REACHING ZERO DEFECTS IN CORE MEASURES. Mary Brady, RN, MS Ed, Senior Nursing Consultant, Healthcare Transformations LLC,

Transcription

1 REACHING ZERO DEFECTS IN CORE MEASURES Mary Brady, RN, MS Ed, Senior Nursing Consultant, Healthcare Transformations LLC, 165 Lake Linden Dr., Bluffton SC 29910, , Primary Author Rita Tomasewski, RN, MSN, ARNP, CCRN, Manager, Telemetry Unit, St. Francis Health Center, 1700 W. 7 th Street Topeka, Kansas , rita.tomasewski@sftks.net Mary Clare Wilson, RN, MSA, Director Quality Department, Saint Francis Health Center, 1700 W. 7 th Street, Topeka, KS 66606, , mwilson@stfrancistopeka.org

2 ABSTRACT Evidence-based medicine is supported by research that demonstrates better outcomes for patients including lower mortality, lower morbidity, less disability, shorter length of stay and fewer readmissions. The public reporting of core measures has created opportunities for hospitals to improve processes and apply evidenced based medicine in order to enhance the quality of care. After a decline in core measure scores, our hospital developed a concurrent abstraction process allowing for real-time identification and correction of defects. The interdisciplinary approach facilitated substantial improvement, thereby allowing us to reach between 95% -100% in core measure appropriate care scores.

3 REACHING ZERO DEFECTS IN CORE MEASURES Core measures are the basic elements of quality care as supported by best practice guidelines from the Joint Commission s priority focus areas in Acute Myocardial Infarction (AMI), Heart Failure (HF), Pneumonia (PN), Surgical Care Improvement Project (SCIP), Children's Asthma Care (CAC) and Pregnancy and Related Conditions (PR). 1 A core measure is the number, reported in a percentage, of eligible patients that receive the care as described by the measure. Core measures are truly the basics or core to providing quality care to these groups of patients. A hospital s core measure scores reflect the quality of care administered to patients. As the public becomes more aware of hospital quality scores, the importance of zero defects cannot be underestimated. This article will describe how our hospital has nearly eliminated defects in our core measure metrics. Creating a Platform for Change Our hospital had reached an all time low in core measure scores and the administration brought in a consulting group to facilitate a process improvement effort. The process improvement methodology involved three distinct phases: assessment and detailed 1 Joint Commission. Performance measurement initiatives.

4 implementation planning, process redesign and staff training, and rapid cycle implementation and performance management. This endeavor led to the development of a concurrent abstraction process that involved teamwork from both the nursing and the quality departments. Process Improvement Plan Phase One: Assessment and Detailed Implementation Planning In order to accomplish the goal of reaching zero defects in our core measure scores, we revitalized our core measure team. The team s membership consisted of nursing, quality, pharmacy, clinical education, and nursing administration. The team s assessment revealed a reactive approach to core measures, lack of education, and the sense that no one department managed the processes necessary to ensure success. The process did not allow us to know our core measure outcomes until they were processed by the regulatory quality database program, which on an average was 90 days retrospective. The lack of concurrent core measure data and the inability to implement defect management prohibited us from correcting our issues in realtime. A registered nurse (RN) learning needs assessment found that over 50% of the in-patient nursing staff stated they needed education on core measures. Physicians and Advanced Registered Nurse Practitioners (ARNPs) surveyed stated they had limited information regarding

5 core measure metrics. The assessment reinforced the need for a more proactive approach to core measures and for further education to all clinicians. Phase Two: Process Redesign and Staff Training The process redesign focused on providing a more proactive management of core measures through concurrent abstraction. This process involved the cooperation of both nursing and quality and created a sense of teamwork as we strived to reach zero defects. The concurrent process involves the following steps: 1. Data collection: Every morning the nurse managers, Lab, and Emergency Department (ED) collect information regarding the core measure patients. Nurse mangers prepare a unit summary on each inpatient unit. The summary lists: current staffing levels, patient census, and identification of core measure patients. The Lab identifies increased BNP s and Troponins on all inpatients. The ED identifies all admissions with a core measure diagnosis. 2. Information Sharing: Nurse Managers, Lab, and ED share this information with the abstractor at the AM Bed Huddle. A core measure list is created by the abstractor based on the information. Information is also shared at each unit s interdisciplinary

