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Direct Difference Digest – August 2026

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Direct Difference Digest

Turning Quality Data into Confident Submissions
The latest news, views, and announcements — Welcome Edition August 2026

Welcome Edition — August 2026

Welcome to the inaugural issue of Direct Difference Digest, a newsletter created exclusively for our partner hospitals. At Direct Difference, we see firsthand how complex quality abstraction and government reporting can be. This newsletter is designed to break down that complexity into clear, practical guidance and actionable steps, ensuring your team can move from data collection to compliant submission and improved care delivery with confidence.

Accurate quality reporting depends on more than just understanding measure specifications; it requires consistent application across charts, abstractors, and reporting periods. Each issue will focus on a core topic, highlight actual chart abstraction insights, and conclude with clear actions you can apply immediately to ensure accurate date collection, reliably demonstrate the care provided, and identify timely opportunities for care improvement.

Executive Brief

  • Inconsistent abstraction is a leading audit risk across quality programs. Small interpretation differences can materially impact reported performance.
  • Proactive and consistent checks reduce rework, delays, and compliance exposure.
  • Direct Difference supports standardized, defensible, abstraction practices.
  • Direct Difference provides full validation support and document review prior to submission.
  • As part of Direct Difference commitment, we have strategically expanded our services to include Cancer Registry and Trauma Registry abstraction.
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❖ Data, Measures & Performance Improvement

✓ Measure Up: Why ED Throughput Matters

ED throughput is how quickly and efficiently patients move through the emergency department system. Efficient throughput improves patient outcomes, hospital capacity, staff workflow, and Hospital Efficiency Regulatory Reporting. Poor throughput can cause ED overcrowding, delayed treatment, and higher complication rates.

CMS Throughput Reporting

Electronic Health Records use timestamps to generate reports required for quality reporting programs, such as those of the Centers for Medicare & Medicaid Services. These measures rely heavily on accurate arrival and discharge timestamps.

  • OP-18: Median time from ED arrival to ED departure for discharged patients
  • OP-22: Median time from ED arrival to ED departure for admitted patients

Common EHR configuration mistakes can lead to incorrect ED discharge timestamps, which affect ED throughput metrics and quality reporting to CMS. Here are real-life ED workflow situations that commonly cause discharge time capture errors. These examples show how normal operational steps can lead to incorrect timestamps in EHR.

1. Provider places the DC order late

Real workflow scenario: Pt evaluated and treated → Provider verbally tells nurse, "Patient can go." → RN begins discharge instructions → Provider gets busy with another patient → Discharge Order entered later in EHR.

Event Actual Time
Patient is ready to leave01:29 am
Pt. transferred from ED to OTF01:59 am
Provider enters discharge order02:11 am
Provider entered addendum notes02:12 am
Pt. Discharged03:27 am
Error: System records 3:27 am as discharge time, increasing ED LOS instead of 1:59 a.m., when the patient was transferred to OTF.
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2. Nurse Completes Documentation After Patient Leaves

Real workflow scenario: Provider places discharge order → Nurse gives verbal instructions and removes the IV → Patient leaves quickly → Nurse documents discharge later when workload allows.

Event Actual time
Discharge order placed4:00 pm
Pt. leaves ED4:10 pm
Nurse documents discharge4:35 pm
Error: EHR may capture 4:35 PM instead of 4:10 pm.

3. Waiting for Discharge Instructions or Prescriptions

Real workflow scenario: Provider decides to discharge → Nurse waits for printed instructions, electronic prescriptions, follow-up paperwork → Documentation may occur at different times.

Event Actual Time
Provider decision5:10 pm
DC order entered5:20 pm
Instructions ready5:35 pm
Patient leaves5:40 pm
Error: System might capture instruction completion time instead of actual departure time.

Why these errors matter: Incorrect discharge times affect Throughput Quality Measures, including: ED Length of Stay (LOS), Door to Discharge time, CMS outpatient quality measures, ED Crowding Analysis, and Operational performance reporting.

Key Takeaway: These examples demonstrate that if an ED discharges 120 patients/day and each discharge is 20 minutes late, the reported ED throughput could be inflated by a total of 40 hours of patients' time per day.

✓ From Chart to Change

Here are recent scenarios regarding quality measure reporting and the importance of accurate documentation and re-abstraction.

