CORE MEASURE AUTOMATION AND CONCURRENT ABSTRACTOR
UTILIZATION
Jody Leckrone RN BSN
jleckrone@mchs.com
Mount Carmel Health System
Problem statement:
A review of the Trinity scorecard resulted in the need to implement system wide
initiatives and accountability around core measure automation.
Project description:
Temporary concurrent abstractors were trained on the two core measures that
needed the most attention and then they were placed at each site within our system. The
two measures they review are VTE and SCIP. They review all new admissions and
surgeries from the day before, look for potential outliers and share those with the units
involved to educate colleagues and reach out to physicians to meet the measure prior to
an outlier occurring. They educate in the moment and assist colleagues with how to
document and what to communicate to physicians. They share the potential outliers daily
with the CNO's at the sites as well to engage administration in the accountability factor of
the project. The concurrent abstractors use multiple reports as well as chart abstraction to
find the potential outliers and make them "great catches". The lead of the project collects
data on incomplete VTE advisors and deferrals. This report is shared weekly with the
VPMA's at each site. This engages administration in physician accountability as well.
Reports are created from all of this data and shared monthly with administration,
managers and front line colleagues to show the progress and areas for improvement. This
process was also developed to hold nursing and physicians accountable along with
pushing out transparency across the system.
Results:
From December of 2013 to March of 2014, the number of VTE and SCIP outliers
reported to the government has decreased tremendously as a result of the implementation
of this project. The daily interaction of the concurrent abstractors with front line
colleagues, CNO's and nurse managers has developed an open line of communication and
trust within the organization. The in the moment feedback to leadership and colleagues
has led to the decrease in outliers for SCIP and VTE which has had a positive impact on
the Trinity scorecard.
Conclusion:
The success of this project and the implementation of concurrent abstractors can
be seen in all the data that has been collected. The need to continue this project is
detrimental to doing what is right for our patients. In order to do this, we need to make
the concurrent abstractor role permanent to support administration, managers and front
line teams in the day to day flow of core measures. Along with this, we can push
physician and nursing accountability and transparency across the system.