Core measures are national standards of care and treatment processes for common conditions. These processes are proven to reduce complications and lead to better patient outcomes. Core measure compliance shows how often a hospital provides each recommended treatment for certain medical conditions.
How Does Johns Hopkins Medicine Perform?
The Johns Hopkins Hospital
Delivery and Newborn Care - Baby electively delivered early
What does this measure mean for quality of care?
The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics have in place a standard requiring 39 completed weeks gestation prior to elective delivery. This measures the percentage of patients who had an early elective vaginal delivery or elective cesarean section before the recommended 39 weeks of gestation.
Sample Size: A hospital’s performance on some of the core measures is based on a sample of patients and may not reflect the hospital’s overall performance on the measure across the larger patient population.
Data Source: The Centers for Medicare and Medicaid Services and Johns Hopkins Medicine.
*Benchmark Source: National and state averages are the most recent calendar year numbers publicly available on the Centers for Medicare and Medicaid Services' Hospital Compare. National and state averages for previous years are not available. Benchmarks for flu immunization reflect the reporting period of October–March.
**National Goal Benchmark Source: The United States Department of Health and Human Services' Healthy People 2020 goal.
What is this measure?
Core measures are national standardized processes and best practices to improve patient care. These processes are designed to provide the right care at the right time for common conditions such as stroke or childhood asthma.
Specific steps for each condition vary, but examples include providing preventative medication to patients at risk for developing blood clots or determining rehabilitation needs for a stroke patient.
U.S. hospitals must report their compliance with these core measures to The Joint Commission, a health care accreditation organization, the Centers for Medicare and Medicaid Services and other agencies.
Examples of Core Measures
One of the core measure sets includes eight steps in caring for a stroke patient.
- VTE prophylaxis – stroke patients received treatment to keep blood clots from forming anywhere in the body within two days of arriving at the hospital.
- Discharged on Antithrombotic Therapy – stroke patients received prescription before discharge for a medication known to prevent blood clots.
- Discharged on statin – stroke patients needing medication to lower cholesterol received prescription before discharge.
- Anticoagulation Therapy for Atrial Fibrillation – stroke patients with an abnormal heartbeat received blood-thinning medication.
- Thrombolytic therapy – stroke patients received medication to break up a blood clot within three hours after symptoms began.
- Antithrombotic Therapy by Day Two – stroke patients received medication known to prevent complications within two days of arriving at the hospital.
- Stroke education – stroke patients received education about stroke treatment and prevention.
- Assessed for Rehabilitation – health care team determined if stroke patients would need rehabilitation after leaving the hospital.
Why is it important?
The core measure processes are proven standards of care that reduce complications and lead to better patient outcomes. Patients and families can use core measure performance to objectively compare hospitals locally or nationally. The higher percentage compliance means the hospital is following the best steps to care for a patient’s particular condition.
The Joint Commission and the Centers for Medicare and Medicaid Services periodically redefine the core measures based on the latest evidence and nationwide hospital performance. The Joint Commission tracks compliance with core measures and each year recognizes the top performing hospitals for key quality metrics.
What is Johns Hopkins Medicine doing to continue to improve?
In 2011 Johns Hopkins Medicine developed a plan to become a national leader in core measures with a goal of reaching 96 percent compliance.
Collaborating Across Hospitals
Ensuring that patients always receive the core measure recommended treatments requires a well-coordinated effort throughout hospital departments.
Peers from across Johns Hopkins Medicine hospitals developed 40 core measure work groups, each focused on improving a specific set of core measures. These teams involved partnerships between quality improvement staff, nurse and physician leads, faculty members, IT staff and others to identify barriers to improvement and develop solutions.
The core measure work groups allowed hospitals to share best practices and lessons learned and improve internal processes to increase core measure compliance. Johns Hopkins Medicine also established a reporting system to track core measure compliance on each unit.
Frontline Perspective
As a stroke compliance specialist, Meta Phillips, R.N., advocates for a personal touch when reviewing patient charts to help improve processes and patient care.
Meta Phillips, R.N.
Stroke Compliance Specialist, Sibley Memorial Hospital
“The core measures reflect how well our hospital follows the best practices of care for stroke patients. By closely reviewing these care processes, we have the opportunity to concentrate on areas that need improvement.
In my experience, good communication is critical to meeting the core measures. Our Stroke Program team is small and communicates well. Our team shares information every day and talks about ways to address problems — both large and small.
Several years ago, our hospital was not meeting a best practice recommended by the American Heart Association. The best practice included using high levels of cholesterol-lowering medications to treat stroke patients. Our team presented these findings to our medications committee, whose support was helpful in educating our doctors on how to change their practice.
Reviewing these best practices requires a team effort. By reviewing our patients’ charts, we can immediately identify what is working and where we can improve. Our team is always trying to make our hospital’s processes better to provide the safest care for our patients.”
How can patients and families support safety?
Patients and families should become familiar with the core measures and talk to their health care team if they have any questions or concerns. You can also ask your health care provider how you can prepare for surgery or other procedures to reduce your risk of complications.
Be sure you clearly understand how to manage your health as you prepare to leave the hospital, such as any new prescription medications you may need.
For more information
- The Joint Commission - Core Measure Sets
- The Centers for Medicare and Medicaid Services - Recommended Core Measures
Patient Resources
Quality and Safety Performance During COVID-19
The organization’s quality and safety performance may have been impacted by the COVID-19 pandemic. We would urge patients to consider more recent performance in combination with historical performance. Patients may benefit from discussing with their healthcare provider the disruptions COVID-19 may have caused on quality and safety of care.
See how Johns Hopkins Medicine prioritizes safety during the COVID-19 pandemic.