Requirements on core performance measures are set to increase

Quality managers bracing for jump in workload

Are you ready to add another set of core measures to your to-do list? There is no doubt that the Joint Commission on Accreditation of Healthcare Organizations’ new requirement for gathering data on an additional set of performance measures, effective January 2004, will increase your workload significantly. In addition, new measure sets to address surgical infection prevention, the intensive care unit (ICU), pain management, and inpatient pediatric asthma are being developed and are expected to become available during the next six to 24 months.

"Core measures are one more responsibility added to our peer review, continuous quality improvement, and regulatory hats," says Linda Golabiewski, RHIA, CPHQ, quality outcomes manager at Maricopa Integrated Health System in Phoenix.

As a quality manager, you’ll need to fine-tune your ability to view departments in a more "data-driven" mode, she says. "It is evident that the Joint Commission wants to put its finger on the organization’s pulse, via data. You could almost say it wants to have a data mart of each organization’s information." You could be facing an uphill battle if your facility hasn’t already begun to collect data for some of the new core measures, Golabiewski warns.

"You may be caught off-guard if you don’t have a good feeling for how you compare to other facilities. It could be a very revealing experience, and one that will require explanation to top leadership," she says.

Even the best-prepared quality managers will be challenged. Although Pam Spach, RN, BSN, CPHQ, director of performance improvement and disease management at NorthEast Medical Center in Concord, NC, already has established data collection for all patients, as opposed to only Medicare patients, and has been referencing all four sets of core measures in the facility’s internal data tracking, she is concerned about another potential problem area. "The new measures for surgical site infection, ICU, pain management, and inpatient pediatric asthma will create additional work," she says. "These pieces of data are not necessarily collected as designated by the Joint Commission."

Numerous additional indicators likely will be added in the coming months, Golabiewski notes. "The quality manager of the future will need a solid understanding and use of statistical methods, severity adjusting, stratification of the data, and the proper way to present it," she stresses.

Here are effective ways to ensure compliance with the Joint Commission’s new core measure requirements:

Use work groups to identify and facilitate specific improvements.

Several systemwide teams and work groups help drive process improvements for the core measure patient populations of acute myocardial infarction and community-acquired pneumonia at Banner Desert Medical Center, a 600-bed hospital in Mesa, AZ, says Maureen Mulligan, RN, BAM, CPHQ, a quality specialist at the facility.

These teams typically meet via telephone conference lines, with documents posted on the corporate intranet site and/or e-mailed to participants. The teams have annual charters, which include several well-defined action items for the coming year, she says. For example, a goal was set to improve documentation of smoking cessation counseling, adds Mulligan. "We found a common theme in our hospital system that smoking cessation documentation, as well as tools utilized, are inconsistent between facilities and between departments within a facility."

Nursing units at the facility’s heart center and the respiratory-telemetry unit both monitor unit-specific smoking cessation counseling rates for acute myocardial infarction patients on a monthly basis, she explains.

These steps were taken to improve that area:

  • A smoking cessation toolkit was developed by the population health management team, including a policy, educational materials for patients in English and Spanish, and a standardized documentation form with discharge instructions.
  • A start date for the policy was established.
  • Each facility was asked to educate staff prior to the start date.
  • Materials were posted on the company intranet site and distributed to the facilities.

"We hope to see improved documentation of smoking cessation counseling for all patient populations, based on this change," says Mulligan.

Similarly, an adult immunization toolkit has been developed to improve consistency of immunizing community-acquired pneumonia patients, and is going through the rollout phase now, she reports.

Choose the third measure carefully.

Consider the following when selecting a core measure population, Mulligan advises:

  • Identify your typical patient populations, as not all facilities care for all core measure patient populations.
  • Use your facility’s mission/vision/values statements for guidance.
  • Assess your ability to implement process improvement activities within the various core measure populations and your ability to collect data within the various core measure populations, considering both staffing resources and whether data are accessible electronically or manually.
  • Make sure you have input from key customers, such as medical staff, administration, managers, and information technology.
  • Consider differences in cost between the various available core measure population projects, both vendor costs and internal costs. Then do a selection matrix with the information, and prioritize your choice accordingly.

Obtain buy-in from staff and administrators.

Each facility’s monthly results for each core measure are posted on secure pages on the corporate intranet site, says Mulligan. "Data also are rolled up by region within our system, so data can be compared at both a facility level and at a regional level," she says.

Facility size, facility-specific goals, corporate goals, and national core measure benchmark results also are posted for comparison, she says.

In 2002, Banner Health began linking a portion of hospital executives’ annual salary to reaching established goals for their facility, including one or more of the core measures, Mulligan reports.

"This helps strengthen the buy-in of executives to make core measure improvements a high priority in their work. It also creates a trickledown effect to make core measure improvements a high priority within the organization," she says.

Keep others informed about progress.

You must keep medical and hospital staff informed of your progress on core measures, Mulligan advises. The facility’s core measure data are reported to the appropriate medical staff committees on a quarterly basis, she adds.

