Critial Path Network

Hospitalwide program results in top core measures scores

Case managers track compliance in ED, on units

Thanks to an intensive program monitoring the core measures requirements throughout the hospital, Methodist Medical Center has been ranked among the top three hospitals in the state of Tennessee for compliance with the core measures for two years in a row.

The Oak Ridge, TN, hospital received the ranking from Health Insights, a nonprofit Medicare Quality Improvement Organization, based on data from the Centers for Medicare & Medicaid Services (CMS).

Case managers in the emergency department and on the units monitor the core measures concurrently, working with the nursing staff and physicians to make sure the recommended care is followed and documented, says Coletta Manning, RN, MHA, CPHQ, director of clinical effectiveness and quality improvement.

The hospital began its core measures initiative with an extensive education program for physicians.

"We showed them what the core measures are, why they are important, and how we were going to be judged on our compliance. We talked about pay for performance and how much it will mean to the facility if we're in the top 10%," she says.

"We tried not to focus on the monetary incentive but rather show the physicians that core measures compliance is the right thing to do for the patient," she adds.

The case managers track the physicians' records when it comes to the core measures, documenting each time a core measure is missed.

In some instances, the case managers shadowed physicians, pointing out when the core measures were called for and occasions when the physicians needed to document that core measures had been implemented.

For the first six months after CMS began tracking the core measures, the case management department collected compliance data and gave them individually to each physician and nurse, to provide feedback for improvement," Manning reports.

After six months, the hospital began sending letters to the physicians, listing their failure to comply with the core measures and educating them on the importance of compliance. The letter becomes part of their employee files and can be used as part of the reappointment process.

Manning compiles the data and gives reports to the physicians, nursing, and the rest of the medical staff on a quarterly basis. The hospital also shares the information with companies with which it contracts for services.

Physicians in the emergency department who don't miss a core measure each quarter receive recognition and a small reward. In one recent quarter, three emergency department physicians had no deficiencies in meeting core measures. There also is a laminated guide in each chart for easy reference.

The case management staff posts reminders of the core measures goals in requirements in the emergency department, staff break rooms, and nursing stations.

In addition, the nursing department has a dashboard on each floor, showing how the unit is doing on each of the core measures appropriate for their patients.

When a core measure is missed, the case manager fills out a form that includes information on what was missed and why the particular treatment or procedure is important.

She gives the form to the manager, who passes it on to the staff person who failed to institute the core measure. The staff person has to respond to the manager as to why the core measure was missed.

The responses are discussed in the quarterly nurse quality meeting attended by the case managers and nurse managers.

"We look at the reasons that people aren't ensuring that the core measures were met and see if there are any process issues we can resolve," Manning says.

For instance, the nursing staff weren't always giving flu shots to eligible pneumonia patients.

"We changed our procedure so we don't need a physician order to give the flu shots. We developed a form with the criteria for pneumonia vaccination on one side and the criteria for influenza vaccination on the other. If the patient meets the criteria, he or she gets the shot," she says.

The case management department has standing time on the agenda at nursing staff meetings to talk about the core measures.

"Nobody wants to fail to give the patient the recommended care. We try to determine why they forget or what other barriers there are to care and determine if it's something we can fix," Manning says.

In addition to the core measures for pneumonia and acute myocardial infarction, the entire emergency department staff are working on getting patients with an acute MI who meet appropriate criteria to the catheterization lab in 90 minutes.

The team includes cardiologists, representatives from the catheterization laboratory, the emergency department manager, the emergency department case managers, and the case manager for cardiology.

Every month, the team studies the medical records of every patient who did not get to the catheterization lab within the 90-minute window.

"We look at every single patient to see what the holdup has been. We also look at those who did get there in 90 minutes to see what we did right," Manning says.

The staff found that the biggest challenge is getting the catheterization lab crew back to the hospital when it's after hours.

"Some of our cardiologists are not interventional cardiologists, and if one of them happens to be on call, it's also a challenge," Manning says.

Methodist Medical Center had already been tracking many of the core measures on the clinical pathways implemented in the early 1990s. The hospital has moved to an electronic version of the care plans, which include standardized order sets. The hospital has specific pathways for certain procedures and diagnoses.

"The core measures were not really new to us. Many had been on our Care Trax since 1992, and we already had physician buy-in for the practices. We have put a lot of things in play to make it better, but we don't have 100% compliance. We're getting there, but until we implement the core measures 100% of the time on every eligible patient, we won't be satisfied," Manning says.