The Hospital Quality Improvement Platform

Know where you are and where you’re going

Introducing the Hospital Quality Improvement Platform, HQI’s most dynamic analytical resource yet! The free Platform shows how you measure-up to hospitals in your area and statewide quality standards, and can help identify challenge areas and trends to improve performance.  It gives you:

  • Current reporting on ED metrics, PSI measures, and more, so you can monitor your HACRP score (and other metrics) to improve performance and compliance
  • Charts and graphs that show your performance against more than 300 measures and your peers as you define them
  • User friendly platform and uploads as the program does not connect to your EHR

The Platform is web-based, completely free, and uses data you already report to the California Department of Health Care Access and Information (HCAI) and NHSN.

The Hospital Quality Improvement Platform tracks and analyzes data for the following:

  • Inpatient episode quality and efficiency
  • Readmissions (3, 7, 14, 30 day)
  • Healthcare-associated infections (NHSN HAIs)
  • Case mix demographics, comorbidities, index
  • CMS hospital-acquired conditions (DRA HAC and HACRP)
  • Cancer surgery volumes
  • ED discharge analytics (comorbidities, volume, demographics, revisits)
  • Adverse drug events (anticoagulants, glycemic control, and opioids)
  • Hospital-acquired conditions (HACs)
  • AHRQ Patient safety indicators (PSIs)
  • AHRQ Inpatient quality indicators (IQIs)
  • Sepsis incidence and mortality
  • Maternity measures
  • Mortality/serious complications/reoperations/length of stay/discharge disposition
  • Nursing-sensitive measures (under development)
  • Recent (SIERA) discharge volume by source (Inpatient, ED, Ambulatory Surgery)
  • Social determinants of health
  • Chronic physical and behavioral conditions

The Hospital Quality Improvement Platforms gives you 15 options for benchmarking your hospital’s performance:

  • All CHA member hospitals
  • Other critical access hospitals
  • Other rural hospitals
  • Other children’s hospitals
  • Other teaching hospitals
  • Your hospital’s past performance
  • Other CHA member hospitals:
    • In the same health system
    • In the same general region
    • In the same health service area (HSA)
    • In the same metropolitan statistical area (MSA)
    • With similar bed size
    • With the same type of control (e.g., non-profit)
    • With the same license type
    • With similar Medicare payer mix
    • With similar Medi-Cal payer mix
    • With the same adult/children’s trauma level designation
    • With similar inpatient discharge volume
    • With the same ED service level (e.g., basic, standby)
    • With similar outpatient visit volume

The Hospital Quality Improvement Platform allows you to filter your reports by:

  • Payer type (e.g, Medicare, Medi-Cal, uninsured)
  • Service line
  • Gender
  • Race/Ethnicity
  • Principal procedure
  • Principal diagnosis
  • Age
  • Type of care (e.g., acute, ED, ambulatory)
  • Discharge disposition
  • Zip code category (e.g., homeless, foreign address)
  • Admission source
  • Language
  • Present on admission status
  • ED treat and release vs. admit

The Hospital Quality Improvement Platform doesn’t require any connection/interface to your EHR system. It uses the following data sources already created and submitted by your hospital:

  • Healthcare-Associated Infections (HAIs):National Healthcare Safety Network (NHSN) data
  • Recent inpatient, emergency department, and ambulatory surgery discharges: California Department of Health Care Access and Information (HCAI) System of Integrated Electronic Reporting and Auditing (SIERA) data sets
  • Historical inpatient, emergency department, and ambulatory surgery discharges: HCAI Limited Data Sets (formerly AB 2876 files)
  • Maternal measures: California Maternal Quality Care Collaborative (CMQCC) data

The Hospital Quality Improvement Platform is available to all California Hospital Association members at no additional charge.

The Platform is supported by a friendly and knowledgeable team. We are here to help address any challenges.

You can reach us at (916) 552-7557 or

Joining the program and using the Platform is easy – please call Dr. Scott Masten at (916) 552-7557 to have him walk you through the process in just a few minutes.

The two forms you’ll need at some point are the Business Associate Agreement (BAA) and Participation Agreement.

HQI is proud to have Dr. Scott Masten, one of California’s leading epidemiologists, at the helm of the Quality Improvement Platform team.

