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Service Delivery Innovation Profile

Health System Expands Pharmacy and Nursing Staff Roles and Institutes Focus on Accountability, Improving Performance on Core Measures


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Snapshot

Summary

To promote provider adherence to the care processes recommended in the Centers for Medicare & Medicaid Services' core measures, Norman Regional Health System shifts responsibility for certain tasks from physicians to pharmacists and nurses, some of whom are new hires dedicated to this task. This approach allows physicians to focus on other aspects of patient care without losing the ability to monitor adherence and take corrective action when appropriate. Related program elements support adherence, including ongoing performance monitoring and reporting, peer review of physicians, and financial incentives for hospital staff. The program has led to steady improvements in performance in all four clinical areas covered by the measures, with adherence rates reaching 96 percent or better for 17 of the 25 measures, above both national and Oklahoma averages.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of performance on the four categories of core measures (heart attack, heart failure, pneumonia, and surgical care improvement), along with comparisons of recent performance to Oklahoma and national averages.
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Developing Organizations

Norman Regional Health System
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Date First Implemented

2005

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). Many hospitals, however, fail to routinely provide these services to eligible patients.
  • Clear, evidence-based standards that improve quality: Clear, evidence-based standards exist for heart attack (also known as acute myocardial infarction), 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 (referred to as "core measures"), developed by the Hospital Quality Alliance and The Joint Commission and voluntarily reported through the CMS Hospital Compare program, have been shown to improve the 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 readmissions. For example, in 2005 (before the implementation of this program), Norman Regional Health System's composite adherence rates in the four clinical areas (heart attack, heart failure, pneumonia, and surgical care) ranged from roughly 50 to 75 percent.

What They Did

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Description of the Innovative Activity

