Date Submitted: 2011-10-17

Actions required:
AMI - Area of Focus:
Primary PCI Received Within 90 Minutes
Process change: Educate all staff on how to notify physicians and cath lab for a Stemi

HF - Area of Focus: ACEI or ARB for LVSD
Process Change:
Education of physicians including new residents of requirements. New process is 100% of the physicians must receive quality orientation before working In their respective area.

PN - Area of Focus:
Preparation for Immunizations
Action: Updated SDMO

SCIP - Area of Focus: VTE timing and ordering.
Process change: Created a “hard stop” in PACU. Patient cannot leave area until orders written. Patients going directly to ICU post op must have VTE orders upon receipt of patient.




Timeframe for completion:
for all CM's listed above: Initiated 8/2011

Responsible parties:
HealthCare Improvement Director

Support / Resources:
Executive leadership is 100% supportive of changes.



Evaluation of Our Progress:
Leading Indicator: Monitoring compliance daily thru Concurrent Review. Lagging Indicator: Compare to hospital and CMS Nat’l rates

 

Date Submitted: 2011-10-17

Actions required:
AMI - Actions have been to maintain gains and to monitor daily use of order sets for standardized care and compliance

HF - Actions have been to maintain gains and to monitor daily use of order sets for standardized care and compliance

PN - Daily monitoring of order sets has not been enough to ensure compliance. Concurrent reviews are now being implemented for all admitted patients to review for medications and vaccine administration.

SCIP - Concurrent reviews are being implemented to help facilitate compliance with antibiotic selection, timing and discontinuation.

Timeframe for completion:
Concurrent monitoring in place for all CM's listed above

Responsible parties:
Nursing and health care improvement director and coordinators

Support / Resources:
Physician support and accountability, nursing support and HCI auditing/education

Evaluation of Our Progress:
Monthly reporting and comparison

 

Date Submitted: 2011-10-24

Actions required:
AMI - N/A

HF - N/A

PN -
Continue concurrent audits by HCI
Education of new SDMO done for all units
Education of new changes to include SDMO as part of the CPP done for all units

SCIP -
Continue concurrent audits by HCI POD1 & 2 with daily email from HCI to nursing, pharmacy and surgery on each surgery patient
Physician SCIP Manual available on each unit and in surgery department
Appropriate antibiotic selections listed on Antimicrobial Prophylaxis for Surgery Order Set and available in every surgery patient chart ongoing
Physician education letter sent regarding documentation of hypothermia
Continue Beta Blocker sticker process for all elective surgery patient
Medication classified as Beta Blocker identified by pharmacy on MAR in Eclipsys implemented and ongoing

All -
Core Measures education provided by HCI for all new nurse hires, weekly
Educational letters were sent to involved Physicians and Nursing for each OFI identified with details and improvement suggestions
Details of occurrences discussed in Hospital Quality Committee, monthly
Individual counseling with bedside leaders involved in OFIs by Unit Manager



Timeframe for completion:
AMI - N/A
HF - N/A
PN - See Above
SCIP - See Above

All - Ongoing for all

Responsible parties:
AMI - N/A
HF - N/A
PN - Team Leads
SCIP - Team Leads
All- HCI, Physicians, Nursing and Pharmacy, Task Force Teams

Support / Resources:
AMI - Physician Champion, Nursing Champion, Unit Managers, and Cardiac Nurse Practitioner

HF - Physician Champion, Unit Managers, and Cardiac Nurse Practitioner

PN - Physician Champion, Nursing Champion, pharmacy, Unit Managers, Supervisors, Acute and Critical Care Directors

SCIP - Physician Champion, Nursing Champion (surgery director), pharmacy, Unit Managers and Supervisors

All - Physician and Nurse Champions, Unit Managers, and Cardiac Nurse Practitioner

Evaluation of Our Progress:
AMI -
Department of Cardiovascular Services and Hospital, bi-monthly and Quality/Best Care Committee using Midas reports and data

HF -
Department of Cardiovascular Services and Hospital Quality/Best Care Committee using Midas reports and data

PN -
Physician Champion and Nursing Champion

SCIP -
Committee Meeting, monthly and Hospital Quality/Best Care Committee using Midas reports and data

All -
Hospital Quality/Best Care Committee using Midas reports and data

 

Date Submitted: 2011-10-24

Actions required:
AMI - Continue HCI concurrent review/audits

HF - Continue HCI concurrent review/audits

PN - Continue concurrent audits by HCI
Education of new changes to include SDMO as part of the CPP planned for \
all units.
New process in place for lab techs to write bld cx times on white board
in pt’s room- RN to write time on nurses notes to verify.
ED doctors to select type of pneumonia on ED transfer of care order set.


SCIP - New OR project collaborative with HCI and OR nurses regarding time out
procedures. Large Time out poster placed in all OR suites with revision
for nurses to write pt’s current abx on poster prior to procedure.

SCIP Abx laminated card created with revised time out poster.

New Pharmacy policy that allows pharmacist to re-time VTE pharm orders
to 20 hrs after AET.

Unit specific computer boards show corresponding red/yellow/green lights
for VTE prophylaxis for each patient.


All- Educational letters sent to involved Physicians for each OFI identified
with details

Details of occurrences discussed at monthly Best Care Meeting

Individual counseling with bedside leaders involved in OFIs by Unit Manager




Timeframe for completion:
AMI - N/A
HF - N/A
PN - See Above
SCIP - See Above

All - Ongoing

Responsible parties:
AMI - NA

HF - NA

PN - Nursing, Physicians, Laboratory, Informatics, Education

SCIP - OR Nurses, Pharmacy, HCI


All- HCI, Physicians, Nursing and Pharmacy, Task Force Teams


Support / Resources:
AMI - Physician Champion, Unit Managers, Nursing, CNS

HF - Physician Champion, Unit Managers, Nursing, CNS

PN - ED Physician Champion, pharmacy, Unit Managers, Supervisors, Laboratory

SCIP - Physician Champion, OR manager, pharmacy, Unit Managers and Supervisors

All - Physician Champions, Unit Managers, CNS

Evaluation of Our Progress:
AMI - Best Care Committee, Nurse Executive Council, Nursing House-wide Council

HF - Best Care Committee, Nurse Executive Council, Nursing House-wide Council

PN - Best Care Committee, Nurse Executive Council, Nursing House-wide Council, ED Council

SCIP - Best Care Committee, Nurse Executive Council, Nursing House-wide Council, Surgery Section Meeting

All - Hospital Quality/Best Care Committee using Midas reports and data

 

Date Submitted: 2011-10-26

Actions required:
AMI - Intense team meetings with AMI team monthly to discuss any and all opportunities for improvement. Group development of action plans where appropriate. Continued taking opportunities to both Hospitalist groups by physician champions. Immediate follow-up with nursing on nursing opportunities.

