Core Measures and time per chart?

Specialties Quality Improvement

Published

Specializes in Cardiovascular.

For any of you out there who abstract from the paper chart, how much time do you average per chart?

We are a 300 bed facility and do 100% of SCIP, AMI, PN, CAC and HF. It seems that with the continual addition of measures to each of the measure sets - especially SCIP, abstraction is becoming increasingly time-consuming - leaving less time for process improvement. We abstract from a paper chart, rather than electronic and gather data on all measures for each of the measure sets - not only APU indicators.

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First of all, I would suggest you go to sampling, it will free up your time to do process improvement and the new outpatient core measures.

Second I would say the average time for me is about 15 to 20 minutes per chart.

This is not including the time to request the medical record or import the data.

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Specializes in Cardiovascular.

Yes, I am a little worried about the OPPS as we have no idea what the volume will be and it looks like I will be abstracting those as well.

At this time, the corporation that owns our facility does not allow sampling, even though our numbers would allow it. For example, SCIP has 500 to 600 per quarter.

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Specializes in NICU, Peds, OB, Home Health.
For any of you out there who abstract from the paper chart, how much time do you average per chart?

We are a 300 bed facility and do 100% of SCIP, AMI, PN, CAC and HF. It seems that with the continual addition of measures to each of the measure sets - especially SCIP, abstraction is becoming increasingly time-consuming - leaving less time for process improvement. We abstract from a paper chart, rather than electronic and gather data on all measures for each of the measure sets - not only APU indicators.

We are a small rural hospital and I abstract from a paper chart. We're currently between 40-50 records a month, with the majority PN & HF. We review 100% of our applicable SCIPs, but we have to sample some of the other charts to get enough.

Our corporate offices say one hour per chart. Which is great if you can find the chart, and when you find it, the chart is complete. Sometimes it's 15 minutes, and sometimes I have to track down a missing x-ray, discharge summary, lab slips...you get the picture. :banghead: And yes, OPPS has me very nervous. Sampling is always an option, but if your numbers are a little iffy, the volume helps a little.

Nikki

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We can only sample SCIP because our volume is not enough with AMI, CHF or PNE. It takes approx 10 per CHF, 15 per AMI, 20-25 for PNE and SCIP.

One thing many vendors and corporations do not figure into the statistics is the analysis of the data. Last year I started having the abstractors also analyze the data. They determine, who dropped the ball with the cases not meeting the indicators. Was it MD, nurse, pharmacy who??? The enter into customized fields the nursing unit, the discharging nurse for the discharge meds missed for example, or who was the nurse in ED who did not give the ASA on admission or who was the pharmacist who timed the last antibiotic for the SCIP measure wrong. We then send them a notification of the error along with their manager and we send letters to the physicians and place a letter in their peer review file.

I now have the abstractors doing all of these steps rather than me opening the chart back up, reading it to get to the understanding they were at when they were reviewing the chart and then me complete all of these steps. It was the wisest way to use our time and also provided the quickest feedback to those who made a mistake.

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Specializes in O.R..

I abstract PN, AMI, OP-AMI, OP-CP. I also abstract stroke for the North Carolina Stroke Collaborative. On average I abstract approximately 70 charts a month. In pt. PN typically takes 20 to 30 minutes. AMI 20 minutes. The OP AMI and CP are short so about 10 minutes each. I abstract onto the paper form while entering the data onto our vendor site. We've created a "reminder" letter that we send to our physicians if they fail to "perform" according to standards. I also run my own reports to see which patients I need to abstract, and pull my own charts. I work 32 hours a week and begin for the new month the first week of the next month. (I began March abstraction the first week of April and will finish March by April 30). In addition I abstract death for Carolina Donor Service and compile the data for our in-house pain charts (approximately 200 patients are sampled each month).

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RE: NCFLYGAL

Can you tell me, do you also place the data into graphs for analysis. Do you present the data at whatever meeting it is presented to at your organization? Do you put the data into a format to have it available for peer to peer comparison. For example: a graph per element that shows all physicians who had patient

s in the sample who had AMI. All of the physician's identification is concealed except the physician getting the individual data. This process is done for all physicians.

I was wondering because I am also over JCAHO and CMS compliance, I abstract AMI-CHF, review all fallouts for all projects, collect, analyze and make presentations for all projects. I am the site administrator for the core measures data so deal with all CMS rejects, the validation on QNet, etc, etc. I am on the Safety Com, Qual. Com, am a Team Leader for LEAN. I am the hospital's "go to" person for research, help seeing the big picture, helping any department figure out a better way to do something.

I like all of the above, don't get me wrong. I am just worried as to whether I will be effective at any of it since so much has come to my plate, some of it through attrition and most of it because I just have a gift to be able to see solutions. I am not bragging, it is just my God given talent.

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We are a small hospital outside Houston. I abstract approximately 90-100 charts a month for AMI, PN, HF, SCIP & OP. We are still using paper charts.

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