4%) received a four-star rating; 1,018 (30.3%), three-star rating; 690 (20.6%), two-star rating; and 204 (6.1%), one-star rating, according to CMS.

Of the hospitals receiving a star rating, 1,585 (50%) received the same rating, 1,423 (45%) shifted up or down one star, and 150 (5%) shifted up or down by two or more stars.

MHSC has a plan in place to meet or exceed benchmarks by Dec. 31, 2021. This is part of the hospital’s goal to return to a four-star rating by the 2023 Star Rating Refresh, which will primarily reflect 2021 data.

Key parts of the plan include strengthening MHSC’s Performance Improvement and Patient Safety Committee, providing additional focused training and education, and reviewing improvement opportunities in real time.

For example, a single case of hospital-acquired C. diff (clostridioides difficile), a bacterium, is cause for concern. The hospital has preventive measures in place to decrease hospital-acquired C. diff.

“We recognized we had the opportunity to improve,” said Noreen Hove, MHSC Infection Prevention, Risk, Compliance & Employee Health Director. “We began improving our processes and ensuring our staff has the appropriate education to keep our patients safe and prevent hospital-acquired infections. We have not had a hospital-acquired C. diff infection since June 2020.”

“Everything we do at Sweetwater Memorial is for the care and safety of our patients and the residents of Sweetwater County,” Richardson said. “That’s our No. 1 job. We take that job seriously and will continue to focus on improvement efforts.”


“Every employee at MHSC is here for our patients,” said Kara Jackson, MHSC Director of Quality, Accreditation & Patient Safety. “They are the reason we are here. It’s our mission to provide ‘compassionate care for every life we touch.’ Our vision is to ensure MHSC is our ‘community’s trusted healthcare leader.’

“The intent of the CMS Star Rating is to provide patients and families with the tools to evaluate the quality of care we provide and choose where they want to receive their care,” Jackson said. “We learn from that. It’s important to us to focus on improving outcomes for our patients.”

Here are some of the many ways the hospital learns from patients and families to improve the care it offers:

Patient & Family Advisory Council: The council was created in May 2019. Its purpose is to create a venue where employees, patients, and family advisors can work in partnership to address challenges throughout the hospital, said Cindy Nelson, MHSC Patient Experience Coordinator. The goal of the council is a commitment to advancing person-centered care, and to work together to improve access, communication, and service with the aim of improving and enhancing the care provided to all hospital patients and families. The group meets monthly.

Mandatory training workshops: Sweetwater Memorial has been a Planetree hospital since 2018. Targeting patient-centered care, the three main goals of the program are to create happier, healthier patients and staff; improve patient experience results; and have a reputation for excellence.

All of the hospital’s 550 employees participate in two of the current active training programs.

  • Planetree Person-Centered Care training: The training began in May 2019. To date, 560 employees have attended the day-long sessions. All new hires must attend.
  • Planetree Language of Caring/Communicating with Empathy Workshop: About 180 employees have gone through the training since the program started in January 2021.

Survey Data: Sweetwater Memorial has recently partnered with Press Ganey to help collect patient experience survey data. The hospital hopes to gather as much feedback as possible regarding patient care and needs, as well as ideas for improvement, said Karali Plonsky, an MHSC quality analyst.

“Press Ganey works with more than 33,000 healthcare institutions around the country,” Plonsky said. “They can offer suggestions and best practices on how to improve our patients’ experience. Plus, their working relationship with other institutions includes rural hospitals like ours. We can collaborate with these hospitals to share improvement ideas.

“These surveys are important to us,” she said. “It’s valuable information we need to know in order to improve. It’s another way of helping our community and meeting patient needs.”

These are just a few of the workshops and programs Sweetwater Memorial uses to gain community feedback. Over the years, feedback and/or surveys have shown the need for a variety of changes and additions – everything from the Sweetwater Dialysis Center to more comfortable chairs in the Emergency Room.


As with any report cards or ratings, each must be interpreted in context, as pointed out by the American Hospital Association and Wyoming Hospital Association. It is unlikely any one report card will provide a robust and reliable portrait of quality in a hospital.

When making healthcare decisions, patients should use all available tools at their disposal, such as talking with friends and family and consulting with doctors, nurses, and other trusted healthcare providers, according to the American Hospital Association.

Some of the data used to calculate hospital grades can be years old and may not reflect more recent performance improvement efforts, according to the national and state associations. In addition, not all measures apply to all patients, which can matter when report cards are used as the primary tool to select a hospital for a specific procedure.

MHSC leadership agrees with the AHA and WHA assessment that overall, the changes to the methodology make the star ratings easier to interpret and are more transparent to hospitals as to how they arrived at particular ratings.

They also agree CMS still has work to do to improve the star rating program. CMS’s peer grouping approach needs ongoing monitoring to ensure it fosters the more equitable comparisons it intends, according to the AHA.

“Like most hospitals, MHSC is working solely to offer the services and skilled-care the people in our community deserve,” Richardson said. “As a community hospital, we want only to strengthen that relationship.

“In the end, providing the best care we can to every patient, every time is our goal,” Richardson said. “Our patients and community are our stakeholders. We’re always seeking ways to improve their health.”


CMS hospital ratings: