Core measures—they're a part of the fabric of hospital life, particularly given their connection to CMS reimbursement numbers. All staff have encountered core measures at some point and have a basic understanding. But how do you ensure that their knowledge level is up to date and sufficient to keep your hospital's reimbursements optimized?
At Regional Medical Center (RMC) of San Jose, the Quality Department created the Core Measures 101 brochure, an educational tool designed to improve new hires' understanding of core measures.
"We give this out in every new employee orientation and to the nursing and medical staff who need core measure education," says RMC quality coordinator Odette Carreon. "It contains all the basic information one has to know about core measure guidelines, including helpful links, resources, and contact numbers of the quality department."
The brochure is printed in full color and distributed to staff. Rather than try to teach employees core measures guidelines from scratch, the brochure is intended as a go-to reference on the fly as well as a reminder or update for experienced staff.
"Most of the staff are very familiar with core measures," says Nancy Fore, chief quality officer at RMC. New hires will have heard about core measures through their previous jobs, but the tool acts as a key reminder for them.
"You can't not know something about core measures in the U.S.," says Fore. "It's every hospital's focus because of the reimbursement factors."
The information contained in the brochure is a collection of facts from The Joint Commission and CMS, with a focus on publicly reported measures. Although the hospital is educating its staff members on all of the core measures guidelines, the brochure sticks with the publicly reported indicators as a way to keep things streamlined. "We had very limited space," Carreon says.
The tool has been well received by the staff. "The colorful presentation helped in delivering the message," says Carreon.
The brochure's minimal size has helped keep it useful for staff as well. "The size of it is convenient—the trifold slips into a lab coat pocket," Fore says. "It's informational as well as convenient."
So convenient, in fact, that certain members of the staff carry it at all times. "Our hospitalists keep it in their pockets and use it during discharge and admissions," says Cindy Stewart, director of quality at RMC.
RMC hospitalists and intensivists use the brochure to verify that they are following the appropriate steps at pivotal times in patient care.
"I equate it to a clinical pathway," says Fore. "They're making sure they've done every step along the way."
The quality department is hoping to expand this go-to style of use to the nursing staff as well.
"Our goal is for every nurse to refer to it also," says Fore. "They don't have the same level of control, in that they're not writing the orders, but they are following up on orders.
"What RMC hopes to achieve, ultimately," she explains, "is that nurses are jarring the memory of physicians: Did they remember to write the order in this instance? The intent is to create a check and balance between caregivers to improve patient outcomes."
The bigger picture
The brochure is only one part of a larger core measures plan. RMC has taken multiple steps to make core measures part of the hospital's culture.
"We've created a core measures binder that contains our forms, checklist, documentation, that's used as a reference binder," explains Stewart. "We also have a core measures team that meets daily. We do ongoing education every step of the way."
The goal of the meeting is to always be looking at RMC's processes, says Fore.
"We want to modify our processes in a concurrent way so we're on top of it and make sure we don't have any fallout for the day where one of the steps wasn't actually instituted," she says. "It's always morphing into something else. The people who sit at the team meeting every day are responsible for taking back the changes and education to their staff. I'd say it's one of the most vibrant performance projects in our hospital."
There's a large amount of energy and resources put toward this project because the impact is so great, Fore explains.
"Adherence to core measure guidelines by everyone in our organization is essential. [The hospital system] is trying to adapt something like this in all its hospitals," she says. "We talk with other facilities in our region about demonstrated best practices. This is a big focus area with our healthcare system."
The biggest challenge thus far has been physician endorsement, which is always present at the start of any change.
"The way we work through that is to educate every day," says Fore. "We're sometimes successful, sometimes not, but the more momentum we've built with our outcome scores, the more [physicians] become involved—just from the competitive nature of healthcare, everyone wants to be successful."
RMC publishes its outcomes all over the hospital, which taps into the competitive spirit of the providers and improves outcomes across the board.
Providing data also helps with physician involvement because physicians respond well when presented with data supporting the change.
"You've got to allocate the resources for this. It's not something you can do with a limited number of resources," says Fore. "Not every quality department has the resources to do this; therefore, everyone in the hospital has to be engaged in core measures."
It also helps to have leadership on your side, firmly behind the tracking and improvement of core measures.
"Leadership definitely supports this," says Fore. "It is coming from the top down. Our CEO is very involved. Every single member of the executive team is familiar with core measure outcomes. It's very much a focus for RMC and [Hospital Corporation of America."
Door-to-balloon time
One core measure indicator that provided additional challenges during RMC's improvement efforts was door-to-balloon time. Door-to-balloon is an emergency cardiac care measurement of time for treatment of ST-segment elevation myocardial infarction (STEMI) and is a core quality measure of The Joint Commission.
The interval starts with the patient's arrival in the emergency department and ends when a balloon catheter crosses the culprit lesion in the cardiac cath lab. Delays in treating a myocardial infarction increase the likelihood and amount of cardiac muscle damage due to localized hypoxia. Guidelines recommend a door-to-balloon interval of no more than 90 minutes.
"Our door-to-balloon time was a challenge," says Stewart. "We've got a multidisciplinary team together to look at our STEMI patients."
"This was a multidiscipline improvement project, working with staff from EKG, cath lab, admissions, laboratory, and more," Fore says. "RMC dropped its door-to-balloon time from 120 minutes to 90 minutes, with more improvements on the way.
