CMS/Expecting Success Measures

Acute Myocardial Infarction: Report: (Date)

Intervention Title:

Improving Staff Compliance With CMS Performance Measures Through Weekly Chart Review – University of Mississippi Medical Center (UMC); Jackson, Miss.


Increase the frequency with which patients with heart failure (HF) and acute myocardial infarction (AMI) receive all measures of ideal care before leaving the hospital.


Staff implemented a process through which all HF and AMI patients' charts are reviewed and learnings discussed weekly by a cardiology multidisciplinary team so that changes and improvements in care and discharge practices may be implemented in a timely manner.


Compliance resulting from the weekly chart review has improved considerably in cardiology. Residents rotating through cardiology are more likely to be aware of Centers for Medicare and Medicaid Services (CMS) performance measures than ever before.


University of Mississippi Medical Center2500 North State StreetJackson, MS 39216P: (601) 984-1000

From the C-Suite:

People inherently want the best for their patients, and they want to do a good job of providing high-quality care. It's important not just to go back and point out areas in which they could be performing better, but also to acknowledge and reward them for getting it right. It's the latter that we don't make time for and often overlook.

Michael Winniford, M.D.Medical Director of Cardiovascular Services, University of Mississippi Medical Center; Professor and Vice Chair, Department of Medicine and Surgery


University of Mississippi Medical Center is a 722-bed academic facility and is the state's main diagnostic and referral center.

Clinical areas affected:

  • Cardiology

Staff involved:

  • Cardiopulmonary rehab personnel member
  • Case management representatives
  • Charge nurse
  • Clinical outcomes coordinator
  • Hospital chaplain
  • Medical residents (4)
  • Patient educator/staff nurse
  • Pharmacy representatives (2)
  • ‘Get with the Guidelines' RN care coordinator


Several months between generating the idea for weekly chart review and implementation


Patricia Hughes, R.N.Clinical Outcomes Coordinatorpfhughes@medicine.umsmed.eduP: (601) 815-1304

Innovation implementation:

UMC leaders knew that some of the hospital's AMI and HF patients were not receiving all of the measures of ideal care that they should, including information about medication, dietary guidelines, smoking cessation tips, exercise recommendations and more. Determining how to efficiently identify and quantify discharge shortcomings, then improve upon them, proved challenging.

While the hospital regularly reviewed its data submitted to CMS, those data were not representative for all cardiac patients. In addition, by the time they were transmitted to CMS through the vendor and back again, they were outdated by approximately four months. Such data were no longer relevant to what was currently happening at the hospital, and most physicians and nurses could no longer remember the patients and specific information associated with the charts.

UMC decided that data needed to be reviewed for lessons learned considerably more quickly, while they were still an accurate snapshot of the care being provided at the hospital and while these particular patients and their circumstances were still fresh in health care providers' minds.

Charts for all AMI and HF patients discharged during the previous week are now pulled each Monday from the hospital's medical records department. They are reviewed for things such as whether the patients received a detailed care plan, appropriate medications and all discharge instructions. Then they are discussed at a multidisciplinary team meeting on Friday. Cardiology is the only team to have multidisciplinary meetings every morning. The meetings are very effective because each discipline sees the impact each service has on the patient.

Results—both positive and negative—are reported back to the physicians, residents, staff nurses and nurse managers who interacted with the patients in the form of a weekly report card.

Advice and lessons learned:

    1. Think through the data needed to assess performance.

    2. Involve a variety of disciplines in data collection.

    3.Reward those who get it right.

Cost/benefit estimate:

Nurses on the cardiology floor created teaching tools and reminders of HF and AMI performance measures. The patient charts on the cardiology floor consistently have pathways, checklists and reminder stickers. When the program began, there was a 1:4 nurse-to-patient ratio in cardiology. Now the ratio is 1:6, but thanks in part to the weekly chart review, the nurses are being held accountable and are continuing to perform as they did when they each had fewer patients. The same model of care will be rolled out to other nursing units. Residents that rotate through cardiology appreciate the pat on the back when they do a good job.

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