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Core Measures at JHM

Physician Sean Berenholtz and beta-blocker workgroup stand in a patient room.

Why It Matters

Core measures are standardized best practices designed to improve patient care. The measures range from requiring that certain steps be followed to prevent surgical complications to educating a teenager and his parents about how to manage his asthma. U.S. hospitals must report their compliance with dozens of these measures every year to The Joint Commission and the Centers for Medicare & Medicaid Services.

Core measures are linked to pay for performance, making up components of the Quality Based Reimbursement (QBR) program for Maryland hospitals and the national Value Based Purchasing (VBP) program.  U.S. hospitals must also submit performance to the Joint Commission and Centers for Medicare & Medicaid Services, and performance on the measures is publicly reported.

What We Are Striving For

The goal is to reach 96 percent compliance with the core measures across all of our hospitals. Last year, workgroups across the Johns Hopkins Health System, with support from the Armstrong Institute for Patient Safety and Quality, exceeded the 96 percent goal in seven targeted core measures:

  • Discharge instructions for heart failure patients
  • Percutaneous Coronary Intervention (PCI) ≤ 90 minutes for heart attack patients
  • Administer beta blocker after surgery, if received prior to procedure
  • Blood culture within 24 hours of arrival and blood culture in Emergency Department prior to initial antibiotics for patients with pneumonia
  • Glucose control for cardiac surgery patients
  • Discharge children with asthma with a home care management plan

The Joint Commission and the Delmarva Foundation recognized hospitals in the Johns Hopkins Health System for their performance in the core measures in 2013.

Now that many groups are meeting their target goals, the next challenge is sustaining performance and focusing efforts on new measures related to stroke, blood clots, psychiatry, surgery and pregnancy care. Starting this year, Maryland hospitals also will report on hospital outpatient measures, such as how often patients left the Emergency Department without being seen, and whether a safe surgery checklist was used for outpatient procedures.

What You Can Do

  • First, find out if the core measures apply to your work area. Visit the Joint Commission for a full list of core measures.
  • Visit the dashboard for performance data on each tracked core measure.
  • Get involved. Dozens of work groups across Johns Hopkins Medicine are meeting. Find out if there is a work group in your area by contacting your local quality improvement leader.
  • Take the lead. Talk with your unit or hospital quality representative about launching a needed performance improvement project.


Learn more about efforts to improve in the core measures from around Johns Hopkins Medicine, as well as at other hospitals across the country.

A line graph depicts the rise in core measures between 2005 and 2014

Core Measures at Johns Hopkins

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