"Our medical center departments also maintain scorecards to measure their department’s progress on their goals," she notes.

For example, several departments monitor their smoking cessation counseling rates on a monthly basis, in addition to other core measures.

Current core measure data are posted for staff to see and are discussed in staff meetings, she notes. Nursing clinical managers and case managers also discuss core measures during their daily rounds with staff and in coordination with patient care discussions, she says.

"Prompters" also are placed on patient charts, such as a sticker stating, "This AMI patient appears to meet ACC/AHA indications for the following drugs:

  • aspirin;
  • beta-blocker;
  • ACE inhibitor;
  • lipid-lowering agent.

Please consider ordering the Rx or document in the medical record the reason(s) why Rx is not appropriate for this patient."

"Now that we have 12 months of data for two of our core measure sets, we feel we are ready to start reporting physician-specific rates of selected core measures to the medical staff committees, as well as to their reappointment files," Mulligan says.

Some of the system’s hospitals send a letter to the physician of record on every outlier case. For example, the letter might state: "Dr. ____, it appears that patient ______ was eligible for a beta-blocker within 24 hours of arrival for an AMI. There may have been contraindications to the use of a specific medication, but none were explicitly documented."

Use customized data fields.

"For us, our vendor’s cooperation to customize our data collection tool has been very helpful," Mulligan reports. The customized fields have made it easier to zero in on the core measure-related issues that are important to each hospital or to units within a hospital, such as smoking cessation counseling, she explains.

"They have also made it easier for us to provide physician-specific data for their reappointment files, helping us to fulfill a Joint Commission requirement," Mulligan adds.

Determine if the upcoming measures will require additional resources.

Several of the hospitals within the system have begun to discuss the ICU core measures, Mulligan says. "We have determined that we will need additional electronic support and additional manpower to meet our ICU data collection needs, including ICU core measure sets," she adds.

Currently, quality management staff do retrospective reviews to obtain core measure data, she explains. "With the surgical site infection and ICU core measure sets, we’ll need to expand that to include infection control nurses and ICU staff, as well as possibly moving toward concurrent data collection for some data sets," she says. "This will require additional planning, monies, and time to make the changes."

The new Joint Commission requirements may convince administrators to invest in resources to allow for increased clinical data collection and use, Golabiewski predicts. A personal digital assistant, wireless, voice recognition, bar-coded, or web-based system could be used to capture clinical data at the point of care, she says.

"We have been working fervently to hardwire as many processes as possible within our documentation systems to capture the information needed for data collection," Spach reports. "That seems to be the key."

Golabiewski gives the example of an emergency department patient whose vital signs are recorded manually on the patient’s chart.

"All of this information could be entered or captured from the devices used to analyze the patient’s condition, such as the thermometer and the blood pressure cuff," she says.

Determine whether your vendor can handle the hospital’s data needs for the additional measures.

A vendor has to address the issues of system scalability, training, and quick turnaround for updates, Golabiewski points out. "Our vendor is going web-based, which will allow them to update the system quickly and give them the capability to increase capacity on their end without us having to allow for network growth."

Data quality control is another key issue, she says, noting that coders are held to coding guidelines and compliance requirements. "The information requested for the core measures is first queried out by coded data." Therefore, it may require a quick lesson for providers in what has to be documented in the chart, such as pneumonias and cardiac results, in order for the coders to assign the appropriate code, Golabiewski explains.

Use one vendor for the entire system.

Try to use one vendor for all core measure sets if possible, Mulligan recommends. "It’s much easier to use your current vendor for an additional population than it is to contract with an additional vendor." While each facility in the Banner Health System independently chooses the core measure sets for which it collects and reports data, a single vendor is used for core measure sets across the 20-hospital system, she reports. Here are several benefits of using a single vendor:

  • Results can be compared more easily. "Having one vendor enables us to more easily compare results between facilities within our hospital system," Mulligan says.
  • Computerized chart information is uploaded in the same way on the same dates for all facilities. This improves consistency and accountability, she adds. "Data uploading dates, chart abstraction due dates, and reporting dates are all scheduled in advance."
  • The corporate office has access to core measure data for all facilities.

Data can be accessed directly by the corporate office, rather than asking hospitals to provide the data to them, Mulligan explains. This means that turnaround time for producing systemwide reports is shorter; customized data collection fields such as physician identifier fields are standardized across facilities; the corporate office can audit for data collection issues such as facilities not using new data collection fields; and the corporate office can query, download, and analyze data from multiple facilities, such as predicted and observed mortality rates.

"There is better coordination and resolution of issues, since the corporate office acts as a go-between to resolve issues between hospitals, information technology, and/or the vendor," she says.

When new core measure patient populations are added, there is no need to go shopping for another vendor, Mulligan says. "This would certainly be a benefit for hospitals that are not part of a system as well. This saves time, stress, and probably money, too."