Proven solutions for two low-compliance areas

Areas deal with pneumonia, CHF patients

The Joint Commission's 2007 report "Improving America's Hospitals: A Report on Quality and Safety" had some good news — hospitals are achieving 90% or better on about half the quality measures tracked since 2002.

But there are two measures with less than 65% compliance: providing pneumococcal vaccination to patients admitted with pneumonia, and providing discharge instructions to patients admitted with congestive heart failure (CHF).

Both measures are complex because they require buy-in and participation from nurses and physicians, says Becky Heinsohn, director of hospital quality improvement for TMF in Austin, TX.

Hospitals that mandate concurrent review, with a designated individual responsible for following up with physicians and staff to ensure all measures are addressed, are more likely to perform well. "When nursing management and staff are held accountable for these measures in their performance evaluations or through incentives, financial or otherwise, compliance improves," she says. "In addition, when patients are involved in their own care, performance improves."

"There are always barriers to quality improvement," says Nancy Jane C. Friedley, MD, CMD, medical director for the Easton, MD-based Delmarva Foundation, a Medicare quality improvement organization.

To be successful, the hospital needs to have an "administrator champion" and the necessary infrastructure, and a "staff champion" who is dedicated to the project and will help maintain the gains that are made. For CHF, this is usually a physician, and usually a nurse or case manager for pneumococcal vaccine.

"Since cost is often a barrier, the hospital system must be willing to spend the resources to effectively implement quality improvement," says Friedley. Your IT system might need to be upgraded to give real-time feedback, or staff may need to be freed up to work on the project.

From the patient's perspective, barriers to implementing core measures may include fear of side effects of a medication or vaccination, cost of the intervention after discharge, or failure with previous interventions, especially those requiring lifestyle modifications.

Barriers to implementation from staff include uncertainty about whether the interventions are effective or safe, notes Friedley. For example, many physicians are still reluctant to give beta-blockers to CHF patients even though data show a decreased mortality for patients given beta-blockers. Likewise, some nurses are unsure about giving a pneumococcal vaccination to a patient who is admitted with an infection or a patient who may have already been immunized. "Time constraints are another obvious barrier, since staff have many interests competing for their time and energy," she says.

Obstacles for discharge instructions

In order to meet the requirements for the CHF discharge instruction measure, six elements must be addressed: activity level, diet, discharge medications, a follow-up appointment, weight monitoring, and counsel on what to do if symptoms worsen.

If all six items are not documented, you will not pass the measure.

"We know that many quality problems occur because of inadequate instructions at the time of discharge," says Dale W. Bratzler, DO, MPH, medical director of the Oklahoma Foundation for Medical Quality, based in Oklahoma City. To improve compliance, he recommends:

  • Creating educational materials that address all of these aspects of care provided to the patient.
  • Having the patient, the family, or caregiver sign forms that highlight education on these issues.
  • Incorporating good discharge planning with documentation of all six elements.

Friedley recommends incorporating the recommendations outlined in the American Heart Association's "Get With The Guidelines" program. She points to statistics showing that in 2006, hospitals improved compliance from 69.6% at baseline to 79.4% after using these materials. (For more information, go to Click on "Science & Professional," "Get With the Guidelines.")

Many top-performing organizations use a formal checklist to ensure that all required elements have been covered with the patient or family before discharge. "Use of a duplicate copy checklist is suggested so that the patient or family has one for reference," says Heinsohn. "The other becomes a permanent part of the patient's medical record as documentation that all elements were covered."

Organizations that perform well on the pneumococcal vaccine requirement have specific protocols in place, staff that are proactively educated on the importance of the vaccine, and an established process by which a doctor's order is not required to administer the vaccine, says Heinsohn. "Hospitals without these key strategies have difficulty with the vaccine requirement."

There are a "host of reasons" that hospitals continue to struggle to achieve high rates of performance with this measure, says Bratzler. These include:

  • Misconceptions about inpatient vaccination, such as believing that the vaccines don't work to prevent disease and complications, or that the vaccines are not safe for hospitalized patients;
  • Physician resistance — some ascribe to the myths above;
  • Systems issues, such as delaying vaccination to the day of discharge, which is a busy time, resulting in missed dosing;
  • Lack of information about the patient's prior vaccination.

"There is little substance to any of the myths," says Bratzler. "Patients well enough to be discharged from an acute care hospital can safely be vaccinated. Adverse events are exceedingly rare." There is no reason to believe that hospitalized patients will react to the vaccine any differently than a patient in a physician's office, and they are probably watched much more closely, he adds.

The pneumococcal vaccine may not always prevent pneumonia, but it has been shown to reduce the complications of pneumonia when it occurs, he notes. He points to two large studies of Medicare patients, which showed that patients who have not had vaccine prior to admission and who do not get it while in the hospital, usually do not get the vaccine after they leave.1, 2

"Hospitalization is a missed opportunity," says Bratzler. "Despite the best intentions to vaccinate the patient in the office, it usually does not happen."

The Medicare conditions of participation were modified in 2002 to drop the requirement for a physician signature to give an influenza or pneumococcal vaccine.

Standing orders are the most effective strategy for improving hospital vaccination rates with pneumococcal vaccination, says Bratzler. With these programs, medical staff approve a protocol for screening and vaccination of hospital patients, and then nursing (or pharmacy in some states) screens and vaccinates the patient without physician intervention or a physician order.

"Nursing can do this without an order, as long as there is a physician or medical staff approved protocol," he says. "No other intervention to increase vaccination rates is as effective. Here, nursing is in the position to save patient's lives by providing vaccine."


  1. Centers for Disease Control and Prevention. Missed opportunities for pneumococcal and influenza vaccination of Medicare pneumonia inpatients – 12 Western States, 1995. MMWR 1997; 46:919-923.
  2. Bratzler DW, Houck PM, Jiang H, et al. Failure to vaccinate Medicare inpatients — a missed opportunity. Arch Intern Med. 2002; 162:2349-2356.

[For more information, contact:

Dale W. Bratzler, DO, MPH, Medical Director, Oklahoma Foundation for Medical Quality, 14000 Quail Springs Parkway, Suite 400, Oklahoma City, OK 73134. Phone: (405) 840-2891 ext. 209. Fax: (405) 840-1343. E-mail:

Nancy Jane C. Friedley, MD, CMD, Medical Director, Delmarva Foundation, 9240 Centreville Road, Easton, MD 21601. Phone: (410) 712-7420. Fax: (410) 712-4357. E-mail:

Becky Heinsohn, Director of Hospital Quality Improvement, TMF Health Quality Institute, Bridgepoint I, Suite 300, 5918 West Courtyard Drive, Austin, TX 78730-5036. Phone: (512) 334-1649. Fax: (512) 327-7159. E-mail: Web:]