franciscan st. anthony health michigan city, in
DESCRIPTION
Franciscan St. Anthony Health Michigan City, IN. St. Margaret Health. Hammond. St. Anthony Health. Michigan City. 80. 80. 90. 90. St. Anthony Health. Crown Point. 65. St. Francis Health. Indianapolis. 65. Franciscan Health Services, Inc. Franciscan Alliance Corporate Office. - PowerPoint PPT PresentationTRANSCRIPT
Franciscan St. Anthony Health Michigan City, IN
Franciscan Health Services, Inc.
Chicago Heights
St. Margaret HealthHammond
St. Margaret HealthDyer
St. Anthony HealthMichigan City
St. Elizabeth HealthLafayette
St. Francis HealthBeech Grove
Franciscan Alliance Corporate Office
65
90
8090
65
St. Anthony HealthCrown Point
St. Elizabeth HealthCrawfordsville
St. Francis HealthMooresville
St. James Health
St. James HealthOlympia Fields
St. Francis HealthIndianapolis
8090
Mishawaka
Franciscan Alliance
Mission Driven Quality Goals
• Adherence to the CMS Core Measures is rooted in the Franciscan Alliance culture at the facility, regional, and corporate level which is accomplished through continuous process improvement and focus on CMS best practice standards with robust communication at all levels, as well as through results reporting on the Franciscan Alliance Corporate Report. The color green on this report is associated with achieving results in line with the top 10% of hospitals in the nation. FSAH used this cultural norm to launch the Quality Rounding Program with the slogan:
It Takes a Team to Go Green!
Purpose and Goal
Purpose:• Assist the facility in compliance with the CMS quality initiatives,
and to move our results on the Franciscan Alliance Corporate Report from red or yellow to green.
• Prepare FSAH to compete as healthcare reimbursement moves to Value-Based Purchasing.
Goal:• The broad goal of the Quality Rounding Program is to assist FSAH
in elevating the quality and consistency of patient care delivery through improvement with compliance to the CMS Core Measure Standards through a collective experience of teamwork, communication and accountability.
Action Plan Caution Zone Way to Go!
Franciscan Alliance Corporate Report – CMS Quality Measures
Value-Based Purchasing (VBP)• In 2010 VBP became required by the Affordable Care Act to provide
value-based incentive payments to hospitals beginning in FY 2013 for two domains: Clinical Process Measures and HCAHPS.
• CMS has outlined proposals for the VBP Program and views it a vital link to moving increasingly toward rewarding better value, outcomes and innovations instead of volume.
• FY 2013 payment determination will be based upon comparing a hospital’s performance of the chosen measures during a performance period (7/1/2011 – 3/31/2012) to a baseline period (7/1/2009 – 3/31/ 2010).
• FY 2014 payment determination will include mortality measures, as well as certain hospital-acquired conditions and patient safety/inpatient quality indicators.
• At risk is a 1% reduction of FY 2013 base operating DRG payments, with a .25% added reduction per year.
VBP Scoring• Total Performance Score:
– 70% Clinical Process Measures– 30% HCAHPS
• Two scores will be awarded for each measure: Achievement and Improvement, with the higher score used
– Attainment• 0 to 10 points awarded for achievement based on where the hospital’s
performance for the measure falls relative to an achievement threshold (proposed to be at the 50th percentile during the baseline period) and the benchmark (proposed to be at the mean of the top decile).
– Improvement• 0 to 9 points scored relative to a hospital’s performance during the
performance period compared to its own performance during the baseline period.
• For HCAPHS, up to an additional 20 consistency points are possible to obtained
• CMS feels that consistency points encourage hospitals to meet or exceed the achievement threshold.
• If all HCAHPS scores are > the achievement threshold than all 20 points will be awarded.
Value-Based Purchasing
CMS CoreMeasures
70%
HCAHPS30%
Achieving and sustaining top box scores will be vital to survival!
