JCAHO, public are watching: Act now to improve cardiac core measure data

Public reporting is strong incentive to identify and correct problem areas

Has your organization posted core measures data for cardiac patients on your web site? If not, is this because your results aren’t something you want to highlight?

"Cardiac care is an attention grabber, and this information is important to our patients and community," says Marian Mosby, RN, MSN, CCM, CPHQ, quality coordinator at Centennial Medical Center in Nashville, TN.

There is no question that the trend toward public reporting of quality data gives you much-needed ammunition to obtain needed resources to improve cardiac core measures, says Monica Ray, director of quality at Carle Foundation Hospital in Urbana, IL.

"I think it adds to our cause and works to our advantage. It puts more emphasis on the quality of care — not only because it’s the right thing to do but also because we want to look as good as possible in the public eye," she says. "We put information about our data right on our own web site — we are very up front with it. In the near future, our actual data, such as the quality initiative measures, will be posted."

This practice can give you lots of leverage with hospital board members, many of whom also are members of the community, Ray adds. "We have informed them about the public reporting process and the impact that it has on a hospital, which can be either positive or negative," she says. "It perks up their ears and gets them to pay attention to it even more."

The unique challenges of cardiac data collection include knowing which databases are being used, keeping the data definitions for each database straight, and identifying and remedying duplicative data collection efforts, Mosby explains.

"We collect cardiac data for several different cardiac databases," she says. "The challenge is identifying commonalities of the databases and sharing the data, thereby reducing duplicative efforts."

The recent alignment of quality measures by the Centers for Medicare & Medicaid Services and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) made the data collection process much easier, Ray adds.

"When they were different, it was a nightmare to collect the data," she says. "We were collecting double data on everything, and it was very difficult to keep it all organized."

Get ideas from others

"We have always distributed the data widely from the board level to the unit staff level, so people can see how we are doing and how we are comparing with other organizations," Ray says.

At Centennial, outcomes data and best practices are shared with the cardiac service line, which has led to development of on-line cardiac core measures educational training, participation in the American Heart Association (AHA)’s "Get with the Guidelines" program, and implementation of chest pain pathways/order sets and point-of-care testing, Mosby explains.

Cardiac core measures data are shared at cardiovascular medicine, nursing leadership, emergency department (ED), medical executive committee, and hospital board meetings.

"One great idea that came about as a result of sharing the data was the development of an auto-generated daily troponin report," Mosby says.

The troponin report is sent automatically to the cardiac case manager and cardiac rehab every day to help them prioritize daily activities and help with early identification of acute myocardial infarction (AMI) patients.

Cardiac physician order sets have been revised to address core measure indicators from admission to discharge, using a multidisciplinary process, Mosby adds.

When sharing data with staff, always emphasize the why behind cardiac core measures data collection, she advises.

"Everyone involved in the system of care for the cardiac patient needs to be knowledgeable of what the cardiac core measures are and why they are important. "It’s easy to become overwhelmed by numbers and lose sight of why we collect data in the first place — to improve the care we provide to our patients," Mosby says.

"We can never forget this. This is the first message we share, and it continues to be the foundation of all our quality improvement efforts," she explains.

At Trinity Medical Center in Rock Island, IL, physicians are given feedback about their individual compliance with the cardiac core measures.

"If you point out that they are below average in whatever measure you are looking at, people will self-correct," says Mark Valliere, MD, vice president of medical affairs. "If they know you are looking, they will try to do better. Nobody wants to be below average."

Standing orders currently are being revised to simplify them, he notes. "For some of the doctors, it was harder to wade through these very comprehensive orders than to just write what they wanted. So we had to go back to the drawing board to simplify those — to keep in the basic stuff that virtually every patient with that condition would get and take out a lot of the frills," Valliere says.

A sticker is used for patients admitted with an AMI or congestive heart failure (CHF) diagnosis to serve as a reminder to either perform the standing orders or indicate contraindications.

"We’re about to mandate that physicians complete that piece of it, or otherwise, it remains an open record," he adds. "A certain amount of the time the doctor is doing the right thing and is just not documenting it, so we are trying to capture that."

For example, the patient may have had a previous echocardiogram that revealed a contraindication, but it may not be documented in the chart.

"If somebody doesn’t give an angiotensin-converting enzyme inhibitor because the patient’s renal function was bad, they did the right thing, but it wasn’t clearly reflected in the chart," says Valliere.

"Or maybe the patient has been in twice in three months with heart failure, and that is why they didn’t get another echocardiogram, but the auditor only looks at the current record," he adds.

Standing orders are not going to be mandated, since physicians are realizing that it’s just easier to use them. "These are all things they were going to write down anyway, but it’s done for them — the five things done for every heart failure patient are already listed, so now they just have to add the six or 10 additional things," Valliere says.

