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Service Delivery Innovation Profile

Concurrent and Retrospective Chart Review, Performance Reporting, and Other Support Significantly Improve Adherence to Core Measures in Four Clinical Areas


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Snapshot

Summary

St. Mary's Health Center implemented a program to increase adherence to 24 process-of-care measures developed by the Centers for Medicare & Medicaid Services (also known as "core measures") in four clinical areas—heart attack, heart failure, pneumonia, and surgical care. The cornerstone of the program involves having a full-time nurse review patients' charts daily during the inpatient stay and after discharge to ensure adherence to these evidence-based processes. Other key program elements that support adherence include internal and external reporting of performance data, department-specific goal setting and measurement, and a physician-led committee that promotes adherence among physicians. Since initial implementation in 2006, the program has led to significant improvement in performance on the core measures in each of the clinical areas, with near-perfect adherence (98 percent or higher) on composite scores being achieved in 2008. St. Mary's has also consistently outperformed other hospitals, and in 2009 placed ninth (in the 99th percentile) in a national ranking based on overall adherence to core measures in the four areas.

Evidence Rating (What is this?)

Moderate: The evidence consists of a comparison of pre- and post-implementation adherence to the care processes included in the 24 core measures, along with comparisons to other hospitals in the region.
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Developing Organizations

St. Mary's Health Center
Jefferson City, MOend do

Date First Implemented

2006

Problem Addressed

Patients having surgery or experiencing a heart attack, heart failure, or pneumonia have better outcomes when they receive certain evidence-based processes1 recommended by the Centers for Medicare & Medicaid Services (CMS), but many hospitals fail to routinely provide these services to eligible patients.
  • Clear, evidence-based standards: Clear, evidence-based standards exist for heart attack, heart failure, and pneumonia care and for the prevention of surgical complications and infections. For example, heart attack patients should receive aspirin on arrival, daily, and at discharge. Heart failure patients should receive an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker and have an assessment of left ventricular function. Patients with pneumonia should receive pneumococcal and influenza vaccinations and an initial antibiotic within 4 to 6 hours of arrival. Surgical patients should receive an antibiotic 1 hour before incision, with the drug being discontinued 24 hours after surgery. These processes, developed by the Hospital Quality Alliance and The Joint Commission, have been shown to improve quality of care.1
  • Failure to adhere to standards: Eligible patients sometimes fail to receive these recommended therapies,1 jeopardizing treatment success and contributing to an increase in readmission rates. For example, in 2005 (before the implementation of this program), St. Mary's Health Center's composite adherence rates in the four clinical areas ranged from 65 to 93 percent, with performance consistently being below that of other hospitals in the nation. (See the Context section for more details).

What They Did

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Description of the Innovative Activity

St. Mary's Health Center implemented a program to increase adherence to 24 CMS process-of-care measures in four clinical areas—heart attack, heart failure, pneumonia, and surgical care. The cornerstone of the program involves having a full-time nurse review patients' charts daily during the inpatient stay and after discharge to ensure adherence to these evidence-based processes. Other key program elements that support adherence include internal and external reporting of performance data, department-specific goal setting and measurement, and a physician-led committee that promotes adherence among physicians. More details on each of these key elements are provided below:
  • Chart review during stay and after discharge: One full-time nurse conducts two stages of chart review: concurrent reviews while patients are still hospitalized and retrospective reviews after discharge.
    • Daily reviews: Each day, the abstractor reviews the previous day's admissions list and other medical reports to identify patients with conditions related to the four sets of core measures. She then goes to the patients' units and checks their charts to see whether the appropriate care processes have been provided and documented. If not, the abstractor notifies the patient's nurse and unit director. If the issue appears to be nursing related, she also notifies the vice president of nursing. For problems related to physicians, the abstractor notifies the vice president of medical affairs, who engages the physician in a peer-to-peer discussion. The goal is to correct the problem that same day by providing the necessary treatment.
    • Retrospective reviews: After discharge, the abstractor reviews charts again to ensure that all appropriate care processes have been provided and documented, with any omissions being subject to medical staff peer review.
  • Sharing performance data internally and externally: The hospital shares performance data on adherence to core measures both internally and externally, as outlined below:
    • Monthly reports for hospital leadership and department heads: The nurse abstractor creates monthly performance reports on adherence and variances for the hospital's administrative council, management group, and board of directors. The reports include current performance, trend data, and explanations of how any variances have been addressed. Performance data are also reported regularly to department leaders, leaders of the hospital's physician comanagement companies, medical staff committees, the performance improvement review committee, and to St. Mary's parent organization (SSM Healthcare), which shares the information in each clinical area across system hospitals (providing comparisons to benchmark facilities within and outside the system).
    • Other internal reporting: Composite scores in each of the four clinical areas are posted throughout the hospital and distributed to employees through newsletters and forums. Clinical departments incorporate the scores into their goals (see below) and also regularly post their monthly performance.
    • External reporting: Performance results are shared with third-party payers, CMS, and The Joint Commission.
  • Department goal setting: Each clinical unit sets improvement goals each year, with employees developing strategies and an action plan for meeting these goals. Progress is discussed with staff on a monthly basis. Whenever there is a variation from a core process, unit managers conduct root cause analyses designed to identify and address barriers to better performance. Improvement goals typically incorporate specific core measures. For example, the emergency department (ED) tracks the amount of time to administer thrombolytics and to perform a percutaneous coronary intervention for heart attack patients, while the operating room tracks the timing of administration of presurgical antibiotics. Individual units track other clinical measures, such as glycemic control and patient falls that cause harm.
  • Physician-led performance improvement committee: A committee of 10 to 15 physicians from a range of specialties plays an important role in enhancing adherence to core measures. The committee engages in the following activities:
    • Peer review: The committee conducts peer review when physicians do not adhere to the standards outlined in the core measures.
    • Physician performance as part of credentialing process: The committee uses physician scorecards as part of credentialing and reappointment processes to promote accountability. The scorecard shows how well each physician performs on a variety of quality indicators, including adherence to the core measures, complications, mortality, and patient management. As part of the reappointment process, the hospital's medical executive committee reviews the scorecard and benchmark goals with physicians.
    • Education: The committee educates medical staff on expectations related to the core measures and quality during staff meetings and through a monthly newsletter.

Context of the Innovation

St. Mary's Health Center is a 167-bed hospital in Jefferson City, MO, that offers cardiovascular, musculoskeletal, and emergency services as well as a network of primary care and specialty clinics. This program to improve scores on core measures began after a 2005 review found that the hospital scored in the 40th percentile nationally for heart attack measures, the 10th percentile for pneumonia measures, and below the 50th percentile for surgical care. In addition, the hospital had a negative operating margin and low patient satisfaction scores (ranging between the 24th and 40th percentile).

Did It Work?

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Results

Since initial implementation in 2006, the program has led to significant improvement in performance on the core measures in each of the clinical areas, with near-perfect adherence (98 percent or higher) on composite scores being achieved in 2008. St. Mary's has also consistently outperformed other hospitals, and in 2009 placed ninth (in the 99th percentile) in a national ranking based on overall adherence to core measures in the four areas.
  • Significant improvement, to near-perfect scores on composite measures: In 2007 and 2008, the hospital achieved near-perfect scores (98 percent or higher) on composite measures in each of the four clinical areas. This performance represents steady improvement in each clinical area between 2005 and 2008, with scores increasing in heart attack care (from 90 to 100), heart failure (93 to 100), pneumonia (76 to 99), and surgical care (65 to 99).
  • Better than vast majority of other hospitals: Compared with hospitals in its region, St. Mary's scored in the 100th percentile for all heart attack and heart failure core measures in 2007; scores on the seven different pneumonia measures ranged from the 93rd to the 100th percentile, while scores on nine surgical care measures ranged from the 96th to the 98th percentile. In addition, a national ranking in December 2009 on the Commonwealth Fund's performance data Web site (http://www.whynotthebest.org) lists the hospital in the top 99th percentile for core measure adherence for heart attack, heart failure, and pneumonia and the 90th percentile for surgical care. Overall (combining rankings in all four areas), the hospital is ranked ninth in the nation, which puts it in the 99th percentile.
  • Contributing to other achievements: Hospital leaders believe the program has contributed to the elimination of ventilator-associated pneumonia and high patient satisfaction:
    • Elimination of ventilator-associated pneumonia: As of December 2009, St. Mary's had experienced no cases of ventilator-associated pneumonia since April 2005.
    • High patient satisfaction: The hospital scored in the 93rd percentile on a national survey in 2009 on a measure asking patients how likely they would be to recommend the facility to others.

Evidence Rating (What is this?)

Moderate: The evidence consists of a comparison of pre- and post-implementation adherence to the care processes included in the 24 core measures, along with comparisons to other hospitals in the region.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Establishing program as priority: Hospital leaders made adherence to core measures a major priority within the institution, showing staff that the measures represented evidence-based practices that would improve patient care. In early 2005, the hospital's medical executive committee, composed of medical staff leaders, issued a statement setting a goal of 100-percent adherence to all core measures, emphasizing that the measures represented the hospital's standard of care and that physicians who varied from these standards would appear before peer review committees. In addition, the hospital's vice president of medical affairs worked one-on-one with physicians to encourage support for the program, sharing research studies and specialty association recommendations that support use of the core measures.
  • Creation of order sets: Preprinted order sets (also known as care pathways) were developed that list the standard steps in treating common conditions, including many of the evidence-based processes included in the core measures. The medical staff performance improvement committee had been working on these order sets before the 2005 directive, but intensified these efforts afterward.
  • Early implementation by ED: ED physicians adopted the core measures first, actively working to ensure adherence. For example, ED physicians compared data on their own adherence with national standards and soon realized they needed to improve. To support improvement on the timeliness of thrombolytic administration and angioplasty for heart attack patients, ED physicians studied and improved processes to reduce the amount of time it took for a patient to see a physician and receive an electrocardiogram. They also borrowed order sets from other hospitals, collaborated with better performers within SSM through the health system's clinical collaborative, and used the "plan-do-study-act" model to reduce variation in care processes.
  • Hiring of nurse chart abstractor: In early 2006, a nurse who had experience in reviewing medical charts expressed interest in working as the hospital's full-time chart abstractor. (Before that, a few individuals conducted only retrospective chart reviews at the end of each quarter.) Program leaders agreed that the use of both concurrent and retrospective chart review would enhance the program, with the new position being formally created in May 2006.
  • Development of physician scorecard: In 2006, St. Mary's developed the aforementioned physician scorecard and made it part of the required credentialing and reappointment processes for physicians.
  • Rollout and expansion: Although there was no formal rollout date, by the end of 2006, all the program components had been adopted throughout the hospital. In 2009, St. Mary's expanded the program to include indicators for obstetrical and mental health care.

Resources Used and Skills Needed

  • Staffing: The program requires one full-time equivalent nurse who conducts chart reviews. All other staff participate as part of their normal job requirements.
  • Costs: The program's major expense consists of salary and benefits for the nurse abstractor. The hospital also hired a third-party vendor to help compile and submit adherence data to The Joint Commission and CMS.
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Funding Sources

St Mary's Health Center
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Tools and Other Resources

The Commonwealth Fund article includes a listing of the 24 core measures and the order set for heart attacks. Available at: http://www.commonwealthfund.org/%7E/media/Files/Publications/Case%20Study/2009/April/St%20Marys%20Case%20Study/1253_SilowCarroll_St_Marys_case_study.pdf

Adoption Considerations

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Getting Started with This Innovation

  • Demonstrate commitment of senior hospital officials: Senior executives, including the chief executive officer, the board of directors, and physician leaders, should set firm expectations with respect to adherence to care standards in both formal and informal communications with staff.
  • Change physician perceptions of core measures: Physicians need to perceive the program as a hospital-based effort that benefits patient care. In St. Mary's case, showing the medical staff clinical evidence on the core measures' benefits and endorsements of the measures by physician-led professional organizations helped to overcome any negative perceptions.
  • Build on standardized order sets: Expanding the use of standardized order sets to incorporate core measures can be a logical, effective way to improve adherence. Having clinicians develop the order sets based on best practices from professional organizations can promote buy-in.
  • Choose nurse abstractor carefully: Because the nurse abstractor is critical to program success, hire an individual with the right background and demeanor for the job. The abstractor should have experience reviewing medical charts and a passion for working with others to achieve quality goals.

Sustaining This Innovation

  • Hold staff accountable: Continuous monitoring and reporting of performance helps to promote improvement by celebrating successes and holding individuals accountable for lack of adherence (e.g., through discussions with supervisors, root cause analyses, and posting of unsatisfactory results).

More Information

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Contact the Innovator

Elizabeth Randazzo
Director, Performance Management and Clinical Outcomes
St. Mary's Health Center
100 St. Mary's Medical Plaza
Jefferson City, MO 65101
(573) 761-7105
E-mail: elizabeth_randazzo@ssmhc.com

Innovator Disclosures

Ms. Randazzo has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Silow-Carroll S. St. Mary's Health Center: focus on core measures improves quality. The Commonwealth Fund. 1253:13. Available at: http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2009/April/St%20Marys%20Case%20Study
/1253_SilowCarroll_St_Marys_case_study.pdf
(If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)

Hospitals' adherence to the care processes is reported to CMS and made public on the Hospital Compare Web site. Available at: http://www.hospitalcompare.hhs.gov

Footnotes

1 The Center for Medicare & Medicaid Services. Medicaid and CHIP Quality Practices Overview. December 7, 2010. Available at: http://www.cms.gov/MedicaidCHIPQualPrac/
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Original publication: April 14, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: October 09, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: April 28, 2011.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.