Report: Hospitals still struggling with many core measure requirements

Quality now has 'direct impact on bottom line'

There is much room for improvement for the vast majority of The Joint Commission's standardized national performance measures, according to data reported in Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2007. A 90% compliance level was achieved for only four of 22 quality-related measures tracked during 2006.

For example, hospitals offered angiotensin-converting enzyme (ACE) inhibitors at discharge for patients with congestive heart failure (CHF) or heart attack only about half of the time. However, there is strong evidence that compliance with core measures does impact the quality of care and patient outcomes, according to the report.

Low compliance with measures required by the Centers for Medicare & Medicaid Services (CMS) is another growing concern for hospitals. "Hospitals will have little choice in reporting on core measures because of the changes in reimbursement issued by CMS," says Patti Muller-Smith, RN, EdD, CPHQ, a Shawnee, OK-based consultant who works with hospitals on performance improvement and regulatory compliance.

Quality measures multiplying

CMS is expanding the quality measures that will be required during 2008 to include 30-day mortality for Medicare patients with pneumonia. Additional quality measures will be required in 2009. "All of the CMS measures can have a direct impact on the bottom line of the hospital," says Muller-Smith. "Hospitals that fail to report quality information will be subject to provision of penalties in payment."

The impact of low performance includes poor patient satisfaction, reduced case volume, and less revenue — both in terms of reduced Medicare payments and being non-eligible for bonus payments, says Kristin Vondrak, MSN, ARNP, BC, AOCN, CAN, system director of quality at Baptist Health in Jacksonville, FL.

"The Medicare and Joint Commission measures are intertwined — both focus on efficiency and effectiveness of care provided," says Vondrak. "As a result of the quality services provided, reimbursement and payment are impacted, thus allowing hospitals to stay in business to best serve our community. So I see them both as equally important."

Lack of support devastating

"The findings in the report are not surprising, because of the lack of support from administration and physicians," says Muller-Smith.

In the past, some hospital administrators and physicians have viewed quality professionals as necessary individuals they had to communicate with, she says. However, the report's findings underscore the growing clout of quality. "You can expect that quality professionals will be an important part of the financial stability of an institution," says Muller-Smith. "In the future, the information that they will provide will be imperative."

Quality professionals often lacked direct access to the decision makers of the organization and did not really have a power base from which to make the changes necessary to be in compliance with regulatory requirements. "Without the full support of administration and physicians, they could collect and present data but there was little else they could do to require compliance," says Muller-Smith.

According to The Joint Commission report, in facilities where quality holds a high level of importance, where support for the quality professional is present, and where all hospital staff are held accountable for complying with the required activities associated with core measures, there is a definite improvement of patient care and outcomes.

"Noncompliance is really no longer an option if the organization intends to remain viable," says Muller-Smith. "Public reporting of quality data will add to the pressure placed on the organization. Quality professionals should see an increased recognition and value for the work they do. It now has dramatic financial implications."

At Virginia Mason Medical Center in Seattle, a major effort has been made to identify patients with disease-specific events in real-time, says Rosemary Tempel, RN, project manager for quality and patient safety. Here are some changes made by the organization:

  • Instead of retrospective auditing, there is now real-time identification of disease-specific cases.
  • Providers are encouraged to declare the diagnosis early to the care team, to ensure timeliness of interventions before discharge. This information is communicated via text pages, face to face, and telephone.
  • Order sets are used to ensure that nursing staff complete patient education. Flow sheets document that the teaching was provided. "Bedside nurses are assisted by clinical nurse practitioners to identify patients and deliver education before discharge," says Tempel. "Discharge checklists have been used to ensure completion."
  • Patient handout materials were simplified and improved.
  • Disease-specific template progress notes list the evidence-based interventions required for disease-specific care and/or list contraindications to document the provider's rationale for non-compliance.

Every day, a list is created of patients identified as potential inclusions for AMI, CHF, and stroke measures, based on test results for cardiac markers, brain natriuretic peptide levels, chest X-rays, CAT scans, and MRIs.

Charge nurses on each unit identify these patients on a communication board with a colored magnet. Then the project manager verifies that staff are aware of the patient's inclusion, that the magnet is in place, and that patient education is done before discharge.

A daily report tracks use of disease-specific order sets, with charts abstracted to determine why elements of care are missing.

Then, direct feedback is given to providers by nurse practitioners in cardiology and neurology, who act as care coordinators. This gives providers the chance to explain their rationale and debate whether certain patients should have been excluded from the measures, says Tempel.

