SummaryCarolinas Medical Center-University implemented a series of initiatives to increase adherence to the care processes outlined in 24 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. Program elements include a multidisciplinary team that identifies and corrects problems, standing orders and reminder systems, manual medication reconciliation, and participation in quality improvement efforts with other hospitals in the same system. The program significantly improved performance on the core measures in all four areas, to levels well above both State and national averages.Moderate: The evidence consists of pre- and post-implementation comparisons of adherence to select care processes laid out in the core measures, along with post-implementation performance on all measures and comparisons of composite performance to State and national averages.
Developing OrganizationsCarolinas Medical Center-University
Date First Implemented2004
Problem AddressedPatients 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 (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 (ACE) inhibitor or angiotensin II receptor blocker (ARB) and receive smoking cessation counseling. 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. Adhering to these processes (which have been outlined in the CMS core measures) has 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 readmissions. For example, in 2005 (before this program had been implemented), Carolinas Medical Center-University scored between 30 and 85 percent on many measures, with performance consistently below that of other hospitals across the nation.
Description of the Innovative ActivityCarolinas Medical Center-University implemented a series of initiatives to increase adherence to the care processes outlined in the CMS core measures. Key program elements include a multidisciplinary team that identifies and corrects problems, standing orders and reminder systems, manual medication reconciliation, and participation in quality improvement efforts with other hospitals in the same system. Details on these elements are provided below:
- Multidisciplinary team to identify, correct problems: A multidisciplinary team meets monthly to discuss performance on core measures and how it can be improved. Team members include physician champions, nurses, pharmacists, clinical case managers, and medical records personnel. The team reviews all care that does not adhere to standards, and sends data and case notes to relevant nurse and physician leaders for review. As part of this work, the team may identify a care process that needs to be redesigned and undertake or assign responsibility for that work. If the team identifies a pattern of nonadherence to a particular process, it initiates a permanent solution, as described in the examples below.
- Standing order for early influenza vaccination: In the fourth quarter of 2004, 20 percent of pneumonia patients received the influenza vaccine and 55 percent received the pneumococcal vaccine. After reviewing evidence suggesting very little risk of a patient reaction, physicians agreed to a standing order for the vaccines, with the physician having an opportunity to exclude contraindicated patients. Nurses also realized that patients were leaving the hospital before they were vaccinated. Nurses changed their practice to assess and screen for the vaccines on admission and administer the vaccines earlier in the patient's stay, rather than waiting for the hectic discharge period. When the hospital converted to a new electronic medical record (EMR) in November 2006, the vaccines would often get pushed to the bottom of the electronic medication administration record (eMAR) and were frequently overlooked. Nursing staff, in collaboration with pharmacy and information services, examined the data, mapped the care process and tested several changes. The vaccines now reside in a more visible position on the eMAR, and there are electronic reminders to the nurse.
- Universal smoking cessation counseling: All inpatients receive smoking cessation counseling, regardless of diagnosis or whether they smoke. This change was made after nurses discovered that some patients did not receive counseling because they had not been identified as having heart failure until late in their stay. The team decided to provide cessation counseling to all patients, with nonsmokers being asked to share the information with a friend or family member who smokes.
- Standing orders and reminder systems: The hospital uses standing orders for many care processes outlined in the core measures, such as screening and administering the pneumococcal and influenza vaccines, and administering the appropriate prophylactic antibiotics before surgery. Postoperative physician order sets are reviewed for the discontinuance of prophylactic antibiotics within 24 hours of surgery. Reminder systems, such as brightly colored sheets in medical charts, prompt nurses to provide and document care.
- Manual medication reconciliation: Because the hospital's EMR does not yet allow physicians to add information or orders to patient's electronic records, medication reconciliation remains a manual, three-step process (as outlined below). Although this process began as part of the efforts to adhere to the care processes within the heart failure core measures, it has become standard practice related to the measures for all four conditions.
- Nurse entry of list: On admission, nurses obtain a list of current medications from the patient or a family member and enter it into the patient's EMR.