To promote adherence to the care processes recommended in CMS core measures, Norman Regional Health System shifts responsibility for certain tasks from physicians to pharmacists and nurses, some of whom are new hires dedicated to this task. This approach allows physicians to focus on other aspects of patient care without losing the ability to monitor adherence and take corrective action when appropriate. Related program elements support adherence, including ongoing performance monitoring and reporting, peer review of physicians, and financial incentives for hospital staff. More details on these key program elements are provided below:
  • Expanded role for pharmacists and pharmacy staff: Because many core measures relate to medication practices, Norman Regional Health System created a new clinical pharmacist position to assist with certain care processes for heart failure, pneumonia, heart attack, and vaccinations, as outlined below.
    • For heart failure patients: The pharmacist plays a critical role in identifying and securing appropriate care for heart failure patients in accordance with CMS core measures:
      • Proactive identification of patients: Before program implementation, Norman Regional Hospital did not routinely provide appropriate discharge planning and education for heart failure patients. An analysis revealed that nurses had difficulty identifying heart failure patients because the diagnosis did not consistently appear in the medical record as the primary diagnosis, and because recorded symptoms could indicate other conditions, such as chronic obstructive pulmonary disease or pneumonia. Now, the clinical pharmacist performs a daily screen to identify potential heart failure patients; this screen includes checking the electronic medical record to identify patients with one or more of the following: a primary diagnosis of heart failure on a previous admission, a cardiology consult, or an elevated brain natriuretic peptide level (an indicator of heart failure). For those identified, the pharmacist reviews medical histories and physical examinations to determine if their current admission is likely due to heart failure.
      • Prompts to provide appropriate care: For those patients identified as having heart failure, a pharmacy staff member leaves a preprinted order on the patient chart as a trigger to initiate heart failure education, including use of a "home journal" that outlines the mandated aspects of care, such as weight monitoring and followup. Additionally, the pharmacist evaluates flagged patients' prior admissions to determine if previous studies of left ventricular function have been conducted. If so, the pharmacist prints the results, stamps them as prior studies, and leaves them on the chart for the physician to review. For patients who are candidates for an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker who have no documentation for such a prescription in the chart, the pharmacist calls the physician or leaves a note urging him or her to consider prescribing such a medication.
    • Concurrent review of emergency department (ED)–initiated order sets for pneumonia, heart failure, and heart attack: More than 90 percent of patients admitted with pneumonia come through the ED, where physicians initiate a standardized pneumonia order set that includes directions for initial antibiotics, blood cultures, and other required care processes covered in the CMS core measures. The order set and physician's instructions are scanned, sent electronically to the pharmacy, and then entered into the medical record. A clinical pharmacist follows up to ensure that patients receive appropriate care and that staff document their actions. Similar concurrent review processes take place for heart failure and heart attack patients who come through the ED, thus giving staff the opportunity in many cases to catch and correct problems.
    • Screening for vaccination status: Pharmacy staff screen all patients for pneumococcal vaccination status (and for influenza vaccination status between October and March). If they discover a candidate for a vaccination, they give nurses an order set to administer the vaccine. This automated process means that physicians do not have to order or document appropriate care.
  • Expanded role for nurses: Nurses assume an active role in monitoring staff actions and collecting data about the core measures.
    • Clinical Quality Council that monitors performance and uses dashboards: The hospital established a Clinical Quality Council, chaired by nurses, to monitor core measure performance and identify and remove obstacles to adherence. The council uses color-coded computer charts known as dashboards to display data on adherence rates for core measures and other performance indicators, such as hand hygiene. Senior nurses perform random observations to ensure that nurses adhere to core measures and appropriately document their actions; unit-level data from these observations are included in the dashboards. Staff can access the dashboards to see how well their unit performs as compared with others. The hospital board and hospital Performance Improvement Committee also receive the dashboard reports.
    • Smoking cessation education nurse: Norman Regional Health System created the position of smoking cessation education nurse to identify patients with a history of smoking, assess their readiness for smoking cessation, and provide them with smoking cessation options to pursue after discharge.
    • Ongoing assessment, reporting, and peer review: To create accountability for performance, Norman Regional Health System dedicates staff to ongoing review and reporting of performance data related to core measures.
      • Medical director review: The hospital turned what had been an unpaid position—medical director of clinical effectiveness—into a paid part-time position, thus allowing a physician to devote more time to performance improvement. This individual spends 10 to 12 hours per week on activities such as reviewing progress on improvement projects, examining cases in which care does not adhere to core measure protocols, and determining underlying reasons for nonadherence. He also reaches out to other physicians to discuss how they might improve their practices or documentation.
      • Data abstractor monitoring: Approximately 2.5 full-time employees (FTEs) abstract retrospective data on adherence to core measures and submit this information to CMS. Additionally, a nurse reviews all cases of nonadherence, providing details and feedback about the "who, what, when, where, and why" to physicians and other staff.
      • Dashboard performance reports: As described above, the hospital uses bright-colored dashboards to report quarterly performance on core measures to hospital board members, administrators, clinical leaders, and staff.
      • Physician peer review: Cases of nonadherence that involve a physician undergo a peer review that results in an "outlier drill-down report." This report explains how care did not adhere to the measures, along with the circumstances and possible causes of nonadherence. The medical director of clinical effectiveness reviews this report and returns it to the relevant physician for his or her response. Managers also review outlier cases with nurses found to have contributed to the process failure. This system often uncovers circumstances that may have prohibited the recommended care from being provided and enables staff to discuss ways to improve care processes. For example, in one case, the medical director for performance improvement contacted a physician who had not ordered an angiotensin-converting enzyme inhibitor for a patient. After both parties reviewed the case, it became clear that the physician was correct in not prescribing the medicine but had failed to document the reason for this exception to the protocol. Going forward, the physician improved his documentation.
    • Financial incentives: From July 2001 until June 2008, hospital administrators implemented a gain-sharing bonus for all health system employees tied both to financial performance and performance on the core measures. Additionally, from July 2005 until June 2008, part of each unit manager's bonus depended on his or her unit's achievement of certain goals related to core measures and patient satisfaction. (Since 2008, the health system board elected not to authorize the payout of performance-based incentives due to financial criteria not being met.)