Goal Attainment Through Focused Objectives
• During Quality Rounding the Quality Services team focuses on the following objectives:
– Performing concurrent review and abstraction– Capturing CMS documentation compliance prior to
discharge– Providing “just-in-time” education and support for
staff and physicians– Ensuring timely feedback of results for
accountability– Identifying and improving processes to eliminate
barriers to compliance through teamwork
Quality ServicesQuality Services
Pharmacy Staff
Pharmacy Staff
Patient CareStaff
Patient CareStaff
Informatics Staff
Informatics Staff
Case Management
Case Management
DocumentationSpecialist
DocumentationSpecialist
Medical StaffMedical Staff
Patient
Key to Success:Multidisciplinary Approach
Quality Rounding Process FlowObtain ReportsCensus Report
Surgery SchedulePneumo/Flu Status Reports
Review PortalTest Results
Admission HxHome Med List
H&P/Dicated Consults
Round on FloorsRead MD Notes
Talk w/ MD/Nursing StaffLeave Rounding Notes
Follow Up
RN Documentation
Issue
MD Documentation
Issue
Discuss w/ RN or Leave Note
on Chart
Discuss w/ MD or Leave Note
on Chart
Record Information on Abstraction Tool
Issue Resolved
Issue Resolved
Abstract Record as Usual
NO
Yes Yes
NO NO
Yes Yes
NO
Day in the Life of a Quality Rounder• Run daily census report and surgery schedule
• Log onto physician portal and review:– Test results
• Labs (cardiac enzymes, BNP level, blood cultures & lipid panel performed)• Chest Xray/CT (congestion, edema, infiltrates, consolidation, etc.)• Abdominal Xray/CT (obstruction, free air, ileus, infarcted bowel, perforation, etc.)• Other Xray/CT/Angiography (fractures, occlusion, aneurysm, etc.) • EKGs, Stress Tests, Echocardiograms
– Admission History• Current smoker or quit within last 12 months• Vaccination status• Past medical history (i.e., CHF)
– Home medication list• Close attention to ACE/ARB, Beta-Blocker, Coumadin, Aspirin, Statin,
Antiboitics, Immunosuppressives– Dictated H&Ps/Consults/Operative Reports– Electronic Nursing Charting
• Pre-op/Intraop/PACU charting• Narrative notes• Clinical documentation (I&O, ADLs, etc)
Day in the Life of a Quality Rounder
• Round on Units - Interventions Include:– Review Emergency Department documentation– Read physician progress notes/physicians orders– Confer with documentation specialist– If patient has a history of HF, an automatic education
referral will be ordered– Talk one-to-one with physicians and/or nurses– Leave rounding notes on chart for physicians and/or
nurses– Follow up on previous day’s active patient records
Core Measure Focus• Heart Failure Measures
– LV Assessment: ? Appropriate testing ordered? LV function/EF documentation within physician documentation? Reason for not assessing documented
– ACE/ARB for LVSD? ACE/ARB ordered? Contraindication documented within physician documentation
If the answer is always no, note left for physician to ensure measure compliance
– Smoking Cessation? Current smoker and/or quit within last 12 months? Education refusal documented / Smoking cessation education ordered ? Education completed
If near discharge and the education not completed, contact Cardiac Services and/or inform patient’s nurse that education has not been done
– HF Discharge Instructions? Admission origin? HF discharge education ordered? Education completed? Discharge medications & Discharge summary match
If near discharge and the education not completed, contact Cardiac Services and/or inform patient’s nurse that education has not been done
If discharge summary is missing a medication that physician ordered/patient went home on, meet with physician to review case. Physician can dictate an addendum within 30 days, if appropriate.