- Physician review and approval: At discharge, the physician reviews the medication list and provides clear instructions on which prehospitalization medications to continue, which ones to terminate, and any new medications.
- Nurse entry of physician directions: Nurses enter the physician's directions into the EMR and print out discharge instructions for the patient related to medication changes. Due to the risk of error during this process, two nurses review and sign the discharge instructions.
- Participation in system-wide quality improvement efforts: Hospital staff work with peers from other hospitals within the Carolinas Medical Center system on ongoing quality improvement efforts, as outlined below:
- Annual Quality Assembly: Senior leadership participates in an annual Quality Assembly, a meeting to set priorities and align the quality and safety agendas of all system hospitals. Major goals fall into four categories: safety, outcomes, service excellence, and clinical efficiency. Some goals directly involve improving adherence to the processes outlined in the core measures, while others relate closely to them, such as reducing hospital-acquired conditions, increasing adoption of evidence-based order sets, and reducing avoidable readmissions.
- Sharing performance data to foster accountability: Each hospital reports its performance to the health system on various quality indicators that align with the priorities set at the Quality Assembly. System leaders discuss variances and improvement plans. Various management and clinical staff at each hospital also have access to these data, using them for benchmarking and quality improvement activities. Friendly competition between the Carolinas Healthcare System hospitals motivates hospital leaders and staff to achieve top scores.
- Quality improvement plans and meetings: Frontline staff and managers at each hospital develop action plans, which senior hospital leaders review. In addition, 8 to 10 working groups tackle various issues designated as high priority during the Quality Assembly, including many related to the core measures. Two system-wide councils made up of leaders from each hospital—one on quality and one on safety—meet via conference call on a monthly basis to discuss these quality initiatives.
Context of the InnovationCarolinas Medical Center-University is a 130-bed public hospital that includes an 8-bed intensive care unit, a 16-bed telemetry unit, 35 beds for medical/oncology patients, 32 beds for postsurgical patients, 28 labor/delivery/recovery/postpartum beds, and 9 special care nursery beds. The hospital operates as part of the larger Carolinas Medical Center system, which includes 32 hospitals in North and South Carolina. This program began after leaders at Carolinas Medical Center-University realized that the hospital did not consistently perform many of the processes laid out in the core measures. In addition, in 2006, leaders at the system level committed to a system-wide approach to quality and safety as part of a plan for growth. To that end, they created quality, safety, and accreditation support teams to foster system-wide improvement. These two developments set the stage for the hospital's initiative to improve performance on the core measures.
ResultsThe program significantly improved the hospital's performance on the core measures in all four areas, to high levels well above both State and national averages.
Moderate: The evidence consists of pre- and post-implementation comparisons of adherence to select care processes laid out in the core measures, along with post-implementation performance on all measures and comparisons of composite performance to State and national averages.
- Significant improvement in all areas: The program led to steady improvements in each of the four clinical areas. Examples of major improvements on specific measures include the following:
- Pneumonia care: The percentage of pneumonia patients receiving influenza vaccinations increased from roughly 20 percent in 2005 to 99 percent in 2008.
- Heart failure care: The percentage of heart failure patients receiving discharge instructions increased from roughly 70 percent in 2005 to 94 percent in 2008.
- Surgical care: The percentage of surgery patients whose preventive antibiotics were stopped within 24 hours after surgery increased from approximately 30 percent in 2005 to 94 percent in 2008.
- High scores on nearly all measures: As of March 2009, the hospital scored 97 percent or higher on most measures, as outlined below:
- Heart failure: The hospital scored 100 percent on three of the four measures in this category, and 92 percent on the fourth.
- Pneumonia: The hospital scored 97 percent or higher on five of six measures, and 91 percent on the sixth.
- Heart attack: The hospital scored 100 percent on five measures and had no eligible patients for the other two measures.
- Surgical care: The hospital scored 97 percent or higher on five of the seven measures. The hospital scored 94 percent on a sixth measure and had no eligible patients for the remaining measure.
