Initiative focuses on eliminating roadblocks

Goal is top 10% in core measures

At Edward Hospital in Naperville, IL, advanced practice nurses take the lead in meeting the hospital's goals of being in the top 10% of the core measures and other performance measures.

The board of directors and senior staff of the health system made a commitment in 2005 to be in the top 10% and appointed a work group to develop ways to improve compliance with the core measures. The group included the administrative staff, coders who handle utilization review, and representatives from the medical records department.

The core measures are part of the clinical scorecard that is reported to senior leadership, the board quality committee, and people in the clinical area.

In the most recent data, the hospital scored in the 90th percentile for 13 out of 23 measures.

The advanced practice nurses worked with the utilization review staff and medical records to analyze the medical records data, looking at ways to improve compliance with the core measures.

The task force met once a week for months to look for reasons that the quality measures were not being followed and to come up with ways to ensure that the core measures would be met.

"It was like peeling back the layers of an onion, trying to figure out all the potential ways to create processes that will make us 100% successful," says Patti Ludwig-Beymer, RN, PhD, administrative director for education and research at the 300-bed regional health care provider.

The heart hospital had been a longtime participant in the American Heart Association's "Get with the Guidelines" initiative and had been tracking data for the myocardial infarction (MI) and heart failure core measures for a long time, says Lynn Cochran, RN, MS, director of cardiovascular inpatient services.

The hospital had standard protocols in place for acute MI, pneumonia, and heart failure.

"Compliance wasn't as good as we wanted. We talked with the physician practice committee to recommend that the protocols be utilized," Cochran adds.

One of the team's first initiatives was to identify where patients whose care falls under the core measures guidelines were likely to be admitted and what staff would be responsible for their care.

"We determined that pneumonia was the most challenging diagnosis to identify. When we examined the records, we found that 80% to 85% of pneumonia patients were in one of two units," says Lynn Wagner, RN, MS, CNAA, administrative director for critical care and the medical-surgical units.

The team found that the patients most likely not to receive the recommended care for pneumonia contained in the core measures were those who were admitted directly to the hospital, rather than those who came through the emergency department.

"We engaged the nursing supervisors on the two units where the vast majority of pneumonia patients were admitted and educated them about the four-hour window for antibiotics," Wagner says.

Access to the medications was one of the time delays in meeting the measure that calls for pneumonia patients to receive antibiotics within four hours of admission.

"We analyzed the data to find where the time delays were. Among the gaps were that nursing was having a hard time getting the physician to order the medication, the order wasn't being received by the unit clerk, or the nurse was busy and didn't give the medications," Wagner says.

The pharmacy department made sure that all of the standard antibiotics for simple and complex pneumonia were in the hospital's medication dispensing system on all nursing units.

"We identified the gaps and eliminated as many as we could. We knew that if the medication was readily available in the medication dispensing system that it would cut down on the time," Wagner says.

At the same time, the team worked to make the staff aware of the four-hour window for antibiotics to be administered to pneumonia patients.

"We found that this recommendation had not been common knowledge among the staff," Wagner says.

Another challenge was making sure patients with multiple comorbidities or ambiguous diagnoses received the treatments recommended under the quality initiatives.

"When someone comes in with an acute MI or heart failure, we know about it and we are aware of the diagnosis for the majority of people who are admitted with pneumonia. However, there are some patients who come in with confusing diagnoses and we don't know the final diagnosis until after discharge," Cochran says.

For instance, a patient may be admitted with a fractured hip and then the physician determines after evaluation that the patient had a heart attack as well. The patient should receive the measures recommended in the core measures for acute MI.

The advanced practice nurses and the coders worked together as a group to determine how the ambiguous cases should be coded.

"Our team had a lot of 'aha' moments while we were working. Until we started to analyze what was going on, we didn't understand all the problems," Cochran says.

For instance, smoking cessation education is a requirement for patients admitted with MI, heart failure, and pneumonia.

They found that six different people in different areas of the hospital were involved in documenting smoking cessation, ranging from the cardiovascular educator to the respiratory therapist.

"We got together to determine who was responsible for what and if we could agree on a similar template for documentation," she says.

For instance, some of the staff who were responsible for smoking cessation counseling don't work on weekends or holidays.

"We had to create a fail-safe mechanism for making sure that the education took place," Cochran adds.

The team involved the clinical and education staff, who agreed on standardization.

Now, if the patient has not received the smoking cessation education, the nurse is prompted to print out the materials and give them to the patient.

Cochran attributes part of the success of the initiative to educating the staff nurses. The hospital held facilitywide training for the nursing staff in the spring to help them understand what the core measures are and why they are being reported.

"We talked about the reasons for the core measures and how the evidence-based medicine behind this practice promotes better patient outcomes. Now that they understand what we are aiming for, the nursing staff wants to participate in helping us meet the core measures," Cochran says.

The initiative has helped in other ways, such as improving documentation in the patient chart. The hospital does not conduct concurrent review but reviews the data retrospectively. In the past, the team on the unit was not aware of problems in documentation.

Because of the collaboration, the chart abstractors alert the advanced practice nurses when a chart doesn't have enough information so the rest of the medical staff can be educated to include the information in the future.

For more information, contact: Patti Ludwig-Beymer, RN, PhD, at e-mail: