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Service Delivery Innovation Profile

Formal Structures and Processes Promote System-Wide Focus on Core Measures, Leading to Significantly Better Performance


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Snapshot

Summary

AtlantiCare implemented formal structures and processes to ensure that performance on quality measures developed by the Centers for Medicare & Medicaid Services (also known as "core measures") remains a consistent focus throughout the organization. A clinical index on the organizational scorecard highlights areas of suboptimal performance, and the annual strategy map includes core measure performance as part of AtlantiCare's strategic plan. Multidisciplinary clinical teams organized around each core measure category develop performance improvement initiatives, with staff nurse "champions" leading implementation on each unit. A dedicated staff member monitors and shares performance data with unit managers and individual employees/physicians, and individual scores are incorporated into the professional review process. The program has significantly improved aggregate and category-specific performance on the core measures, allowing AtlantiCare to achieve top decile performance across the state and nation.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of performance on the four categories of core measures (myocardial infarction, heart failure, pneumonia, and surgical care improvement), along with comparisons to hospitals across the state and nation.
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Developing Organizations

AtlantiCare
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Date First Implemented

2004

Problem Addressed

Patients having surgery or experiencing a heart attack, heart failure, or pneumonia have better outcomes when they receive certain evidence-based services and processes recommended by the Centers for Medicare & Medicaid Services (CMS),1 but many hospitals fail to adhere to these recommendations.
  • Clear, evidence-based standards: Clear, evidence-based standards exist for heart attack (myocardial infarction), heart failure, and pneumonia care and for the prevention of surgical complications and infections. For example, myocardial infarction patients should receive aspirin on arrival, daily, and at discharge. Heart failure patients should receive an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) and have an assessment of left ventricular function. Patients with pneumonia should receive pneumococcal and influenza vaccinations and an initial antibiotic within 4 to 6 hours of arrival. Surgical patients should receive an antibiotic 1 hour before incision, with the drug being discontinued 24 hours after surgery. Adhering to these processes has been shown to improve quality of care.1 In 2002, to improve a hospital's adherence to evidenced-based protocols, CMS began the Hospital Compare program, which provides financial incentives to high-performing hospitals that voluntarily report adherence to 10 quality measures related to heart failure, myocardial infarction, and pneumonia.2 Since that time, these measures (referred to as "core measures") have been expanded to include a fourth category (surgical care); the complete set now includes 24 process measures (which gauge the percent of eligible patients receiving recommended processes) and 3 outcome measures (which gauge the percent of eligible patients achieving the desired outcome).2,3
  • Failure to adhere to standards: Eligible patients sometimes fail to receive recommended therapies and/or achieve desired outcomes,1 thus jeopardizing treatment success and contributing to an increase in readmission rates. For example, in 2003 (before implementation of this program), AtlantiCare's composite performance on the core measures consistently ranked below that of most other hospitals in New Jersey and across the nation. (See the Context section for more information.)

What They Did

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Description of the Innovative Activity