If a physician forgets to perform one of the core measure requirements, such as a left ventricular function (LVF) assessment, a safety net of clinical pharmacists, case managers, or nurses will remind them, he says.

"We ensure that AMI or CHF patients don’t go home until somebody looks at the records to make sure that everything is done, so it’s not totally dependent on the physician," Valliere notes.

The organization’s goal is to be in the JCAHO’s top 10 percentile, but this is proving to be an elusive goal despite continual improvements, he points out.

"We’ve not made it with all of our measures, not because we haven’t improved, but because everybody else is also improving. We’re close, but the problem is that everybody else is getting good at this too, so the top 10% keep creeping up," Valliere says. "For some of these markers, such as aspirin on arrival or oxygenation for pneumonia patients, you’ve got to have 100% compliance to be in the top 10%."

Use data to revise processes

"It takes time to really sit down and look at the data, to analyze them, and see how you are doing over time," Ray adds. "The goal is to point out when things are askew and when they need to be addressed, and coordinate groups to do that. We have worked on the whole process of caring for the patient, taking it apart and improving each section as needed."

Here are examples of changes the organization made in response to its cardiac core measures data:

  • When data showed that door-to-electrocardiogram (EKG) times had increased, a group was charged with finding ways to shorten time frames. Interventions included synchronizing all clocks on EKG machines, looking at the point in the process the records were being timed, and determining how quickly EKG techs can respond to a call. "Our latest change is placing a full-time EKG tech in the ED, to be there at all times," Ray notes.
  • To reduce delays in door-to-procedure time for cardiac catheterization, the process was changed for how the team is called in after hours.
  • Coders were inserviced to ensure cases were appropriately coded so data are accurate.
  • For a goal of improving statin use, the cardiology group was asked to change the point at which they were prescribing to the patient so it was done in a more timely manner.

Although there is a lag time in getting reports back when data collection is done retrospectively, if the data abstractor notices a trend while collecting the data, Ray is notified so a quicker response is possible.

"That is how the changes with the EKG time and calling in the cath lab team came about — we were able to jump on it instead of waiting months for the report to come back," she says.

At Quincy, IL-based Blessing Hospital, the quality management analyst retrospectively collects and summarizes information, with reports distributed to the board of trustees, the medical staff quality advisory committee, and nursing leadership, says Tena Jones, MT(ASCP), director of quality management.

"Improvements are sustained through continued monitoring and surveillance," she says.

After the organization’s AMI data were presented to the department of family practice in aggregate form, the department was curious as to its performance compliance.

"We then began to split out their departmental discharges from the aggregate," she says. "Their increased awareness and interest in the measures contributed to their improvement. Currently, five of six rate measures are at 100% compliance."

Here are key changes that were made:

1. An acute coronary syndrome order set was developed to address each core measure.

2. Performance data are presented by quality management staff to the medical staff departments of the ED, family practice, and medicine.

3. Cardiac care managers are involved in the surveillance of patients admitted with an elevated troponin level, to ensure aspirin and beta-blockers are given within 24 hours of patient arrival.

"By using the report to identify new potential AMI patients, the cardiac care managers review the charts for aspirin and beta-blockers, and will follow up with the physician if indicated," Jones says.

4. Core measures and cases that fall out of performance standards are included in the medical staff peer review process for the department of family practice.

5. A checklist is used by the organization’s clinical documentation specialists during chart review of cases with a primary AMI diagnosis, to check for aspirin and beta-blocker on arrival or within 24 hours or documentation of contraindication to medications, smoking history/ smoking cessation, and echocardiogram report/ LVF assessment.

"We hope that it will serve to educate physicians on the potential inclusion of patients into the AMI measure and prompt them to initiate the evidence-based order set," Jones adds.

[For more on cardiac core measures data, contact:

Tena Jones, MT(ASCP), Director, Quality Management, Blessing Hospital, 1005 Broadway, Quincy, IL 62301. Phone: (217) 223-8400, ext. 6673. Fax: (217) 228-3097. E-mail: TJones@blessinghospital.com.

Marian Mosby, RN, MSN, CCM, CPHQ, Quality Management Department, Centennial Medical Center, 2300 Patterson St., Nashville, TN 37203. Phone: (615) 342-4788. Fax: (615) 342-4775. E-mail: Marian.Mosby@HCAHealthcare.com.

Monica Ray, Director of Quality, Carle Foundation Hospital, 611 W. Park St. Urbana, IL 61801. Phone: (217) 383-4877. E-mail: monica.ray@carle.com.

Mark Valliere, MD, Vice President, Medical Affairs, Trinity Regional Health System, Rock Island, IL, Phone: (309) 779-3200. E-mail: vallierem@trinityqc.com.]