Concurrent and Retrospective Chart Review, Performance Reporting, and Other Support Significantly Improve Adherence to Core Measures in Four Clinical

Concurrent and Retrospective Chart Review, Performance Reporting, and Other Support Significantly Improve Adherence to Core Measures in Four Clinical Areas

Snapshot
Summary
St. Mary's Health Center implemented a program to increase adherence to 24 process-of-care measures developed by the Centers for Medicare & Medicaid Services (also known as "core measures") in four clinical areas—heart attack, heart failure, pneumonia, and surgical care. The cornerstone of the program involves having a full-time nurse review patients' charts daily during the inpatient stay and after discharge to ensure adherence to these evidence-based processes. Other key program elements that support adherence include internal and external reporting of performance data, department-specific goal setting and measurement, and a physician-led committee that promotes adherence among physicians. Since initial implementation in 2006, the program has led to significant improvement in performance on the core measures in each of the clinical areas, with near-perfect adherence (98 percent or higher) on composite scores being achieved in 2008. St. Mary's has also consistently outperformed other hospitals, and in 2009 placed ninth (in the 99th percentile) in a national ranking based on overall adherence to core measures in the four areas.

Evidence Rating
Moderate: The evidence consists of a comparison of pre- and post-implementation adherence to the care processes included in the 24 core measures, along with comparisons to other hospitals in the region.

Developing Organizations
St. Mary's Health Care

Jefferson City, MO
Date First Implemented
2006

Original publication: April 14, 2010.

Last updated: April 14, 2010.

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