Core measures are 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 of them. 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 (CA), 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 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. 

The biggest challenge thus far has been physician endorsement, which is always an obstacle 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].”

“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.” 

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 ED 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,” Stewart says. “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 predicts. “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 information 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.

How many patients one nurse can care for is a difficult question to answer with certainty. Some days more. Some days less. Any nurse will tell you it all comes down to the individual patient and how much care they need.

This is why acuity-based staffing models are so popular. A shift’s staffing needs are based on the patients’ level of care complexity. Saint Joseph Hospital in Chicago implemented a software program—Res-Q from Concerro—to track and predict nurse staffing needs based on acuity. The program allows nurses to assign relative weight to patients that indicate how much care those patients need. For example, whether they require ventilation or have a central line.

Saint Joseph’s is part of the Resurrection Health Care system, which assembled committees across the system to develop standards and assign weights to different patient types.

Mary Anne Harper, clinical manager of maternal child services, explains that before launching the program, her department discussed the amount of time nurses spend on the various patient types in maternal-child nursing, e.g., a normal newborn. The weights assigned were reviewed and agreed upon by the entire system.

Once the program was implemented, she says it was fairly easy to roll out to nurses. Two hours before the end of their shift, nurses enter information about their patients into the computer system. They select attributes for patients from lists already entered, such as whether patients are receiving blood transfusions or have total care needs, whether they are in isolation, and so on. The program assigns a weight to each patient that indicates the acuity needs.

“The charge nurse on each shift will review after everyone has entered,” says Harper. “They run a report to determine needs. How many people are level 1 acuity, how many people are level 2, etc. The charge nurse looks at the numbers and determines her staffing needs.”

Harper says the charge nurse may find the unit has a lot of patients with high acuity, which may mean they need more nurses. Sometimes they may have low acuity—for example, if a lot of patients are simply waiting to go home—and may need fewer nurses.

Each unit has varying levels of acuity. Harper’s maternal-child unit has seven different levels because it includes women in labor, women in delivery, C-sections, the operating room, and post-partum patients.

Harper says her unit relies on the software to support why they do things. “Charge nurses do acuity assessments every eight hours to examine staffing needs. The program helps them identify what happened on the shift and anticipate what may happen on the next,” she says.

“In my area, someone in early stages of normal labor doesn’t need as much nursing time,” she says. “We put (the) IV in, put them on the monitor, etc. When they get into second stage, they need more time, such as monitoring, pain medications, and emotional support. Then when delivery occurs, we need more people.”

The system tracks patients as they get more or less acute and Harper says it helps to justify staffing. A manager may look at a report that showed eight nurses for 10 patients on one shift, which sounds like a lot, but the acuity report will demonstrate the patients were all high acuity.

Harper says the system is appreciated by nurses because it allows nurses to determine their staffing needs. “It’s the nursing staff that identifies the needs of the patient and what’s going on with the patient,” she says. “It’s their decision. It’s not a higher-up decision. They are the ones who select the patient acuity. Staff nurses put this together—it’s not the managers who decided it.”

Hospitals with ANCC Magnet Recognition Program® (MRP) designation are always seeking better ways to educate their nurses to ensure quality outcomes. For many facilities, part of this education process comes in the form of competency days. And for some, such as Saint Francis Hospital and Medical Center in Hartford, CT, these competency days turn out to be a raging success.

Saint Francis is in its third year of using competency days for nursing education, and, according to Erica Siddell, PhD, RN, director of nursing education and professional development in Saint Francis' Center for Nursing Education and Practice Innovation, most of the bugs have been worked out.

The competency days are hosted once per month. The sessions are about four hours long, and each session will see about 100 nurses pass through.

The competency days began when the nursing education structure at Saint Francis was evolving at the same time.

"It was a different organizational structure prior to 2005," says Marge Freeland-Wasel, APRN, ACNS-BC, a clinical nurse specialist at Saint Francis. "We were the Department of Nursing Clinical Excellence, composed of all nurse specialists, no nurse educators."

The nurse specialists had many roles, and one of them was nursing education. However, they were torn between these many roles.

