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NURS 3110A Week 3 Section 04 Information Management and Patient Care Technologies

Comparing Organizations Using Benchmark Data

In order to provide high-quality care, it is crucial to assess the quality of care being delivered. Clinical quality measures (CQMs) serve this purpose by tracking elements of structure, process, and outcomes using data recorded in electronic health record systems (EHRs) (Cholan et al., 2019). These measures identify gaps in care and provide evidence-based guidelines to address them. Facilities’ ability to meet benchmarks within CQMs often impacts reimbursement (Cholan et al., 2019). This paper aims to explore the impact of CQMs in the clinical setting by comparing the benchmarks of two organizations and examining contributing factors and differences.

Description of Two Organizations

The organizations under comparison are Asante Three Rivers Medical Center (TRMC), the author’s workplace, and Asante Rogue Regional Medical Center (RRMC), another hospital within the same healthcare system located approximately 35 miles south. Although not direct competitors financially, there is a level of competition among employees. Both hospitals publicly post outcomes from CQM benchmarks and satisfaction surveys, motivating staff to improve their scores through competition.

TRMC is a rural, suburban medical center situated in Grants Pass, Oregon. It is a 125-bed acute-care hospital and a level three trauma center. TRMC has received the ‘Pathway to Excellence’ designation from the American Nurses Credentialing Center (ANCC) three times since 2012, making it one of only 23 hospitals nationwide with this achievement. Additionally, TRMC is the first hospital in Oregon designated as ‘Baby Friendly’ by the World Health Organization and UNICEF (Asante, n.d.).

NURS 3110A Week 3 Section 04 Information Management and Patient Care Technologies

RRMC, on the other hand, is an urban medical center located in Medford, Oregon. It is a 378-bed acute-care hospital, regional referral center, and level 2 trauma center. RRMC’s services include a neonatal intensive care unit and a hospital-based sleep center. Asante, which includes TRMC and RRMC, has been recognized as one of Watson Health’s 15 Top Health Systems in the nation for seven consecutive years, with the Mayo Clinic being the only other health system achieving this distinction (Asante, n.d.).

Comparison of Two Organizations

One of the quality measures being compared is the percentage of patients who left the emergency department before being seen, which falls under timely emergency department care. The national and Oregon averages for this benchmark are both 2%. RRMC performs below these averages at 1%, while TRMC significantly exceeds them at 5%. This substantial difference in TRMC’s performance suggests potential issues related to resource availability or staff capacity to provide timely and effective care in their emergency department (Medicare, n.d.).

Another quality measure being compared is the rate of readmission after hip/knee replacement, which falls under unplanned hospital visits. This measure takes into account patients readmitted to any hospital, even if it is a different one, and includes readmissions unrelated to the recent surgery. The national average for this benchmark is 4%. TRMC performs better than the national rate, while RRMC’s performance is on par with the national rate, according to Hospital Compare. Both facilities meet or exceed the goal, indicating that TRMC may be slightly more effective at preventing complications (Medicare, n.d.).

Analysis of Factors Contributing to Performance Measures

Nurse staffing could be a contributing factor to TRMC’s lower percentage in the timely emergency care measure. The quality of care delivered by nurses is influenced by adequate staffing levels, as it enables efficient and effective assessments and interventions to prevent adverse events and promote positive patient outcomes (Clarke & Donaldson, n.d.). In the context of the emergency department, the percentage of patients leaving before treatment completion (LBTC) is a critical performance indicator, and studies have shown a direct correlation between RN and physician staffing and waiting time, which is a significant driver of LBTC (Anderson, 2016).

NURS 3110A Week 3 Section 04 Information Management and Patient Care Technologie

Another contributing factor for the difference in the rate of readmission after hip/knee replacement could be the quality of discharge instruction provided by nurses. Nurses play a crucial role in developing and delivering discharge plans to patients (Pieper, 2006). Unmet discharge needs have been found to correlate with patient readmissions and poorer outcomes (Pieper, 2006).

Data Standardization to Improve Quality Comparison Measures

According to the Centers for Medicare & Medicaid Services (CMS), standardizing data is essential for quality improvement (CMS, n.d.). By eliminating randomness and uncertainty in free-text data entry and adopting a systematic approach to recording data, structured data analysis becomes more effective, reducing errors and increasing positive outcomes. Data standardization improves the quality of measures and facilitates the identification and improvement of issues in patient care (CMS, n.d.).

NURS 3110A Week 3 Section 04 Information Management and Patient Care Technologies Conclusion

Tools like the Hospital Compare website can be valuable in identifying and comparing areas of concern and gaps in care using CQMs. CQMs, along with data standardization, are crucial for accurately recording, analyzing, identifying, and improving issues in patient care. Nurses play a significant role in each of these steps and have the potential to impact measure outcomes and the overall quality of care.


Anderson, D., Pimentel, L., Golden, B., Wasil, E., & Hirshon, J. M. (2016). Drivers of ED efficiency: a statistical and cluster analysis of volume, staffing, and operations. American Journal of Emergency Medicine, 34(2), 155–161.

Asante. (n.d). Retrieved from https://www.asante.org/ Center for Medicare & Medicaid Services (CMS). (n.d.) Quality Measure and Quality Improvement. Retrieved from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Quality-Measure-and-Quality-Improvement-.html Cholan, R. A., Weiskopf, N. G., Rhoton, D. L., Colin, N. V., Ross, R. L., Marzullo, M. N., … Dorr, D. A. (2018). Specifications of Clinical Quality Measures and Value Set Vocabularies Shift Over Time: A Study of Change through Implementation Differences. AMIA Annual Symposium proceedings. AMIA Symposium, 2017, 575–584. Clarke S., Donaldson N. (n.d.). Nurse Staffing and Patient Care Quality and Safety. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 25. Medicare. (n.d). Hospital Compare. Retrieved from https://www.medicare.gov/HospitalCompare/compare.html#cmprTab=2&cmprID=380002%2C380018&dist=100&lat=42.3330418&lng=-123.3730521&loc=97527&cmprDist=7.8%2C34.5

Pieper, B., Sieggreen, M., Freeland, B., Kulwicki, P., Frattaroli, M., Sidor, D., … Garretson, B. (2006). Discharge information needs of patients after surgery. Journal of Wound Ostomy and Continence Nursing, 33(3), 281–289.

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