The 623-bed medical center has been known for its quality outcomes, especially in the cardiac arena, for many years. This opportunity gave the organization a forum to really push quality to the highest levels possible.
In launching the project, it became clear that the medical center's electronic medical records software would play a vital role. Early in the project, a team was developed and a review of baseline data was completed. The various data elements were reviewed and sources for each element identified. The elements, however, could be found in multiple locations within the medical record, making data abstraction difficult and ensuring compliance unreliable.
The team began to look for the largest gap in the data to start the improvement cycles. The team consisted of bedside staff, physicians and clinical leaders along with clinical informatics, medical records and performance improvement staff. The multidisciplinary team looked at common data elements, and not just data by disease category. This helped to drive improvement across all patient groups served, which accelerated rates of change.
The first focus was on documentation of smoking status and the offering of counseling. The team quickly determined the current assessment of smoking status was often incomplete. It was often documented in multiple locations within the electronic record, such as nursing notes, physicians' progress notes and discharge information. The team decided to display the specific questions in the nursing admission history of the electronic record along with a script to help the staff in the process.
As a result, the system now automatically reminds staff to offer smoking cessation counseling throughout the hospital, not just on the specific diagnoses that were the focus of the project. In addition to the required fields, another query was added to automatically make a referral to the community education center to help patients quit after discharge if the patient was interested in additional help.
This simple change quickly moved the compliance score for offering smoking cessation counseling to chronically ill patients to 100%.
Other Measures
With the success of collecting this data in the electronic record, the team identified other quality measures that could be added. Staff was involved throughout the process to ensure the changes were part of their work flow and not an added burden. This approach was utilized on other interventions, including discharge instructions, medication reconciliation and vaccination screening.
The most complex of all the interventions was the screening for vaccination history as well as eligibility to receive the vaccine while in the hospital. The standard questions on vaccination status already existed in the electronic record, which noted the flu immunization needed to be updated annually.
A group from clinical informatics, nursing and performance improvement spent several months working on screen triggers that would pop up depending on how previous questions had been answered. If the patient was interested in receiving an immunization, the staff member would go through a series of questions. If the software determined that the patient was eligible, an order would automatically print. The team also developed a "suggested" order if the patient had risk factors but was not age-eligible to alert the physician that vaccination could benefit this patient.
As a result of these efforts, we were able to get appropriate patients vaccinated and achieve 100% compliance.
Sacred Heart was able to achieve the top pay out in the Medicare pay-for-performance project for year three of the program-$385,000-as a result of leveraging electronic medical records to better support key processes of care and capture the documentation of these measures. The cases involved included treatment of patients with heart attacks, coronary bypass grafts, heart failure and total joint.
Involving the clinical staff in recommending, testing and championing all the changes proved critical for success.
As the medical center introduces new quality measures, one of the first steps we now take is to determine how to document the relevant information within the electronic medical record during the care-delivery process.
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