Core Measure Focus• AMI Measures
– Aspirin on arrival? Aspirin given within 24 hours prior to arrival or administer within 24
hours after arrival? Contraindication documented within physician documentation
– EKG positive & Angioplasty performed? Balloon/Stent inflated/deployed within 90 minutes? Reason for delay documented
– ACE/ARB for LVSD ordered? ACE/ARB ordered? Contraindication documented within physician documentation
– Aspirin at discharge? Aspirin ordered? Contraindication documented within physician documentation
If the answer is always no, note left for physician to ensure measure compliance
Core Measure Focus• AMI Measures (cont)
– Beta-Blocker at discharge? Beta-Blocker ordered? Contraindication documented within physician documentation
– Statin at discharge? Statin ordered ? Contraindication documented within physician documentation
If the answer is always no, note left for physician to ensure measure compliance
– Smoking Cessation? Current smoker and/or quit within last 12 months? Education refusal documented / Smoking cessation education ordered ? Education completed
If near discharge and the education not completed, contact Cardiac Servicesand/or inform patient’s nurse that education has not been done
Core Measure Focus• Pneumonia Measures
– Antibiotic given within 6 hours of arrival– Appropriate antibiotic given– Blood Culture collected before antibiotic
The above measures do not allow for a yes/no answer…it is what it is!
– Smoking Cessation? Current smoker and/or quit within last 12 months? Education refusal documented / Smoking cessation education ordered ? Education completed
If near discharge and the education not completed, contact Cardiac Services and/or inform patient’s nurse
that education has not been done
– Pneumococcal / Influenza vaccinations? Patient up-to-date with vaccines ? Contraindication documented? Vaccine administered
Note left for nursing staff on patient’s Kardex as a reminder that patient qualifies and vaccine(s) need to
be given before discharge or document contraindication…daily re-checks and calls to nurse until vaccine given
Core Measure Focus• SCIP Measures
– Beta-Blocker within appropriate timeframe? Beta-Blocker given / taken prior to surgery? Contraindication documented within physician documentation
If the answer is always no, note left for physician to ensure measure compliance
If patient’s nurse failed to document date & time of last home dose, the nurse to re-interview patient to obtain information.
– VTE prophylaxis ordered? Appropriate mechanical/pharmacological VTE prophylaxis ordered? Contraindication documented within physician documentation
– Foley discontinued by POD 2 • Foley discontinued• ICU patient and receiving IV Lasix• Reason to keep documented
– Antibiotic stopped within 24 hours of anesthesia end time? Appropriate post-op antibiotics ordered (Q8 X 2 doses, Q12 X 1 dose)? Post-op infection documented
If the answer is always no, note left for physician to ensure measure compliance
Core Measure Focus• SCIP Measures (cont)
– VTE prophylaxis given / on? Ordered VTE prophylaxis given / status documented
Nurse contacted and reminded that the medication needs to be given by X time and/or mechanical prophylaxis needs to be documented on.
– Antibiotic prior to incision? Pre-op infection? Pre-op antibiotic given and documented
Contact Anesthesia Medical Director to review and follow up
– Perioperative temperature management? Forced air warming unit documented as on patient during surgery? 1st post-op temperature documented
– Hair Removal? Hair removal method documented
Contact Surgery / PACU Manager to review and follow up
Measure Awareness• Ensuring that all
are aware of the CMS measures, this document is laminated on bright yellow paper and placed in nursing staff and physician areas of the hospital (i.e., break rooms, lounges).
CMS QUALITY INITIATIVES REVISED 9/22/2010
HOSPITAL QUALITY ALLIANCE (INPATIENT)
Acute Myocardial Infarction Patients • Aspirin on arrival • Aspirin prescribed at discharge • ACE-I or ARB for LVSD • Adult smoking cessation advise/counseling • Beta blocker prescribed at discharge • Thrombolytic Agent within 30 minutes of hospital arrival • PCI received within 90 minutes of hospital arrival • Statin at discharge (beginning 1/1/2011)
Heart Failure Patients • Discharge instructions • LV function assessment • ACE-I or ARB for LVSD • Adult smoking cessation advice/counseling
Pneumonia Patients • Pneumococcal vaccination • Blood cultures performed in the Emergency Department prior to initial antibiotic received in hospital • Blood cultures within 24 hrs prior to or 24 hrs after arrival for patients transferred or admitted to ICU within 24 hrs of arrival • Adult smoking cessation advice/counseling • Initial antibiotic received within 6 hrs (360 min) of hospital arrival • Initial antibiotic selection for Community-Acquired Pneumonia (CAP) in Immunocompetent patient • Influenza vaccination
Surgical Patients (SCIP) • Prophylactic antibiotic received within 1 hour prior to surgical incision • Prophylactic antibiotic selection for surgical patients • Prophylactic antibiotic discontinued within 24 hrs after surgery end time • Cardiac Surgery patients with controlled post-operative serum glucose (POD 1 & 2) • Surgery patients with appropriate hair removal • Surgery patients on a beta-blocker prior to arrival who received a beta-blocker during the perioperative period • Surgery patients with recommended VTE prophylaxis ordered • Surgery patients who received appropriate VTE prophylaxis within 24 hrs prior to surgery to 24 hrs after surgery • Urinary catheter removed on post-op day 1 or 2 • Surgery patients with perioperative temperature management
Pediatric Asthma Patients • Relievers for inpatient asthma • Systemic Corticosteroids for inpatient asthma • Home Management Plan of Care
HOSPITAL OUTPATIENT PROGRAM PRESENT ON ARRIVAL (POA) MEASURES • Object left in surgery Acute Myocardial Infarction & Chest Pain • Air embolism (patients seen in the ED and discharged/transferred to a short-term acute care hospital for inpatient care)
• Blood incompatibility • Catheter-Associated urinary tract infections
• Median time to fibrinolysis • Pressure ulcers (decubitis ulcers) stages III and IV • Fibrinolytic therapy received within 30 minutes • Vascular catheter-associated infection • Median time to transfer to another facility for acute coronary
intervention • Surgical site infection – mediastinitis after CABG surgery • Hospital acquired injuries – fractures, dislocations,
• Aspirin at arrival intracranial injury, crushing injury, burn, etc. • Median time to ECG • Manifestations of poor glycemic control Outpatient Surgery • Antibiotic timing • Antibiotic selection Imaging Efficiency • MRI Lumbar Spine for Low Back Pain • Mammography Follow-up Rates • Abdomen CT - Use of Contrast Material • Thorax CT - Use of Contrast Material
CMS Tri-fold Pocket Guide• In keeping with our facility motto…It takes a Team to go GREEN, a pocket sized
education tool was developed.• These guides will be provided to our physicians and nursing staff
– A small but great reminder of SAM’s commitment to the CMS quality measures
Educational Tools
Appropriate antibiotic selection tables posted in the physician dictation areas within Surgery, Outpatient Surgery, ICU and the medical/surgical inpatient units.
Request for Documentation
• Below is the documentation request that is left for the physicians when there is a potential measure non-compliance.
• Contact with the individual physician/surgeon occurs when note is not addressed.
Variances• When a variance is identified, the Quality Rounders
update a spreadsheet and issue a letter of non-compliance.
• Real-time information is available to department director and vice president.
Measure VariancesAntibiotic Selection January 100% compliant
February 100% compliantMarch 100% compliantApril 100% compliantMay 100% compliantJune 100% compliantJuly 100% compliantAugust 1 = only one appropriate abx (Rocephin) ordered in the ED / EBOS not used, guideline recommends tw o (Rocephin & Zithromax)
PN Variances - 2010
Improvement in ACM Scores
Appropriate Care Measure (ACM) Set
Total Year (before QR)(2008)
Total Year(2009)
Year To Date (2010)
Acute Myocardial Infarction (AMI) 86.6% 89.4% 97.7%
Heart Failure (HF) 90.0% 95.7% 98.8%
Pneumonia (PN) 68.2% 91.5% 93%
Surgical Care Improvement Program (SCIP) 78.3% 85.5% 94.1%
• Source: SSFHS Quality Improvement CMS BIS Report-AMC Scores. Retrieved: 4/18/2011
CMS Quality MeasuresIt takes a Team to go GREEN!
AMI (Acute MI) Top 10% Betw een National Mean 1st Q 2nd Q 3rd Q 4th Q Jan-11 Feb-11 Mar-11
Aspirin on arrival 100% 94% 97% 100% 100% 100% 100% 100% 100%
Aspirin prescribed at discharge 100% 91% 100% 100% 95% 100% 100% 100% 100%
ACEI or ARB for LVSD 100% 89% 100% 100% 100% 100% N/A 100% 100%
Beta blocker prescribed at discharge
100% 92% 100% 100% 100% 100% 100% 100% 100%
Fibrinolytic therapy received w ithin 30 minutes of hospital
100% 82% N/A N/A N/A N/A N/A N/A N/A
Primary PCI received w ithin 90 min. of hospital arrival
97% 82% 100% 100% 100% 100% 100% 100% 100%
20112010
HF (Heart Failure) Top 10% Betw een National Mean 1st Q 2nd Q 3rd Q 4th Q Jan-11 Feb-11 Mar-11
Evaluation of LVS function 100% 87% 100% 100% 100% 100% 95% 100% 100%
ACEI or ARB LVSD 100% 88% 100% 100% 96% 100% 100% 100% 100%
Adult smoking cessation advise/counseling
100% 90% 100% 100% 100% 100% 100% 100% 100%
Discharge instructions 97% 71% 98% 100% 98% 98% 100% 100% 100%
20112010
Celebrate the Green!!
CMS Quality MeasuresIt takes a Team to go GREEN!
PN (Pneumonia) Top 10% Betw een National Mean 1st Q 2nd Q 3rd Q 4th Q Jan-11 Feb-11 Mar-11
Pneumococcal vaccination 97% 82% 92% 100% 96% 100% 100% 100% 100%
Influenza vaccination 97% 82% 94% 98% 100% 100% 100%
Initial blood cultures collected in the ED prior to antibiotic
99% 90% 96% 100% 97% 100% 90% 100% 100%
Adult smoking cessation advise/counseling
100% 87% 100% 100% 100% 100% 100% 100% 100%
Initial antibiotic received w ithin 6 hours (360 min) of hospital arrival
100% 93% 100% 96% 100% 97% 100% 100% 100%
Initial antibiotic selection for Community-Acquired Pneumonia (CAP) in Immunocompetent patient
97% 87% 100% 100% 95% 96% 100% 100% 100%
SCIP (Surgical Care Improvement Project)
Top 10% Betw een National Mean 1st Q 2nd Q 3rd Q 4th Q Jan-11 Feb-11 Mar-11
Prophylatic antibiotic received w ithin 1 hour prior to surgical incision
98% 85% 96% 97% 100% 97% 100% 100% 94%
Prophylatic antibiotic selection for surgical patients
99% 92% 97% 99% 97% 99% 100% 100% 100%
Prophylatic antibiotic discontinued w ithin 24 hours after surgery end time
98% 83% 100% 96% 98% 97% 96% 100% 94%
Cardiac surgery patients w ith controlled blood Glucose in days right after surgery
100% 86% 100% 100% 100% 83% 100% N/A 100%
Appropriate hair removal 100% 95% 100% 100% 100% 100% 100% 100% 100%
Appropriate VTE prophylaxis ordered
97% 82% 100% 98% 100% 98% 100% 92% 92%
Receive appropriate VTE prophylaxis w ithin 24 hours prior to surgery to 24 hours after surgery
96% 82% 100% 98% 100% 98% 100% 92% 92%
Urinary catheter removed w itin tw o days of surgery
97% 82% 98% 95% 100% 99% 100% 100% 100%
Surgery pateints w ith perioperative temperature management
100% 99% 100% 100% 100% 100% 100%
2011
Data Not Published
2010
Continually work on opportunities
Continuous ImprovementProphylactic antibiotic received within 1 hour prior to surgical incision
30/3219/20
24/25
30/3116/17 17/18
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
Jan-
09
Feb-0
9
Mar
-09
Apr-0
9
May
-09
Jun-
09
Jul-0
9
Aug-0
9
Sep-0
9
Oct-
09
Nov-0
9
Dec-0
9
Jan-
10
Feb-1
0
Mar
-10
Apr-1
0
May
-10
Jun-
10
Jul-1
0
Aug-1
0
Sep-1
0
Oct-
10
Nov-1
0
Dec-1
0
Jan-
11
Feb-1
1
Mar
-11
SAM Monthly Data Top 10% Scoring Hospitals National Average State Average
March 2010Emergent ruptured AAAs - Quality educated physicians on requirement for 1hr abx to include even emergent casesApril & May 2010New CRNAs beganOctober 2011OR at 1044 and abx given at 0910 December 2011OPS RN gave abx at 0820 but OR did start until 1257 - CRNA didn't redose abx.March 2011Abx given at 0920 and incision occurred at 1038, 18 mintues too late
