Strategies to ease data collection burden
New core measure sets coming from JCAHO
Four years after the Joint Commission introduced standardized core performance measures with its 2002 ORYX initiative, quality professionals still are struggling to improve compliance with core measure data collection.
Compliance remains poor at many organizations, with only 55% of heart failure patients receiving necessary discharge instructions, according to a new study.1 The study found that compliance with performance measures for heart attacks, pneumonia, and congestive heart failure is spotty, with wide variances in quality across regions and sometimes even in the same hospital.
Researchers at the Harvard School of Public Health used newly available data from the Hospital Quality Alliance to look at 10 indicators from the Centers for Medicare & Medicaid Services at 3,558 hospitals in the first half of 2004. They found that treatments were not provided for 11% of heart attack patients, 19% of patients with congestive heart failure (CHF), and 29% of pneumonia patients.
Part of the problem may be that data collection struggles are increasingly burdensome. "The time commitment and resources needed to capture the information have become quite challenging," says Linda Gaul, RN, senior consultant for quality at St. Vincent in Indianapolis. "It has also been rather challenging keeping up with definitions. It seems every week there needs to be clarification regarding abstraction. Just when you think you understand an indicator’s definition, we learn something new."
Organizations have found it necessary to add additional staff to manage data collection and analysis. "We have added one FTE data abstractor for a total of two, and a QI director to oversee core measure data collection," says Renee Shalosky, director of quality improvement at Southeastern Ohio Regional Medical Center in Cambridge. "Both abstractors are responsible for core measure data for the CHF, acute myocardial infarction (AMI), and pneumonia measures."
The upcoming new core measure sets from JCAHO for pediatric asthma, intensive care unit (ICU), and pain management undoubtedly will add to the data collection burden, says Shalosky. "The ICU measures are extensive and time consuming," she adds.
Additional resources for the upcoming new measure sets will "absolutely be needed," says Gaul. The organization currently is in the process of implementing an electronic medical record. "We hope this will relieve some of the abstraction burden. But we will have to consider additional resources to review for accuracy and to keep up with the actual export. We are adding staff to our quality team now and are anticipating the need for dedicated IS staff in the near future."
Education is the way to improve core measures compliance, including one-on-one inservices as needed, says Shalosky. "We’ve done so much education on the importance of these measures. We’ve started trending per person to identify any trends there," she reports. "We’ve also been educating one-on-one with those that have been identified as not complying."
Here are strategies to improve core measure data collection:
• Put a progress note in the patient’s chart.
St. Vincent has implemented a progress note, called a "Quality Note," which specifically addresses core measures. The attending physician receives a letter reminding them of the indicator requirements for any case that continues to be out of compliance. "This has greatly improved our results, but we do recognize there is room for improvement," says Gaul. "Our goal is to build the evidence-based logic into our electronic medical record to assist physicians and staff."
The quality note is placed in patient charts for case managers, clinical data abstractors, and physicians to refer to and serves as a communication tool between caregivers regarding compliance.
"We have seen the greatest improvement for those indicators which require documentation of a contraindication for not utilizing recommended drug therapies," reports Gaul. "The note allows the physician to either check a contraindication or serves as a gentle reminder that a patient needs a particular drug therapy."
• Have clinical staff perform data abstraction.
All data abstractors at St. Vincent are nurses. "It is difficult for non-clinical staff to grasp the nuances of each indicator and what the intent of the indicator is," says Gaul. "Physicians also tend to have a better relationship when the nurse is speaking to them about core indicators and their results."
The nurses also are responsible for ICD-9 coding, abstraction for other national and state registries, reporting indicator results to their assigned QI committee, and assisting caregivers, managers, and physicians with understanding areas that need improvement, says Gaul.
Nurses have the best understanding of the specific deficiencies and the actual indicator definitions and are visible on the units, says Gaul. "The actual implementation of agreed-upon action plans is the responsibility of the physicians, managers, and nursing units," she explains.
• Do concurrent collection.
At Southeastern Ohio Medical Center, most data collection is done retrospectively, including indicators for CHF, AMI, and pneumonia, says Shalosky. "None of the core measures are done concurrently," she says. "I would definitely like to increase the amount so that action plans are done in real time — proactively — instead of retrospectively."
Abstraction is done concurrently whenever possible at St. Vincent, providing an opportunity to prompt the physician for missing documentation, such as contraindication to drug therapies. "Each nurse is responsible for their list of patients based on medical record terminal digit. Oftentimes the care the patient is receiving is appropriate but the actual documentation is lacking."
Reference
- Jha AK, Zhonghe L, Orav J, et al. Care in U.S. hospitals—the Hospital Quality Alliance program. N Engl J Med 2005; 353: 265-274.
[For more information, contact:
Linda Gaul, RN, Senior Consultant Quality, St. Vincent Indianapolis Hospital 2001 West 86th Street, Indianapolis, IN 46260. Telephone: (317) 338-8199. Fax: (317) 338-2801. E-mail: [email protected].
Renee Shalosky, Director of Quality Improvement, Southeastern Ohio Regional Medical Center, 1341 Clark Street, Cambridge, OH 43725. Telephone: (740) 435-2339. E-mail: [email protected]]
Four years after the Joint Commission introduced standardized core performance measures with its 2002 ORYX initiative, quality professionals still are struggling to improve compliance with core measure data collection.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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