    Context of the Innovation

    Norman Regional Health System, which includes the 337-bed Norman Regional Hospital and the 45-bed Moore Medical Center, is a publicly owned trust based in the community of Norman in south-central Oklahoma. Norman Regional Hospital, the only full-service acute care hospital in Norman, purchased Moore Medical Center in February 2007, after which the organization adopted the name Norman Regional Health System. The system includes the two hospitals along with affiliated outpatient diagnostic centers, physician practices, and a primary care network. The organization's efforts to improve performance on core measures dates back to 2001, when Norman Regional Hospital became involved in two collaboratives: the Surgical Infection Prevention project, sponsored by CMS, and the Quality In, Quality Out collaborative, sponsored by Oklahoma's Quality Improvement Organization. Hospital leaders found significant room for improvement after examining scores on the core measures, with performance being just average on some measures. These findings prompted the chairman of the board and the vice president of medical affairs to commit time and resources to additional strategies for improving performance.

    Did It Work?

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    Results

    Since implementation in 2005, the program has led to steady improvement in performance on core measures in each of the four clinical areas (heart attack, heart failure, pneumonia, and surgical care). From April 2008 through March 2009, the two hospitals in the system achieved adherence rates of 96 percent or better on 17 of 25 measures, above both national and Oklahoma averages.
    • Steady improvements in all clinical areas: From 2005 (before implementation) to the first quarter of 2009, Norman Regional Health System's performance in all four clinical areas included in the core measures has trended upward. Within each area, roughly 90 percent of eligible patients received the recommended processes outlined in the core measures during the first quarter of 2009, up from between 50 and 75 percent in 2005. The system experienced a decline in performance on some measures in 2007 and early 2008 (due to the acquisition of a smaller hospital and adoption of a new electronic medical record system), but performance has since stabilized and rebounded.
    • Above-average recent performance: From April 2008 through March 2009, the two hospitals achieved adherence rates of 96 percent or higher on 17 of 25 measures, generally above both national and Oklahoma averages.
      • Heart failure: The hospitals achieved 96 percent or better on three of the four measures, well above national averages (which range from 77 to 92 percent across the measures) and Oklahoma averages (62 to 88 percent).
      • Pneumonia: The hospitals achieved 96 percent or better on five of the six measures, above both national (85 to 93 percent) and Oklahoma averages (80 to 94 percent).
      • Heart attack: The hospitals achieved 96 percent or better on four of six measures, with a fifth measure not having any patients who met the criteria for inclusion. By comparison, national averages range from 79 to 96 percent on these measures and Oklahoma averages range from 80 to 94 percent.
      • Surgical care: The hospitals achieved 96 percent or better on six of eight measures, generally above both national (85 to 94 percent) and Oklahoma averages (79 to 96 percent).

    Evidence Rating (What is this?)

    Moderate: The evidence consists of pre- and post-implementation comparisons of performance on the four categories of core measures (heart attack, heart failure, pneumonia, and surgical care improvement), along with comparisons of recent performance to Oklahoma and national averages.

    How They Did It

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    Planning and Development Process

    Key steps included the following:
    • Quality committee meetings: The hospital's multidisciplinary quality committee, initially formed to direct the hospital's involvement in the Quality In, Quality Out collaborative, continued to meet twice a month after this collaborative ended. The seven-member committee includes senior hospital administrators, a physician, a pharmacist, and a nurse; other staff also regularly participate. In 2004, the committee began focusing on improving the hospital's performance on core measures in the four clinical areas.
    • Creating and implementing order sets: The committee developed and preprinted order sets that define and sequence standardized tasks for specific diagnoses, procedures, or symptoms. Implementation of these order sets began in 2005, with an initial focus on those measures where hospital performance lagged.
    • Getting physician buy-in: To promote physician buy-in, the vice president of medical affairs and the medical director of clinical effectiveness met with members of the medical staff in small groups. They reviewed the protocols, explained how they work, and asked for feedback. The duo met individually with physicians who resisted using the order sets, explaining the evidence behind them and the need to improve performance. ED physicians represented a high priority, since they treat many pneumonia and heart attack patients before admission.
    • Training pharmacists and nurses: Pharmacists received training on their expanded role in a series of department meetings led by the hospital's director of pharmacy services and performance improvement. Senior nurses held similar sessions for nursing staff.
    • Forming employee satisfaction teams: Aware that successful implementation would require participation by all hospital staff, hospital leaders worked on improving employee satisfaction. They formed nine management-led employee teams tasked with developing behavioral standards for employees, conducting and following up on employee satisfaction surveys, improving communication within the hospital, developing ways to reward and recognize employee performance, and improving physician satisfaction and efficiency. This initiative resulted in a consistently low turnover rate among nurses and physicians, which, in turn, has helped the hospitals maintain high performance by reducing the need to teach the care protocols and introduce the culture of quality improvement to new staff.