Continuous ImprovementPrimary PCI received within 90 minutes of arrival - AMI patients
(breaks in data = no population)
2/3
1/2
40%
45%
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
Jan-
09
Feb-0
9
Mar
-09
Apr-0
9
May
-09
Jun-
09
Jul-0
9
Aug-0
9
Sep-0
9
Oct-
09
Nov-0
9
Dec-0
9
Jan-
10
Feb-1
0
Mar
-10
Apr-1
0
May
-10
Jun-
10
Jul-1
0
Aug-1
0
Sep-1
0
Oct-
10
Nov-1
0
Dec-1
0
Jan-
11
Feb-1
1
Mar
-11
SAM Monthly Data Top 10% Scoring Hospitals National Average State Average
Quality Rounders workwith physicians to educate regarding thorough documentation for compliance
Continuous ImprovementSurgery patients on a beta-blocker prior to arrival who received a
beta-blocker during the perioperative period
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
SAM Monthly Data Top 10% Scoring Hospitals National Average State Average
Action:Quality Rounding continually educated Nursing staff on documenting date & time of patient’s last home dose.
Attended Nursing and Physician Department meetings to review measure and results.
Anesthesia pre-op assessment form revised to ensure compliance.
Continuous ImprovementCHF Discharge Instructions - HF Patients
13/1419/20 19/20
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
Jan-
09
Feb-0
9
Mar
-09
Apr-0
9
May
-09
Jun-
09
Jul-0
9
Aug-0
9
Sep-0
9
Oct-09
Nov-09
Dec-09
Jan-
10
Feb-1
0
Mar
-10
Apr-1
0
May
-10
Jun-
10
Jul-1
0
Aug-1
0
Sep-1
0
Oct-10
Nov-10
Dec-10
Jan-
11
Feb-1
1
Mar
-11
SAM Monthly Data Top 10% Scoring Hospitals National Average State Average
July 2010MD ordered med on d/c but it was not put on pts med list for homeOctober 2010Discharge medications did not match. Discharge summary did not list all medications patient went home on. MD dictated addendum but was over 30 from discharge.January 2011Discharge medication did not match. Discharge summary did not list all medications patient went home on.
Continuous ImprovementPneumococcal Vaccination Administered prior to Discharge - PN Patients
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
SAM Monthly Data Top 10% Scoring Hospitals National Average State Average
Continuous ImprovementUltrasound Guided Biopsies
Pre-operative Antibiotic Documented(breaks in data = no patients)
60%
11%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Action:July 2009 - changed vendors for CMS data submission.
October 2009 - Began abstraction of 3Q2009 data.
Previous vendor did not capture ultrasound guided biopsies in patient population. Abstracted missing population and resubmitted cases. During abstraction of these cases identified issue with no documentation of pre operative antibiotic.
Continuous ImprovementPacemaker Procedures
Appropriate Antibiotic Selection(breaks in data = no patients)
80% 75%80%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Action:Change in practice identified w ith particular practitioner. Quality Services, along w ith Infection Control, met w ith practitioner to explain measure guidelines.
Pre-printed pre and post operative order set changed to include guidelines, which w ill ensure compliance.
Quality Rounding (QR)• Highlights of our teamwork…
2E ACEI/ARB for LVSD
Per cardiology consult pt had moderate decrease in LV function. However, no ACEI was prescribed during stay or on discharge. Situation identified during QR, and QR spoke with MD who then dictated the reason for not prescribing in the discharge summary. Contraindication dictated in discharge summary – record excluded.
ICU Beta-Blocker Beta-Blocker ordered on admission MAR but was not on medication list. QR re-faxed paperwork to Pharmacy during rounding. Medication now on current MAR – measure passed.