HF -
Continue monthly meetings with Hospitalists, Physician Champion and HCI department. Physicians in both Hospitalist groups agreed to meet with nursing prior to discharge and review the Medication Reconciliation form for accuracy. Physicians agreed to dictate discharge summary (medications pt. is going home on) with Medication Reconciliation form to ensure both are accurate.
There has been improvement in compliance – continue the momentum.
ACEI or ARB for LVSD at Discharge at 98.51% surpassed the target of 95% this quarter but does not appear to be hard wired as of yet. Continue to take to Peer Review for discussion and education of Physicians. HealthCare Improvement coordinators are following up real time with areas to educate and help identify what next steps are in complying with the criteria.

PN - Opportunities revolve around 1 – 2 patients - ED evaluating each case for areas presenting delays. Identified an issue with delay in timing of radiology reporting back to ED. Working with both areas to decrease that time.
Standing Delegated order for both Influenza and Pneumovac Education as to documentation required if pt. is not a candidate for vaccine.
Epidemiologist follows up with each physician not using appropriate combination of antibiotics. Pneumonia order set changed to reflect TJC antibiotic combinations recommended.
Unit based educators working with staff to educate new global SDMO - standing delegated medical order.


SCIP - Postop serum glucose: met the target this quarter but is not yet hard-wired. Working with TCV department to make the Diabetologist consult mandatory for all high risk patients.

Urinary catheter removed POD#1 or POD#2 – met target of 95% this quarter but not hardwired.
Continuous monitoring of
Presence of stamp which was developed to remind Physician of the need to remove Urinary Catheter by POD 2 or give reason catheter needs to remain.
Hand-off Process developed between surg ical ICU and receiving floor – basically check off list to ensure catheter removal. Nursing staff following –up with communication flow sheet from ICU to floor to remind receiving floor to remove catheter by POD #2 if catheter remains on transfer.
Concurrent review via electronic medical record initiated by Healthcare coordinator for all time stamped elements – if not completed, coordinator follows up with nurse at the bedside to complete the requirement – also provides a teaching moment 1:1 with staff.


Timeframe for completion:
AMI - By end 3rd quarter 2011 – met the goal to date. Process is not hard wired at this point – will continue all efforts to improve on an individualized and team basis.
Target for end of year 2011 – 95% or greater


HF - By end of 3rd quarter 0.8% from Target of 95%. Should meet or exceed All or None Bundle of 95% by end of 2011. Continue with previous efforts to ensure hard wiring and operationalize concurrent monitoring where possible.

PN - Increased compliance but continue to have opportunities for maximizing goal
Target for end of year 2011 – 95% or greater.


SCIP - Results continue to present opportunities to improve, although improvement is being made. Target is solid – 95% for All or None Bundle by end of year.

Responsible parties:
AMI - Physicians, AMI team members, Best Care Council, Social workers

HF - Accountability physicians , nursing staff, heart failure team, Social workers

PN - Physicians, Nurses, Pharmacy input. Pneumonia team, facility leaders, Social workers

SCIP - Accountability Physicians, Nursing staff, pharmacy, Anesthesia, Pre-Admit staff, SCIP team,

Support / Resources:
AMI - Strong Admin support - Chiefs of Cardiology and Internal Medicine Physician and Physician Champions as well as nursing staff

HF - Strong Administrative support, Chiefs of Cardiology and Internal Medicine, Physician Champion, Best Care Council and Nursing support, nursing leadership support,

PN - Strong Administrative support, Physician Champion, Best Care Council, Nursing support, hospital leadership

SCIP - Administrative support, Physician and nurse managers , hospital leadership, physician champions , Best Care Council

Evaluation of Our Progress:
AMI - All or None bundle had been 97% end of Year 2010 – Statin had been 100% - Reeducation of Cardiologists, Internal Med MD’s and Nurses. By end of 3rd quarter 2011 All or None bundle was 97.22%; Statin prescribed at discharge was 100% ; Beta Blocker at discharge was 100% Monthly we present individual and cumulative reports for each core measure to the Best Care Councli (multidisciplinary council composed of unit based educators, physician champions, leadership, quality, risk and patient safety representatives, pharmacy leadership, etc) – Comparative reports – demonstrating outcomes of all facilities within the system are reviewed as well as State and national benchmarks. Opportunities to improve outcomes are addressed and action plans put in place. This occurs for all core measures.

HF - Progress is evaluated monthly at BUMC Best Care Council. (multidisciplinary council) Strategies for improving process discussed and accountability assigned. Discharge “Pause” form developed to be used as a tool for hand off communication per shift to remind oncoming nurse of what remains to be completed to ensure meeting the core measure.
In addition, Care Coordination has partnered with the health care team to address core measure compliance in twice weekly huddles on the units.


PN - Progress is evaluated monthly at BUMC Best Care Council. (multidisciplinary council) Strategies for improving process discussed and accountability assigned.
Nurse managers where appropriate invited to Best Care to discuss action plans for unit.

SCIP - Progress is evaluated monthly at BUMC Best Care Council. (multidisciplinary council) Strategies for improving process discussed and accountability assigned.

 

Date Submitted: 2011-10-31

Actions required:
SCIP: Antibiotic within 1 hour of incision. 98.8% (81/82)
Intervention: Reinforce with OR staff need to verify antibiotic selection and timing during the surgical time out process. Academic detailing for involved MD and RN. Reminder posted in OR locker room and on the anesthesia board.

PN2: Pneumococcal vaccine 94.4% (34/36)
Intervention: Concurrent monitoring by HCI with intervention when applicable. Nursing’s daily chart check expanded to include review of vaccination status.

PN5C: Antibiotic within 6 hours of arrival 94.4% (17/18)
Intervention: Academic detailing for involved RN stressing the need for a sense of urgency when administering the initial dose of antibiotics.

PN6: Antibiotic selection for Non-ICU patients 87.5% (14/16)
Intervention: Academic detailing for involved MDs. Case referred to pneumonia team meeting or process review.




Timeframe for completion:
SCIP 100% compliance with SCIP all-or-none bundle by 4th Q 2011.

PN2: 100% compliance with SCIP all-or-none bundle by 4th Q 2011.

PN5: 100% compliance with SCIP all-or-none bundle by 4th Q 2011.

PN6: 100% compliance with SCIP all-or-none bundle by 4th Q 2011.