    Resources Used and Skills Needed

    • Staffing: Several pharmacists, nurses, and data abstractors (2.5 FTEs) spend most or all of their time on the core measures program. One physician spends about one-fourth of his time on the program in his role as medical director of clinical effectiveness.
    • Costs: The program's major expense consists of salary and benefits for the program staff outlined above. Other program-related expenses included bonuses paid to employees based on the hospitals' performance on the core measures from July 2001 until June 2008.
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    Funding Sources

    Norman Regional Health System funds the program out of its operating budget.end fs

    Tools and Other Resources

    A Commonwealth Fund article includes an appendix listing the core measures, the order set for pneumonia, and an example of a dashboard (for surgical care improvement); it is available at http://www.commonwealthfund.org/Publications/Case-Studies/2010/Jul/Norman-Regional-Health-System.aspx.

    Detailed background information on the core measures can be found on the U.S. Department of Health and Human Services' Hospital Compare Web site, available at: http://www.hospitalcompare.hhs.gov/Data/AboutData/Measures-Displayed.aspx.

    Adoption Considerations

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    Getting Started with This Innovation

    • Secure commitment of senior leaders: Program success depends on the support of hospital leaders, administrators, and the health system's board. Norman Regional Health System's board chair and top physician administrator serve as champions for this program and for quality improvement in general.
    • Enlist nurses and pharmacists: Expanding the roles of nurses and pharmacists helps to avoid the perception among physicians that the weight of the program falls on their shoulders. Physicians will likely support the effort once they realize that their day-to-day practices do not change dramatically and that the quality of patient care is likely to improve.
    • Set realistic expectations: Improving performance on core measures takes time. Because many different protocols exist, consider focusing first on those areas where performance lags farthest behind (and hence where opportunities to improve are greatest). By starting with this "low-hanging fruit," the hospital can demonstrate quick improvement (hence building enthusiasm for the program) and also maximize the impact on patient outcomes.

    Sustaining This Innovation

    • Provide detailed feedback: Meet with relevant staff whenever processes recommended in core measures have not been followed. During these sessions, review the specifics in detail to determine if an error occurred and, if so, why it occurred and how to avoid repeating the mistake.
    • Engage staff on ongoing basis: Staff satisfaction affects patient and physician satisfaction, staff turnover, and the hospital's image and ability to attract and keep talented employees. These factors, in turn, affect the quality of care. Consequently, hospitals need to have programs in place to gauge employee satisfaction on an ongoing basis, address problems quickly as they arise, and, if possible, reward staff financially for strong performance.

    More Information

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    Contact the Innovator

    Darin Smith, PharmD
    Director of Pharmacy Services and Performance Improvement
    Norman Regional Health System
    901 North Porter Avenue
    Norman, OK 73071
    (405) 307-1956
    E-mail: dsmith@nrh-ok.com

    Innovator Disclosures

    Dr. Smith has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

    References/Related Articles

    Silow-Carroll S. Norman Regional Health System: A city-owned public trust dedicated to improving performance. Commonwealth Fund pub. 1393. Vol. 44. Available at: http://www.commonwealthfund.org/Publications/Case-Studies/2010/Jul/Norman-Regional-Health-System.aspx

    Footnotes

    1 The Center for Medicare & Medicaid Services. Quality Measures Compendium V.2.0: Medicaid and SCHIP Quality Improvement Compiled by the Division of Quality Evaluation and Health Outcomes, Family and Children's Health Programs Group. 2007.
    Comment on this Innovation

    Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

    Original publication: April 13, 2011.
    Original publication indicates the date the profile was first posted to the Innovations Exchange.

    Last updated: April 09, 2014.
    Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

    Date verified by innovator: March 12, 2014.
    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.