Scott Masten, PhD
Vice President, Measurement Science & Data Analytics
Hospital Quality Institute

Scott Masten joined HQI in 2016 to help develop the Hospital Quality Improvement Platform data warehouse and advance our data processing, analysis, and reporting capabilities, as well as provide statistical consulting, program evaluation, and education for member hospitals. He has a multidisciplinary background in injury epidemiology (PhD, UNC Chapel Hill) and experimental psychology (MA, CSU Sacramento) and is skilled in a large array of statistical techniques including ARIMA time series analysis, logistic regression, Cox proportional hazards survival analysis, generalized linear regression modeling, factor analysis, ANOVA/MANOVA covariate models, non-parametric techniques, stratified epidemiological analysis, meta-analysis, power analysis, comparisons of complex samples, and psychometric reliability and validity.

Click here to be taken to the Hospital Quality Improvement Platform.

1. What are the data sources that HQIP uses for their reports?

HQIP primarily uses three data sources.

The first set of sources are the historical discharge data sets made by HCAI for inpatient discharges, emergency department visits, and ambulatory surgery visits. We collectively call this set of data files the AB 2876 files throughout the website.

The second set of sources are the data files that hospitals sends to HCAI to create their historical data sets. These data files are called the System of Integrated Electronic Reporting and Auditing (SIERA) files. Hospitals are required to send these files to HCAI periodically throughout the year.

The last set is the data you submit to National Healthcare Safety Network (NHSN).

2. What do you need from me in regards to each data source?

For the AB 2876 files, we ask that you submit a request to HCAI for these files to be given to HQI. We require a custom data set, which necessitates a custom data request and therefore variable justification must be given, which we will provide.

For the SIERA files, we ask that you upload the files through our secure uploading function on our website once HCAI has accepted your file and it passes their requirements. You may upload your files more often than is required by HCAI at your own liking.

For NHSN data, you must simply join our NHSN group.

3. How soon after uploading my SIERA data will it appear in reports?

We will be able to complete data analysis within a few days and, at worst, your data will appear on the following Monday after you upload (if uploaded before 5PM EST Friday).

4. How new is the data you are reporting on?

The data we show in our reports is either as new as the latest AB 2876 data or as new as the data in the SIERA files you upload.

5. Will I be able to see a specific hospital’s data? Will other hospitals see my hospital’s data?

No, you cannot see other hospitals data nor can they see yours. You will be able to select a pre-made comparison group of hospitals and see that groups averages. As well, you can see individual hospital rates in the comparison group, but the hospital name is hidden. Furthermore, you will not even know which hospitals are in the group.

6. Does the data platform require a connection to my hospital’s Electronic Health Records (EHR) system?

No. Discharge files your hospital already creates for HCAI are uploaded manually and easily into the data platform without the need to connect to your EHR.

7. Can my hospital use our own BAA instead of HQI’s?

Yes. Our legal counsel will review and if it’s deemed sufficient, we can just use your hospital’s BAA.

8. Where can I access the data platform?

9. Is there a limit to the number of users allowed at my hospital?

No. Just send us their names and emails to and we’ll make accounts for as many persons as you’d like. Alternatively, click the “Request Access” button at the link above.

10. Is there any cost for additional users?

No. You can have as many users as you’d like.

11. On the MSA, what do we put in for term and end dates?

It is completely up to you.  If a date is not inserted for an effective date, the effective date becomes the date you sign.  And as far as termination, it is basically at will as you can send in written notice 30 days prior to terminate.  Some users choose one year, some two years and some leave it open ended.  Our suggestion would be to leave it open as you always have the right to terminate.

12. How do I log on to the platform?

If you do not already have a user name, click here to get one.  If you already have a user name, click here to access the logon page. You will need to install Google Authenticator on your phone to login because the system uses multifactor authentication (MFA) to protect your data. Instructions for logging in using MFA are available here.

13. Is the platform Evident Thrive & Centriq Healthland Compatible? Have you been unable to participate in collaboratives in the past because your hospital uses an EHR that requires you to correct data in the HCAI SIERA system? Good news — now you can! The new HCAI upload data portal (SIERA) allows you to download your corrected data, which can then be loaded directly into our HQIP portal so you can access quality analytics based on your corrected discharge data.

Click to see Dr. Scott Masten demonstrate the features and value of the Hospital Quality Improvement Platform.