need help with core measure project

[Francesca RN]

So I some how I got suckered into being in charge of coming up with a way to help with compliance of the core measures outlined by Joint Commision. Right now on my floor, we have a checklist on the front of our charts. It has the four main core measures (AMI, CHF, Pneumonia, SCIP). If the patient falls under one of those CM's, we have to fill in the check boxes and make sure that the requirements for that particular CM is met. Some nurses are complaining saying that it isn't our job to 'check up' and make sure the doctors are doing their jobs, EI: CHF- an echo was ordered, or ace inhibitors or an ARB was prescribed to the patient. So I am trying to formulate a way that will not take a lot of time and looking through the carts to make sure we are complying. Do you all have any suggestions or advice on what you do at your hospitals or facilities to help with compliance for the CM?

Thanks

Francesca

[3rdcareerRN]

Two suggestions:

- Step back and look at who should do this checklist and/or chart review. In my experience, either a quality analyst/RN most often does this as a centralized operation or charge nurses (or department managers) do it on each shift in each department. If this is delegated to staff nurses, the data-collection quality might be uneven unless this task is given management-attention priority equal to that of patient care.

-Step even further back and ask whether this data collection can be automated, using the billing information. Not everything in CM will have billing attributes (such as how many mintues from pt. arrival to first anticoagulant) but anything that is ordered should have a billing code (charge-master code).

Good luck!