Hardwiring a Core Measures Review Process: Ownership of Improvement in a Large Tertiary Medical Center

Meeting: Hospital Medicine 2012, April 1-4, San Diego, Calif.

Abstract number: 97742


Core measures are publicly reported measures that gauge the quality of the process of patient care reflecting compliance to standards of care. This organization has employed many real–time electronic record enabled tools and clinical decision support to optimize the process of care for every patient every time. After discharge, a random sample of patients are abstracted for required core measures. When a failure is identified, communication and subsequent improvement activities take place.


Following any core measures failure, hardwire a process of accountability for performance improvement and sustainment of successful process change.


A multilayer approach was designed and hard–wired to drive excellence in core measures. –Engagement of a multidisciplinary team including physicians, nursing, business intelligence, and quality to drive change was a critical first step. –Goal identification: drive excellence in outcomes, safety, and experience for all patients. –Development of failure review process: abstractor review, secondary review by quality director, consultation with appropriate physician or nursing personnel as required, and ultimately final decision re: concur or further follow up needed. –Development of performance improvement process: the gaps in performance are trended and from this analysis priorities for improvements are set. Examples of successful enhancements include: short–cycle measures for smoking cessation, vaccinations, education, VTE assessments, normothermia, and beta blockers to provide a worklist at a unit level. Additionally, decision support in EHR is used to create prompts and stops to encourage compliance to selected measures. The teams have oversight from the Quality and Patient Safety Institute, and forums exist where their challenges and improvements are communicated to disseminate best practices across the organization. A continuous educational process is in place to ensure hardwiring of best practices. Specific cases are frequently shared as teaching opportunities. Finally, core measures performance is transparent across the organization from frontline to executive leadership. Performance is measured, improvements implemented and results are recognized. In the last 6 months core measures appropriateness of care at the main campus improved from 94% to 98%.


In a new era of transparency and accountability, ownership of performance improvement is crucial. Hardwiring of best practices for improvement is fundamental to decrease variability in practice. Elements of this hardwiring include: (1) establishing meaningful, patient–centered objectives, (2) developing reliable processes to measure progress against the objectives, (3) driving improvement, (4) recognizing results, including communicating progress, sharing best practices, and leadership engagement.

To cite this abstract:

Warmuth A, LaRochelle D, Bergomi G, Henderson J, Auron M, Phillips S, Vitagliano S. Hardwiring a Core Measures Review Process: Ownership of Improvement in a Large Tertiary Medical Center. Abstract published at Hospital Medicine 2012, April 1-4, San Diego, Calif. Abstract 97742. Journal of Hospital Medicine. 2012; 7 (suppl 2). https://www.shmabstracts.com/abstract/hardwiring-a-core-measures-review-process-ownership-of-improvement-in-a-large-tertiary-medical-center/. Accessed March 28, 2020.

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