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Service Delivery Innovation Profile

Formal Processes Ensure System-Wide Focus on Heart Attack, Heart Failure, Pneumonia, and Surgical Care, Improving Performance on Core Measures

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Memorial Healthcare System implemented formal processes to ensure that performance on quality measures developed by the Centers for Medicare & Medicaid Services (also known as "core measures") remains a consistent focus throughout the organization. The system's hospitals identify and track all patients who meet core measure inclusion criteria, monitor gaps in care, investigate care variances, and share data and best practices. The program significantly improved performance on the core measures in all four clinical areas (heart attack, heart failure, pneumonia, and surgical care), putting Memorial in the top 5 percent of hospitals across the State and nation.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of performance on the four categories of core measures (heart attack, heart failure, pneumonia, and surgical care improvement), along with comparisons to hospitals across the State and nation.
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Developing Organizations

Memorial Healthcare System
Hollywood, FLend do

Date First Implemented


Problem Addressed

Patients having surgery or experiencing a heart attack, heart failure, or pneumonia have better outcomes when they receive certain evidence-based services and processes recommended by the Centers for Medicare & Medicaid Services (CMS),1 but many hospitals fail to adhere to these recommendations.
  • Clear, evidence-based standards: Clear, evidence-based standards exist for heart attack (myocardial infarction), congestive heart failure (CHF), and pneumonia care and for the prevention of surgical complications and infections. For example, heart attack patients should receive aspirin on arrival, daily, and at discharge. Heart failure patients should receive an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB), and have an assessment of left ventricular function. Patients with pneumonia should receive pneumococcal and influenza vaccinations and an initial antibiotic within 4 to 6 hours of arrival. Surgical patients should receive an antibiotic 1 hour before incision, with the drug being discontinued 24 hours after surgery. Adhering to these processes has been shown to improve quality of care.1 In 2002, to improve adherence to evidenced-based protocols, CMS began the Hospital Compare program, which provides financial incentives to high-performing hospitals that voluntarily report adherence to 10 quality measures related to heart failure, heart attack, and pneumonia.2 Since that time, these measures (referred to as "core measures") have been expanded to include a fourth category (surgical care); the complete set now includes 24 process measures (which gauge the percent of eligible patients receiving recommended processes) and 3 outcome measures (which gauge the percent of eligible patients achieving the desired outcome).2,3
  • Failure to adhere to standards: Eligible patients sometimes fail to receive recommended therapies and/or achieve desired outcomes,1 thus jeopardizing treatment success and contributing to an increase in readmission rates. For example, in 2004 (before implementation of this program), Memorial Hospital Pembroke's composite performance on the core measures consistently ranked below that of most other hospitals in Florida and across the nation. (See the Context section for more information.)

What They Did

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Description of the Innovative Activity

Memorial Healthcare System's hospitals follow formal processes to promote consistent adherence to the processes laid out in the CMS core measures. Quality management staff receive daily computerized reports that identify all patients who meet core measure inclusion criteria and help track these patients to identify gaps in care and highlight them for providers. Quality managers also investigate care variances and share performance data with staff and hospital/health system leaders. Representatives from all system hospitals and health system leaders meet on an ongoing basis to share best practices. Each hospital has similar processes, although specific details may differ across institutions. A general description of the processes follows:
  • Reports identifying eligible patients: Each morning, the hospital's computer system produces a patient census, and a computerized algorithm identifies patients with a diagnosis related to the core measures. The computer also generates a list of each identified patient's troponin level (a marker for heart attack) and/or brain natriuretic peptide level (BNP, a marker for CHF).
  • Documentation of core measure-related care: Nurses review the reports daily and place a purple form listing all CMS core measures in each patient’s chart. (The form may already be in the chart of patients admitted through the emergency department or ED.) Physicians and nurses provide care to the patient as clinically appropriate, and nurses document all care steps related to the core measures on the purple form, dating and initialing the form next to each process as completed.
  • Real-time review of patient care: Quality management staff visit the units to review patient charts and purple sheets each day, checking for adherence to the relevant core measure processes, notifying nursing staff or the patient's physician of any gaps in care, and following up to ensure completion of the requisite care steps.
  • Investigation of variances: Quality management teams review daily census reports to identify variances or "failures" (situations in which patients have been discharged with a gap in care). For each identified variance, quality management staff notify the nurse manager, who initiates an investigation. During the investigation, representatives from quality management, clinical staff, and nurse managers perform a root cause analysis to determine why the failure occurred and produce a short written report about the variance. The teams meet with the nurse managers every 2 weeks to review these investigations and overall performance on core measures. All variances are discussed with involved staff as an educational opportunity, and then reported during the hospital’s monthly operating review.
  • Additional measure-specific initiatives: The health system has developed initiatives geared toward improving performance on specific measures. For example, analyses revealed that the Memorial Healthcare System hospitals struggled in particular with providing appropriate discharge instructions to heart failure patients. As a result, the hospitals implemented a "red zone," which is a designated quiet area where two nurses meet to review a checklist of discharge instructions and perform medication reconciliation without interruption.
  • Ongoing sharing of performance data: All staff receive feedback on performance on the core measures, allowing them to see the positive impact of their actions and to identify and address problems quickly.
  • Sharing and spreading of best practices: Teams from all hospitals come together on a monthly basis to share ideas and report on successes so that best practices can spread throughout the system. These meetings have led to the system-wide implementation of certain ideas, such as the purple sheet. In other cases, ideas have been adapted by individual hospitals to meet their specific processes and cultures. As needed, staff can visit different system facilities to learn about their successful initiatives.

