What Are Core Measures?
Core Measures track a variety of evidence-based, scientifically-researched standards of care which have been shown to result in improved clinical outcomes for patients. CMS (the Center for Medicare & Medicaid Services) established the Core Measures in 2000 and began publicly reporting data relating to the Core Measures in 2003. Currently, we report on 30 inpatient core measures and 4 outpatient core measures. We expect this number to rise to 44 measures by 2011.
How Do Core Measures Help?
“The strength of the Core Measures is that they are really grounded in science," says Diane Leach, NMC’s Vice President of Quality and Medical Services. “They are not put out there with the directive to ‘do it because we want you to’, but rather— they have been carefully researched and have scientifically shown they will improve outcomes.” As such, the Core Measures have proven very helpful in NMC’s work to improve patient care. They have provided a focus for the development of Clinical Pathways and Standard Orders, both of which assist in the consistent provision of optimal care to 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 NMC. Say NMC got an 83% on a Heart Failure indicator. Does that mean that 17% of patients got substandard care or that patients at a hospital which scored 90% got better care? Not necessarily. A small hospital like NMC may well have only 6 patients in a quarter who qualify for that indicator. Say for one of those six, 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 5 of our 6 patients are counted as appropriate and NMC gets a score of 83% (see graph on page 5). As an improvement tool, that allows us to relocate documentation. As a hospital rating, the temptation is to say, “Oh, 83% - 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.
What Is The Core Measure Process?
Let’s look at a Core Measure in Surgical Care, the prevention of Deep Vein Thrombosis (DVT—blood clots that can occur following surgery.)
The evidence-based, scientifically-research standard of care says that patients undergoing certain surgical procedures must be treated with either medication (such as Coumadin) or mechanical prevention measures (such as compression stockings) to reduce the risk of DVT (blood clots). What is measured is the percentage of a hospital’s patients in a time frame (typically a calendar quarter) who had the specified surgery and whose chart shows the appropriate DVT prevention strategies were used. 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 transparency with the public. Currently, the State of Vermont re-reports that data once a year as part of the mandated Act 53 Hospital Report Cards.
What Does The Future Hold?
The Report Cards are not the only use of the data which is not directly tied to improvement purposes. We anticipate that in future years, CMS itself 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”.
Does All This Have A Cost To It?
With the current system, the tracking and reporting of Core Measure performance is a huge amount of work which occupies multiple clinical staff members. “This is another unfunded mandate,” says Leach. “It is well intentioned, but there is no funding for the mandate, so the cost of tracking and reporting the data is ultimately passed on to our community. As the number of Core Measures expand (and they are expected to expand dramatically), the workload and cost will increase”.