AtlantiCare implemented formal structures and processes to ensure that performance on core measures remains a consistent focus throughout the organization. A clinical index on the organizational scorecard highlights areas of suboptimal performance, and the annual strategy map includes core measure performance as part of AtlantiCare's strategic plan. Multidisciplinary clinical teams organized around each core measure category develop performance improvement initiatives, with staff nurse "champions" leading implementation on each unit. A dedicated staff member monitors and shares performance data with unit managers and individual employees/physicians, and individual scores are incorporated into the professional review process. Key elements of the program include the following:
  • Clinical index and strategy map to guide goal setting: To facilitate the identification of actionable goals designed to stimulate improved performance on core measures, AtlantiCare created a "clinical index" and included the priority in the annual "strategy map."
    • Clinical index: The clinical index, part of AtlantiCare's organizational scorecard, outlines clinical performance on the core measures. This index informs the identification of appropriate goals for the system's two hospitals and for individual units within those hospitals.
    • Strategy map: Each year, AtlantiCare creates a "strategy map" that highlights particular goals for the year, including top decile performance on core measures, that align with the organization's strategic plan. Every physician and employee receives this map; on the back, individuals document how their department and their personal actions will support achievement of these goals.
  • Multidisciplinary team review of performance: Three teams representing the core measure categories (pneumonia, surgical care improvement, and cardiac diagnoses, which combines myocardial infarction and heart failure) regularly review organization-wide performance on each of the core measures within their category. Teams are led by an administrative leader and physicians, and consist of staff nurses and representatives from nutrition, laboratory, radiology, home care, and other relevant departments. Teams also monitor core measure updates from CMS, new evidence-based practices/guidelines promulgated by professional societies and other organizations, and revisions to Joint Commission and state regulations.
  • Targeted performance improvement initiatives: Based on their findings, the three teams develop performance improvement initiatives targeting those core measures for which organization-wide performance is below the top decile (a level of performance articulated in the annual goals included in the strategy map).
  • Unit-based implementation led by nurse champions: The multidisciplinary teams communicate the recommended improvement initiatives to unit-based clinician champions (staff nurses), who then lead the implementation process on their units. (The number of clinical champions depends on unit size; a 50-bed unit might have 10 champions, while a 12-bed unit might have 2.) Over time, the teams have developed various tools to promote better performance, including documentation tools and standardized order sets to improve adherence to recommended processes. For example, one performance improvement initiative involved the development of a transfer form to ensure safe care transitions; the form lists the key elements for pneumonia, cardiac, and surgical care highlighted in the core measure set. Placed on top of the patient's chart, this form allows caregivers involved in patient handoffs to quickly review completed care steps and identify those still needed.
  • Performance feedback to physicians and staff: AtlantiCare uses printed scorecards to communicate performance on the core measures to individuals units and clinicians (both physicians and other staff), with additional communication on individual cases as necessary.
    • Scorecards for unit and system leaders: The medical center's information system tracks patient care activity related to each core measure and produces weekly scorecards that highlight individual and unit performance for distribution to unit leaders. Color codes indicate strength of performance—blue represents performance that exceeds the target, green denotes at-target performance, yellow means borderline or low performance, and red designates performance well-below target. The system also produces quarterly scorecards, distributed to hospital and health system leaders, on aggregate performance for each campus and for the medical center as a whole.
    • Communication of performance data to individuals and units: A dedicated staff member, known as the DRG Coordinator, shares the performance scorecards with unit managers, who discuss aggregate data with individual physicians and nurses to encourage improved performance on measures highlighted in yellow or red.
    • Additional informal communication on specific patients as needed: As needed, the coordinator may also communicate more informally (in person, via telephone, or e-mail) with clinicians on a daily basis to discuss individual instances where they have not adhered to recommended processes or achieved desired outcomes included in the core measures, with the goal of addressing the immediate care needs of a particular patient.
  • Incorporation of performance into professional reviews: AtlantiCare employees receive annual performance reviews, while physicians are reviewed every 8 months. AtlantiCare incorporates core measure performance into the "clinical excellence" section of the review form. For example, on units treating heart failure patients, each nurse's and physician's individual rate of adherence to heart failure core measures (e.g., prescription of an ACE inhibitor or ARB for patients with left ventricular systolic dysfunction for physicians, provision of smoking cessation counseling, and comprehensive discharge instructions for nurses) becomes part of his or her professional review.
  • Ongoing education and sharing of best practices: New employee and physician orientations emphasize the importance of performance on the core measures. In addition, units share educational information and details about performance improvement activities during regularly scheduled meetings. AtlantiCare also hosts an annual 2-day "best practice-sharing" event that includes poster presentations describing effective strategies being used across the organization for improving performance on core measures.

Context of the Innovation

A not-for-profit health system located in southeastern New Jersey (a geographic area with a population of roughly 430,000), AtlantiCare operates the AtlantiCare Regional Medical Center, a 2-campus, 589-bed teaching hospital that treats more than 32,000 inpatients and 122,000 emergency department patients annually. With approximately 3,800 employees, AtlantiCare is the largest non-casino employer in the region. The impetus for this program came after hospital leaders learned that the organization's 2003 performance on the CMS core measure "starter set" (10 measures related to myocardial infarction, heart failure, and pneumonia) ranked among the bottom of the state's 82 hospitals. This suboptimal performance, combined with the health system's desire to participate in the Baldrige National Quality Program, spurred hospital leaders to develop performance improvement strategies geared toward the core measures. In 2009, AtlantiCare received the Malcolm Baldrige National Quality Award.

Did It Work?

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Results

The program significantly increased aggregate performance on core measures, with improvement in all four categories. The organization now ranks in the top 10 percent of performers in New Jersey and nationally.
  • Significantly better performance: In 2003, AtlantiCare's aggregate rate of performance on the core measures averaged approximately 80 percent. In 2010, that figure reached 98 percent. Examples of improvements in specific categories appear below:
    • Pneumonia care: In 2003, AtlantiCare's performance with respect to pneumonia measures averaged 77 and 84 percent at its two hospitals; as of 2010, that rate improved to 98 percent in both facilities.
    • Heart failure care: In 2003, AtlantiCare's performance on heart failure measures averaged 85 and 90 percent at its two hospitals; in 2010, performance on these measures at both campuses also averaged 98 percent.
    • Heart attack care: AtlantiCare's performance on heart attack measures averaged 72 percent for both hospitals in 2003 and reached 98 percent as of 2010.
    • Surgical care: On measures relating to surgical care, AtlantiCare's performance for both hospitals increased from 67 percent in 2003 to 97 percent in 2010.
  • Leading to top-decile performance: In 2003, AtlantiCare ranked near the bottom of all 82 New Jersey hospitals regarding performance on core measures. As of 2010, AtlantiCare's performance ranks in the top 10 percent in New Jersey and nationally.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of performance on the four categories of core measures (myocardial infarction, heart failure, pneumonia, and surgical care improvement), along with comparisons to hospitals across the state and nation.

