Hospital receives achievement award

Quality projects recognized

Award recognition programs are another strategy being used locally to spur quality improvement among health care facilities that contract with Medicare.

For example, the Peer Review Organization of New Jersey (PRONJ) recently awarded Columbus (NJ) Hospital, an affiliate of the Cathedral Health-care System, with an achievement award for its work in Medicare’s Sixth Scope of Work quality improvement projects.

The projects included acute myocardial infarction, atrial fibrillation, heart failure, pneumonia, and stroke/transient ischemic attack.

"PRONJ has a contract for the state of New Jersey through Medicare, and Medicare has on a national basis mandated these QI projects," says Michele Kearney, RHIA, senior director of information services for Columbus.

The state of New Jersey abstracted 1998 records to come up with baseline figures for participating hospitals, Kearney explains.

"Based on those results, they told each hospital what their baseline was, as well as the target for improvement. In all of our projects, we submitted a QI plan indicating who would do what, updated our forms as we implemented the projects, and we surpassed all targets," she adds.

The hospital was provided with software to abstract the records for all quality indicators, and then submitted the data back to PRONJ.

Work started on the projects in early 2000, Kearney recalls. "Basically, I outlined the plans and took them to our quality assessment committee and they approved it," she says, noting that Columbus is a small (210 beds) community hospital. The quality assessment committed was comprised primarily of medical staff, with representatives from nursing and health care utilization resources as well.

PRONJ assisted all participating hospitals along the way, providing free publications, posters, and pocket cards to physicians. "At each departmental meeting, doctors presented their data, and reminders were put in our newsletter as well," notes Kearney. "It was mainly a matter of keeping awareness high."

Results were monitored at monthly quality assessment committee meetings. "Whatever we found, it was reported to the physicians present at the meetings," Kearney observes. "In some cases, we found that if an area was not meeting its target, it was a documentation omission rather than a failure of performance, so we revised the discharge instruction forms to make reporting simpler."

Need More Information?

For more information, contact:

  • Michele Kearney, RHIA, Senior Director of Information Services, Columbus (NJ) Hospital. Telephone: (973) 268-3674. Web site: