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Hospital Uses Pocket-Sized Handout to Improve Core Measures Compliance

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   August 10, 2010

Core measures are 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 of them. 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 (CA), 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 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. 

The biggest challenge thus far has been physician endorsement, which is always an obstacle 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. 

Providing data also helps with physician involvement because physicians respond well when presented with data supporting the change.

“You’ve got to allocate the resources for this. It’s not something you can do with a limited number of resources,” says Fore. “Not every quality department has the resources to do this; therefore, everyone in the hospital has to be engaged in core measures.” 

It also helps to have leadership on your side, firmly behind the tracking and improvement of core measures. 

“Leadership definitely supports this,” says Fore. “It is coming from the top down. Our CEO is very involved. Every single member of the executive team is familiar with core measure outcomes. It’s very much a focus for RMC and [Hospital Corporation of America].”

“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.” 

Door-to-balloon time
One core measure indicator that provided additional challenges during RMC’s improvement efforts was door-to-balloon time. Door-to-balloon is an emergency cardiac care measurement of time for treatment of ST-segment elevation myocardial infarction (STEMI) and is a core quality measure of The Joint Commission. 

The interval starts with the patient’s arrival in the ED and ends when a balloon catheter crosses the culprit lesion in the cardiac cath lab. Delays in treating a myocardial infarction increase the likelihood and amount of cardiac muscle damage due to localized hypoxia. Guidelines recommend a door-to-balloon interval of no more than 90 minutes. 

“Our door-to-balloon time was a challenge,” Stewart says. “We’ve got a multidisciplinary team together to look at our STEMI patients.”

“This was a multidiscipline improvement project, working with staff from EKG, cath lab, admissions, laboratory, and more,” Fore says. “RMC dropped its door-to-balloon time from 120 minutes to 90 minutes, with more improvements on the way.

“Very soon it will be 60 minutes,” she predicts. “We’ve been under 90 minutes for the better part of a year. The way we will be able to meet that 60-minute target in our geographic area is to have a countywide STEMI program.”

The ambulances and paramedics in the region, once they recognize symptoms of chest pain, are able to run an EKG and determine with good certainty what they are dealing with.

This information is transmitted to the closest facility, and the paramedics can start medications in the field.

“We know exactly what our goal is when the patient arrives—we’re taking them right to the cath lab,” says Fore.

There are eight STEMI-designated emergency rooms in the county, which had to prove they could provide patients with a door-to-balloon intervention in a window of under 90 minutes. RMC’s emergency room is one of the eight.

“Our next challenge will be to add more diagnoses to core measures,” says Fore.

RMC’s next target will be in perinatal initiatives.

This article was adapted from one that originally appeared in the May 2010 issue of Briefings on The Joint Commission, an HCPro publication.


Rebecca Hendren is a senior managing editor at HCPro, Inc. in Danvers, MA. She edits and manages The Leaders' Lounge blog for nurse managers. Email her at

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