In addition, clinical pathways, guidelines of care, provider order sets, and patient education materials were developed by multidisciplinary teams to standardize care delivery for many core measures.

Core measures for CHF and community-acquired pneumonia (CAP) presented a special difficulty, says Tempel, because such patients are diversely located across the medical center, and are cared for in the ED, critical care units, and general medical/surgical wards.

"Centralizing patients to geographical locations, educating staff, and keying in on identifiable risk factors or presenting signs and symptoms has reduced the challenge," says Tempel.

At University of California at Los Angeles Medical Center, several measures had been challenging, including the CAP measure requiring antibiotic administration within four hours. "We initially tried a number of approaches that weren't as successful," says Tod Barry, MHA, CPHQ, RRT, director of quality management. "We finally achieved significant improvements by doing some things that we hadn't previously tried."

One of those changes involved earlier identification of patients who fall within the core measures. An analysis is now done with every pneumonia case as soon as possible, to see if criteria are met. "If not, we drill down on what specific issues were responsible," says Barry. "That is a strategy that we have applied across a number of the core measures, particularly for heart failure and myocardial infarction."

Data are shared with physicians much more quickly than the official data that are sent back from CMS or The Joint Commission. "By the time they are officially released to the facility, they are anywhere from four to six months old. When the data are that old, it really isn't very useful to changing practice," says Barry.

Data are now shared within weeks, not months, and with individual physicians, to show how they compare against their peer group. "We have found this to be the best method to achieve practice change," says Barry. For example, a physician might be told that, of the seven heart failure patients he has seen in the past month, several records did not reflect documentation that they received all drugs within the proscribed time frame.

"Once we started drilling down, we not only saw practitioner issues, but more often identified systemic reasons why an order hadn't been administered," says Barry.

Changes made for problem areas

At Baptist Health, a multidisciplinary discharge process team was formed to ensure that CHF patients received discharge instructions. A standardized discharge summary form in triplicate format was created to assist with the abstraction and verification process, and a customized discharge summary tab was added to the electronic medical record. "We also assigned a CHF clinical outcomes specialist to focus on this patient population," says Vondrak. Surgeons, internists, intensivists, hospitalists, and general medicine physicians — not just cardiologists — were alerted about the importance of all CHF patients receiving ACE inhibitors at discharge and documentation of contraindications. "Also, physician dashboards are used to identify improvement opportunities," says Vondrak.

At UCLA, order sets for CHF, AMI, and pneumonia were standardized and updated, making it more difficult for someone to omit an order or not document a specific contraindication. "We set out to make it as easy as possible, by putting checkboxes on order forms and various other places where a physician would chart in the medical record," says Barry.

Another difficult measure was ensuring all appropriate patients are given the opportunity to receive pneumococcal vaccine. "We were able to resolve this by making some significant process changes that heavily involved the pharmacists," he says.

A pharmacist now sees virtually every patient within the first 24 hours of coming to the hospital in order to perform medication reconciliation, and as part of that process, also checks to see whether the patient has received or needs the vaccine. "Just as importantly, we empowered the pharmacist to order these vaccinations. That made a dramatic difference," says Barry.

As part of the effort to improve compliance with the requirement that pneumonia patients receive antibiotics within four hours, a new ED protocol was established allowing triage nurses to order chest X-rays and basic lab tests for patients presenting with certain symptoms. If the test is indicative of pneumonia, that information is immediately relayed to an ED physician who can rapidly assess the patient and start antibiotics.

"We saw our compliance improve to over 90%," says Barry. "It's essential to keep sight of the big patient care picture as well — we're careful not to sub-optimize our improvement efforts and ensure deployment of these systemic changes across all clinically relevant patient populations."

[For more information, contact:

Tod Barry, MHA, CPHQ, RRT, Director, Quality Management, University of California at Los Angeles Health System, Box 951783, Suite 900, 924 Westward Blvd., Los Angeles, CA 90095-1783. Phone: (310) 794-2375. E-mail:

Patti Muller-Smith, RN, EdD, CPHQ, Administrative Consulting Services, Box 3368, Shawnee, OK 74802. Phone: (405) 878-0118. E-mail:

Rosemary Tempel, RN, Project Manager Quality & Patient Safety, Clinical Practice Improvement, Virginia Mason Medical Center, 1100 Ninth Ave., Seattle, WA 98111. Phone: (206) 223-6731. E-mail:

Kristin Vondrak, MSN, ARNP, BC, AOCN, System Director of Quality Management, Baptist Health, 800 Prudential Dr., Jacksonville, FL 32207. Phone: (904) 202-3247. Fax: (904) 202-1726. E-mail:]