Responsible parties:
Team Leads, OR staff, Physician champions, HCI

Support / Resources:
Physician champions, HCI, Senior leadership

Evaluation of Our Progress:
SCIP Hospital Quality/Best Care Committee using Midas reports and data
SCIP Committee Meeting, monthly and Hospital Quality/Best Care Committee using Midas reports and data

PN Hospital Quality/Best Care Committee using Midas reports and data
PN Physician Champion and Nursing Champion

 

Date Submitted: 2011-11-08

Actions required:
AMI - maintain 100%

HF - Medication Reconciliation Team re-established to review and identify issues related to process failure. Met with appropriated physicians and discussed why copies of prescriptions would not meet requirements for compliance. Reviewed requirements with physicians and staff. Form revised to make sure instructions are clear and precise.
Flyers posted to remind staff of requirements. Will continue to monitor.


PN - Each case is evaluated using RCA methodology to identify opportunities for improvement. The initial diagnosis for CAP was inclusive on admission and physician was concerned regarding overuse of antibiotics. Physicians have agreed to be proactive by using high index of suspicion to treat until diagnosis is ruled out.
Antibiotic Selection for ICU patient was related to the late diagnosis. 1st chest x-ray did not indicate pneumonia. Will continue to monitor


SCIP - Physician used order set from office instead of hospital order set. Office Order set was outdated. Physician’s office staff notified and all office order sets replaced with appropriate antibiotic selection. Antibiotic List posted in all OR Suites and provided to physician offices.

Timeframe for completion:
AMI- Maintain

HF - Completed 10/27/11

PN - Completed 10/1/11

SCIP - Completed 10/1/11



Responsible parties:
AMI - Emergency Department physician and staff,

HF - Hospitalist, Med/Surg Manager, ICU Manager, HCI

PN - Emergency Department physician and Hospitalist.

SCIP - HCI staff provided antibiotic list to physician’s office. Physician Champion authorized changes to order sets in office. OR Director responsible for posting Antibiotic list in the ORs.

Support / Resources:
AMI - Physician champions, CNO, HCI

HF - Physician Champion,CNO, HCI

PN - HCI Director, Administration,Physician champions,Nurse Manager

SCIP - CNO, Physician champion, Nurse manager, nursing leadership

Evaluation of Our Progress:
AMI - Maintain 100% with measures currently in place

HF - 100% compliance since forms changed and physicians educated on requirements.
Physicians benchmarked against each other and other hospitals within system.

PN - 100% compliance since education completed. Data reviewed monthly by physician and all system hospitals

SCIP - 100% compliance since new order sets implemented. All data is reviewed monthly comparing physicians within the facilities and hospitals within system.

 

Date Submitted: 2011-11-10

Actions required:
Working in CPSI system to learn Core Measure program which electronically gathers data; learning ad hoc reporting in CPSI system.

Timeframe for completion:
By next quarter

Responsible parties:
Nursing Administration

Support / Resources:
Admin

Evaluation of Our Progress:
Data reports

 

Date Submitted: 2011-11-14

Actions required:
All:
PHYSICIAN OUTLIER INTERVENTIONS
• Accountability via progressive discipline plan starting with November outliers. The first outlier will result in an educational letter to the provider; a second outlier will result in a phone call from a medical staff or administrative leader, the third outlier will result in an invitation to the Medical Staff Quality Committee for discussion. TIMEFRAME: Complete / in place now and on-going monthly
• An educational core measure brochure has been developed and placed in all of the Physician Lounges’.
TIMEFRAME: Complete / in place now
• At the March Medical Executive Committee meeting, the group approved the Best Care Committee recommendation to begin posting the physician outlier names in the Physician’s Lounge.
TIMEFRAME: Complete / in place now and on-going monthly
NURSING OUTLIER INTERVENTIONS
• Roll out of real-time core measure check sheets has taken place among all of the inpatient nursing units for concurrent reviews
TIMEFRAME: Complete / in place now in all nursing areas
• On-going audits and spot checks regarding appropriate use of the core measure check sheets is on going with results being e-mailed to the appropriate nurse manager, nurse director and HCID for follow-up.
TIMEFRAME: In place now and on-going weekly
• Nurse Managers will continue to receive regular communications regarding outliers identified / abstracted that took place on their unit with the expectation that they will complete a drill down analysis and bring that information to a weekly core measure meeting (every Tuesday)
TIMEFRAME: In place now and on-going daily
• Summary report of the drill down information reported at the weekly core measure meeting will be consolidated into a report card that the nursing directors or HCID will use to report outliers, root causes and process corrections at the weekly 1:00 Director Productivity Meeting (core measures will be reported every Tuesday).
TIMEFRAME: In place now and on-going weekly
• HCI worked with Access Services in accurately entering the patients’ admitting diagnosis into Meditech to facilitate improved accuracy in the daily core measure report sent out by HCI.
TIMEFRAME: Complete

PHARMACY INTERVENTIONS
• Pharmacy has worked with nursing to improve the accuracy of identifying newly admitted AMI, CHF and PNE core measure patients in the Meditech Admission History module. This report is generated every morning and refreshed each afternoon for pharmacy review. Newly admitted PNE patients will be reviewed by pharmacy for the appropriate abx selection for core measure compliance. AMI and CHF patients will have their existing medications reviewed for the presence of ASA, BB, ACE/ARB and STATIN. A progress note to the physician will be left in the record if a medication is missing, prompting their documentation of a contraindication or reminder to order.
TIMEFRAME: In place now and on-going daily.
• Pharmacy now identifies all SCIP patients for review of abx discontinuation and VTE orders.
• TIMEFRAME: In place now and on-going.
• Pharmacy has incorporated core measure compliance goals into all pharmacists’ annual performance evaluation process.
TIMEFRAME: In place now and on-going annually


Timeframe for completion:
All - Noted with each action above under Actions Required

Responsible parties:

All:
Monthly oversight / management is conducted through the local Best Care Committee, which reports to the Medical Executive Committee. Ongoing compliance efforts are the responsibility of the Charge Nurses on the floor, the Nurse Manager, Nurse Director, HCI Director, COO/CMO, Pharmacy Manager and Pharmacy Director.

Support / Resources:
All:

As Noted under Responsible Parties

Evaluation of Our Progress:
All:
Evaluation of our processes is taking place via daily House Supervisor core measure audits with findings for follow-up communicated each morning.

 

Date Submitted: 2011-11-14

Actions required:
AMI: Achieve and maintain 99% or greater compliance.

HF: Achieve and maintain 99% or greater compliance.

PN: Achieve and maintain 99% or greater compliance.

