Lindsay I. Varga, PharmD, BCPS
Clinical Pharmacy Specialist in Internal Medicine

Elizabeth Marino Sabo, PharmD, BCPS
Clinical Pharmacy Specialist in Infectious Disease

Jacqueline M. von Vital, PharmD
Clinical Pharmacy Specialist in Anticoagulation

Suzanne Y. Brown, MS, RPh
Director of Pharmacy Services

Pennsylvania Hospital
Philadelphia, Pennsylvania

Core measures (CMs) are a set of evidence-based quality indicators created by the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission. They have been shown to reduce the risk for complications, prevent recurrences, and otherwise promote optimal treatment of patients presenting with specific conditions. Failure to comply with the CMs may result in decreased reimbursement. At Pennsylvania Hospital, we saw an opportunity to leverage a unit-based clinical pharmacist model to help achieve and sustain CM compliance goals. Pharmacist involvement enabled the hospital to improve compliance in all the medication-related CMs that were targeted, with 100% compliance in a majority of the measures.

Implementation Plan

The Department of Pharmacy Services saw an opportunity to use its established unit-based clinical pharmacist model to help achieve and sustain CM compliance goals. Together with the hospital’s Quality Management Department, they identified 9 medication-related CMs as opportunities for pharmacist involvement (Table 1). In March 2011, the hospital’s Pharmacy and Therapeutics Committee approved the new pharmacy-initiated program. Before the program’s launch in April 2011, an education plan was developed for pharmacists and house staff. Pharmacists were educated on the areas covered in the CM initiative—acute myocardial infarction (AMI), heart failure (HF), and pneumonia (PN)—and were given an introduction to CMs. House staff were educated about CMs and the potential of pharmacy to help the hospital achieve compliance goals. In November 2011, when stroke was added to the hospital’s CM dashboard, education related to stroke therapeutics was provided to the house staff.

Table 1. Targeted Medication-Related Core Measures (as of August 2012)
Measure Set Measure ID No. Measure Short Name
Acute myocardial
infarction (AMI)
AMI-2 Aspirin prescribed at discharge
AMI-5 β-Blocker prescribed at discharge
AMI-10 Statin prescribed at discharge
Heart failure (HF) HF-3 ACEI or ARB for LVSD
Pneumonia (PN) PN-6 Initial antibiotic selection
Stroke (STK) STK-1 Venous thromboembolism prophylaxis
STK-2 Discharged on antithrombotic therapy
STK-6 Discharged on statin
ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; LVSD, left ventricular systolic dysfunction
Based on reference 1.
Figure. Portion of a patient-specific core measure worksheet for acute myocardial infarction.

Pharmacy realigned its workflow model to accommodate the new responsibilities. Unit-based clinical pharmacists identified patients with an “admitting diagnosis” of AMI, HF, PN, or stroke every weekday via an emailed list from clinical data analysts. They also screened patients for CM diagnoses during daily patient care rounds. Pharmacists assessed medication-related CM compliance using patient-specific worksheets created by the pharmacy clinical specialists in internal medicine, infectious disease, and anticoagulation (Figure). After the unit-based clinical pharmacists evaluated the patients and discussed them with the multidisciplinary team, they determined which of 3 actions were required, and they proceeded accordingly (Table 2).

Table 2. Actions Required After Compliance Assessment
Compliance Level Action Required
Patient compliant with all medication CMs No action needed
Patient noncompliant with medication CMs due to contraindication Document contraindication in permanent medical record
Patient noncompliant with medication CMs and no contraindication identified Communicate with provider and recommend compliance
CM, core measure

Clinical pharmacists maintained patient review worksheets to facilitate communication between covering pharmacists, and after discharge the worksheets served as monitoring tools to assess monthly pharmacy interventions and trends.

In December 2011, after 8 months of this paper process, the Pharmacy Department implemented a computerized pharmacy clinical surveillance program, Pharmacy One Source Sentri7. This program interfaced with the hospital’s electronic charting system and computerized provider order entry system to extract relevant clinical patient data related to CM areas. With this data, the Pharmacy Department built and generated rules-based report lists. These lists identified patients with specific admitting diagnoses who were not ordered an appropriate medication (eg, “AMI diagnosis without appropriate meds”). The pharmacy created similar lists for each CM set.

Electronic clinical surveillance streamlined the screening process and created a more efficient workflow for the pharmacists. The interface with the hospital’s electronic medication administration record system provided faster real-time patient identification. Pharmacists also documented interventions directly into the surveillance program and added notes to communicate with other pharmacists in the department.

Monitoring of Process

The hospital’s quality management team monitored and reported CM compliance monthly at a Core Measures Task Force meeting. The Pharmacy Department also monitored and reported the following data at each meeting:

  • Number of patients reviewed by the pharmacists
  • Number of documentations made in the patient medical record by pharmacists
  • Number of recommendations to the provider
  • Provider acceptance rate of recommendations made by pharmacists

During the first 17 months of the pharmacy-based initiative, pharmacists reviewed 2,742 patients, made 218 documentations in patient charts, and made 224 recommendations, with an acceptance rate of 96%. With the addition of pharmacy involvement, the hospital was able to improve compliance in the 9 targeted medication-related CMs, with 100% compliance in a majority of the measures.

Keys to Success

Due to the success of the pharmacy CM program, we believe that the same type of service could be replicated at other organizations. The group efforts of the Department of Pharmacy, the Department of Quality and Patient Safety, the performance improvement leadership, and clinical data analysts provided an optimal interdisciplinary platform for success. Institutions should consider several factors to optimally replicate the program.

Departmental Partnerships

An integral aspect of this project is the relationship of the Pharmacy Department with the Department of Quality and Patient Safety and performance improvement leadership. Working together allows us to share ideas and optimally identify patients who are appropriate for CM assessment. The Department of Quality and Patient Safety reviews compliance rates on a monthly basis and shares patient cases with the Pharmacy Department.

Staff Education

Education on pathophysiology and therapeutics of disease states, as well as on the background of CMs, is vital in preparing unit-based clinical pharmacists to become contributing members of the health care team in assessing CM compliance.

Workflow and Accountability

This project was integrated into our department’s operational structure, which includes unit-based clinical pharmacists who are deployed on the floors and closely interact with the patients, nurses, dieticians, and providers on a daily basis. The unit-based clinical pharmacists are held accountable for completing the CM checklists and communicating information to the rest of the health care team.

Standardized Clinical Surveillance Process

Whether a paper or electronic process is used, the establishment of a consistent method for identifying and evaluating patients is integral to success.

Interdisciplinary Patient Care Rounds

The unit-based clinical pharmacist is a member of an interdisciplinary team that meets daily during patient care rounds. During these rounds, valuable information about the patient is presented that allows the team to screen patients using the CM checklists and identify those who would benefit from pharmacy intervention. Without this coordinated effort among the disciplines, the screening process would be much more challenging.

Ongoing Monitoring And Feedback

Compliance rates and intervention data are gathered and reviewed each month at a Core Measures Task Force meeting. This data also is shared with the unit-based clinical pharmacists and house staff. The pharmacy CM program is dynamic, and pharmacists’ suggestions to improve the program are encouraged and integrated into the program.


Based on our experience at Pennsylvania Hospital, we feel that a unit-based clinical pharmacist model can be leveraged to support a hospital in achieving CM compliance. Success in such a program is best achieved with interdisciplinary partnership, staff education, and standardization, as well as ongoing monitoring and feedback.


  1. Centers for Disease Control & Prevention and The Joint Commission. Specifications Manual for National Hospital Inpatient Quality Measures. Version 4.0. January 2012.