Core Meaures

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Read the Patient Safety and Quality Improvement Act of 2005 (FOUND BELOW) and review the information on the Measures (FOUND BELOW).
web page of The Joint Commission website. Pick one of the core measures
from the list on the right-hand side of this web page. For this
assignment, create a PowerPoint presentation in which you explain how a
hospital would typically put policies and procedures into place to
ensure that it is following your selected core measure.

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In your presentation,

  • Describe the core measure you chose.
  • Analyze how your hospital will follow the requirements in the chosen core measure.
  • Examine the penalties that will occur if this policy/procedure is not followed.

You are basically creating the policy/procedure and presenting it on the PowerPoint as if you were presenting to an audience.

Create a PowerPoint presentation using the guidelines below. Your
presentation must utilize at least two scholarly sources from the last
five to seven years, in addition to the textbook, that contain research
regarding how your policy and/or procedure would be put into place in a
hospital setting.

The Core Measures PowerPoint presentation assignment

  • Must be five to seven slides (excluding the title slide and
    reference slides) and be formatted according to APA style.
  • Must use speakers notes as follows: (GIRL VOICE PLEASE)
    • The Patient Safety and Quality Improvement Act of 2005

      Patient Safety and Quality Improvement Act of 2005 (Public Law 109-41),
      signed into law on July 29, 2005, was enacted in response to growing
      concern about patient safety in the United States and the Institute of
      Medicine’s 1999 report, To Err is Human: Building a Safer Health System.
      The goal of the Act is to improve patient safety by encouraging
      voluntary and confidential reporting of events that adversely affect

      The Patient Safety and Quality Improvement Act signifies the Federal Government’s commitment to fostering a culture of patient safety. It creates Patient Safety Organizations
      (PSOs) to collect, aggregate, and analyze confidential information
      reported by health care providers. Currently, patient safety improvement
      efforts are hampered by the fear of discovery of peer deliberations,
      resulting in under-reporting of events and an inability to aggregate
      sufficient patient safety event data for analysis. By analyzing patient
      safety event information, PSOs will be able to identify patterns of
      failures and propose measures to eliminate patient safety risks and
      Many providers fear that patient safety event reports could be used
      against them in medical malpractice cases or in disciplinary
      proceedings. The Act addresses these fears by providing Federal legal
      privilege and confidentiality protections to information that is
      assembled and reported by providers to a PSO or developed by a PSO
      (“patient safety work product”) for the conduct of patient safety
      activities. The Act also significantly limits the use of this
      information in criminal, civil, and administrative proceedings. The Act
      includes provisions for monetary penalties for violations of
      confidentiality or privilege protections.
      Additionally, the Act specifies the role of PSOs and defines “patient
      safety work product” and “patient safety evaluation systems,” which
      focus on how patient safety event information is collected, developed,
      analyzed, and maintained. In addition, the Act has specific requirements
      for PSOs, such as:

      • PSOs are required to work with more than one provider.
      • Eligible organizations include public or private entities, profit or
        not-for-profit entities, provider entities, such as hospital chains,
        and other entities that establish special components.
      • Ineligible organizations include insurance companies or their affiliates.

      Finally, the Act calls for the establishment of a Network of Patient
      Safety Databases (NPSD) to provide an interactive, evidence-based
      management resource for providers, PSOs, and other entities. It will be
      used to analyze national and regional statistics, including trends and
      patterns of patient safety events. The NPSD will employ common formats
      (definitions, data elements, and so on) and will promote
      interoperability among reporting systems. The Department of Health and
      Human Services will provide technical assistance to PSOs.

      For Additional Information

      To contact PSO Office staff, go to the PSO site at

      Page last reviewed October 2014
      Page originally created June 2008
      Internet Citation: The Patient Safety and Quality Improvement Act of
      2005. Content last reviewed October 2014. Agency for Healthcare Research
      and Quality, Rockville, MD.

      In early 1999, The Joint Commission solicited input from a wide variety
      of stakeholders (e.g., clinical professionals, health care provider
      organizations, state hospital associations, health care consumers) and
      convened a Cardiovascular Conditions Clinical Advisory Panel about the
      potential focus areas for core measures for hospitals. In May 2001, the
      Joint Commission announced four initial core measurement areas for
      hospitals, which included acute myocardial infarction (AMI) and heart
      failure (HF).

      Simultaneously, The Joint Commission worked with the Centers for
      Medicare & Medicaid Services (CMS) on the AMI, and HF sets that were
      common to both organizations. CMS and the Joint Commission worked to
      align the measure specifications for use in the 7th Scope of Work and
      for Joint Commission accredited hospitals. Hospitals began collecting
      AMI measures for patient discharges beginning July 1, 2002.

      In November of 2003, CMS and The Joint Commission began to work to
      precisely and completely align these common measures so that they are
      identical. This resulted in the creation of one common set of measure
      specifications documentation known as the Specifications Manual for
      National Hospital Inpatient Quality Measures to be used by both
      organizations. The Manual contains common (i.e., identical) data
      dictionary, measure information forms, algorithms, etc. The goal is to
      minimize data collection efforts for these common measures and focus
      efforts on the use of data to improve the health care delivery process.

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