SCIP: Achieve and maintain 99% or greater compliance.

Timeframe for completion:
AMI, HF, PN, SCIP: Ongoing to maintain success

Responsible parties:
AMI, HF, PN, SCIP - Physician champions, HCI dept, nursing leaders on each team

Support / Resources:
AMI, HF, PN, SCIP - Physician champions, HCI dept, nursing leaders on each team

Evaluation of Our Progress:
AMI, HF, PN, SCIP - Physician champions, HCI dept, nursing leaders on each team

 

Date Submitted: 2011-11-15

Actions required:
Continue with concurrent review that began last quarter to maintain those gains. TO improve physician driven measures, we did a series of orientations with new Texas Tech residents and new physicians on the medical staff in July. We continue to do orientation with new physicians as they are brought on staff. In September, a new Hospitalist on staff took on the challenge of developing order templates for 20 different diagnoses.These included some of the Core Measures, and QM worked with the Hospitalist to include the specific measures in the order sets.

Timeframe for completion:
Most oreinetation sessions were concluded in July; however, new physician orientation is on-going.

Responsible parties:
All the Core Measure abstractors.

Support / Resources:
Received a lot of cooperation from the Hospitalist Program, Medical Staff office, and Physician Relations' coordinator in bringing new physicians to the Quality Mgmt office for orientation. The QI COmmittee of the Board also got involved in improving compliance by bringing in a surgeon who was historically non-compliance with DVT prophylaxis, and having him explain why he was not compliant.

Evaluation of Our Progress:
Heart Failure compliance continues to be 100% in all measures. DVT prophylaxis is improving; although it is not yet up to the CMS national average.

 

Date Submitted: 2011-11-22

Actions required:
AMI: Continue monthly reporting at hospital best care, staff meetings, MEC and Board of managers. Include transparency with opportunities for improvement. Display outcomes presentation in staff lounges. Provide monthly newsletter including “Core Measure” updates. Identify trends and action plans related to any identified trends. Provide notification to physicians and staff when an OFI occurs. This process is through email and USPS certified mail


HF: Continue monthly reporting at hospital best care, staff meetings, MEC and Board of managers. Include transparency with opportunities for improvement. Display outcomes presentation in staff lounges. Provide monthly newsletter including “Core Measure” updates. Identify trends and action plans related to any identified trends. Provide notification to physicians and staff when an OFI occurs. This process is through email and USPS certified mail


PN: Continue monthly reporting at hospital best care, staff meetings, MEC and Board of managers. Include transparency with opportunities for improvement. Display outcomes presentation in staff lounges. Provide monthly newsletter including “Core Measure” updates. Task force developed to improve compliance with influenza and pneumococcal vaccines. Multiple hard wire processes have been implemented including a daily report of eligible patients with f/u from charge nurse and house supervisor. Provide notification to physicians and staff when an OFI occurs. This process is through email and USPS certified mail


SCIP: Continue monthly reporting at hospital best care, staff meetings, MEC and Board of managers. Include transparency with opportunities for improvement. Display outcomes presentation in staff lounges. Provide monthly newsletter including “Core Measure” updates. A task force was developed to improve all areas where there are opportunities to improve. Provide notification to physicians and staff when an OFI occurs. This process is through email and USPS certified mail




Timeframe for completion:
All Core Measures - Concurrently and ongoing




Responsible parties:
All Measures - HCI, Supervisors, clinical staff, house supervisors, ACNP, pneumococcal/influenza task force, pharmacy, task force was developed to improve all areas where there are opportunities to improve.

Support / Resources:
All Measures - Physician and Senior Leadership, Nursing Leadership and HCI

Evaluation of Our Progress:
Evaluations of these processes begin with staff, hospital best care, medical executive committee and the board of managers. Our results are also reviewed by the healthcare system best care and the healthcare system board of managers.

 

Date Submitted: 2011-11-22

Actions required:
AMI - Achieve and maintain 99% or greater compliance.

HF - Achieve and maintain 99% or greater compliance.

PN- Achieve and maintain 99% or greater compliance.

SCIP - Achieve and maintain 99% or greater compliance.

Timeframe for completion:
All Core Measures - concurrent and ongoing

Responsible parties:
All Core Measures
Physician Leadership, Senior Leadership, Nursing and HCI

Support / Resources:
As noted above

Evaluation of Our Progress:
Best Care summary reports, Midas, benchmarking

 

Date Submitted: 2011-11-22

Actions required:
Q311-AMI-Continue our work with the AHA on STEMI projects through Mission;Lifeline. Continue team meetings within a week after each STEMI to analyze case and look for all opportunities to improve.

Q311-HF-Discharge instructions rate 80% of 5 patients. Q211 we implemented the EXIT CARE discharge instructions program to improve educational materials that could be sent home for all diagnosis. We found the ability to tailor information to the patients presented a challenge for hardwiring CHF discharge instructions. Further during Q311 we found that selection of other diagnosis that are related to CHF such as pleural effusion had to be locked so that specific data elements were not removed or altered on the patients discharge instructions. The ability to tailor our instructions for our patients was the reason we selected the program but is also the reason our rate has dipped. Quality is working with Education to disemminate information to the nurses to recognize related diagnosis groups to CHF and verify all 6 data elements are included on all discharge instructions. We would like to see concurrent coding become part of our effort but that is not possible @ this time for this facility. Physician outliers for medication lists continue to be problematic and those are to continue to go to physician peer review.
PN-Q311-Maintain our scores @ 100%, A 4-part series of articles was written and distributed with The Hospitals newsletter this summer, ending with a kick off for the return of the seasonal flu vaccine measure.
SCIP-Q311 Improve rates for
Abx within an hour of surgical incision 98% of 54
Abx selection 96% of 54
Home BB patients receiving BB within 24 hrs of anesthesia end time 90% of 11
Physician outliers are the main source of failure related to Abx selection. We will continue to go to physician peer review with physician failures. CABG patients are the only outlier related to Abx timing therefore it has been decided that once the Abx is started for a CABG the hang time is to be verbalized and a time alarm set for 55 minutes at which time the surgeon may opt for redose as appropriate if the incision has not been made by then. FMEA was done with preop and intraop personnel to initiate a process to improve BB administration. Common BB lists were done on red paper and laminated. Patients identified @ preadmission as being on a BB @ home have the laminated red sheet placed in the front of their chart and anesthesia personnel have been educated to verify the last dose on the pre-anesthesia record. In addition Pharmacy has become involved with Abx selection during order verification for both SCIP and PN measure sets.


