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Case Study


NorthShore University Health System: Achieving Rapid Improvement on Core Measures

In 2007, NorthShore University Health System achieved 97 percent compliance with Centers for Medicare and Medicaid Services (CMS) process-of-care measures, a 12-point increase in one year. The measures relate to achievement of recommended treatment in: heart attack, heart failure, pneumonia, and surgical care. The health system’s rapid improvement was the result of making the CMS measures a priority. Northshore pursued the following improvement strategies: a systemwide staff education initiative led by the quality department, including the essential engagement of medical staff, pharmacists, and nurses; promoting physician buy-in by encouraging them to contact CMS with questions about the care standards; use of an electronic health record system as a tool in education, care management, and performance tracking; and use of real-time data for concurrent review of patient care, made possible by exporting data from the EHR. NorthShore has sustained improvements, scoring 96 percent on 23 of 25 measures through June 2008.

This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Commonwealth Fund–sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area of interest, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied institutions' experience that will be helpful in their own efforts to become high performers. Even the best-performing organizations may fall short in some areas or make mistakes—emphasizing the need for systematic approaches to improve quality and prevent harm to patients and staff. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case study series is not an endorsement by the Fund for receipt of health care from the institution.

Publication Details



J. Edwards, NorthShore University Health System: Achieving Rapid Improvement on Core Measures, The Commonwealth Fund, July 2009.