"The clinical nurse specialists in a particular unit would say they were going to run some competency days for my units, but there was no mandate that 100% of the staff would get there, or remediation if they didn't attend," says Freeland-Wasel.

The other issue was time—the clinical specialists could only provide so much education when torn between several roles. And it wasn't just the clinical specialists who were short on time.

"Surgery did their own competency days, medicine did their own, critical care—they were run on the unit. Staff would come out and still be thinking about patient care during the education," says Freeland-Wasel. "They had to get back to patient care."

And if the nurses still had patients waiting in the wings for them, it was very difficult to make these education days educationally sound. But then the educational council took on the responsibility, and shared governance went live.

"The educational council and the education fair happened around the same time," says Lynn Morris, RN, MSN, nurse educator at Saint Francis. The initiative came out of the council.

"At the time, my mother was working in another hospital out of state and used to send me flyers if she thought they might be of interest," says Morris.

One of those flyers was for a full-day educational fair for all employees. The concept was different from what Saint Francis would eventually implement, but it sparked an idea.

"We decided we needed to do something away from the bedside," says Morris.

Planning
It took a full year of planning before Saint Francis piloted the fair. It was extremely well received by staff members, says Morris, giving them a full eight-hour day away from patients to focus on education.

The first question, of course, was how to get nurses away from the bedside and still maintain patient safety.

"Initially, we had to get permission to get staff in off their scheduled hours," says Morris.

They looked at the number of employees, how many employees they could manage in a given day's fair, and how many fairs they could manage in a year. Staff was responsible for signing up.

They also figured out how to make sure employees showed up to the competency day.

"I think one of the drivers of our success is that in the last couple of years, attendance has become an enforced expectation," says Siddell.

Prior opportunities for education were offered and staff members were supposed to attend, but there really were no repercussions if they skipped out. Starting in 2008, however, if staff did not attend the mandatory session, it affected their ability to get their annual raises on time. The impetus behind this was tied to The Joint Commission's requirement for annual competency testing of staff, says Siddell.

Who's involved
As previously discussed, over the past few years, there has been an evolution in the nursing shared governance structure at Saint Francis. When the competency day program began, the education department was a more collaborative practice of clinical nurse specialists, says Siddell. They had direct care consultants as advanced practice RNs (APRN), but they were also responsible for unit-based education.

When a new CNO arrived in 2006, she mandated structural changes—one of these being a requirement that nursing education become a collaborative process with nurse educators and clinical nurse specialists to support the new shared governance structure.

"We were looking at the way the nursing council worked," says Siddell. "This new approach had to be vetted by our nursing management council, and some discussions were had with human resources and also at the director level to drive down accountability and make sure staff were attending. It was a cultural shift for us."

Structure
All nurses come through the competency day at some point during the year. They are scheduled away from their work area.

"We house it all in the educational department," says Kathy Urban, RN, MSN, nurse educator at Saint Francis. "The educators are responsible for different stations."

Aside from a pacemaker company that Saint Francis requested send a representative for competency education, all other stations are managed in-house, says Urban.

"One of the things Kathy did that was very successful was create a steering committee of nurse educators," says Siddell. "We've had to go back to Joint Commission requirements looking at high-risk/high-frequency, high-risk/low-frequency types of activities. We've worked with colleagues to come up with standard templates for each [education] area."

They have also looked at key skill areas and knowledge bases for various groups—critical care, for example, has competency requirements that look different from behavioral health, which are different from women and children, and so on.

"Each year, we look at what's been going on in the hospital and decide where we want to focus across the board," says Siddell. For example, the hospital purchased smart pumps in 2007 and found some knowledge gaps in the equipment at first, so they made competency training a requirement for everyone. Other years, there may be a type of medication error that needs to be focused on. Restraints are often a focus point.

"When we first went to the department about the steering committee, we asked, 'How do we define competency?' There wasn't any defined method of doing that in the department," says Urban. "What we did was made a definition, created a mission statement, developed a policy with human resources on competency, and determined who is responsible for what."

The steering committee meets with educators, managers, and representation from HR, and the group looks globally at what nurses need to be validated on to have their core competencies covered.