Context of the Innovation

Memorial Healthcare System, a public health system in South Broward County, FL, operates six hospitals (Memorial Hospital Miramar, Memorial Regional Hospital, Memorial Hospital Pembroke, Memorial Hospital West, Memorial Regional Hospital South, and Joe DiMaggio Children's Hospital) and other operations that collectively have 1,776 beds and 10,500 employees. In 2004, Memorial Healthcare System participated in the CMS/Premier Healthcare Quality Incentive Demonstration Project and performed more poorly than expected. In fact, system performance significantly lagged behind that of many other participants, with performance in the sixth decile for heart attack care (meaning that at least 30 percent of project participants performed better), the seventh decile for heart failure care, and the eighth decile for pneumonia care. Disappointed in this performance, system leaders developed this program to promote greater adherence to the core measure processes.

Did It Work?

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The program significantly improved performance on core measures in all four categories of care. The organization now ranks in the top 5 percent of hospitals, both nationally and in Florida. Selected examples of improvements in each care category appear below:
  • Pneumonia care: In 2004, only approximately 20 percent of eligible Memorial patients received the care processes laid out in the pneumonia measures. By the third quarter of 2009, this figure had reached between 99 and 100 percent in all system hospitals. For example, the percent of pneumonia patients given antibiotics within 6 hours of arrival reached 99 percent, above both the national (94 percent) and Florida (95 percent) averages. Similarly, the percent assessed and given an influenza vaccine reached 100 percent at all system hospitals, again above both the national (86 percent) and Florida (93 percent) averages.
  • Heart failure care: In 2004, only approximately 30 percent of eligible Memorial patients received the care processes outlined in the heart failure measures. By the third quarter of 2009, this figure had reached between 99 and 100 percent for evaluation of left ventricular systolic function (above the national average of 91 percent and State average of 97 percent), 97 to 100 percent for giving ACE inhibitor or ARB for left ventricular systolic dysfunction (vs. 90 percent nationally and 94 percent in Florida), and 100 percent for smoking cessation advice/counseling (vs. 93 percent nationally and 99 percent in Florida).
  • Heart attack care: In 2004, only approximately 40 percent of eligible Memorial patients received the care processes outlined in the heart attack measures. As of 2009, between 99 and 100 percent of heart attack patients received aspirin at arrival, while 98 to 100 percent got a beta blocker at discharge. These figures compare favorably to the national average of 94 percent and State average of 97 percent for both measures. In addition, by the third quarter of 2009, 92 percent of Memorial's heart attack patients underwent percutaneous coronary intervention within 90 minutes of arrival, up from 60 percent in 2005 and meaningfully higher than the 2009 State and national averages (both 88 percent).
  • Surgical care: In 2004, Memorial followed only coronary artery bypass graft, hip, and knee surgery patients, and its performance was suboptimal (hard data not available). As of the third quarter of 2009, between 98 and 100 percent of eligible surgery patients received an antibiotic within 1 hour before surgery, above both the national (93 percent) and Florida (96 percent) averages. Similarly, one Memorial Healthcare System hospital had 100 percent of their patients achieve good blood sugar control in the days following surgery (again above the national and State averages of 91 percent), while between 98 and 100 percent received treatment to prevent blood clots, above the national average of 89 percent and Florida average of 93 percent.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of performance on the four categories of core measures (heart attack, heart failure, pneumonia, and surgical care improvement), along with comparisons to hospitals across the State and nation.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Sharing data to engage employees: System leaders shared the aforementioned results of the CMS/Premier project with employees throughout the system to highlight the need for a serious focus on core measure performance.
  • Attending "CMS Fair": Nurses attended a mandatory "CMS Fair" in a conference room where they viewed presentations describing the core measures and then took a quiz testing their knowledge.
  • Creating teams: Each hospital created a team to design specific solutions for improving performance. As noted, these teams meet regularly with nurse managers to review overall performance and specific cases classified as "failures."