"Very soon it will be 60 minutes," she adds. "We've been under 90 minutes for the better part of a year. The way we will be able to meet that 60-minute target in our geographic area is to have a countywide STEMI program."
The ambulances and paramedics in the region, once they recognize symptoms of chest pain, are able to run an EKG and determine with good certainty what they are dealing with. This is transmitted to the closest facility, and the paramedics can start medications in the field.
"We know exactly what our goal is when the patient arrives—we're taking them right to the cath lab," says Fore.
There are eight STEMI-designated emergency rooms in the county, which had to prove they could provide patients with a door-to-balloon intervention in a window of under 90 minutes. RMC's emergency room is one of the eight.
"Our next challenge will be to add more diagnoses to core measures," says Fore.
RMC's next target will be in perinatal initiatives.
This article was adapted from one that originally appeared in the May 2010 issue of Briefings on The Joint Commission, an HCPro publication.
A major concern in healthcare today is the nursing shortage, which promises to get worse as the number of people choosing this profession declines while demand for their services continues to grow.
During my career as a registered nurse, I experienced the lifestyle of these caregivers. While nursing is very rewarding, it comes with struggles: long hours, unexpected overtime, and erratic schedules. This can make nurses' lives emotionally and physically draining.
If we could normalize nursing schedules, not only could we make their lives a little less stressful, we could maximize staffing efficiency for providers, lower their personnel costs, and perhaps contribute to the long-term viability of this important profession.
Here are some of the steps to take to improve conditions for nurses:
Don't let scheduling be an afterthought. Make sure there is a structure in place so that administrative scheduling doesn't fall on nurses who should be providing care. Be ready for last-minute changes and have a system in place so that everyone knows what to expect.
Provide staff schedules in advance. Scheduling problems can make it challenging for nurses to manage family commitments and maintain a satisfying quality of life. Nurses often work long hours and inconsistent shifts, leading to burnout, fatigue, and health problems. Some are given their schedules just two weeks in advance and are frequently asked to work overtime shifts without notice, which makes it hard for them to take care of the day-to-day activities we all take for granted. Hospitals that offer nurses regular schedules, months in advance, will be more successful at recruiting and retaining them. This gives a hospital the upper hand in an industry where there is a shortage of talent and constant competition for the best.
Increase continuity of care. Continuity of care, when nurses provide care for a patient for consecutive days, allows nurses to get to know their patients, their conditions, and their treatment plans much better than if they are assigned to a different patient every day. This can improve patient safety and patient satisfaction. An efficient staff-scheduling process can have a major effect on the ability to provide maximum continuity of care.
Every healthcare organization should step back and evaluate the scheduling process for nurses. While this may seem like a small issue on the surface, it can have a serious effect on a company's bottom line. The largest expenditure for a hospital is its nurses. While it is expected that the nursing staff will naturally have some overtime, approximately 2%-3% of the budget, most hospitals are experiencing unnecessarily high overtime, around 6%-8% of the budget. By harnessing this overspending, a hospital can save a significant amount of money, and free funds to be reinvested into patient care, equipment to improve overall care and efficiency, or other strategic projects.
The potential to provide a safer patient experience is reason enough to pursue the goal of a more balanced scheduling approach, but the additional opportunity to take care of precious and scarce human and financial resources drives the issue to the forefront. We have an opportunity to make a very positive impact on all involved by managing our staff scheduling process better.
Karla Schnell is a consultant with North Highland and works with major national providers throughout the United States. She began her career as a nurse in Canada more than 20 years ago and quickly moved up the ranks to become one of the youngest nursing directors in the Province.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
With two days to go before a planned strike, the Minnesota Nurses Association is going public with stories of alleged poor patient care to back its assertion that hospitals are dangerously understaffed. The union, which says hospital staffing is at the core of its dispute with management, has scheduled a news conference to tell some of those stories. "We don't think the general public truly understands just how unsafe things are inside our hospitals, and that it's getting worse," said Cindy Olson, a member of the nurses' negotiating team.
A nurses strike seemed all but inevitable after talks broke down between the Minnesota Nurses Association and 14 hospitals, with each side blaming the other for refusing to compromise. Before the afternoon was out, the nurses and hospitals were shifting gears to prepare for the scheduled one-day walkout, which would start at 7 a.m. June 10. Hospital officials are vowing to operate as normally as possible, saying they hope to keep patient disruption to a minimum with the help of thousands of replacement nurses, the Minneapolis Star Tribune reports.
More than 12,000 nurses in California are set to hold a one-day walkout June 10, taking part in what could be the largest registered nursing strike in the country's history. The nurses plan to walk off their jobs at five University of California hospitals—San Francisco, Davis, Los Angeles, Irvine and San Diego—and three hospitals in Los Angeles County. Nurses from the same union in Minnesota are also planning to strike that day, bringing the number of striking nurses nationwide to more than 24,000.
Nearly 2,400 nurses from other states have flooded the Minnesota nursing board with license applications in the last month, 10 times the normal volume, as hospitals line up replacements for a possible strike June 10. The 14 hospitals have said they're preparing to stay open if a walkout occurs, and staffing agencies are offering as much as $2,200 a day to recruit temporary replacement nurses. Already, some elective procedures are being postponed, and some doctors are starting to field questions from patients about what to expect if a strike occurs.