To keep requirements reasonable, the committee determined that there would be no more than 10 core competencies covered to avoid overwhelming the staff. These 10 can be made up of a combination of core competencies required globally, as well as those for individual units. This year, for example, the steering committee decided on six core competencies, leaving four additional competencies to be identified for individual units.

Those requirements are identified after the core competencies, when educators go back to speak with managers to discuss what areas they feel nurses need to be validated in to ensure competency.

Scheduling challenges
Timing and resources are everything when planning a competency day. Making sure you have the resources to man the stations and identifying the number of offerings you need to have can be a challenge.

"It takes time," says Freeland-Wasel. "We needed to go back to see how many could go through the fair at the same time."

"One of our struggles at first was scheduling; the mandatory nature of it," says Siddell. "We were setting up approximately three days a month, and during the first part of the year, they were not well attended."

Then, when staff members realized they still needed to attend a competency day, attendees would swell to unmanageable numbers. The education department went back to examine exactly how many attendees it could handle at once. It then went back to managers to organize the number of staff who would be scheduled to attend each fair.

"Doing this helped us push the issue about being more proactive about how they were scheduled," says Siddell.

Another issue was that Saint Francis originally scheduled some point-of-care testing during the competency days, and it was a struggle at first to get managers and staff to plan accordingly.

The hospital has seen a massive jump in staff finishing their competencies since taking on a more structured scheduling process, says Urban.

"We probably had around 40% finishing their competencies at first, and now we have over 90%," not including nurses on maternity leave, leaves of absence, or other excused absences, says Urban.

It all ultimately ties into the MRP journey, Siddell says. With St. Francis' focus on revamping the shared governance structure and some of these core processes, the ultimate goal in mind is the highest quality education and training.

One piece of advice for a hospital just starting to revamp its competency training: Don't go at it alone.

"I would say to someone starting from scratch: Talk to a hospital that is already doing it," says Urban. "Starting from square one, it took us from 2005. It's a process."

When Athens (GA) Regional Medical Center (ARMC) implemented shared governance five years ago, the initial drive of the program was met with different levels of success. Unit councils excelled in some areas and struggled in others, leading to inconsistent results.

The organization decided it was time to change that-and it pursued clear data to back up its decision-making process.

"We saw varying success, especially in our unit councils," says Nancy Arata, RN, BSN, MBA, from the ARMC Office of Professional Excellence. "We wanted to be able to determine if there were particular factors that influenced our success."

Based solely on gut reaction to existing success rates, ARMC's nursing leadership could see that some unit councils were outperforming others, with great results and projects coming out of the units. One of those great results: higher nursing satisfaction scores.

"Our question was, 'Could having a productive unit-based council correlate with high nurse satisfaction? Are you going to have happier nurses in units where nurses are making decisions?' " says Arata. The leadership team decided to look for evidence proving or disproving the theory-and that meant conducting a research study.

Looking for evidence
The team developed a survey and distributed it to the unit-based council members and chairs. The 11-question anonymous survey included an area where respondents were asked to list specific decisions made from the previous year.

The survey also looked at how long the council had been in existence, whether it had an elected chair, how involved the director of the unit was in the council, and whether he or she acted as a mentor.

"When we asked them to give a number of decisions they had made in their unit council, the results were really interesting," says Arata. "Some units couldn't come up with a number or list out the decisions that had been made. But others could be very specific about these things."

Based on these results, the researchers scored each unit. The scores were then correlated with nurse satisfaction survey results.

"We saw a correlation between the number of decisions the unit council had made and nurse satisfaction-it confirmed what our gut feeling was telling us," says Arata.

Once the data were correlated, researchers rated existing councils using three levels of maturity:

• Beginning: early stages; not yet making decisions and/or purpose not clearly realized
• Competent: capable of making change but still encountering barriers at times
• Mature: fully developed; making clear decisions on a quarterly basis that impact nursing practice, work environment, or quality

 

Interestingly, the actual lifespan of the council-how long it had been in existence and functioning-didn't correlate with nurse satisfaction. What came into play was the council's own sense of its maturity-for example, councils that felt they were just starting out tended to have beginning-level scores, regardless of how long they had been in existence.