Scenario 1: Cath Lab Documentation - NCDR Cath/PCI Registry Focus

Stress Test Documentation Requirements:

  • Stress test performed before the procedure.
  • Documented date of the stress test.
  • Type of stress test noted (e.g., exercise stress, stress echo, stress nuclear, or Stress Image with CMR).
  • Level of risk clearly documented (e.g., low, intermediate, or high risk).
  • Results are described clearly and consistently with the risk assessment.
Key Takeaway: Complete stress test documentation, including the date performed and the level of risk, provides the necessary clinical context for correct Appropriate Use Criteria (AUC) classification in the NCDR Cath/PCI Registry. Clear documentation ensures that procedures are evaluated fairly and that clinical decision-making is accurately reflected, whereas missing or vague entries may negatively impact scoring.
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Scenario 2: Numerator Exclusion Trigger

Scenario: A chart initially met the numerator for a quality measure.
Change: Post-discharge documentation clarified a condition that triggered an exclusion.
Outcome: The chart required a re-review to ensure accurate and compliant reporting.

Key Takeaway: Clear internal guidance on when re-abstraction is required is essential to prevent inaccurate submissions and potential audit findings.

✓ Data to Difference

Objective: To ensure that abstraction decisions are defensible, repeatable, and fully aligned with current specifications.

Frequently encountered common challenges:

  • Documentation Timeliness: We need to ensure documentation is completed promptly to accurately capture data fields that impact star ratings and outcome measures.
  • Consistency in Interpretation: Inconsistent interpretation of exclusion logic across the abstraction team.
  • Data Accessibility: Key details are frequently located in scanned documents rather than in structured fields or free-text notes, which complicates data retrieval.
Key Takeaway: If two abstractors reach different conclusions on the same chart, compliance risk increases. At Direct Difference, we conduct Inter-Rater Reliability (IRR) reviews monthly on abstracted charts, aiming for 95% accuracy or higher.

❖ Compliance Corner

Consistency is the foundation of compliance. Even small differences in interpretation can lead to missed exclusions, inconsistent results, and increased audit risks.

Helpful Tips:

  • Review internal timelines to allow for re-abstraction before final submission
  • Ensure abstraction notes clearly justify inclusion or exclusion decisions
  • Maintain a centralized reference for the interpretation of measures
  • Define a process for handling late documentation
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Deadline Watch

Hospital Quality Reporting Important Dates and Deadlines (All dates are subject to change.)

CMS Hospital IQR Program & HAC Reduction Programs

Discharge Quarter HCAHPS Submission Population & Sampling Submission1 Clinical Submission (SEP-1) NHSN HAI Submission3 (IQR: CAUTI & CLABSI-Onc; HACRP: HAI)
Q3 202501-14-2026102-02-2026202-17-2026202-17-20262
Q4 202504-08-2026105-04-2026205-18-2026205-18-20262
Q1 202607-08-2026108-03-2026208-17-2026208-17-20262
Q2 202610-14-2026111-02-2026211-16-2026211-16-20262

Validation Deadlines

Discharge Quarter HACRP HAI Validation Templates Estimated CDAC Record Request Estimated Date Records Due to CDAC
Q1 2025Targeted: 03-30-2026Targeted: 04-06-2026Targeted: 05-05-2026
Q2 2025Targeted: 04-20-2026Targeted: 05-05-2026Targeted: 06-03-2026
Q3 2025Random: 02-17-2026
Targeted: 05-20-2026		Random: 02-28-2026
Targeted: 06-30-2026		Random: 03-27-2026
Targeted: 07-02-2026
Q4 2025Random: 05-15-2026
Targeted: 06-03-2026		Random: 05-25-2026
Targeted: 07-02-2026		Random: 06-23-2026
Targeted: 07-31-2026

eCQM Validation

Fiscal Year (FY) / Calendar Year (CY)Estimated CDAC Record RequestEstimated Date Records Due to CDAC
CY 2025 / FY 2028Spring 2026Spring 2026

FY 2027 APU

Measure / RequirementReporting PeriodSubmission Deadline / Period
Web-Based Structural / Process Measures4January 1, 2025 – December 31, 2025April 1, 2026 – May 18, 2026
DACA (Data Accuracy and Completeness Acknowledgement)January 1, 2025 – December 31, 2025April 1, 2026 – May 18, 2026
eCQMs (Electronic Clinical Quality Measures)January 1, 2025 – December 31, 2025March 2, 20262

FY 2028 APU

Measure / RequirementReporting PeriodSubmission Deadline / Period
Influenza HCP VaccinationOctober 1, 2025 – March 31, 2026May 18, 2026
Hybrid HospitalWide-Mortality and Hybrid HospitalWide-ReadmissionJuly 1, 2025 – June 30, 2026October 1, 2026