Resources Used and Skills Needed

  • Staffing: Although exact figures are not available, this program required some reallocation of staff and new hires to serve as quality managers. One quality manager handles approximately 30 to 35 patients for whom the core measures apply.
  • Costs: Data on program costs are unavailable; costs consist primarily of the salaries and benefits for the newly hired quality managers.
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Funding Sources

Memorial Healthcare System
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Tools and Other Resources

More information about the CMS core measures is available at

The CMS process-of-care core measures can be found at

The CMS outcomes core measures can be found at

Adoption Considerations

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Getting Started with This Innovation

  • Align goals with concrete initiatives: Set specific organizational goals regarding performance on core measures; for example, Memorial set a goal of 100 percent for each measure. This step encourages an ongoing focus on achieving goals by both leaders and frontline staff.
  • Emphasize quality and safety to achieve buy-in: Emphasize that the core measure care processes represent best practices based on clinical evidence. Staff will be more likely to support new processes if they understand the link between performance on core measures and the quality of patient care. Furthermore, this approach allows the investigation of "failures" to be viewed as an opportunity for education rather than as a cause for blame, making staff more receptive to discussing gaps in care.
  • Dedicate quality managers to specific units: Quality managers should be assigned to the same units consistently so that they can develop good working relationships and comfortable communication patterns with the unit’s nurse managers, nurses, and physicians.
  • Create vehicle(s) to share best practices: Systems adopting this program should create a forum whereby individual hospitals can freely share their activities, successes, and lessons learned, thus allowing best practices to be spread across facilities.

Sustaining This Innovation

  • Tell stories: Broadly share the story behind each care gap so that staff understand how the failure to adhere to core measure processes can negatively affect the life and well-being of an individual patient.
  • Monitor and report on performance: Clear and frequent reporting on performance helps to ensure that individuals remain focused on improvement and know how personal actions can lead to improvement.
  • Integrate core measures into everyday operations: Having dedicated teams focus on core measure-related initiatives has helped Memorial to maintain its focus on performance. In addition, using quality managers to review gaps has made review of core measure performance an everyday part of operations, thus ensuring self-sustaining, ongoing attention to the issue.

Additional Considerations

  • Memorial Healthcare System received the 2010 Premier Healthcare Alliance Award for Quality, 1 of 3 organizations (out of 346 within Premier) to do so. This award recognizes excellence in performance on CMS process, outcome, and efficiency measures.

More Information

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Contact the Innovator

Jennifer Kadis, MSN, RN, CPAN
Administrative Director of Clinical Effectiveness
Memorial Healthcare System
1131 N 35th Ave
Hollywood, Florida 33021
(954) 265-5449

Innovator Disclosures

Ms. Kadis has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Edwards J. Memorial Healthcare System: A Public System Focusing on Patient-and Family-Centered Care. The Commonwealth Fund. July 7, 2010. Available at:


1 The Centers for Medicare & Medicaid Services. Quality Measures Compendium V.2.0: Medicaid and SCHIP Quality Improvement Compiled by the Division of Quality Evaluation and Health Outcomes, Family and Children's Health Programs Group. 2007.
2 Centers for Medicare & Medicaid Services. Hospital Quality Initiatives: Hospital Compare. July 13, 2010. Available at:
3 Centers for Medicare & Medicaid Services. Hospital Quality Initiatives: Inpatient Measures. July 13, 2010. Available at:
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: April 13, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 30, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 20, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.