Another determining factor: If the unit director coached the council-"coached" being the operative word, rather than "directed"-the unit tended to have higher satisfaction scores.

"There was a definite correlation between the number of decisions the councils had made and RN satisfaction scores," says Arata. "If you feel like you have the authority to make decisions to impact patient care and your work environment, our study showed a correlation between that and nurse satisfaction."

Focus groups
The next step upon correlating the data was to reach out to council members and leaders to get feedback and input in real time. This meant organizing focus groups.

These sessions were mandatory for every unit chair and leader. The organizers, however, were gracious in scheduling the meetings to make sure they would work well for attendees by using multiple dates, including in the evening.

"It's hard to get away from the bedside, but if you take that time to have a conversation and gain a deeper understanding of the shared governance process and outcomes, you will see it is worth it for the patient," says Arata.

"There were about 10 people in each group, and we gave lunch passes to those who attended," she says. "We had conversations: 'What is working on your unit? What isn't? What is frustrating? Where are your barriers to improvement?' "

They also asked these groups about how management and leadership helped encourage decision-making and change.

"We took that information, along with the research study, and totally revamped our nursing governance structure," says Arata. At the organization and unit level, this meant reeducating leaders. The organization provided what amounted to a shared governance 101 program, with the thought that since the program had been in existence for half a decade, it was time to revisit its core.

"Why is this important? What is its purpose? What can it impact?" says Arata. "It's ultimately about patient outcomes, and that is impacted by nursing satisfaction, and higher nurse satisfaction leads to higher patient satisfaction."

This revamp looked at specific ways to improve accountability in the process. Every nursingwide unit-based council now has a standard template for tracking progress.

"It's a simple form that allows them to track who is coming to meetings, percentage of participation, action items, decisions made," says Arata. "They submit that to nursing administration. One of our nursing councils is the leadership council, made up of formal and informal leaders. They look at these reports."

This is not a "g

otcha" process-the leadership council takes note and praises good work, and the reports are published internally so various units can learn from each other and their individual successes.

"If, for example, surgery is doing great work on preventing central line infections, other units can look at what they've been doing and learn from them," says Arata.

On the other hand, if leadership finds that a unit is not making decisions, it has an opportunity to contact that unit's chair and ask how it can help and what barriers the unit is struggling to circumvent. Leadership provides tools and education to help make the unit council ready to take the next step in decision-making.

"We want our units to be innovative," says Arata.

The new structure
Specific changes to the shared governance program took effect in January. ARMC plans to resurvey in October to collect data on the results of these changes.

"We're hoping to have strong data from that," says Arata.

In the meantime, however, there are signs of great successes throughout the organization.

"One of our units started this process on their own a year ago," says Arata. "They revamped all of their unit-based councils so that they got everyone in the unit involved in a council."

Apparently involvement leads to satisfaction-this unit was surveyed recently and was found to be in the top 10th percentile for the nation in nurse satisfaction. "They have some of the highest nurse satisfaction scores in the country," says Arata.

This confirmed the results of ARMC's research. "We'd done our research study, and this particular unit had already started making changes," says Arata.

There were lessons learned along the way, as well. "We definitely would have had the accountability part in place five years ago," says Arata. "It's a big part of the work we're doing."

Also, don't be afraid to reeducate your staff. "It's never too early to go back and reeducate everybody," says Arata. "Everyone had been educated at some point in time. We had a workshop in November but decided it was still important and necessary to get people into small groups."

The workshop was attended by more than a hundred nurses, but breaking them into smaller groups-where people were more likely to open up, make suggestions, and speak their minds-was an even more effective educational tool.

"Looking back, we would have done those sharing sessions sooner," says Arata. There was a learning curve. Initially, nurses were nervous about updating or changing the processes.

"Once they start making decisions that impact the care they give, it's like a light bulb comes on," says Arata. "Especially when they see improvements that they were a part of creating. That's when the nursing staff really can embrace the whole philosophy of shared decision-making."

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This article was adapted from one that originally appeared in the July 2010 issue of HCPro's Advisor to the ANCC Magnet Recognition Program®, an HCPro publication.