Stand Out With Improved Publicly Reported Measures

Break out with a Record of Quality

Our roots stem from a deep understanding and appreciation associated with working within the healthcare industry full time. So as we are busy designing, developing and implementing performance-based training for your organization, we’re also thinking about the public impact that improved record of quality will have.  Over the past 20 years, Direct Difference has delivered hundreds of training programs with the full appreciation of the ‘melt-water’ effect that the improvements will bring:

Using Core Measures as an index of Quality

Core Measures track a variety of evidence-based, scientifically-researched standards of care which have been shown to result in improved clinical outcomes for patients. CMS (the Center for Medicare & Medicaid Services) established the Core Measures in 2000 and began publicly reporting data relating to the Core Measures in 2003. Currently, we report on 30 inpatient core measures and 4 outpatient core measures. We expect this number to rise to 44 measures by 2011.

Why worry about the Core Measures record?

“The strength of the Core Measures is that they are really grounded in science,” says Jane Catton, RN, NMC’s Director of Process Improvement. “They are not just thrown out there with the directive to ‘do it because we want you to’, but rather— they have been carefully researched and have scientifically shown they will improve outcomes.” As such, the Core Measures perform as they are intended – to offer a road map to improvement in patient care. WE know that, but does everyone else know it?

Core Measures “Report Card” effect.

As we know, Core Measures results can create misleading representations when used not as an improvement tool, but as a rating tool. We in the healthcare industry understand this distinction, but members of the news media and the general public do not.

The problem is particularly acute for small hospitals. Say your small hospital received an 83% on a Heart Failure indicator. Does that mean that 17% of patients got substandard care or that patients at a hospital which scored 90% got better care? No. Not at all. A small hospital may only see 20 to 25 patients in a year who even qualify to be included in that indicator. That means in a given quarter, maybe 6 patients are included in the statistical sample.

Then, one of the six patients has a problem. The attending physician included discharge instructions in the “Doctors’ Orders” section of the chart instead of the “Discharge Summary” section. The patient is fine. But in the mandated abstraction process, the error in the record counts as a “miss” because it wasn’t documented correctly. End result: only 5 of our 6 patients are counted as appropriate and your small hospital gets a score of 83%.

Retraining and Monitoring

The example above is just one snip of what we have seen. The fact is, no matter what the local nonprofit organization or news reporter may choose to report, Core Measures is an improvement tool that allows us to refine documentation. When used to rate a hospital, the associated ‘grading’ is unfair and defeats the original purpose. But there is an easier solution than worrying about public perception of an unfair grade: Awareness brought about by regular coaching can help your organization avoid the most frequent causes of lower Core Measure results. And this kind of help is actually a lot more affordable that you may think.

Direct Difference has a long standing record of helping healthcare organizations dramatically improve their publicly reported measures.

Contact us today to learn more.


This information is provided as a courtesy to our clients and friends.

Information about Core Measures from the Joint Commission

Where is the SCIP Core Measure Set?

SCIP measures are found in the Specification Manual for National Hospital Quality Measures

Where is the Heart Failure Core Measure Set?

Heart Failure measures are can be found in the Specification Manual for National Hospital Quality Measures

Where is the AMI Core Measure Set?

The AMI measures are found in the Specification Manual for National Hospital Quality Measures

Where is the Pneumonia Core Measure Set?

The Pneumonia measures can be found in the Specification Manual for National Hospital Quality Measures

Where is the Hospital Outpatient Department Core Measure Set?

View The Specifications Manual for Hospital Outpatient Department Quality Measures developed by the Centers for Medicare & Medicaid Services.

Where is the VTE Core Measure Set?

The VTE measures can be found in the Specification Manual for National Hospital Quality Measures

Stroke (STK) Core Measure Set

Eight NQF-endorsed measures have been approved as a core measure set for use in the Joint Commission’s ORYX program, and will be available for selection by hospitals to meet their 4 core measure set accreditation requirement effective May 1, 2009, dependent upon vendor support of this measure set.