- Favorable comparisons to national and State averages: The hospital's performance on the 21 measures for which it had eligible patients exceeds both national and State averages, with the hospital now ranking in the top 3 percent of all U.S. hospitals on a composite indicator that incorporates all core measures.
Planning and Development ProcessKey steps included the following:
- Formation of core measures team: Towards the end of 2004, the hospital formed the previously described multidisciplinary team to work on improving performance on core measures, which currently meets monthly.
- Obtaining physician buy-in: Because over 80 percent of the hospital's non-obstetrics admissions originate in the emergency department (ED), ED doctors and hospitalists play an especially important role in achieving high scores on core measures. Members of the core measures team made an extra effort to obtain their buy-in, with physician champions meeting in small groups and one-on-one with these doctors to review the importance of strong performance on core measures and their role in achieving such performance.
- Staff training: As the team developed new procedures, team members organized a series of training sessions and prepared educational material for relevant personnel. For example, initially all nurses were required to attend an educational session on the core measures. Presently core measure education is included in hospital orientation, unit specific orientation, and at the annual Professional Development Days. New initiative education is provided by the core measure team members on their units, with missed opportunities being identified by the core measure team and shared with staff and management. Physician champions and team members educate their peers, and presentations are made at the department meetings.
- Gradual rollout: The hospital rolled out the new processes gradually, with refinements being made on a continual basis.
Resources Used and Skills Needed
- Staffing: The core measures team and other staff participate as part of their normal job requirements.
- Costs: Costs for the initiatives are primarily associated with paid time for staff to attend the monthly core measures team meeting, which includes a provided meal so that staff working the day of the meeting can limit their time away from patients. Additional costs are related to copying educational materials and celebrations of successes.
Funding SourcesCarolinas Medical Center-University
Tools and Other ResourcesThe CMS inpatient process-of-care core measures are available at https://www.cms.gov/HospitalQualityInits/18_HospitalProcessOfCareMeasures.asp#TopOfPage.
The CMS inpatient outcomes core measures are available at https://www.cms.gov/HospitalQualityInits/20_OutcomeMeasures.asp#TopOfPage.
Getting Started with This Innovation
- Avoid lingering on disadvantages: Staff at public hospitals may believe they will have a harder time than those at private hospitals in adhering to process-of-care standards. However, public hospitals can use many of the same tools to promote adherence, such as creating multidisciplinary teams, taking guidance from the evidence, hardwiring improvements, measuring and feeding back performance data, and assigning accountability to clinicians.
- Build support among ED doctors: Strong performance on core measures depends in large part on having the full support of ED-based physicians and hospitalists, who see many core measure-eligible patients before they reach an inpatient unit.
- Do not discount manual processes: Success in improving performance need not wait for technology enhancements. In fact, manual approaches to quality monitoring, such as using checklists and entering medications into patients' EMRs, can work well. Although the upcoming implementation of a computerized provider order entry system will eliminate many manual steps, the hospital has still made dramatic progress to date with mainly manual processes.
Sustaining This Innovation
- Maintain focus: Complacency can sometimes set in once performance improves on most core measures. To avoid this problem, the core measures team continues to meet monthly, reviewing audits and focusing on new processes to maintain performance on most measures and improve on the few measures where scores presently remain under 95 percent.
Contact the InnovatorPhyllis Justus, RN, MSN, NE-BC
Director of Nursing, Professional Practice
Carolinas Medical Center-University
P.O. Box 560727
Charlotte, NC 28256
Rose Brandau, RN, MSN
Vice President/Chief Nurse Executive
Carolinas Medical Center-University
P.O. Box 560727
Charlotte, NC 28256
Innovator DisclosuresMs. Justus and Ms. Brandau have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile.
References/Related ArticlesEdwards J. Carolinas Medical Center: Demonstrating high quality in the public sector. The Commonwealth Fund. June 2010. Available at: http://www.commonwealthfund.org/Publications/Case-Studies/2010/Jul/Carolinas-Medical-Center.aspx
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.
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Original publication: April 13, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: July 03, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: April 20, 2012.
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.