Total Hip Arthroplasty / Total Knee Arthroplasty (THA/TKA) PRO-PM Reporting

FYReporting PeriodSubmission Deadline / Period
2028 Mandatory ReportingProcedure Performed: July 1, 2024 – June 30, 2025
Post-op Data: April 27, 2025 – August 29, 2026		Post-op Data: September 30, 2026
2029 Mandatory ReportingProcedure Performed: July 1, 2025 – June 30, 2026
Pre-op Data: April 2, 2026 – June 30, 2026		Pre-op Data: September 30, 2026

1 The HCAHPS deadline has been extended by one week due to the new survey being implemented beginning with CY 2025 discharges.
2 Submission deadline falls on a weekend or holiday and is moved to the next business day.
3 Hospital Acquired Condition (HAC) Reduction Program Healthcare-Associated Infection (HAI) measures include CAUTI, CLABSI, SSI (Colon & Abdominal Hysterectomy), MRSA, and CDI.
4 Web-based structural measures include mandatory reporting of Maternal Morbidity, Age-friendly, and Patient Safety.

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Hospital Quality Reporting: Important Dates and Deadlines

  • Generally, data must be submitted no later than 11:59 PST on the submission deadline, except for HCAHPS, which must submit by 11:59 CST.
  • Data for clinical measures, eCQMs, hybrid core clinical data elements, structural measures, population and sampling, DACA, and THA/TKA PRO-PM are transmitted within the HQR Secure Portal.
  • HAI validation Template data are transmitted within the HQR Secure Portal via Unified File Management (UFM), Managed File Transfer (MFT).
  • HAI, CAUTI-Onc, CLABSI-Onc, Influenza, and patient safety Structural measure data are submitted to the CDC through NHSN.

Data Submission Guidelines

Data Submissions must be timely, accurate, and complete.

Collect chart-abstracted clinical data for each quarter and submit these data by the deadline. For the CY 2028 payment determination, the applicable patient encounter quarters for chart-abstracted data are as follows:

Patient Encounter QuarterClinical Data Submission Deadline
Q1 2026 (January 1 – March 31)Aug 3, 2026
Q2 2026 (April 1 – June 30)Nov 2, 2026
Q3 2026 (July 1 – September 30)Feb 1, 2027
Q4 2026 (October 1 – December 31)May 3, 2027

Note: Hospitals with fewer claims per quarter for any measure (e.g., Stroke) will not be required to submit patient-level data for that measure for that quarter, though voluntary submission is allowed.

Web-Based Measures: Data submission opens Jan 1, 2027 through May 17, 2027 for CY 2026 encounters.

Patient Survey Measures (HCAHPS):

Patient Encounter QuarterData Submission Deadline
Q1 2026 (January 1 – March 31)Jul 8, 2026
Q2 2026 (April 1 – June 30)Oct 14, 2026
Q3 2026 (July 1 – September 30)Jan 13, 2027
Q4 2026 (October 1 – December 31)Apr 14, 2027

eCQMs: For CY 2028 payment determination, three self-selected quarters of data from CY 2026 reporting period are required. The submission deadline is May 17, 2027.

Hospital Outpatient Quality Reporting (OQR) Program Validation Efforts

Every year, CMS selects up to 500 hospitals for data validation of chart-abstracted measures through the Hospital OQR Program. Selection for CY 2027 payment determination was completed in August 2025.

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CY 2027 OQR Estimated Medical Records Request Dates

Encounter QuartersEstimated Medical Records Requests Sent
1Q 2025 (Jan 1 – Mar 31)August 2025
2Q 2025 (Apr 1 – Jun 30)November 2025
3Q 2025 (Jul 1 – Sep 30)February 2026
4Q 2025 (Oct 1 – Dec 31)May 2026

Direct Difference serves as your abstraction partner for all clinical data and provides full validation support for both randomly selected and targeted facilities at no extra cost. Please follow this process each quarter upon receiving your selected patient list:

  1. 1Post Case Selection: Immediately upload the case selection Excel file to the shared drive and notify your Account Manager and Clinical Liaison. Direct Difference will then conduct a second review of each case.
  2. 2Share PDF Charts: Once your HIM team has the PDF charts ready, post them to the shared drive. This allows us to locate all data elements, identify chart nuances, verify EMS records, and ensure no inappropriate documentation is present.
  3. 3Await Clearance: Direct Difference will review all PDF charts and notify your facility when the charts are ready for submission for that quarter.
  4. 4Review Results Together: Post your validation results to the shared drive immediately. In the event of a mismatch, Direct Difference will investigate and, if validators are incorrect, prepare an educational review for submission before the 30-day deadline.

