Impress Joint Commission and public with dramatic core measure results

You now have another powerful incentive to improve data collection

There’s no denying that paying close attention to performance measures can improve patient safety at your organization, but here’s another powerful motivator: Your core measure data will have a wider audience this summer when the Joint Commission on Accreditation of Healthcare Organizations begins making its Quality Reports publicly available.

Your organization’s performance on key indicators of quality of care will be rated as above, similar to, or below the performance of other accredited organizations, with comparative analysis done at both state and national levels.

"This is a good catalyst for change in any health care organization," says Lisa Mead, RN, MS, director of quality and organizational effectiveness at Scottsdale (AZ) Healthcare. "Health care providers always want to provide the best evidence-based practices for patients, but now there is an added dimension — that everyone else knows how you are doing. Hospitals aren’t used to our data being out there in the public eye."

The hospital currently is exploring how to make its performance results available through the Internet, Mead says.

Some payers now have implemented reimbursement incentives for quality indicators, says Patricia A. Duclos-Miller, MS, RN, CNA, former director of quality improvement at Sisters of Providence Health System in Springfield, MA. For example, Blue Cross and Blue Shield of Massachusetts is asking hospitals to consider identifying indicators to measure clinical outcomes and tying the results to reimbursement.

Here are effective ways to improve core measure results:

Work with a multidisciplinary group.

When pneumonia indicators were assessed, both vaccination and documentation clearly were lacking, Mead says. "This is going to be one of our hospital’s public reporting indicators, and we were not meeting standards we needed to be hitting," she explains.

Quality managers met with a group of nurses, educators, respiratory therapists, and emergency department (ED) physicians to find solutions. The group created an adult patient admission form for pneumonia, an inpatient pneumococcal influenza assessment form, and a wallet-sized immunization record card for patients to carry.

The forms make the documentation process easier and are used for both ED and direct admits, says Mead, who expects statistics to improve significantly this coming winter when 100% of pneumonia patients will be audited.

"Prior to these efforts, our admission record relied on the patient or family completing this section," she says.

Instead of relying solely on clinical staff to document pneumococcal screening and vaccination with a standing order and documentation tool, quality managers at Sisters of Providence are working with pharmacists to determine whether this information can be added to the medication administration records. "We are proposing vaccinating anyone over the age of 65 years with no contraindications to the vaccine," Duclos-Miller adds.

At Scottsdale, each service line monitors its core measures on a monthly basis. "If we see any negative variance in a result, then we involve the appropriate parties, facilitated by a quality consultant," Mead says. "Most of it is really getting the right people together and taking the problem apart as a workgroup."

Always get input from frontline staff.

After core measure data are abstracted, the findings are shared with nursing management leadership who keep staff informed, she notes. "When we do workgroups, it’s not the managers who are sitting on the teams — it’s nurses on the unit."

Nurses always are involved in efforts to improve core measures and often identify necessary tools or redundant work processes, Mead emphasizes.

"Maybe they are documenting something too many times in too many places. Or maybe the patient is telling them that they were already vaccinated in their doctor’s office, but that isn’t being documented," she explains.

At the Regional Medical Center of Orangeburg & Calhoun Counties (SC), frontline staff came up with an effective solution to solve a problem with discharge instructions, which often were given but not documented, says Indun Whetsell, director of quality management.

"We just didn’t have one central location to do this," she says. To address that situation, the nursing staff created the "Green Sheet," an educational tool for congestive heart failure patients. "All the components are in one place, with all i’s dotted and t’s crossed. This has made our statistics improve dramatically. The people at the bedside know more than everybody else how to fix things."

The new form follows the patient from admission to discharge, at which point weight monitoring, medications, smoking cessation, and dietary and activity restrictions are addressed. During the organization’s recent Joint Commission survey, surveyors were very pleased with the form, Whetsell reports.

Eliminate nonvalue-added data collection.

In light of the continually growing list of performance measures requiring heaps of data to be collected and analyzed, you’ll need to think strategically. "If you are looking at an indicator that is telling you nothing is wrong, or if you are picking indicators that you aren’t going to fix, then you need to stop collecting that data," Mead advises.

For example, if you know that nothing will be done to fix a problem with pneumonia vaccination rates, you probably shouldn’t collect the data in the first place, she says. Instead, zero in on indicators that do have adequate resources allocated for improvement.

"We should collect data only for things we are going to take action on," Mead explains. "Of course, some things are mandatory, but typically because they need to be. I don’t think there is much mandatory data collection that isn’t reasonable."

Also, don’t assume that 100% of charts need to be audited, she suggests. "Once your results are stable, you can decrease your sample size."

Assign data collection based on service lines.

"We have now assigned each indicator that needs improvement to a specific discipline," says Duclos-Miller. "This is the only way to make great strides."

By doing this, specific individuals will be held accountable if there is lack of progress in their assigned indictors. For example, the congestive heart failure discharge instructions indicator is assigned to care managers; pharmacy is responsible for implementation of standing orders for heart failure and community-acquired pneumonia; documentation of smoking cessation is assigned to nursing; and ED physicians are going to modify their disease-specific worklist to meet the acute myocardial infarction indicators.

In doing this, turf issues are eliminated, adds Duclos-Miller. "Nursing felt it belonged to the physicians, and the physicians believed it belonged to nursing. What was missing in the recent past was strong leadership support."

The organization now has a new chief quality officer who also is a physician, who was a great help in obtaining buy-in from the medical staff, she reports.

At Scottsdale, abstracting and consultant support also is assigned by service line, which decreases the amount of time spent reviewing charts and pulling medical records. For instance, the same abstracter assigned to pneumonia patients and cardiovascular indicators also does the database for the cardiac catheterization lab. "Otherwise, you will have somebody going in the same chart and pulling for different reasons," Mead says.

Use indicators that can be collected electronically when possible.

According to Mead, the first question you should ask when collecting core measure data should be, "Is there an easy way to pull this through our automated system?"

"As long as you can find it in a database somewhere, we can pull it out," she says.

For instance, the critical care department recently was able to choose several indicators that could be pulled right off the database. "We asked, What are other people looking at? What are the indicators being considered by Joint Commission and [the Centers for Medicare & Medicaid]? What can we pull out right from our reports? And does that give us enough to get started?’" Mead adds. "There may be other burning issues that need to be addressed, but this way, you can prioritize, because there are only so many of you."

[For more information about improving core measure results, contact:

  • Lisa Mead, RN, MS, Director, Quality and Organizational Effectiveness, Scottsdale Healthcare, 3621 Wells Fargo Ave., Scottsdale, AZ 85251. Phone: (480) 675-4217. Fax: (480) 994-1597. E-mail:
  • Indun Whetsell, Director, Quality Management, The Regional Medical Center of Orangeburg & Calhoun Counties, 3000 St. Matthews Road, Orangeburg, SC 29118. Phone: (803) 533-2688. Fax (803) 539-4011. E-mail:]