Timeframe for completion:
Changes in processes in Q311 for all measures are in place currently and are being evaluated on an ongoing basis to be able to adjust as necessary to meet the challenges of continual change.

Responsible parties:
Quality-Monitor processes
Physicians-Comply with measures
OR personnel-Follow processes to identify abx selections, timing of abx and BB
Floor personnel-Follow processes to relay correct information to patients, verify with quality when tailoring instructions to avoid dropping data elements.
Education Nurse
Charge Nurses
Pharmacy personnel

Support / Resources:
Admin
Pharmacy
Physician
Nursing
IT

Evaluation of Our Progress:
Data is reported to the medical staff on quarterly basis. Rate reports are broken down to be physician specific as well as the core measure rate that goes out to HHS.gov
Small volume hospital must set goal @ 100% as one miss can pull our rate to less than the medicare compliance rate.
The progress while reported quarterly is analysed biweekly to catch errors or offenders of the new system as well as daily concurrent review to invoke immediate correction and direction of care for our patients.

 

Date Submitted: 2011-11-29

Actions required:
We have asked our core measure coordinator who completes the concurrent review to assist the nursing staff in completing the HF discharge teaching if the need arises to due increased patient load, etc. This will also incorporate teamwork versus leaving it to fall on one individual.
We plan to have our marketing department make signs to post throughout the facility to increase awareness of CHF discharge instructions as well as place letters in physician boxes to ensure that they are aware as well.
We are going to medi-tech 6.0 in February and will hopefully have a system in place on the discharge disposition for patients with a diagnosis of CHF that prompts the nurse to give teaching instructions. We are also thinking of doing a checklist that must be signed by two caregivers to ensure that all elements of the discharge process are covered including the home med list.

Timeframe for completion:
We would like for our signage from Marketing to be up by January 1, 2012. Our core measure coordinator has already started on concentrating on HF 1 during concurrent review and has initiated several of the teaching processes to ensure it is completed and to facilitate teamwork. Our goal is to have 100% on HF teaching by the end of 1Q2012 and to maintain the 100% for HF-1.

Responsible parties:
We are all responsible in ensuring that our patients are educated to their particulr diagnosis.
Marketing will be responsible for the signage
Core measure coordinator- will be responsible for ensuring the teaching is complete prior to discharge through concurrent review
Nursing staff caring for patient are responsible for doing the discharge teaching.
Discharge nurse- responsible for all elements on the discharge disposition including patient teaching.
Charge Nurse- would be responsible to double checking all elements prior to patient being discharged.
IT department- responsible for building element in discharge disposition to remind staff that HF teaching needs to be complete prior to discharge.

Support / Resources:
Our core measure team consists of Nursing Directors, VP of Quality, CNO, Core measure team leader and core measure coordinator. Everyone plays an important role to ensure that front line staff are educated and aware and support from administration is always available. This team meets on a monthly basis but does have indepent break out meetings as needed for certain core measures.

Evaluation of Our Progress:
Will present this PIP report to the next Core measure meeting and use to determine a hard wiring process. Will also research what other peers are doing at different facilities to meet this measure at 100%.

 

Date Submitted: 2012-01-18

Actions required:
I.Actions - Urinary Catheters
•Implement best practice reminder to alert physician and nursing staff to remove the urinary catheter by POD2 or to document reasons for continuing to keep the urinary catheter in place
•Revise Procedure Specific Antibiotic prophylactic order sets to include an area to document reasons for keeping the urinary catheter in place
•Nursing leadership re-educating nursing staff urinary catheter guidelines
•Nursing staff utilizing SBAR report to communicate the time the urinary catheter was inserted
•Nursing staff actively calling physicians to pursue discontinuing the urinary catheter or if reasons exist for not discontinuing the urinary catheter information is clearly documented
•Internally, our organization is revitalizing and restructuring the Core Measure teams to enhance frontline staff engagement and improve multidisciplinary collaboration

II. Actions - Beta blockers
•Individual cases reviewed by SCIP Champions and team members
•Current EMR system reviewed to determine appropriate fields where text documentation capability exists to support beta blocker documentation
•Physician and nursing staff educated on EMR fields that are available for documentation of beta blocker usage.
•Physician and nursing staff educated on required documentation to include date and time the patient took last dose of their beta blocker
•Internally, our organization is revitalizing and restructuring the Core Measure teams to enhance frontline staff engagement and improve multidisciplinary collaboration



Timeframe for completion:
September 2011

Responsible parties:
SCIP Physician Champions, Surgeons, Nursing, Anesthesiology, Quality Management Services

Support / Resources:
Administration, Quality Dept.

Evaluation of Our Progress:
SCIP Core measure outcome reports and Quality Scorecards are utilized to determine progress on specific SCIP metrics and identify performance improvement opportunities. Monthly reports are disseminated to Service Line, Quality Review and Performance Improvement Committees to highlight progress on SCIP metrics and identify performance improvement opportunities.

 

Date Submitted: 2012-01-18

Actions required:
Performance Improvement concurrent review nurses will meet with Emergency Department leadership every Monday to review any potential core measure fallout patients from the prior week to do a drill down to determine if documentation is located, if not, what went wrong with process and how do we prevent it from happening again. Nurses involved in a fallout will be required to attend an educational course titled PI Boot Camp where core measure best practices are a part of the course materials.

A new educational program is being designed and implemented for ICU staff regarding a needs assessment for foley catheters and the criterial for removal.

All Physician related fallout issues will be reported to the CMO for one-on-one meetings regarding requirements.




Timeframe for completion:
The interaction with the Emergency Department began on May 23, 2011 and will continue weekly until such time as their processes become more stable regarding timing sequence of care and appropriate documentation.

The foley educational program for ICU will be ready for implementation by June 3, 2011.

Individual Physician reporting for one-on-one discussions to CMO began May 2, 2011.

Responsible parties:
Weekly review meeting in Emergency Department will involve PI concurrent nurses, and Emergency Department director and manager. Other staff may be called in, as needed.

The SCIP concurrent review nurse will work with our Infection Control Preventionist as well as the ICU director and managers regarding needs assessment and foley removal in the ICUs.

The PI concurrent nurses will noticy the CMO of physician issues and CMO will schedule one-on-one meetings with the physicians involved.

Support / Resources:
We continue to have the support of administration, nursing leadership, physician champions and our shared governance team. Information is also reported to the Quality and Safety Council which is an interdisciplinary membership committee which includes physicians, nursing, administration, and board of trustee members.

