North Shore–Long Island Jewish Health System

Completing a project under the direction of senior leadership of the North Shore–Long Island Jewish Health System Quality Management Department, the administrative residents had the opportunity to determine why the compliance rate for smoking cessation advice/counseling and documentation of congestive heart failure patients does not meet Joint Commission on Accreditation of Health Care Organizations (JCAHO) standards and the Center for Medicare and Medicaid Services (CMS) core measures. Proper identification of these patients and documentation of the necessary advice/counseling is among the new publicly reported core measures for hospitals put in place by CMS. As part of the project, the administrative residents interviewed managers and medical directors, used a number of findings and recommendations to hospital and system-wide workgroups as well as senior administration.