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Elliot Health System is a non-profit organization serving your healthcare needs since 1890.

Quality & Safety at Elliot Health System

Center for Clinical Excellence

The Center for Clinical Excellence (CCE) is Elliot’s multidisciplinary team of Continuous Improvement Specialists, Analysts, Report Writers/Programmers, Program Managers, Accreditation Specialists and Clinical Partners. We are committed to learning, leadership and excellence by providing quality support services to our health system.


‘Always Ready for Every Patient’

Accreditation is the process in which a health care organization undergoes a survey to demonstrate compliance with standards developed by an official agency. Adherence of these standards promotes and continually improves our quality and safety of care and services.

Centers for Medicare and Medicaid Services:
The Centers for Medicare and Medicaid Services' (CMS) (CMS) purpose is to ensure effective, up-to-date healthcare coverage and to promote quality care for its beneficiaries. CMS’s hospital survey process is part of the hospital provider’s agreement for Medicare and Medicaid reimbursement and can be conducted also by a deemed authority.

CMS develops Conditions of Participation (CoPs) and Conditions for Coverage (CfCs) which healthcare organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs. These minimum health and safety standards are the foundation for improving quality and protecting the health and safety of beneficiaries.


Our Analytics team provides consulting, analysis, and reporting support for Quality, Utilization, Regulatory, and Performance Improvement initiatives. It is responsible for the design and development of intuitive data-driven tools that inspire self-directed decision making. The analytics team leverages Elliot Health System’s vast collection of patient health data using numerous tools, including SAS Visual Analytics, Business Objects and MS SQL Server.

If you have an interest in turning data into meaningful and actionable information with sophisticated insights, please contact

Continuous Improvement

Our Continuous Improvement Team lead and facilitate improvement projects within the organization
using improvement science and methodologies such as lean and six sigma. This includes working with and coaching members of senior leadership, area leaders, and front-line teams using a data-driven, scientific problem-solving approach while teaching continuous improvement methods. We aim to build the capability of all our colleagues across our health system to solve problems. We promote a culture of continuous improvement within the organization by taking on a central teaching and coaching role. Our current focus is developing and spreading a daily management system which supports and drives daily continuous improvement.

Program Management

Our team provides program and project management support to regulatory, accreditation and partner programs.

Programs Managed:

  • Meaningful Use
  • Quality Payment Program (MIPS)
  • National Surgical Quality Improvement Program (NSQIP)
  • Care Gap Outreach Program
  • Ongoing Professional Practice Evaluations (OPPE)
  • Core Measure Implementation/Quality Improvement
  • Pay-for-Reporting Core Measures
    • Inpatient Quality Reporting (IQR)
      • Electronic Clinical Quality Measures (eCQM)
    • Outpatient Quality Reporting (OQR)
    • Inpatient Psychiatric Facility Quality Reporting (IPFQR)
    • Ambulatory Surgery Center Quality Reporting (ASCQR)
  • Bariatric Surgical Registry
  • American College Radiology Reporting Program (ACR)
  • Quality Reporting
    • Foundation for Healthy Communities Reporting (HIIN)
    • Press Ganey Reporting
    • Critical Value and Test Reporting
    • Value Based Purchasing (VBP)
    • Hospital Acquired Conditions Reduction Program
    • Hospital Readmissions Reduction Program
  • Payer Programs (commercial)
    • Anthem Partner program (including Q-HIP)
    • Cigna Partner program
    • Harvard Pilgrim Health Care
    • Humana Partner program
    • Wellsense
  • Payer Programs (CMS)
    • ACO programs including: Medicare Shared Savings Program (MSSP)