Getting to the Core

If you are a practicing nurse today, especially one working in an acute care facility, you should be keenly aware of the Joint Commission’s Core Measures for patient care, and most likely delivering care directly related to these quality measures.

The Core Measures are a group of evidence-based practices developed by the Joint Commission and the Centers for Medicare and Medicaid Services (CMS). Taken together, these quality indicators have been shown to provide the best treatment and care for patients presenting with these frequently occurring diagnoses.

Requiring high levels of compliance with evidence-based practices is primarily aimed at ensuring high quality patient care with measureable, comparable outcomes and is directly related to your organizations’ accreditation and reimbursement.

With increasing organizational transparency and pay-for-performance (i.e., value-based purchasing) programs looming around healthcare organizations, 100 percent compliance is the expected organizational norm and you play an important part in the delivery of optimal patient care, regardless of your nursing role.


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The Center of It All

Believe it or not, the Core Measures were initially finding root 25 years ago.

In 1986, the Joint Commission developed and tested the first six sets of performance measures related to perioperative care, obstetrical care, trauma care, oncology care, infection control and medication use.3

Twelve years later, in 1998, accredited hospitals and long-term care facilities were required to submit data to the ORYX initiative, the first national program aimed at collecting data and measuring hospital quality.1, 3

In 2002, hospitals desiring Joint Commission accreditation were required to report data on at least two of the four measures in existence at the time (i.e. acute myocardial infarction, heart failure, pneumonia, and pregnancy).1

In 2003, the Centers for Medicaid and Medicare Services and the Joint Commission aligned the measures for which both organizations were collecting data in an effort to reduce redundancies and expense to healthcare facilities. Financial penalties were imposed when discrepancies were noted in the reporting to these organizations.1

Today, the list of Core Measures includes: AMI; children’s asthma care (CAC); Heart Failure; Hospital Based Inpatient Psychiatric Services (HBIPS); Hospital Outpatient Department Measures (HOP); Immunization (IMM); Perinatal Care (PC); Pneumonia (PN); Stroke (STK); Surgical Care Improvement Project (SCIP); Venous Thromboembolism (VTE); Emergency Department (ED); Tobacco Treatment (TOB); and Substance Use (SUB), the final three having been added in January 2012.

As part of current Joint Commission requirements for accreditation, hospitals are now required to collect and report data on a minimum of four core measures or a combination of core measures and non-core measures of their choosing.6 Each of the Core Measures has an associated list of accountability measures, most of which are evidence-based.

Evidence of compliance with these accountability measures is carefully tracked by individual hospitals and is reported to the Joint Commission and CMS. The Joint Commission refers to this data in its accreditation process. CMS uses the data in combination with HCAHPS (Hospital Consumer Assessment of Healthcare Personnel and Systems) scores to calculate reimbursements made to hospitals.

Highly Functioning Collaboration

In many ways, the Core Measures and their associated accountability measures neatly package optimal care for patients. Healthcare providers can better focus patient care provided a collaborative, interdisciplinary approach is followed.

Achieving 100 percent compliance with each of the measures can be challenging regardless of the particular Core Measures chosen.

Heart Failure compliance can be particularly demanding as it involves highly functioning collaboration from many disciplines. The four specific measures associated with the Heart Failure include:

  • Documentation of assessment of left ventricular function
  • ACEI or ARB define both abbreviations prescription at discharge for an ejection fraction of less than 40 percent (or documentation of moderate or severe systolic dysfunction)
  • Adult smoking cessation counseling
  • Complete discharge instructions including:
  • education regarding proper diet;
  • worsening symptoms of heart failure;
  • activity level;
  • all discharge medications;
  • proper weight monitoring; and
  • instructions for appropriate follow up care.


Evidence of compliance with every component is required to be fully compliant. High quality interdisciplinary collaboration can make this happen and nursing plays an increasingly key role in realizing this achievement.

In our continuing effort to achieve and sustain 100 percent compliance with the Heart Failure requirements, our institution created a multidisciplinary team to evaluate the trends and create solutions based on our data collection.

Successful Strategies

Two initiatives that have proven to be most successful in our pursuit of 100 percent compliance include Daily Core Measure rounds on each unit and use of the discharge time out.

Daily Core Measure rounds are attended routinely by the primary care nurse, charge nurse, nurse manager and quality assurance coordinator in an effort to concurrently identify that the measures are being adequately addressed in a timely way.

Social work, case management and other patient care coordinators are frequently in attendance, as well. Rounds are accomplished within 30-60 minutes for an entire unit and with practice cause minimal patient interruption for the bedside nurse.

Daily concurrent review serves to assure the highest quality of patient care as well as providing daily education to our nursing staff. In this way, all nursing staff now understands the importance of these measures to both the patient and the hospital.

In several instances, daily rounds have allowed for identification of patients who may not have presented with the primary diagnosis of HF or developed complications during an admission that relate to a Core Measure.

We successfully piloted this approach in our CICU and have since required it on each in-patient unit.

Opportunity for Improvement

We initially realized measureable positive results but soon ascertained that compliance with complete discharge instructions presented a specific opportunity for improvement.

Concurrent daily review could not assure all six components of the discharge instruction requirement were fulfilled as patient discharges occur at all times throughout the day.

In an effort to specifically address this opportunity, a Discharge Time-out requiring the signature of two nurses was initiated.

In this way, we hoped to establish nursing collaboration that would serve as a double check, especially in regard to the discharge medication reconciliation, a highly individualized part of the requirement.

We have realized further success as a result of this practice. Additionally, it has allowed us an opportunity to easily identify and re-educate individuals as necessary when specific deficiencies are discovered.

We have realized 100 percent compliance in regards to LVF assessment, ACEI or ARB at discharge and adult smoking cessation consistently, and much more steady compliance with complete discharge instructions with the inception of these initiatives.2


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Giving 100 Percent

Delivering care of the highest quality is our goal as nurses with every patient interaction.

The Core Measures aim to improve the quality of care delivered to healthcare consumers through the prevention of complications and/or reoccurrences with the delivery of evidence-based care.

Keeping accountability measures in mind helps sharpen our nursing practice and contribution to the interdisciplinary care of patients.

We’ve found reaching our goal of 100 percent compliance for every measure for every patient requires interdisciplinary team collaboration, education for all levels of professional staff and daily commitment to realizing this achievement.

Knowledge of the specific Core Measures your institution is concentrating its efforts toward and commitment to the achievement of 100 percent compliance with these measures will help you provide care of the highest quality to all your patients.

References for this article can be accessed here.

Kathi Hoffman is Clinical Educator, Pompton Plains, NJ, and a grad student at Ramapo College of New Jersey.

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