ICU ACEI/ARB for LVSD
No documented reason why patient was not prescribed an ACE/ARB for LVSD. Quality Services spoke with Cardiologist. Cardiologist stated patient is allergic to ACE and ARB. Allergy order documented within chart – measure passed.
3S HF Education QR left per protocol order in chart for HUC to order. Called Cardiac Services 5/11/2010 because referral not completed and patient getting ready for discharge. QR spoke with Cardiac Services RN. Education completed – measure passed.
2S Continued post-op abx
MD ordered one dose of Ancef past 24 hr timeframe which would result in noncompliance. During rounding, QR paged MD and explained criteria for ordering post op ABX. MD then cancelled the order for Ancef as criteria not met – measure passed.
Rounding SuccessesVariances Corrected Prior to Discharge
Measure 1Q2009 2Q2009 3Q2009 4Q2009 1Q2010 2Q2010
Pneumococcal Vaccines
0 issues 2 issues corrected
w/o corrections = 91%
Actual = 96%
3 issues corrected
w/o corrections = 86%
Actual = 96%
0 issues 0 issues 3 issues corrected
w/o corrections = 88%
Actual = 100%
Pre-operative Antibiotics
2 issues corrected
w/o corrections = 78%
Actual = 82%
5 issues corrected
w/o corrections = 91%
Actual = 99%
5 issues corrected
w/o corrections = 88%
Actual = 95%
2 issues corrected
w/o corrections = 94%
Actual = 98%
5 issues corrected
w/o corrections = 86%
Actual = 96%
7 issues corrected
w/o corrections = 88%
Actual = 97%
LV Assessments 1 issue corrected
w/o corrections = 97%
Actual = 99%
3 issues corrected
w/o corrections = 96%
Actual = 100%
2 issues corrected
w/o corrections = 97%
Actual = 100%
3 issues corrected
w/o corrections = 94%
Actual = 100%
3 issues corrected
w/o corrections = 95%
Actual = 100%
3 issues corrected
w/o corrections = 94%
Actual = 100%
VTE Documented Timely
0 issues 4 issues corrected
w/o corrections = 85%
Actual = 100%
0 issues 0 issues 2 issues corrected
w/o corrections = 95%
Actual = 100%
2 issues corrected
w/o corrections = 94%
Actual = 98%
Objectives Met:
• Performing concurrent review and abstraction– QR uses the daily census report and surgery schedule
– Specific admission reports
– Daily discussions w/ charge nurse, and the clinical documentation specialist for identification for chart review.
Objectives Met:
• Capturing CMS documentation compliance prior to discharge– QR identifies standard compliance opportunities and
discusses individual cases w/ nurses and MD’s
– Calls MD’s directly, or leaves rounding notes
– Emails clinical mgrs and supervisors w/ open cases
– The QR team also works with the EBOS Facilitator to ensure CMS compliance
Objectives Met:
• Providing “just-in-time” education and support for staff and physicians– The success of this program is relationship driven
– QR has developed a good report with physicians and staff through continual communication offering daily support while rounding on the units
– The QR team has developed a one page Core Measure Fact Sheet and CMS Pocket Guide
– Quality Services page on the Intranet which includes CMS data definitions.
Objectives Met:
• Ensuring timely feedback of results for accountability– Provides daily feedback via:
• rounding• staff meetings• email alerts• variance reporting through letters to physicians and
clinical managers• reporting variances at medical staff meetings
Objectives Met:
• Identifying and improve processes to eliminate barriers to compliance– When trends are identified while rounding, the QR team
brings stakeholders together more timely to work on processes.
Overall Impact:
Improved teamwork, awareness, and accountability through relationship building and ongoing and timely communication among Quality Services, Medical Staff, Nursing and Ancillary Staff resulting in increased quality of care delivery, consistency in practice and compliance to standards as evidenced by our results!
Amy Baker, ADCMS Data [email protected]
Deborah Kelley, LPNClinical Data [email protected]
Genevieve Koehler, RN, CPHQDirector of [email protected]