St. Mary's Health Center: Focus on Core Measures Improves Quality

In 2005, under pressure to improve performance on indicators of financial well-being, patient satisfaction, and clinical quality, St. Mary's Health Center leadership made a deliberate decision to focus on Centers for Medicare and Medicaid Services process-of-care measures, or "core" measures. They set in motion a series of activities that resulted in striking improvement in core measure scores across four clinical areas (heart attack, heart failure, pneumonia, and surgical care improvement), eventually reaching the top percentile nationwide. The main strategies were: clear communication of the new directive by the hospital's president and Board of Directors; physician-led committees taking responsibility for performance improvement and communicating the goals to medical staff; intensified efforts to standardize core measure and other clinical processes through order sets; dedicating a full-time staff member to data abstraction and initiating a system of concurrent and post-discharge review of medical charts; continuous measurement and analysis of performance data; providing feedback to staff through reporting, scorecards, and follow-up when performance varies from the care standard; and sharing successes, lessons, and tools across hospitals in the health system.