Evidence-based performance measures, known as core measures, have been established by The Joint Commission to improve the quality of care for patient populations, such as those with acute myocardial infarction (AMI), heart failure, and community-acquired pneumonia (CAP), as well as to improve the quality of surgical care--the Surgical Care Improvement Project (SCIP) measures. Hospital administrators have traditionally held academic and community physicians and hospital clinicians accountable for integrating the core measures into daily practice. Such efforts have often led to suboptimal results because of the belief that the "organization" (macrosystem) is the appropriate level at which to work to improve quality. Stanford Hospital and Clinics (Stanford, California) has instead held leaders of clinical microsystems--the clinical units where care is provided--accountable to improve performance on the core measures. The strategic approaches taken for this initiative include engagement of the hospital's board of directors; clear assignment of accountability among interdisciplinary care teams to drive the change; implementation of a unit-based medical director program; transparency of core measure performance at the microsystem, mesosystem, and macrosystem levels; and concurrent monitoring with rapid feedback of results.In 2007, the first year of this initiative, the 24-metric composite compliance score for all four core measures increased from 64% to 82%. The composite score was sustained at a minimum of 90% during 2009 and Quarter 1 of 2010.Holding clinical microsystems accountable for improving unit performance proved beneficial to macrosystem performance of the Joint Commission core measures.
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