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Montrose Memorial Hospital Quality & Core Measures

What are Core Measures?

Core Measures monitor a variety of evidence-based, scientifically researched standards of care which have been shown to result in improved clinical outcomes for patients.  The Center for Medicare and Medicaid (CMS) established Core Measures in 2000 and began to publicly report hospital Core Measures findings in 2003.  Currently, there are 26 Core Measures related to four areas of reporting and monitoring: Heart Failure, AMI (Heart Attack), Pneumonia and Surgical Site Infection prevention.

How Do Core Measures Help?

All of these Core Measures have been carefully researched and scientifically shown that success in these areas by a hospital will improve patient outcomes.  These measures have provided a focus for the development of Clinical Pathways and Standard Orders, both of which assist in consistent provision of optimal and quality care for our patients.

Is This A Report Card On Quality?

Unfortunately, the scores on the Core Measures can create misleading impressions when used not as an improvement tool, but as a hospital rating tool, particularly for small hospitals such as Montrose Memorial Hospital (MMH). Say MMH got an 80% on a Pneumonia indicator. Does that mean that 20% of patients got substandard care or that patients at a hospital which scored 90% got better care? Not necessarily. A small hospital like MMH may well have only 4 patients in a quarter who qualify for that indicator. Say for one of those four, the physician noted the discharge instructions in the “Doctors’ Orders” section of the chart rather than in the “Discharge Summary” section. In the mandated abstraction process, that counts as a “miss” because it wasn’t documented in the right section. So, only 3 of our 4 patients are counted as appropriate and MMH gets a score of 75%.  As an improvement tool, that allows us to relocate documentation and improve our discharge process. As a hospital rating, the temptation is to say, “Oh, 75% - that’s a B” and favor the hospital which got the 90% without understanding what is really behind the measure. The other hospital might have 50 patients who qualify for the indicator and have provided non-standard care (or not documented care correctly) on 5 of those. That earns a 90% rating. Which is better? You can’t tell without investigation; because the data is designed to assist improvement, not to appear as a grade on a report card regarding the performance of the hospital.

What Is The Core Measures Process?

Let’s look at a Core Measure in AMI (Heart Attack), the administration of Aspirin on arrival to the Emergency Department.  The administration of Aspirin is given to reduce heart damage as the result of a heart attack.

The evidence-based scientifically-research standard of care says that Aspirin must be given to heart attack patient on arrival to the Emergency Department to help reduce damage to the heart. What is measured is the percentage of a hospital’s patients in a time frame (typically a calendar quarter) who had a heart attack and whose chart shows Aspirin given on arrival to the Emergency Department. The goal, clearly, is to provide that “best practice” care for all the patients, document it thoroughly, and achieve a 100% score on the measure.

Then, 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 results of this review are then submitted on a quarterly basis to CMS, who publicly reports the data to aid in hospital improvement efforts and makes the information available to the public.

What Does The Future Hold For Core Measures?

 We anticipate that in future years, CMS will link hospital reimbursement (most likely a factor known as “the market basket adjustment) to each organization’s performance on the Core Measures; a strategy known as “pay for performance”.

Montrose Memorial Hospital

800 South Third Street

Montrose, CO  81401

(970) 249-2211  (970) 240-7350  Fax