Core measures: Are needed changes getting made?

Concurrent data collection is best

At Gautier, MS-based Singing River Hospital System, quality professionals were struggling with a lack of timely feedback on core measure compliance due to a retrospective data collection process.

Abstraction and reporting of core measures was the responsibility of the case management department. "We were responsible for all utilization, resource management, and discharge planning functions, in addition to the abstraction and reporting of quality data and core measures," says Kathy Dier, RN, director of the organization's new "clinical data management" department, which now handles all core measure data collection.

At times, other areas were covered as well, including infection control, risk, and workers' compensation, with the required core studies abstracted post-discharge. "This could be up to one month after discharge," says Dier. "We tried to educate the case managers and do concurrent intervention, but did not make the progress we wished. We were not able to consistently intervene and impact process."

The quality department campaigned to have duties split, with case management re-organized and all quality and core measure duties pulled out. "I showed administration how a dedicated focus on these issues would make a difference, and presented a plan for staffing," says Dier.

A concurrent process was implemented to abstract charts real-time, identify opportunities for improvement, and intervene to impact patient care and core measure scores.

The hospital launched the process in November 2006. Four registered nurses now work throughout the hospital system, abstracting information and intervening with physicians and staff to change practice. The nurses came from the case management department so it was kept budget neutral.

"Education is a daily, even hourly occurrence. These nurses partner with all caregivers within the hospital to affect change, and teamwork is key," says Dier. "We do informal and formal inservices, and meet with physicians and staff individually or in groups."

For example, nurses look at an acute myocardial infarction patient's chart the day of admission, to be sure the patient received aspirin and beta-blockers. "If not, we go to the physician and either get the order or have them document the contraindication," she says.

When staff were having difficulty determining the current pneumococcal vaccination status of nursing home patients, the clinical data management nurses went out to the local nursing homes to work out a better process. "A form change was made, and this issue was resolved," says Dier.

For heart failure, if documentation is not noted in the chart, nurses pull all the appropriate paperwork, partner with the floor nurse, and get the education done.

In addition to the work of the clinical data management nurses, the physician-led "Total Quality Management" committee reviews core measures and other quality data, and makes recommendations for practice changes.

Singing River's core measure compliance scores have increased dramatically from October 2006 to September 2007. For acute myocardial infarction, compliance increased from 78% to 94%; for heart failure, 78% to 91%; for pneumonia, 59% to 98%; for Surgical Care Improvement Project (SCIP) measures 1-3, 63% to 92; and for SCIP measures 1-7, 76% to 95%.

Team effort

At San Ramon (CA) Regional Medical Center, a 123-bed hospital, quality managers do concurrent review for pneumonia, heart failure, and AMI core measures. "The concurrent review really is effective, because we can and do prevent missed opportunities, says Janet Abernathy, RN, clinical quality manager.

Abernathy says she works with coders, asking them for educated opinions on some of the more complex cases. "I also attend staff and department meetings to educate about core measures, and I run a weekly core measure meeting attended by all nursing directors to discuss where we are in performance for core measures," she says.

ED and staff nurses identify core measure patients on admission and start a "core measure-specific packet" that goes with the patient chart. "The core measure patients are put in yellow charts to differentiate them," she says. "The staff nurse has a checklist that stays on the front of the chart with some of the pertinent indicators that they have to fill in, which is not part of the permanent record."

The charge nurse completes an audit tool with more detailed information, which does become part of the medical record and is reviewed by Abernathy. During bed control meetings, which are held Monday through Friday, the charge nurses present all their core measure audit tools and the director of nursing or her designee reviews these.

On the physician side, Abernathy reports on core measure data at departmental meetings, and created posters to remind physicians of the indicators for all the core measures. She also created pocket cards with indicators for pneumonia, heart failure, and AMI on one side and the guideline-concordant antibiotic regimens for pneumonia on the other side. AMI core measure scores increased from 88.6% in 2006 to 95.1%, heart failure scores increased from 80.3% to 86.7%, and pneumonia scores rose from 78.5% to 87.4%.

As the data are abstracted, Abernathy goes in and takes a more careful look at the cases that had missed opportunities, to be sure that it was a true missed opportunity. "Additionally, every quarter we do internally validate our data abstraction, and do an inter-rater reliability sampling as well, so we can be sure of the accuracy of our abstraction."

Abernathy also does a case-by-case drill down on all cases with missed opportunities. If the opportunity was missed due to nursing error, the case is forwarded to the appropriate nursing director, who is responsible for further investigation and action plan development. If the missed opportunity was due to physician error, the case is forwarded to the appropriate peer review group.

One challenge is to get all the required information, such as the patient's ejection fraction, in each episode of care for patients who have frequent admission. "The staff may have just documented it a week ago, but the patient has been discharged and then readmitted," says Abernathy.

To make it easier for physicians and nurses to provide discharge instructions to patients, the process was simplified. "We have pared down the amount of printed discharge information given to the patient significantly," says Abernathy.

Identifying core measure patients concurrently is a task that gets easier over time, says Abernathy. With concurrent data collection, staff can be given instant feedback on performance and are held more accountable.

"Concurrent review is the only way I can think of that gives you an opportunity to improve your patient care and raise your scores by fixing problems as they arise, instead of just reporting on them afterwards and hoping that staff won't make the same mistake again," she says.

[For more information:

Janet Abernathy, RN, Clinical Quality Manager, San Ramon Regional Medical Center, 6001 Norris Canyon Rd., San Ramon, CA 94583. Phone: (925) 275-8435. Fax: (925) 275-6170. E-mail:

Kathy Dier, RN, Director of Clinical Data Management, Singing River Hospital System, 2012 Hwy 90, Gautier, MS 39564. Phone: (228) 497-8861. Fax: (228) 497-8875. E-mail:]