Because Every Patient Counts

19 Dec 2012

By participating in the national AF4Q program to reduce 30-day readmission rates for heart failure (HF), Carson City Hospital in Michigan was able to use the lessons it learned to focus the staff on performance on other core measures.

At the time, the floor nurses were familiar with core measures but didn’t fully understand what they were all about and how important documentation is to the hospital meeting its performance targets. To educate and re-energize the staff, the hospital created the “Because Every Patient Counts” project.
The initiative, which began in the summer of 2010, focuses on achieving a perfect care score for every patient. That means the patient got all the care he or she should have received for the diagnosis.
The campaign was named Because Every Patient Counts not only because the 77-bed acute care hospital embraces that philosophy, but also because even one miss on an indicator can hurt the facility’s overall score on a measure due to small patient volumes, said Joan Sweet, vice president and chief quality and risk officer.
The initiative emphasizes one Centers for Medicare & Medicaid Services (CMS) core measure each week. The measures are color coded by diagnosis and described in a one-page sheet posted in nursing units and in a weekly newsletter. In addition, managers and supervisors review the material with staff.
The measure sheets include the diagnosis, performance measure name, the measure’s description, the rationale behind it, the type of measure, and the elements—including documentation—needed to pass the measure.
“They’re a quick reference so nurses can look at them to see what they need to do,” Sweet said. Performance is reported back to the units by nurse managers to share with frontline staff.
The project, which began with heart failure measures, went beyond the one-page measure sheets. The staff went back to the drawing board and developed a standardized HF care plan, patient education, and discharge instructions.
Frontline nurses were part of these efforts. “The nurses have to be involved in designing the process because they’re the ones who are actually doing it,” Sweet said. “It’s easy for me to say, ‘That’s how I’d do it,’ but I don’t actually work on the floor.”
Nurses want to be involved in quality efforts, and a lot of time it’s just a matter of enabling them to get off the floor briefly to attend quality meetings, Sweet said.
After heart failure measures, the Because Every Patient Counts campaign moved on to measures for the surgical care improvement project, pneumonia, and acute myocardial infarction. “That was the goal: to learn from heart failure,” Sweet said. “What can you take from that and then apply to other diagnoses or groups of patients?”
Just as with heart failure, a measure of the week was selected for special attention, including the one-page sheets posted in the nursing units, to help the staff achieve the goal of 100 percent compliance with the surgical care improvement, pneumonia, and acute myocardial infarction measures.
A big part of the quality campaign is education, and not just for nurses. At every leadership meeting, a quality item is included on the agenda, Sweet said. The hospital’s performance on core measures is rolled into the payfor- performance incentive system for hospital leaders. “If we do well on our core measures, then everybody benefits,” Sweet said.
The pay-for-performance incentives are expected to be rolled out to staff members in 2013. Nurse incentives will be tied to their units’ performance on the core measures. “Every unit will sink or swim on its own merit,” Sweet said. “Everybody passes, or everybody fails. It’s not just one individual.”
The campaign also includes physician education. Information about coremeasure- of-the-week sheets was boiled down into a short document for doctors that laid out the various measures and what is required to pass them.
The hospital’s efforts quickly showed results. The compliance rate for measures of ideal care rose from 83 percent in the third quarter of 2010 to 94 percent in the third quarter of 2011.
For heart failure, the hospital has reached 100 percent compliance for nearly two years in giving patients discharge instructions, Sweet said. It’s gone more than half a year without a single miss on any heart failure measure, she added.
CMS data showed that the hospital’s 30-day readmission rate for heart failure was 24.2 percent around the time the project began. It is now down to 22.5 percent, Sweet said. Nationally, the median 30-day readmission rate for heart failure is 24.8 percent (the range is from 17 percent to 33 percent), according to CMS.
Another measure of the campaign’s success is that the hospital is expecting to get incentive pay under the new Medicare Value-Based Purchasing Program, which was created by the Affordable Care Act of 2010, Sweet said. Conversely, thousands of hospitals soon will be subject to Medicare payment penalties under value-based purchasing.
Carson City Hospital’s project reflects the measures used in the Medicare
Value-Based Purchasing Program for acute myocardial infarction, heart failure, pneumonia, and surgical care. Other factors in the Medicare initiative are health care-associated infections and patient satisfaction scores.
The hospital has no plans of letting up on its campaign, Sweet said, and continues to select additional measures for the measure-of-the-week sheets and staff education. For example, it is targeting respiratory conditions—not just pneumonia, but also asthma and chronic obstructive pulmonary disease.
The Because Every Patient Counts project is helping to drive a lasting culture of quality at the hospital, said Duane C. Miller, senior vice president for finance. “Everybody is a lot more sensitized to making sure that certain things happen because of the downside risks on patients and on us as a facility.”
Lessons Learned
  • Don’t assume your quality message is being heard. At Carson City Hospital, the nurses were familiar with the core measures but didn’t understand what it takes to be compliant with them. 
  • Involve frontline nurses in the performance improvement effort, including the design of processes, because they’re at the bedside providing the care.
  • Keep things simple. The hospital creates one-page “core measure of the week” sheets that are posted in the nursing units as quick reference on performance measures, what they entail, and what documentation is needed.