Do you lack resources for data collection? Use these strategies
Do you lack resources for data collection? Use these strategies
Ever-growing requirements are a major challenge
With ever-growing data collection requirements from the Centers for Medicare and Medicaid Services, The Joint Commission, health plans, and state hospital associations, how can quality professionals keep up without adding an army of data abstractors?
"This is a growing challenge for our hospital," says Carol Ruscin, RN, MSN, quality improvement specialist for the department of clinical excellence and patient safety at University of Colorado Hospital in Denver. "FTEs, which have to be hired for reviewing and abstracting elements out of the medical record, are very costly."
In addition, organizations are hiring abstractors with clinical backgrounds instead of entry-level individuals. "The additional skill set comes with a higher price tag," says Ruscin.
Quality professionals are struggling to manage this growing workload with limited resources. "We are very concerned about the rate of new reporting requirements and how we balance those against existing work," says Julia Napper, RN, BSN, CHCQM, director of performance improvement and patient safety at Parkland Health & Hospital System in Dallas.
At Jewish Hospital & St. Mary's HealthCare, hospital outpatient quality data are collected, along with data for core measures and cardiac databases for the American College of Cardiology and the Society of Thoracic Surgeons. "It has been a challenge over the last several years," says Nancie Robertson, corporate director of quality and accreditation. "And the requirements will continue to increase under value-based purchasing."
To add to the burden, some of the organization's facilities are responsible for peer review and other quality monitoring. "All quality departments are now challenged to do more," says Robertson. "We need to look for opportunities to be more efficient."
Here are strategies used by quality professionals to manage growing data collection requirements:
• Take advantage of any data that are available electronically.
Currently, medical records are a hybrid of paper and electronic data at Jewish Hospital & St. Mary's. "As a hospital system, we have a plan in place to move to a single platform, with core measure requirements built into the system as much as possible for ease of abstraction," says Robertson. "As requirements continue to increase, the use of electronic data and pulling the data into vendor systems will be a key to limited resources."
Ruscin estimates that three to five minutes per record could be saved on average, if all the required data elements were available electronically. "The abstractor is reading text and not having to interpret or figure out someone's handwriting legibility," she says. "If there are 250 records in the sample size and all are electronic, you save significant time."
Since Parkland is in the early stages of implementing its electronic medical record (EMR) system, data collection remains a significantly manual process. "We are trying to hold our FTEs flat, and shift resources within the department," says Napper. "Given that we are about two years away from a fully implemented EMR, I don't want to place people in positions that I can't justify two years from now."
The new EMR system allows some data to be accessed electronically already. This includes patient demographics on age, race, ethnicity, location, admission source, and discharge disposition, as well as administrative data on diagnosis and procedure coding and charges.
"The first modules of our EMR have just gone live. We are anxiously anticipating decreases in chart abstraction and improvements in the time data are available for teams to use to drive improvement," says Napper. "For our purposes in quality, we will mostly be pulling reports on a weekly or monthly basis."
This will be a significant improvement over the current abstracting process, which usually is done after the patient is discharged and after medical record processing of charts.
Some data will be available for query from the EMR immediately. "Once the emergency department goes live, we will be able to extract data on care processes such as antibiotic timing and cath lab activation without having to wait for the paper record to be available," says Napper.
However, electronic data are only useful when providers are comfortable with their accuracy. "If the data are suspect, time has to be spent resolving concerns," says Napper. "For data that will be attributed to a provider, we address the comfort issue through standard interrater reliability activities."
However, Napper says she doesn't think the "comfort issue" will be completely addressed until the EMR is fully implemented, with entries and orders tied electronically to a provider. "When the accuracy issue arises for data that we are using to monitor processes, we work with our physicians to help them understand that monitoring process changes doesn't require the same degree of rigor as a research study," she says.
• Centralize access to data.
If you are collecting data manually, communication between departments is critical to avoid duplicative efforts. "One of the best strategies to reduce redundancy is to know what is being collected and by whom, so that the work of abstraction isn't repeated unnecessarily," says Napper. "We work very closely with the department that abstracts the data for our publicly reported measures."
Some data are placed on secure shared drives, so multiple departments can access the same data. After the charts are abstracted, the information is placed into a database on a shared drive. Performance improvement analysts can access it to identify problem areas and create reports. These are used by improvement teams for core measures, and shared with senior leadership and the hospital's board of managers.
Some of the same data are queried for physician credentialing and The Joint Commission's requirement for ongoing professional practice evaluation, adds Napper.
In addition to the publicly reported measures data, data on compliance with The Joint Commission's requirements for "do not use" abbreviations, legibility, and universal protocol are also available on shared drivers.
At Jewish Hospital & St. Mary's, core measure teams are working to centralize key data that are required for abstraction of the medical record.
