Hospital Uses Pocket-Sized Handout to Improve Core Measures Compliance

Briefings on The Joint Commission, June 8, 2010

Core measures—they're a part of the fabric of hospital life, particularly given their connection to CMS reimbursement numbers. All staff have encountered core measures at some point and have a basic understanding. But how do you ensure that their knowledge level is up to date and sufficient to keep your hospital's reimbursements optimized?

At Regional Medical Center (RMC) of San Jose, the Quality Department created the Core Measures 101 brochure, an educational tool designed to improve new hires' understanding of core measures.

"We give this out in every new employee orientation and to the nursing and medical staff who need core measure education," says RMC quality coordinator Odette Carreon. "It contains all the basic information one has to know about core measure guidelines, including helpful links, resources, and contact numbers of the quality department."

The brochure is printed in full color and distributed to staff. Rather than try to teach employees core measures guidelines from scratch, the brochure is intended as a go-to reference on the fly as well as a reminder or update for experienced staff.

"Most of the staff are very familiar with core measures," says Nancy Fore, chief quality officer at RMC. New hires will have heard about core measures through their previous jobs, but the tool acts as a key reminder for them.

"You can't not know something about core measures in the U.S.," says Fore. "It's every hospital's focus because of the reimbursement factors."

The information contained in the brochure is a collection of facts from The Joint Commission and CMS, with a focus on publicly reported measures. Although the hospital is educating its staff members on all of the core measures guidelines, the brochure sticks with the publicly reported indicators as a way to keep things streamlined. "We had very limited space," Carreon says.

The tool has been well received by the staff. "The colorful presentation helped in delivering the message," says Carreon.

The brochure's minimal size has helped keep it useful for staff as well. "The size of it is convenient—the trifold slips into a lab coat pocket," Fore says. "It's informational as well as convenient."

So convenient, in fact, that certain members of the staff carry it at all times. "Our hospitalists keep it in their pockets and use it during discharge and admissions," says Cindy Stewart, director of quality at RMC.

RMC hospitalists and intensivists use the brochure to verify that they are following the appropriate steps at pivotal times in patient care.

"I equate it to a clinical pathway," says Fore. "They're making sure they've done every step along the way."

The quality department is hoping to expand this go-to style of use to the nursing staff as well.

"Our goal is for every nurse to refer to it also," says Fore. "They don't have the same level of control, in that they're not writing the orders, but they are following up on orders.

"What RMC hopes to achieve, ultimately," she explains, "is that nurses are jarring the memory of physicians: Did they remember to write the order in this instance? The intent is to create a check and balance between caregivers to improve patient outcomes."

The bigger picture
The brochure is only one part of a larger core measures plan. RMC has taken multiple steps to make core measures part of the hospital's culture.

"We've created a core measures binder that contains our forms, checklist, documentation, that's used as a reference binder," explains Stewart. "We also have a core measures team that meets daily. We do ongoing education every step of the way."

The goal of the meeting is to always be looking at RMC's processes, says Fore.

"We want to modify our processes in a concurrent way so we're on top of it and make sure we don't have any fallout for the day where one of the steps wasn't actually instituted," she says. "It's always morphing into something else. The people who sit at the team meeting every day are responsible for taking back the changes and education to their staff. I'd say it's one of the most vibrant performance projects in our hospital."

There's a large amount of energy and resources put toward this project because the impact is so great, Fore explains.

"Adherence to core measure guidelines by everyone in our organization is essential. [The hospital system] is trying to adapt something like this in all its hospitals," she says. "We talk with other facilities in our region about demonstrated best practices. This is a big focus area with our healthcare system."

The biggest challenge thus far has been physician endorsement, which is always present at the start of any change.

"The way we work through that is to educate every day," says Fore. "We're sometimes successful, sometimes not, but the more momentum we've built with our outcome scores, the more [physicians] become involved—just from the competitive nature of healthcare, everyone wants to be successful."

RMC publishes its outcomes all over the hospital, which taps into the competitive spirit of the providers and improves outcomes across the board.

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