How They Did It

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Planning and Development Process

Key elements of the planning and development process included the following:
  • Developing clinical index and strategy map: Each year, the organization develops a strategic plan to set annual priorities and a strategy map to align departments, units, and individuals around the goals outlined in the plan. To address core measure performance, the senior leadership team incorporated this priority as part of the strategy map and created the clinical index to provide a composite of core measure performance and highlight areas of poor performance, with the aim to stimulate improvement.
  • Creating category-specific teams: The senior leadership group created three teams to monitor performance on the core measures and assigned a senior leader to be accountable for the performance of each of the teams. The leaders selected team members based on their skills set and ability to represent their units or departments and serve as an information liaison. Unit managers or directors approached potential team members to explain the role expectations and discuss their willingness to commit to the team.
  • Hiring DRG coordinator: The health system hired a full-time staff member, referred to as the DRG coordinator, to monitor and share performance data with physicians and staff on an ongoing basis. The current DRG coordinator is a master's-prepared nurse with leadership skills and knowledge of regulatory reporting requirements.
  • Ongoing research and initiative design: On an ongoing basis, the three teams research best practices in each clinical area, and design documentation tools, standardized order sets, and other initiatives to improve performance.

Resources Used and Skills Needed

  • Staffing: The health system hired one full-time individual to fill the DRG coordinator role; all other staff incorporate the program into their daily routines.
  • Costs: The salary and benefits for the DRG coordinator constitute the majority of program-related expenses; other minor expenses are sometimes associated with individual improvement initiatives.
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Funding Sources

AtlantiCare
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Tools and Other Resources

The CMS inpatient process of care measures are available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits
/InpatientMeasures.html


The CMS inpatient outcomes core measures are available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits
/OutcomeMeasures.html


More information about the Baldrige National Quality Program can be found at http://www.nist.gov/baldrige.

The Baldrige National Quality Program Criteria for Performance Excellence are available at http://www.nist.gov/baldrige/publications/business_nonprofit_criteria.cfm.

Adoption Considerations

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Getting Started with This Innovation

  • Align goals with concrete initiatives: Set specific organizational goals regarding the core measures, and then develop initiatives designed to achieve each goal.
  • Emphasize potential impact on quality to achieve buy-in: Emphasize that the core measures are based on clinical evidence and best practices and that they represent a minimum standard of care that should be exceeded. Staff will be more likely to support the initiative once they understand the link between core measure performance and the quality of patient care.
  • Embed focus at all levels: Organization-wide and unit-level leaders should be made responsible for understanding and communicating core measure performance and improvement initiatives. In addition, various individuals—such as an assigned staff member (in AtlantiCare's case, the DRG coordinator), unit leaders, and clinical champions—should be empowered to address individual cases of nonadherence with other clinicians. This broad empowerment helps to ensure that a focus on core measures permeates the organizational culture.

Sustaining This Innovation

  • Maintain formal reporting and followup: Clear and frequent reporting of performance helps to ensure that each individual remains focused on improvement and knows how his/her personal actions can lead to better performance.
  • Create organizational structure to ensure program continues: By creating category-specific clinical teams and a standard data reporting format, the organization can maintain its focus on performance despite inevitable transitions in staff.
  • Ensure knowledge transfer: To promote initial and sustained attention, embed information about core measure performance into new employee/physician orientation and into annual education events. Also, develop mechanisms to educate staff as core measure definitions change.

More Information

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Contact the Innovator

Mary Law, RN
Director of Quality and Accreditation
AtlantiCare Regional Medical Center
65 Jimmie Leeds Road
Pomona, NJ 08240
(609) 748-4067
E-mail: mary.law@atlanticare.org

Innovator Disclosures

Ms. Law has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Centers for Medicare & Medicaid Services. Hospital Quality Initiatives: Inpatient Measures.  Available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits
/InpatientMeasures.html


U.S. Department of Commerce National Institute of Standards and Technology. Baldrige National Quality Program. 2009 Award Recipients. AtlantiCare. Available at: http://patapsco.nist.gov/Award_Recipients/index.cfm

Footnotes

1 The Centers for Medicare & Medicaid Services. Quality Measures Compendium V.2.0: Medicaid and SCHIP Quality Improvement Compiled by the Division of Quality Evaluation and Health Outcomes, Family and Children's Health Programs Group. 2007.
2 Centers for Medicare & Medicaid Services. Hospital Quality Initiatives: Hospital Compare. July 13, 2010. Available at: http://www.medicare.gov/hospitalcompare/search.html.
3 Centers for Medicare & Medicaid Services. Hospital Quality Initiatives: Inpatient Measures. July 13, 2010. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits
/InpatientMeasures.html
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: December 08, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 04, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: January 22, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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