Implementation Plan Paper
A core measure is a particular thing related to a hospital that can be conveniently determined using a particular technique. Using a set of standardized, valid, evidence-based and consistent procedures, the progress in a hospital can be monitored accurately so that everyone can benefit (GHA). The Joint Commission on Accreditation of Health Care Organization (JCAHO) utilizes certain core performance measures which several hospitals in the US have to adhere.
The Core measure for the Baptist Memorial Hospital is for patients suffering from acute myocardial infarction (AMI).The implementation plan that was developed by the JCAHO was known as the “ORYX-Initiative” (JCAHO, 1999). The accreditation process is continuous and is data-driven. The performance of the hospital is continuously monitored using appropriate data. This ensures that the accreditation is relevant and valued.
The hospital could use certain internal quality control mechanisms along with comparing their performance with that of a national database. The area of focus of the core measures would be AMI. The various steps involved in the implementation plan included:-• Identification and selection of the core measure – a consensuses-based process was utilized and inputs were being gained from several relevant parties including the hospitals, purchasers, consumer groups, professional groups, medical systems, etc. All the interested parties had to coordinate their preferences to the JCAHO. The JCAHO further met to bring out certain core measures based on evidence-based and credible information. The core measures include about 10 performance measures concerning a particular area.
Once the measures have been formulated, it was sent to the Board of Commissioners to be evaluated.The Board may approve certain measures, disapprove some and even suggest changes to others. 8 core measures have been approved by the Board for AMI. Over a period of time, the core measures would be reviewed by the Board so that any gaps would be filled-up appropriately. The core measures implemented are continuously monitored by several accreditation organizations so that strategies can be developed in the future.
• The preliminary set of core measures profiles are released by the JCAHO to several hospitals and organizations.The JCAHO would develop more individual measure specifications after getting the feedback from the several medical organizations and institutions. The measure specifications are released by the JCAHO, and the measurement systems of each organization would select a relevant measure set that is supported by their system. The measurement systems are given some time by the JCAHO to adapt the specifications according to the system. The pilot testing of the core measures will take about 2 years. The pilot trial helps to gain a lot of knowledge from implementing the core measures over a limited period of time.
Any technical issues faced by the measurement system can be appropriately addressed. The cost of implementing the core measures faced by the measurement system can be determined. The staff members can be trained and data can be collected in this regard. The quality of data collected, its costs and the feasibility can be closely assessed. The transmission of data from the hospital to the JCAHO is made on a regular basis. • The hospital has to choose at two measure sets from the available five within the given time frame.
The hospital has to further obtain data from the JCAHO which are readily available (especially administrative data).Following this, the hospitals would have to collect data only with respect to the opted measure set. Hospitals need not follow the non-core measure requirements. The hospital from time to time would have to collect information of the core measures.
Simultaneously, the hospital would also have to reduce non-core measures from six to four. If a hospital is unable to collect and transmit the data regarding any of the core measure sets, as it may be irrelevant to its health services, it would have to collect and transmit data on six non-core measure sets.The JCAHO is also considering utilizing national performance measurement indicators for its core measure sets. • From January, 2002, the hospitals would be collecting data regarding core measure sets, and would simultaneously modify the non-core measure. The hospitals would be transmitting the core measure sets data to the JCAHO as per the schedules.
• The core monitor sets would be continuously followed-up by the JCAHO and other interested organizations. The criteria would be regularly modified and the measure sets would be altered as and when required.The JCAHO would be making efforts to keep the modifications to the minimum. The measures may be frequently rotated in and out of the core measure set. The measure set specifications would be changed only if needed. Any changes to the measure set or its composition would be notified to the hospital as soon as possible.
The feedback from the public would also be received regarding changes to the core measure sets. • The JCAHO feels that rotation of the core measure sets would be required from time to time. The JCAHO and the relevant health organizations would develop these changes.A hospital may rotate its core measure sets from time to time to suit its internal quality standards. When a hospital has achieved its core measure sets, it could be asked by the JCAHO to rotate its measure sets. • The core measure sets should support the performance improvement objectives of the hospital.
The effectiveness and the value of the measure sets should be closely assessed. The JCAHO has to setup ideal communication links between itself and the accredited hospitals. Certain data transmitted should be maintained confidential. The core measure sets should be compliant with the HIPAA, 1996 guidelines.The ORYX strategy tries to ensure that the HIPAA guidelines are maintained.
• Several issues need to be considered by the hospital before selecting and implementing the core measure sets. It is also important that a relationship between the measures and the standards exist. The hospital should ensure that the measures are implemented without much difficulties or problems. Even modifications should not cause any problems to the basic operations of the hospital.
Every effort should be made to include the feedback provided by the public.Monitoring of the core measure sets by the hospital is also required. The measure set definitions for Ami include:- 1. AMI-1 – Administrating aspirin to the patient before or after arriving at the hospital within 24 hours.
2. AMI-2 – Administering aspirin to the patient after discharge. 3. AMI-3 – AMI patients suffering LVSD are administered ACE inhibitors or AR blockers during the discharge. 4. AMI-4 – Stoppage of the smoking habit immediately.
5. AMI 5 – Administration of beta blockers after arrival. 6. AMI 6 – Beta blockers administered at discharge.AMI 7 – Administration of a thrombolytic agent to patients with elevated ST segment and LBB block immediately after arriving at the hospital. 8.
AMI 7a – Administering thrombolytic agents within 30 minutes after arriving at the hospital. 9. AMI 8 – Performing PTCA as fast as possible in case patients suffers from LBB Block or ST elevation. 10. AMI 8a – Performing PCI within 90 minutes from arriving at the hospital. 11.
AMI 9 – The fatalities that develop from AMI. The main aim of implementing the core measures by the Baptist Memorial Hospital is to include evidence-based practices and to increase the care of patients suffering from AMI.The core measures are to be implemented in such a way that they help the Hospital to achieve its objectives (which include to increase the smoking cessation rates, to increase the PCI interventions and to decrease the time within PCI is provided) (Roger, G. , et al 2006). For core measures to be implemented, a thorough coordination is required between the physicians, nurses, quality department, performance indicators, administrators and the managers of the hospital. The core measure effectively removes any barriers that exist between various departments within the hospital.
The core measures require proper documentation and accountability in the hospital system. Regarding the performance in the nursing and the medical sector, physicians and nurses may be given dashboards to mark any area in which the performance has been below the expected level. Efforts can be then made to improve the performance in the future. A provision for feedback and improving the quality of care should also be incorporated in the system (TCM, 2007).ReferencesCore Options – JCAHO Measure Set Definitions, Retrieved from June 15, 2007, from