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April 2009

CORE MEASURES 101

By Ella Nix, RN, BSN, CCS-P

CMS (the Center for Medicare & Medicaid Services) established the Core Measures in 2000 and began publicly reporting data related to the Core Measures in 2003. Currently, there are 26 Core Measures including areas such as: Heart Failure, AMI (Heart Attack), Pneumonia, and Surgical Infection Prevention.

A Core Measure is the percentage of eligible patients that receive care represented by the measure. For example: The percentage of AMI patients that receive aspirin on arrival. If 100 patients with Acute Myocardial Infarction are admitted during one quarter to the hospital with Acute Myocardial Infarction and 78 of those patients receive aspirin on arrival, as documented by the medical records, that hospital’s core measure for the core measure of Aspirin on Arrival is 78 percent.  

The purpose of the Core Measures is for hospitals to use them as an improvement tool. The hospital’s goal would then be to devise methods to improve that value from 78 percent to a higher number. The data collection results are then submitted on a quarterly basis to CMS, who publicly reports the data to aid in hospital improvement efforts and transparency with the public. The reasons hospitals try to improve their core measure rates is to assure their community and their Board of Directors that the hospital is providing high quality care. Hospitals that reach certain benchmarks receive higher reimbursement from Medicare and other payers.

This data is usually collected after the patient is discharged. A nurse on the hospital staff goes back through the patient chart to determine if the patient was an eligible Core Measure patient, if the appropriate care was delivered, and if the documentation was in accordance with the mandated abstraction process. The information abstracted is then entered into software that compiles the statistics and submits the report to CMS.

With the current system, the tracking and reporting of Core Measure performance is a huge amount of work which occupies the time of multiple clinical staff members. No funding is provided by CMS for the mandate, so the cost of tracking and reporting the data is ultimately absorbed by the hospital. The number of Core Measures is expected to expand dramatically, as will the workload and cost involved. In order to increase success with the performance measures, frontline care staff needs to understand measure requirements and take greater ownership of associated care processes in real-time.

Some hospitals use a more labor intensive manner. Some hire quality improvement nurses, called patient care analysts, to work with frontline providers to improve their practice patterns and use of evidence-based interventions. The analysts are responsible for reviewing patient care and records while the patient is still in the hospital. The analysts spend a significant proportion of their time in daily rounds on the medical and cardiac units, reviewing patient records. Once the analyst identifies a record where there may be a counseling, education, or documentation opportunity, the analyst works with the appropriate physician or nurse one-on-one. Identifying the “failures” in real-time gives staff and physicians the opportunity to comply with evidence-based standards and improve the hospital's performance on the specific measures. This is an expensive, but real-time method to improve patient care.

Some of the problems with reporting core measures occur when a conflict of interest arises with a hospital using their own employees to report their own measures. When there is pressure to improve the numbers, sometimes only the numbers improve and not the care. Researchers are still studying whether the Core Measures program really does reduce morbidity and mortality.  Another problem that can occur with the scores of Core Measures is that the result can create misleading impressions when used not as an improvement tool, but as a hospital rating tool, particularly for small hospitals. Small hospitals do not see a large enough volume of patients in some areas and thus their data may be skewed. Additionally, small hospitals may not be able to afford dedicated personnel to the Core Measures project that have enough training.

Accurate and complete documentation is becoming more essential at every level of the health care industry. It is critical not only in quality improvement and patient safety efforts, but is also increasingly vital to maximizing reimbursement. For more information on the CMS Core Measures visit www.qualitynet.org.

Editor’s Note: Ella Nix, RN, BSN, CCS-P is a Data Abstractor in Winston-Salem, NC for Clinical-Insights.

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