Evaluation of Our Progress:
As we have stated previously, the educational opportunities just never go away. Staffing may have nurses rotating from their normal units. While they may be aware of the criteria for one type of core measure patient, they may not be as aware of the criteria for another type of core measure. Therefore, we must continue to be vigilant in providing as much information as possible to as many staff members as possible and is as many ways as possible to promote good learning tools. We are making progress but know that we cannot become over confident or comfortable that best practices will always be followed.

 

Date Submitted: 2012-02-02

Actions required:
HF-Quality has injected themselves into the daily charge nurse, casemanagers meeting to identify patients that could potentially fall into this population. This last quarter patients identified by Quality are given their CHF teaching during their stay to reduce the patient being overwhelmed with information at the time of discharge. Medication reconciliation for patients identified as potentially falling into the CHF population the physician is required to list each medication out on his discharge orders. The nurses are to use only the list on the orders for their discharge medication. A physician who adds a medication on the discharge summary not included on his discharge orders is subject to progressive disciplinary action. A first offense results in notification that a second offense will go to peer review.
Nurse educator is being requested to do a series of educational events at regular staff meetings on medication reconciliation to give the staff tips for success.
SCIP-BB are analyzed as most frequently missed by nursing NOT being compliant to filling in the last dose a patient has taken a medication. With the EMR system that has been implemented starting Jan 2011 we have requested our IT to build a query that will be sent daily to Quality that shows if the last dose taken was filled in and who the staff member was that was filling out the form. Progressive discipline from immediate managers will be taken managers are notified the morning of the missing information many times before the patient leaves OR, giving us the ability to have anesthesia order the BB for the patient.

Timeframe for completion:
HF-Q411 Quality began attending the daily charge nurse / case management meetings this has had a great impact in getting ready for the new Global IMM measure beginning Jan 2012 as we address PN and FLU vaccine status for each patient as we go through the list of patients.
SCIP-Q411 IT built and implemented the daily report sent to Quality for Last Dose Missing report. The report takes some analysis as preop nurses adding information to the patients record the day prior to surgery come out on the list, we will be working with IT to see if we can resolve that and tweek the query. Thus far we were able to catch 2 patients that could have potentially failed the data element.

Responsible parties:
Quality-Monitor processes
Physicians-Comoliance and champion support
OR personnel-Follow processes to identify BB prior to arrival
Floor personnel-Follow processes to relay correct information to patients, verify with quality when tailoring instructions to avoid dropping data elements.
Education Nurse
Charge Nurses-support monitoring processes and precepting new hires
Pharmacy personnel
Nurse managers-Compliance with discipline measures if required

Support / Resources:
Admin
Pharmacy
Physician
Nursing
IT


Evaluation of Our Progress:
Monitoring reports are broken down to catch errors by staff regardless whether they are physcians, nursing or support staff and redirect the error to teach the staff the best practices on a real time basis.
Small volume hospital must set goal @ 100% as one miss can pull the rate to less than the medicare compliance rate.
The progress of the new processes are analyzed daily while the progress of our hardwire processes that have proven themselves to maintain reliability are monitored and reported quarterly and/or biweekly to catch errors or offenders of the new or old systems as well as daily concurrent review to invoke immediate correction and redirection of care for our patients.

 

Date Submitted: 2012-02-11

Actions required:
HF measures: New physician educated on documenting "see home medication list" on discharge summary, instead of re-listing the medications on discharge summary.
SCIP measures: letter of non-compliance to staff & physician re. abx continued past the 24 hr cut-off time, with no documentation of infection.

Timeframe for completion:
Completed during Qtr 3, 2011.
Since that time, these measures have been 100%.

Responsible parties:
Responsible parties are CMO, CNO, Quality Director.

Support / Resources:
CMO & CNO have been instrumental in their support.

Evaluation of Our Progress:
Since the processes above have been implemented and these instances of non-compliance have been addressed, these measures have been at 100% compliance.

 

Date Submitted: 2012-02-14

Actions required:
Heart Failure: Discharge Instructions-Medication reconciliation discrepancies (transcription error and uniformity with educational tools)
Practitioner discharge medication orders were documented by the discharging practitioner and were transcribed by the discharging nurse. The transcribed list of medications was given to the patient and used as their source of medications instructions to follow at home. The problem identified was transcription error. Medications were found to be missing, duplicated, or added in error on the final medication list given to the patient being discharged. Staff practitioners and nurses were educated by the heart failure quality coordinator about the importance of discharge medications. A “buddy check” system was implemented as a means to compel the discharging nurse to slow down during the discharge process and double check the medication list prior to discharge.

Heart failure educational pamphlets, booklets, checklists, and packets differed from unit to unit. These educational tools were available throughout the hospital, however not all units had the most recent up- to- date materials for their patients. This gap was addressed by the multidisciplinary team and up current heart failure educational tools were distributed throughout the hospital.

SCIP: Discontinuation of Foley no later than POD 2
The SCIP Team reconvened to address identified gaps in our process. It was decided to place a pink sticker on the Foley bags when the patients leave the PACU with the day of surgery documented on the sticker. The pink sticker serves as a reminder to the nursing staff when the Foley should be removed.

A stamp is placed on the Physician Order sheet once the patient reaches the nursing unit to guide the physician to document a reason to medically continue or discontinue a Foley. This stamp is signed by the physician the morning of POD# 2 if there is no other order directing the fate of the Foley. Most surgeons have tailored their pre-printed post operative orders to include an order directing the removal of the Foley on POD 1 or POD 2. A nurse is designated (usually the Charge nurse or manager) for every nursing area to perform daily Foley catheter surveillance on every patient to ensure the Foley catheters are appropriately ordered. If discontinuing the Foley is in the best interest of the patient, the physician is then contacted.


Timeframe for completion:
The SCIP and Heart Failure team continues to meet monthly to monitor the outlier drill downs for any patterns. During 4Q2011 the outliers that did occur, which were fewer than the previous quarter showed no trend. All related teams will continue to meet on a monthly basis.

Responsible parties:
• Pharmacy
• Surgical Services (OR, PACU)
• Women Services Department (GYN)
• Medical/Surgical Units
• Intensive Care Units
• IT&S
• Core Measures PI Coordinator


Support / Resources:
CEO, CNO, CMO, and CFO, President of Medical Staff (Overall Core Measure Physician Champion), Medical Director of Core Measures (Hospitalist), VP of Clinical Performance Improvement, Quality Director, PI Supervisor, Pneumonia and SCIP Team, Concurrent Reviewers, Clinical Support Staff Leaders/Directors, Core Measure Oversight Committee

Evaluation of Our Progress:
After implementing the action items for Surgical Care Improvement Project –Discontinuation of Foley no later than Post-op Day 2, we have seen an increase in our compliance rate. We have increased our percentage from 89.1% in 1Q11 to 93.1% for 2Q11.