6 team conference where all patients are discussed including their admitting diagnosis, current needs, progress towards care plan goals, and core measure progress. 3. Chart Review: The abstractor concurrently reviews all inpatient charts, with a core measure diagnosis, with regards to the compliance with the metrics. If a metric is not complete, the abstractor notifies the nurse caring for the patient, the unit s nurse manager, and the physician if appropriate. This notification can be written and/or verbal. 4. Measurement: The data from the concurrent review is entered into an Excel database which is sent to all nurse managers, the Chief Nursing Executive and the Director of Quality on a daily basis. Additionally, the abstractor uploads the data into the regulatory quality database program in order to decrease the workload after the chart is coded. 5. Follow-up: The nurse manager follows up daily with the staff nurses to ensure that the previously noted defects have been corrected. During the following day s concurrent review, the abstractor verifies correction of any defects and enters the correction into the Excel database and into the regulatory quality database program.

7 6. Time-out: A time-out process provides a final opportunity for core measure review prior to the patient s discharge. During the discharge time out, a check list is used that lists the components of the core measure and either the nurse manager or the charge nurse reviews the checklist with the staff nurse to ensure that all measures are met. If a defect is identified, the defect is corrected prior to the patient s discharge. The form is signed by both the staff nurse and the nurse manager or charge nurse. The form ensures compliance with all the indicators, enhances staff accountability, and is a resource for all staff on the components of the core measure for each population group. Prior to implementing the concurrent abstraction process, all nursing and medical staff were re-educated on the core measure metrics. Mandatory on-line education was completed by inpatient unit RN s, the Operating Room RN s, and CRNA s. The ED nurses received 1:1 education regarding the metrics that needed to be completed in the ED. Physicians were educated at department meetings and through poster boards in their lounge. Phase Three: Rapid Cycle Implementation and Performance Management Within 3 weeks of our first core measure team meeting we began the new concurrent abstraction process. The team used Deming s Plan-Do-Study-Act (PDSA) methodology to test

8 the new process. The Institute for Healthcare Improvement provides many reasons for using the PDSA cycle: to determine if a change leads to improvement, to assess to what extent a process can be improved, to determine if in reality a change will have the expected outcome, and to estimate the cost of change. 2 The team revised various aspects of the process as a result of this methodology, such as modifying the Excel database to include Appropriate Care Scores (ACS). This score is determined by computing the number of times a hospital performed the appropriate action across all metrics for that condition, divided by the number of opportunities the hospital has to provide appropriate care for that condition. Throughout this process improvement initiative, we kept our focus on enhancing the process, rather than blaming someone or some group for our current failures. Performance is managed through the continued meetings of the core measure team. The initial focus was achieving buy-in from the physicians and staff which was accomplished through education and inclusion in the process changes. Additionally, nurses and physicians are individually notified of any defects in the core measures and staff is made aware of their performance during monthly 2 Institute for Healthcare Improvement. Testing Changes.

9 staff meetings. A key element of our performance management is the strong support of senior leadership, functioning in the role as champions to the process improvement. Results We were able to have our redesign completed and implemented by the end of July At the time this process improvement project started, our ACS for CHF was 42% and AMI, PN, and SCIP scores were in the 80% ranges. Since that time our scores have shown much improvement as depicted in Figure 1. As of March 2010 our hospital reached the system goal of achieving 95% ACS for all measures. In this day of continual change in the healthcare arena, it is important to put processes in place that are sustainable over time. A frequent mistake is to dedicate significant resources, time and energy into an improvement project which is not managed resulting in staff reverting to previous behaviors. However, as demonstrated through this interdisciplinary approach results are sustaining and positive. Reaching zero defects in core measures is not about improving the percentages, but rather giving the patient the evidenced-based care at the right time.

10 Figure 1. Appropriate Care Scores for our health center before and after process improvement. Implementation of Concurrent Abstraction

11 References 1. Joint Commission. Performance measurement initiatives Institute for Healthcare Improvement. Testing changes. ngchanges.htm