Collecting core measures data is a part of everyday life at most healthcare facilities, affecting various types of staff members and CMS reimbursement. Assessing whether your facility is managing those data well and using the information contained in your core measures data is vital to improvement, according to Ken Rohde, senior consultant in patient safety and process at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA. Rohde spoke on the topic at the 4th Annual Association for Healthcare Accreditation Professionals Conference in May.
"Data that do not validate or change our behaviors are not very useful," said Rohde. "It's important to consider control loops and to make sure your core measures are part of formal control loops."
A closed control loop is one in which data and responses are connected. For example, if your data collection surrounding the heart failure core measure is telling you that patients are not receiving appropriate discharge education on medications 100% of the time, your response should be to try to control that.
A broken control loop is one in which the data and the response are not connected, meaning that data are collected but there is no indication that behavior is changing as a result of what the data say.
Another key item to consider when looking at data measurement with respect to core measures is why things are occurring, said Rohde.
"Core measures tell us what's happening, but we need to analyze why it's happening. The key thing to do is convert data from 'what' into 'why,' " he said. Improvement on a specific core measure will only come after staff understand why goals for that core measure are not being reached.
Connecting core measures to processes
Ultimately, core measures are really looking at internal process measures, said Rohde. You have to connect your core measures data to your processes and thereby the people who use those processes. However, because the core measures are not organized by hospital process, it's easy to lose sight of which processes are ultimately in control.
"When we start looking at core measures, which is a relatively large burden, we really see that they break down into these processes," he said.
For example, throughout the entire set of core measures, a large majority fall into the medication process, with a significant amount of those being medication ordering process measures, said Rohde. If the facility is aware of which processes may be breaking down or not working properly, it might be able to fix the processes, thereby improving core measures.
However, core measures improvement requires change at a behavioral level. Looking at core measures data provides vitally important process and culture of safety information, said Rohde.
"We need to ask, 'What behaviors do we need to be connecting to make sure we're getting the right things done?' " he said.
To read more about data management with respect to core measures, see the July issue of Briefings on Patient Safety, a product of Patient Safety Monitor.