Meeting Standards Set by Center for Medicare and Medicaid Services - "Bringing Down the Number of Medical Record Delinquencies"
Transforming Medical/Surgical Care
MEDICATION SAFETY- Bedside Medication Verification/Electronic Medication Administration Record Project
For Information about these or any of the quality improvement projects at Northeastern Vermont Regional Hospital, contact:
Colleen Sinon, VP Quality Management
802-748-7349
c.sinon@nvrh.org
PO Box 905
St. Johnsbury, VT 05819
| TITLE: Meeting Standards Set by Center for Medicare and Medicaid Services - "Bringing Down the Number of Medical Record Delinquencies" |
TIME FRAME: September 2005 and ongoing
PROBLEM: Verification of entries, by signature, in the medical record not done in a timely manner.
PROJECT GOAL: Bring excessive number of delinquencies of incomplete medical records in compliance with Center for Medicare and Medicaid Services standards.
DESCRIPTION AND BACKGROUND: The Center for Medicare and Medicaid Services (CMS) and the Joint Commission on Accreditation for Healthcare Organizations (JCAHO) require that documentation in a medical record be complete within 30 days of discharge. Adequate documentation is defined as a record of all that transpired during the medical encounter and authentication by signature of the healthcare provider of all entries into the chart.
There are certain standards and time frames for such entries as the “history and physical”and progress notes and discharge summaries. The medical records/dictation department at NVRH addressed these issues internally many years ago, and we have very few delinquencies in these areas.
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The area that we did not have good compliance was authentications of entries -signatures from doctors and mid-level providers. The CMS survey in the Fall of 2005 concluded that NVRH had too many incomplete or delinquent charts, and was not in compliance with the standards.
The medical records department at NVRH began the process for improvement with an internal brainstorming session. As a result, we implemented the following procedures in an attempt to increase compliance:
• We color coded all charts- assigning each doctor a “color” and placing these colored tabs in the chart where their signature was needed.
• We have electronic signature available through our hospital information system. We encouraged the doctors to sign their charts electronically.
These measures only minimally improved our compliance - we were still not getting an adequate number of signatures; therefore, the charts were still considered incomplete.
When CMS returned for a follow up visit we still did not meet their standards. CMS told us they expected us to have zero incomplete charts by January 31, 2006.
To meet the deadline the medical records personnel implemented the following processes:
• For missed dictations: We call the physicians office to notify them of the missed
dictation.
• For Signatures: We made an extra effort to get physicians on-line with electronic signature. We worked with the Information Services department and the hospital information system (Meditech) to made “e signing” possible on the attestation (face sheet).
• We bring the charts for the practitioners of the Women's Wellness Center to their weekly meeting.
• We bring charts to the O.R. on the days the surgeons are there with surgical cases. They sign their charts in between cases
• We bring charts to the monthly medical staff meetings. Physicians review and sign during breaks.
OUTCOMES: The delinquency rate was decreased from as many as several hundred at month’s end to ZERO.
EVALUATION: The main method of evaluation was reaching the goal of compliance with the CMS standards. There is also significant positive feedback from the physicians on the new processes.
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| TITLE: Transforming Medical/Surgical Care |
TIME FRAME: September 2005 - September 2006
PROBLEM: The medical/surgical unit is where much of the inpatient care is delivered in America. Research has shown that patient safety on these floors can be improved. Nurses play a central role in ensuring quality care in a hospital; however, turnover is usually the highest on the medical/surgical unit.
PROJECT GOAL: To initiate a program to improve care on the medical/surgical floor. The intent of the initiative is not to simply fine tune current systems, but to transform the elements that affect care, including care delivery processes, nursing care models, physical environments, organizational cultures, and care team collaboration and performance
DESCRIPTION: The transforming care in the medical/surgical unit initiative is a partnership with the Institute for Healthcare Improvement (IHI) and the Robert Wood Johnson Foundation (RWJF). NVRH joined the IHI Transforming Care at the Bedside initiative in 2005.
NVRH formed a transforming care team. The team participated in national IHI Learning Sessions during the twelve months of the initiative.