Currently, documentation might be located on multiple forms in the medical records, which is time-consuming for the abstractors. "We are in the process of implementing a form for heart failure that will be a permanent part of the medical record. The form will include three measures, so we only have to go to one source," says Robertson. "This will be built on as we move to a new electronic system in the future."
• Have charts abstracted in a short time frame.
Last year, the quality department at St. Jewish Hospital & St. Mary's set a benchmark that all core measure charts are to be abstracted within 45 days of patient discharge. This allows prompt feedback to be given to the organization's medical staff.
Prior to developing this benchmark, charts were typically not abstracted for up to 80 days. "This has helped to focus our team," says Robertson. "We are now able to get out dashboards on a monthly basis, and it stays in the forefront."
• Cross train abstractors to collect data for any of the core measures.
At St. Jewish & St. Mary's, the quality staff attend monthly conferences to stay up to date with current measures for public reporting. This helps them to be experts in the abstraction process.
"We have identified individuals in our facilities that are cross trained to abstract all measures," says Robertson. "This has helped in meeting our goals."
Previously, certain individuals abstracted specific measures, such as acute myocardial infarction or pneumonia. "This led to problems when one person would be on vacation or on medical leave," says Robertson. "We have moved toward each quality team member being able to do any of the measures. This has helped with productivity and timeliness of abstraction."
• Obtain additional resources.
Three years ago, quality professionals at University of Colorado did a business case to support hiring a position for medical record abstracting. "A year later, based on the increase in requirements, we did a second business case for an additional position and were approved," says Ruscin. "We currently have 1.5 FTEs dedicated to data abstraction, and an additional .30 FTE clinical positions dedicated to oversight of these requirements."
Ruscin recommends doing a time study to determine the average amount of time it takes to abstract an easy record and a difficult record. That information, along with the number of records to abstract, will give you the data needed to justify an additional FTE.
"We compared my salary to an entry-level person who we could train," says Ruscin. "[Our] work force did not give us too much of an argument."
• Go into the chart only once.
When collecting data manually, capture all the data points as possible while you are in the record. "With our publicly reported measures, we have seven additional empty data fields we use to collect data for other projects," says Ruscin.
Data are simultaneously collected for The Joint Commission's National Patient Safety Goals, hospital performance improvement initiatives, regulatory compliance, and publicly reported data. On one record, data can be captured on antibiotics, timeout, handoff of patient information, medication reconciliation, completeness of the medical record, and verbal order completion.
"As the raw data are reviewed and analyzed, we can do several of these projects at the same time, so we are working as efficiently as possible," says Ruscin.
To keep up with all the requirements, Napper tries to ensure that data being collected manually satisfy both internal and external reporting needs. A software program is used to create data collection tools, which can be scanned for data capture, decreasing the amount of time spent on data entry.
"When new projects are expected to have a longer data collection life cycle, we create a tool we can scan," Napper explains. For example, a tool is used to track moderate sedation outcomes. The procedure labs complete the tool at the conclusion of a moderate sedation case and send it to performance improvement.
"We scan the tool and create reports," says Napper. "With several high-volume procedure labs, we estimate this tool has saved several hundred hours of chart abstraction time annually."
An analyst was trained by the hospital's IT system vendor to extract the necessary data for quality and safety surveillance and reporting from the hospital's mainframe system. "Several IT staff members have also been trained to pull reports, but we felt we had to have our own resource within the department," says Napper. "Even though we have limited clinical data available electronically, any time we save on data abstraction is time available for improvement activities."
When a chart is being abstracted for core measures, the quality staff at Jewish Hospital & St. Mary's also do all other required reviews, such as peer review and mortality.
"One of our facilities has always tried to review a chart for both quality indicators and mortality screens while doing the core measure abstraction," says Robertson. "This way, I don't have two individuals going in the chart at two different times. The chart is touched one time, which is the most efficient model."
[For more information, contact:
Julia Napper, RN, BSN, CHCQM, Director, Performance Improvement & Patient Safety, Parkland Health & Hospital System, 5201 Harry Hines Boulevard, Dallas, TX 75235. Phone: (214) 590-0356. E-mail: [email protected].
Nancie Robertson, Corporate Director of Quality and Accreditation, Jewish Hospital & St. Mary's HealthCare, 200 Abraham Flexner Way, Louisville, KY 40202. Phone: (502) 367-3358. Fax: (502) 361-6029. E-mail: [email protected].
Carol Ruscin, RN, MSN, Quality Improvement Specialist, Department of Clinical Excellence and Patient Safety, University of Colorado Hospital, 4200 East Ninth Avenue, Denver, CO 80262. Phone: (720) 848-4601. E-mail: [email protected].]
With ever-growing data collection requirements from the Centers for Medicare and Medicaid Services, The Joint Commission, health plans, and state hospital associations, how can quality professionals keep up without adding an army of data abstractors?Subscribe Now for Access
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