We have also seen a tremendous increase in our heart failure discharge instructions after the process put in place for the medication reconciliation component of that indicator from 98.9% in 1Q11 to 99.0% in 2Q11.

Our plan is to continue to strive toward a 100% compliance rate for both indicators with the action items put in place 2Q11. Physician engagement and awareness has increased as well as accountability. We will continue to make accountability a high priority for all levels of our facility. Leadership has been very supportive of all efforts put in place to provide the best quality of care for our patients.

 

Date Submitted: 2012-02-14

Actions required:
The following were used to implement changes to improve core measure scores for HF, PN, SCIP and IMM.

HF: daily chart review to identify patients with CHF. Order protocol is engaged for patients identified with CHF. Any existing echocardiogram is placed on patient chart for the physician. Chart review identifies if patient is a candidate for ACE/ARB therapy, if it is on their home medication list, and if they are receiving it while an inpatient. Physician is notified if medication is indicated and not currently prescribed.

PN: concurrent chart review focusing on antibiotic selections. Commonly used antibiotic regimens are supplied to physicians on laminated cards and are posted at each physician workstation and dictation desk. The antibiotic selections and any cases not meeting the numerator are discussed at Medical Staff meeting every other month.

SCIP: all inpatient surgical charts concurrently reviewed. Daily rounding with surgical patients by utilization review to monitor status and communicate with physician.

IMM: preparation for core measure beginning 2012. Pre-printed order sets for the screening and administration of Pneumonia and Influenza vaccine reveiwed by Medical Director/Chief of Staff and distributed to all admitting physicians for review and approval. Presentations given at Nurse Staff Meetings with each shift and information posted on nurse bulletin board.

Timeframe for completion:
HF: Goal for completion is to be 100% by Sept 1, 2011. Daily rounding and chart review processes will remain implemented.

PN: Goal for completion is to be 95% by Sept 1, 2011. Daily rounding and chart review proceses will remain implemented.

SCIP: Ongoing effort to remain in place. Goal is 100% for 4th quarter 2011.

IMM: Goal for order approval by physicians is November 2011. Implementation of pre-printed order sets will begin December 2011 with staff training, nurse education, and concurrent chart review to evaluate progress.

Responsible parties:
HF: Concurrent chart review and physician communication by Quality Improvement nurse.

PN: Concurrent chart review and physician communication by Quality Improvement nurse. Maintenance of dictation desk references by Health Information Management Department.

SCIP: Concurrent chart review by Quality Improvment Nurse. Daily rounding and physician communication by Utilization Review nurse.

IMM: Preparation and updating of order sets by Quality Improvement nurse in conjunction with Physician Chief of Staff. Nursing team leaders, nurse manager, and DON trained by QI staff on the new measure sets and guidelines. Pharmacy involved in reviewing orders and ensuring proper strengths, dosages, and administration considerations for varying population age. Admission nurse is responsible for screening the patient for need of vaccine and for initiating the set protocol for ordering the vaccine. Physicians will e-sign each vaccine order through the electronic medical record and the discharging nurse will be responsible for ensuring that the vaccine has been administered during the hospital stay. The Medical-Surgical Nurse Manager will internally monitor and report to QI through monthly reports the rate of appropriate screening, order entry, refusals to vaccine, and administratio prior to discharge.

Support / Resources:
HF: All physicians collaborated on implementing process for evaluating all CHF patients to ensure LVSD is addressed. Charge nurses for each shift are responsible to make sure protocol has been followed for each CHF patient.

PN: Physician Chief of Staff works with peers and reviews records not meeting criteria when notified by QI.

SCIP: All physicians support concurrent chart reviews.

IMM: Support from CEO, DON, and physicians.

Evaluation of Our Progress:
HF: Goal met, 100% for evaluation of LVSD and prescribing ACE/ARB therapy.

PN: Goal met, 100% for CAP antibiotic selection guidelines.

SCIP: 1 chart did not meet criteria, reviewed with surgeon and attending physician. Surgical unit education session to address SCIP criteria and key points to pass along when reporting to other units.

IMM: Internal review of screening process and order entry at 66%. Implemented changes and staff education. Concurrent chart review to address incorrect screening data while still inpatient. Reviewed criteria and guidelines at Nurse Staff Meetings for all shifts to improve before mandatory reporting period begins.

 

Date Submitted: 2012-02-14

Actions required:
Initiative Type: Improve upon existing system

- Mandatory education for nursing staff for all the core measures
- Daily review with nursing staff of concurrent core measures on nursing units
- Monthly medical staff meetings include core measure discussion
- Begin mandatory “Clinical Practice” meetings for nurses to explain actions when core measures fail.

SCIP:
- Recruit and retain surgeon champion
- Create / Implement new SCIP resource guide for nursing staff
- Reminders to physicians and nursing staff for foley removal and need for VTE prophylaxis

HF:
- 1:1 nursing education regarding the discharge process
- 2 nurses to check discharge paper work for completion and accuracy
- Coders to inform abstractor of chart with HF dx when available for early review of D/C summary


Timeframe for completion:
SCIP:
- Surgeon champion to be recruited by Aug. 2011
- Reminders for foley removal / VTE prophylaxis daily as needed and ongoing
- Aug. 2011: SCIP Reference guide completed, ready for use
- Sept 2011: Mandatory nursing education including SCIP measures

HF:
- 1:1 nursing education regarding HF discharge process continues as new employees are hired
- Coders to begin contacting abstractor July 1, 2011, will be ongoing
- Sept. 2011: 2-nurse discharge process to begin
- Sept. 2011: Mandatory nursing education including HF measures


Responsible parties:
SCIP:
- Physicians responsible for completion of order or documenting contraindication for foley / VTE prophylaxis
- RN (primary care or charge RN) responsible to notify physician for foley / VTE prophylaxis order if needed
- Quality Director led mandatory SCIP education
- Quality Analyst (Concurrent Reviewer) responsible for daily education

HF:
- Quality Analyst responsible for ongoing staff education
- Quality Director led mandatory Core measure education
- Primary care RN & Charge RN responsible for 2-nurse discharge process
- Coders responsible for notifying abstractor when charts with dx of HF are available
- Quality Analyst responsible for early review of charts


Support / Resources:
- Quality Analyst (Concurrent Reviewer)
- Director of Quality
- Physician Champions
- Core measure reference guides


Evaluation of Our Progress:
- HF scores were maintained at 97% into 4th quarter.
- Foley catheter removal scores improved; VTE prophylaxis scores dropped slightly.

 

Date Submitted: 2012-02-15

Actions required:
Noted to have some new employees on the Nursing Unit which required individual education sessions. Unit specific orientation to include a separate education session on SCIP guidelines and order sets.

Timeframe for completion:
Completed immediately upon data analysis of fallout. Charts are reviewed daily for process completion. Immediate discussion with unit manager who in turn meets individually with the employee for re-education.

Responsible parties:
Department managers are responsible for unit specific orientation, and individual employee education needs.

Support / Resources:
Nursing Leadership is the available resource for this measure fallout due to its nursing process failure.

Evaluation of Our Progress:
Noted consistent improvement over time with this measure.

 

Date Submitted: 2012-02-15

Actions required:
AMI
Actions required- Initiative type (new process, redesign of existing system) and implementation strategy (methods to enhance adherence, compliance, repercussions of noncompliance).
• Began approval process for updated, evidence based, standardized order sets for Cardiac patients. The order sets will be mandatory in order to ensure compliance and the best outcome for our patients. Non-compliance to new order sets will be reported to our Medical Executive Committee as part of our monthly Core Measure Report.
Timeframe for completion: Implementation 1Q2012
• Noticed delays in notifying the Cardiologist on call and Cath Lab from the ED. Delays from non-interventionalist cardiologist notifying interventionalist. Implemented a concurrent running chart that is posted the day after the STEMI in the ED physician area, the ED nursing lounge, the Cath Lab physician area and Cath Lab nursing lounge. The running chart measures: Door to EKG, EKG showing STEMI to Cardiologist page and Cath Lab page, Cardiologist arrives in the ED, Patient leaves the ED, Door to Cath Lab, Door to Needle, Door to Balloon. This implementation created feedback from the doctors and opened lines of communication on process issues since the names of the team members are listed under each case.
Timeframe for completion: Implemented October 19th, 2011
• Noticed delay in transfer of 10-14 minutes from ED to Cath Lab. The delay was attributed to the elevator the staff take from the ED to the Cath Lab. A bid was submitted for a Rapid Response Panel and approved.
Timeframe for completion: February, 2012
Heart Failure
Actions required- Initiative type (new process, redesign of existing system) and implementation strategy (methods to enhance adherence, compliance, repercussions of noncompliance).
• Implemented a new computer program for discharge instructions. This new program should help with medication reconciliation and patient education /understanding. It will provide a more consistent and hardwired process.
Timeframe for completion: Implementation October 2011
Pneumonia
Actions required- Initiative type (new process, redesign of existing system) and implementation strategy (methods to enhance adherence, compliance, repercussions of noncompliance).
• Began approval process for updated, evidence based, standardized order sets for Pneumonia patients. The order sets will be mandatory in order to ensure compliance and the best outcome for our patients. Non-compliance to new order sets will be reported to our Medical Executive Committee as part of our monthly Core Measure Report.
Timeframe for completion: Implementation 1Q2012
SCIP
Actions required- Initiative type (new process, redesign of existing system) and implementation strategy (methods to enhance adherence, compliance, repercussions of noncompliance).
• Pilot initiated on Post Surgical Unit with revisions to current Urinary Catheter Order and process to simplify the current order for better understanding by the nursing staff and surgeons/physicians.
Timeframe for completion: After adequate education and feedback on the unit, pilot order initiated mid November, 2011. Data collected and will be pushed out house-wide 1Q2012.
• Began approval process for updated, evidence based, standardized order sets for DVT prophylaxis for all adult patients. The order sets will be mandatory in order to ensure compliance and the best outcome for our patients. Non-compliance to new order sets will be reported to our Medical Executive Committee as part of our monthly Core Measure Report.
Timeframe for completion: Implementation 2/6/2012



Timeframe for completion:
See Above

Responsible parties:
The Core Measure Coordinator/Nurse will oversee the re-evaluation of the processes on a monthly basis and report any issues to the Director of Quality and the CEO. Our Core Measure Teams meet monthly and the members responsible for implementing the weekly test changes communicate daily as needed. Additional team leader oversight of weekly initiatives have been added as content experts to help drive process changes and ensure hardwiring of processes.


Support / Resources:
-Core Measure Team members/content experts
-Director of Quality
-CEO, COO, CMO, and CNO are very active and provide support and feedback
-Directors for units are very engaged with Core Measures.
- Hospital Performance Improvement Committee. This committee will be the oversight to ensure progress in our Core Measures, HCAHPS, Infection Control, Regulatory and Accreditation initiatives.
-Medical Executive Committee provides a team of physician champions willing to meet with physician outliers to devise appropriate action plans for improvement. The physician peer review process has an accountability structure for physicians with Core Measure compliance issues.
-Board of Governors is provided a monthly report with our struggles and successes for their involvement, leadership oversight and support.
-Corporate Quality Department



Evaluation of Our Progress:
Evaluation of Our Progress:
• We are measuring changes to processes with simple evaluations for compliance
• We are receiving more feedback than in the past from physicians and nursing staff
• Developing closer working relationships with Directors and Unit Educators for improvements and feedback
• Monthly Core Measure meetings evaluate process for the last month and brainstorm on changes/improvements

 

Date Submitted: 2012-02-17

Actions required:
New process. Teach medical record staff where to put information.
Also teach nursing how to enter information


Timeframe for completion:
To complete by 6/1/2012

Responsible parties:
Chelsea Slayton RN, MSN
Melissa Ereman RN
Cindy Colgden MR director

Support / Resources:
Administration and nursing leadership

Evaluation of Our Progress:
Will use a report in background thru meaningful use tool to help track and trend

 

Date Submitted: 2012-02-20

Actions required:
Utilize electronic documentation format so that documentation of HF discharge instructions is done automatically electronically. Move away from all paper format to decrease rate of confusion as to whether or not the document was actually given.

Re-educate nursing staff on importance of HF discharge instructions for patient safety and compliance.

We have hired a Core Measure Coordinator to complete concurrent review and in the event there is a patient without HF teaching, she is to complete it and document it in the electronic medical record.

Timeframe for completion:
By the end of 1Q2012

Responsible parties:
Core MEasure Coordinator, Nursing staff

Support / Resources:
Administrative support and Core Measure team support is available.

Evaluation of Our Progress:
Concurrent review of ALL patients with a diagnosis of CHF to determine if teaching was completed. If teaching not completed, need to determine where it fell out at. If the patient was discharge during Mon-Friday during normal buisness hours, it should have been caught during concurrent review. If the patient discharged on the weekend then the discharging nurse should be held responsible.