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OUTCOMES: Guided by the Institute of Medicine (IOM) aims for care and the goals that RWJF established for the project, IHI created a framework for transforming medical/surgical care around four main themes.
The outcomes for the project to date under each theme are listed below:
1. Patient Centered Improvements - NVRH implemented the following improvements:
• Patient care hours modifications
• Blanket warmer in place on medical/surgical unit
• Beds set up with orthopedic frames
• Additional heat in shower room
• Comfortable extended stay stretchers
• Consolidation of night care resulting in less interruptions in sleep for the patients
2. Safety Centered Improvements - NVRH implemented the following improvements:
• Created job description to clarify role of “one on one companions” (cadre workers)
• Adopted SBAR communication system to insure doctors and nurses communicate patient information in a clear and concise manner to eliminate misinterpretations and error potential. SBAR stands for communicating first the Situation, then the Background, the Assessment, and the Response needed.
• Rapid Response Team established
• Adopted the use of insulin pens, replacing the need for vials of insulin and syringes. Insulin pens are also easier for the patients to use when administering their own insulin.
• Standing orders sheet for sliding scale insulin
• Equipment storage for wheel chairs and commodes moved out of the clean utility room
3. Lean Measures Improvements - NVRH implemented the following improvements:
• Created a standing order set for blood work
• Orthopedic frames mounted on beds
• Patient care hours modifications
• Equipment moved into patient rooms
• Consolidation of night care resulting in less interruptions in sleep for patients
• Observation charges entered electronically on the medical/surgical unit at time of discharge
• Computerized documentation
4. Care Team Vitality Improvements - NVRH implemented the following improvements:
• Unit based shared governance council
• Hospitalist name added to communication workboard at nurse’s station
• White communication board mounted in report room
• Locker room organized for improved storage
• Daily hospitalist rounds
EVALUATION: Value added staff time, defined as the time spent on patient care related task rather than time spent on unnecessary tasks such as searching for equipment, increased from 54% to 68%.
Team vitality increased based on measurement of staff perception/satisfaction that their working environment supports their professional development and work as a team.
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| TITLE: MEDICATION SAFETY- Bedside Medication Verification/Electronic Medication Administration Record Project |
TIME FRAME: January 2005 and ongoing
PROBLEM: In 1999, the Institute of Medicine (IOM) published "To Err is Human: Building a Safer Health System." In 2000, the Institute for Safe Medication Practices (ISMP) released the Medication Safety Health Assessment for Hospitals. These reports identified the need for system changes to make hospitals nationwide more safe.
PROJECT GOAL: Implement technological solutions to reduce medication errors.
DESCRIPTION: NVRH formed the Medication Error Reduction Team (MERT) in 2000, and joined the Medication Error Prevention Initiative (MEPI) in 2002. MERT uses the ISMP outline of ten categories to impact patient safety: patient information, drug information, communication, drug labeling, drug storage, devices, environment, staff education, patient education, quality assurance.
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In 2006, NVRH implemented the use of Bedside Medication Verification (BMV) and an Electronic Medication Administration Record (eMAR) as a pilot project in it's Birth Center. BMV uses bar-code technology to scan the patient's wristband to identify the patient and access the patient's medical record through the (eMAR), and to scan medications just prior to administration as verification that the Right Patient, is receiving the Right Medication, at the Right Time, in the Right Dose, via the Right Route. This administration information is then included in the eMAR and available through the hospital's Meditech Information System, providing all clinicians with real-time access to the patient's medication use, supporting the patient care decision making process.
Following this pilot project in the Birth Center, within the next year, the remaining inpatient units will begin using the BMV and eMAR systems.
OUTCOMES:
- Increase in safety due to more accurate medication verification
- Increased sharing of patient medication information among healthcare providers
- Improvement in decision-making by healthcare providers due to real-time access to patient's medication use
EVALUATION: Use of automated and electronic methods for medication verification are considered "best practices" by the Institute for Safe Medication Practices and the Medication Error Prevention Initiative; therefore, no independent evaluation was done by NVRH.
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