The Joint Commission’s core measures serve as a national, standardized performance measurement system providing assessments of care delivered in given focus areas (1-3). The current set of hospital-based Joint Commission core measures represents the results of a stepwise development process including input from multiple stakeholders (clinicians, hospitals, consumers, medical societies), a testing/validation phase, and alignment of patient care indicators among organizations such as the Centers for Medicare and Medicaid Services, Institute for Healthcare Improvement, and National Quality Forum (4-6). To augment the core measures and promote specific improvements in patient safety, the Joint Commission has also issued National Patient Safety Goals (7). Despite widespread dissemination of the core measures, safety goals, and related quality guidelines, there is significant variation in their application across hospitals (8-13). Reasons for this variance are complex and may include differences in guideline familiarity, provider training, and tools and systems to ensure that recommended care is provided and documented (8). In addition, hospital type, size, and location have been found to correlate with compliance rates (9, 12). Other hospital characteristics such as physician leadership and organizational support also appear to contribute to the consistent use of evidence-based processes of care (14-17).