✓ CMS Compass

Updates and Clarifications: IQR / OQR Measure Retirement & Additions

CMS has updated the 2026 Hospital Inpatient Quality Reporting (IQR) Program. Key updates include:

  • Removed Measures: COVID-19 vaccination coverage and health equity/SDOH measures are being removed.
  • New Requirements: Two oncology-stratified Healthcare-Associated Infection (HAI) measures and additional hospital-harm eCQMs have been added.
  • Hybrid Measures: Lowered reporting thresholds and provisions allowing limited missing data.
  • Claims-Based Measures: Measures such as COMP-HIP-KNEE and MORT-30-STK now include Medicare Advantage patients and utilize a shorter 2-year performance window with ICD-10 coding.
  • Future Adjustments: Removal of COVID-19 exclusions across measures starting FY 2028.
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Office Hours: Your Questions Answered


This newsletter is one of the many ways Direct Difference supports our partners by sharing insights drawn from actual abstraction experience across hospitals nationwide. If there are specific topics you would like us to cover in a future issue, or if you have questions, please reach out to your Direct Difference contact or email us at ASKDD@directdifference.com.

✓ Common Client Question of the Month

Q: If documentation is clarified after abstraction, do we need to update the record?

A: If the new documentation affects eligibility, numerator status, or exclusions, the abstracted data should be updated to reflect the most accurate and compliant interpretation. When in doubt, consistency and documentation are your strongest defenses.

Newsletter Editor: Sherry Watson Lawler

Contributors: Debra Aruffo, Brenda Clemens, Andrea Romo, Tracy Summerfield, Debbie Liverman

The Difference Update

✓ Direct Difference New Service Capabilities — Message from CEO Debra Aruffo

"At the heart of Direct Difference, Inc. is a steadfast commitment to loyalty, integrity, and long-term partnership. We seek to cultivate enduring relationships with healthcare leaders—partnerships grounded in trust, transparency, and a shared responsibility to advance the quality of care.

As part of this commitment, we have strategically expanded our services to include abstraction of the Cancer Registry and the Trauma Registry. This expansion reflects our continued investment in supporting hospitals and health systems as they navigate increasing regulatory complexity, accreditation requirements, and quality improvement expectations.

High-quality cancer and trauma registry data are foundational to outcomes analysis, performance benchmarking, research advancement, and reimbursement integrity. Our expanded team brings deep expertise in registry standards, compliance frameworks, and rigorous clinical abstraction to ensure that data is accurate, reliable, and decision ready."

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Direct Difference, Inc. | Turning Quality Data into Confident Submissions

End of August 2026 Welcome Edition


Download the Client Newsletter – August 2026 in PDF Format

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The Direct Dispatch
A Newsletter For Healthcare Providers

November 2017

This month’s Direct Dispatch focuses on Get With The Guidelines Comprehensive Stroke. If you are interested in anything stroke related please read below for valuable information. Whether you are already participating, just thinking about it, or haven’t thought about it at all, I am sure you will find something new in the information below.

Why Comprehensive Stroke?

Simply put – healthier patients means healthier hospitals

According to the American Heart Association since the inception of GWTG-Stroke in 2003 more than 1,656 hospitals have entered more than two million patient records. The program’s success in achieving measurable patient outcome improvements have now been published in numerous studies.

AHA Comprehensive Stroke Certification

How to get started

It is easy to get started. Just contact your local American Heart Association representative and they will assist you through the enrollment process.

Find your local AHA representative!

We are happy to help you as well! Contact us for further information.

Contact Us

Comprehensive Stroke Facts

There are eight standardized Comprehensive Stroke (CSTK) measures. Data for these eight CSTK measures is collected in addition to the eight stroke (STK) core measures required for primary stroke center certification.

Participating hospitals report

  • improved quality of care to patients
  • demonstrated commitment to a higher standard of service
  • a framework for organizational structure and management
  • a competitive edge in the marketplace
  • enhanced staff recruitment and development

AHA Comprehensive Stroke Certification

Are You A Teaching Institution?

Researchers can conduct investigator led research projects using data for The Get With The Guidelines Stroke program. Interested in a proposal? Submit today GWTG Data Request Form

National Cyber Security Awareness

Our increasingly digital lives may put us in harm’s way. When it comes to cyber-crime an ounce of prevention is worth a pound of cure. Protect yourself and your business from online attacks. Visit Stay Safe Online for more information.

Stay Safe Online

Need additional services? We can help!

Did you know we provide abstraction services for core measures, non-core measures, registry, OPPE-FPPE, NHSN, peer review, and others? If you have any data abstraction needs please contact us for more information. All you have to do is respond to this email to get started.

340 E. 1st St, #306
Tustin, California 92781

(800) 805-4880

info@directdifference.com

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