How to Make Big Strides in Your Sepsis Performance

If the news that CMS is moving its Severe Sepsis and Septic Shock: Management Bundle (SEP-1) measure into the Hospital Value Based Purchasing (HVBP) Program for FY 2026 has you feeling a little ho-ho-hum this holiday season, you’re not alone. In our June 2023 survey of more than 250 quality leaders nationwide, only 25% said they were “in favor” or “adamantly in favor” of the move.

But here’s the good news: it is totally possible to take control of your sepsis performance in time for the big move. Just ask the quality team at Medical University of South Carolina Health (MUSC), which has the daunting task of managing its sepsis performance at 16 hospitals across the state. In just one year, the team at MUSC has created system-wide process improvements that have dramatically transformed its SEP-1 compliance rates and set the stage for their successful SEP-1 transition into the HVBP Program. Here’s an inside look at how they did it.

Name: Danielle Bowen Scheurer, M.D.
Job Title: Chief Quality Officer

Name: Patterson Burch
Job Title: Director of Quality Reporting & Improvement

Name: Shelby Kolo, Pharm.D.
Job Title: Quality Safety Manager II

Name: Christie Merritt 
Job Title: Manager for Quality Outcomes and Regulatory Performance

Your team tracks and reports your sepsis performance across 16 facilities. What kind of manpower does that take?

Shelby: It’s a big collaboration across the MUSC health system, and it requires clear communication. What our team uncovers when we abstract cases gets communicated directly to our clinical teams. And vice versa, our clinical teams are communicating back to us the opportunities for improvement that they’re seeing on the units. One of my roles is to serve as the sepsis liaison to make sure all the different parts keep moving forward.

Danielle: We also work continuously with our medical records team to improve our documentation workflows, so that we can all meet the measures without having to overthink every step. You have to embrace the fact that it’s a constant work in progress.

Patterson: It also helps that we systematized some of our roles, including Shelby’s and mine. Up until late 2020, we had been disjointed in how we approached sepsis, and we were often working in siloes. Now, we are doing a much better job of making sure the right hand is talking to the left hand, and prioritizing sepsis at a system level.

Has the streamlining of your roles and communication led to an improvement in your SEP-1 performance?

Patterson: Absolutely. The reason we decided to systematize some of our roles was because our sepsis performance at our flagship location, Charleston, was lagging. We were a little shell-shocked by that. Since making the organizational changes, we’ve boosted our rates across the board. Charleston is up by 20-25 percentage points. At Columbia, our compliance rate has almost doubled.

Wow! That’s quite an improvement. Were there any specific moves you made as a streamlined team that you can attribute to that leap?

Danielle: We’ve started meeting every Thursday morning at 9:30am to review every failure. We have representation from each campus participate on the call. We call them Fail Fast calls. You fail, you review it fast, and you move forward. Whatever the issue is—abstracting, coding, clinical input—we identify the lessons learned, get decisions made, and, if needed, get the appropriate documentation incorporated into the EHR to help us pass the case, where appropriate.

Patterson: We’re actually doing Fast Fail reviews in four areas now: sepsis, perinatal care, our IPFQR psych measures, and our ED imaging measures, which are part of the ABIM’s Choosing Wisely initiative to reduce unnecessary medical tests and have been adopted into our state’s BlueCross BlueShield payer program. Having that opportunity to review failures and learn together has been so beneficial.

What is one of the biggest lessons learned that you have uncovered in your Fail Fast reviews?

Christie: That the process of abstracting the SEP-1 measure is not easy or obvious. For example, with the repeat lactate question, sometimes our abstractors will mark it as yes and enter in a date and time when it should be marked no, and vice versa. This requires us to double check each measure, as it affects the accuracy of our overall data. So much of our success with sepsis relies on the accuracy of our documentation and abstraction.

How have you worked with your abstractors to improve accuracy?

Christie: It’s all about education. Constant education. We have five abstractors working on sepsis. We get together as a group to review the sepsis breakdown and all the areas that can trip you up, down to making sure the attending physician attribution is correct.

Shelby: Another piece, too, is making sure our abstraction team is embedded with our clinical team as much as they can be. We have a rule of thumb that, if a clinical team is reviewing core measure abstracted data, we make sure the assigned abstractors are present. We want our abstractors to completely understand the clinical workflow so that they’re not just blindly abstracting in the chart.

Patterson: We have our entire abstraction workflow—from where you find the data elements in our EHR to where you enter them into Medisolv—documented in a Word document. It’s a living document that gets refreshed as soon as anything changes.

You also moved from monthly to weekly sampling. Has that contributed to your improvement?

Christie: Yes, we made that move in 2021 and it was a big help. Now we’re about 10 days out from discharge.

Danielle: Agreed. When you’re reviewing cases that are a month old or even older, it almost feels meaningless. Getting as close as humanly possible to real-time review is critical because then your providers actually remember the case. Especially in those instances where a simple documentation change will make a difference, the weekly sampling has been a huge help.

Shelby: It’s especially helpful for us with the fluids part of the measure. That’s the area where we most often see physicians failing to document properly. Typically, there is a legitimate reason why a patient was not given the full amount of fluids that’s required. We’re almost always able to get those errors corrected and remove these types of failures simply by doing more timely reviews.

You have made incredible system-wide strides. Does that make you feel more prepared for CMS’s announcement that it’s moving SEP-1 into the Hospital Value-Based Purchasing program in FY2026?

Danielle: I think we feel the same amount of dread as every other hospital does [laughs]. It’s just not an easy measure. But yes, if you look at our system as a whole, we have really increased our scores over the course of just one calendar year from 2022 to today. So, I think I speak for us all when I say I’m very excited to see what we can achieve next.