PROJECT NAME: Improving Core Measures in an
Academic Institution
Institution: UTMB Galveston
Primary Author: Lindsay Sonstein, MD
Secondary Author: Greg White, MD; Susan Seidensticker; Mary Lofaro
RN; Samantha Russell, RN; LaDonna Strait RN
Project Category: General Quality Improvement
Overview: Core measures are sets of nationally recognized, evidence based
quality performance measures created by the Joint Commission to improve quality
of care. They are required for Joint Commission accreditation, tied to CMS
reimbursement, and publically reportable. Each accredited hospital is required to
report on four different performance measures. UTMB has chosen to report on
Acute Myocardial Infarction (AMI), congestive heart failure (CHF), pneumonia, and
surgical care improvement project (SCIP).
A review of our institutional compliance rates showed that our average
compliance rates for AMI, CHF and pneumonia core measure have been at 85%
which is well below the institutional goal of 92%. To address this issue we
developed an intervention to help achieve core measure compliance by focusing
on the discharge process. This project took place at UTMB Galveston and
involved faculty and residents in Internal Medicine and Family Medicine. Baseline
period was 2009-2010 and intervention period was 2011.
Aim Statement (max points 150): We AIM to increase core measure
compliance rates (or pass rates) for Acute Myocardial Infarction (AMI), Congestive
Heart Failure (CHF) and Pneumonia to 92% by December 1, 2011.
Measures of Success: Our institution uses UHC as our vendor for core
measure reporting. We used UHC data for tracking overall core measure
compliance. For this project data is reported as a monthly percentage, which
indicates the percentage of the time we met (or passed) the core measure
checklist. A manual chart audit was utilized to follow usage and compliance of the
core measures discharge summary check list.
Use of Quality Tools (max points 250):
First we examined the process of admission, discharge and data extraction for a
patient hospitalized for AMI, CHF or pneumonia and created a flow map detailing
out the process (Fig. 1)
Fig. 1
Then we brainstormed possible causes of low core measure compliance using a
fish bone diagram. (Fig. 2)
Fig. 2
We then conducted a retrospective review of patients selected as a core measure
case from 2009-2010, to measure the frequency of each error identified in the
Fishbone Diagram. We found that 82% of our deficiencies occurred on discharge.
After discovering this we decided to direct our intervention to a discharge process.
Interventions (max points 150 includes points for innovation):
After baseline data revealed that majority of errors occur on discharge we
decided to implement a discharge summary checklist. This checklist was
embedded into the EMR on every discharge summary for the departments of
Internal Medicine and Family Medicine beginning January 2011. This was
completed for every patient discharged with a discharge diagnosis of AMI, CHF or
pneumonia. The intervention was first piloted on a single medical – surgical unit.
After 3 months the intervention was expanded all other units at UTMB John Sealy
Hospital (March 2011) and later to the Texas Department of Criminal Justice
(TDCJ) hospital (October 2011).
Following implementation of the checklist an educational campaign was
started. This included educational lectures to Internal Medicine and Family
Medicine faculty and residents about the CMS requirements for core measures
and targeted feedback about the overall core measure compliance and their
discharge summary check list compliance.
Fig. 3 Snap shot of Discharge Summary Checklist for AMI
Fig. 4 Snap Shot of Discharge Summary Checklist for CHF
Fig. 5 Snap Shot of Discharge Summary Checklist for Pneumonia
Results (max points 250): Overall baseline core measure compliance rate was
86%. Disease specific core measure compliance rates for the baseline period
were 92% for AMI, 81% for CHF and 84% for pneumonia. After implementation of
the discharge summary check list overall core measure compliance rates
increased to 92% overall, 93% AMI (Fig. 6), 90% CHF (Fig. 7), and 94% for
pneumonia (Fig. 8).
Fig. 6 AMI Core Measure Compliance
Fig. 7 CHF Core Measure Compliance
Fig. 8 Pneumonia Core Measure Compliance
Compliance rates increased even further if the discharge summary checklist was
used. For cases in which the checklist was used compliance rates were 98% for
AMI (Fig. 9), 95% for CHF (Fig. 10) and 97% (Fig. 11) for pneumonia.
Fig. 9 Compliance rate with checklist – AMI
Fig. 10 Compliance rate with checklist – CHF
Fig. 11 Compliance rate with checklist – Pneumonia
The likelihood of compliance with the core measure was high if the checklist was
used. (Fig. 12)
Fig. 12 – Likelihood of passing core measure – overall
Use
N=
Likelihood
724
Yes
No
Pass
96%
84%
Fail
4%
62%
Revenue Enhancement /Cost Avoidance / Generalizability (max
points 200): Implementation costs and sustainability costs are minimal and
related to team member time for development and monthly chart audits. Return on
investment is hard to quantify. Core measures are designed to improve the quality
of care and decrease cost of these patient populations. High compliance with the
core measures should lead to a decrease in readmissions for these diseases and a
shorter length of stay.
Value based purchasing and CMS withholding is also based on core
measure performance. At our institution, we are scheduled to earn 1.22% of our
base value DRG, which means that we will be able to earn more than was withheld
(1% mandatory withholding) due to our improved performance on core measure.
This increases the revenue for our hospital.
Conclusions and Next Steps: Overall the discharge summary check list
has improved our core measure compliance rates. It has improved discharge
documentation errors and serves as a reminder for the discharging provider.
Our next steps include modifying the existing insert for the new core
measure changes and adding a vaccination text to all discharge summaries to help
our compliance rates with the new global vaccine measure. We also plan to
convert the phrase into an EPIC ‘smart text’ which can be tracked and
automatically reported. This will eliminate the manual chart audit, lower
sustainability costs and lead to an even greater return on investment.
UTMB has raised the institutional goals for these measures due to our
current success.