obtaining success our journey to 100%

MITCHELL COUNTY HOSPITAL

CORE MEASURES

PRESENTED BY: VICKI COX, RN MSN

Obtaining SuccessOur Journey to 100%

Identifying Areas of Weakness

HF - discharge instructionsPN - documentation of blood culture time

prior to antibiotic initiation

•DISCUSSED IMPORTANCE OF CORE MEASURES WITH OUR PHYSICIANS AND NURSES

•STRESSED SIGNIFICANCE OF BUY-IN TO ASSIST IN ACCOMPLISHING SUCCESS

•WELCOMED SUGGESTIONS FOR IMPROVEMENT

Engaging the people that matter

1)ACTIVITY LEVEL2)DIET/FLUID INTAKE

3)FOLLOW-UP WITH MD AFTER DC4)ALL DC MEDICATIONS

5)WHAT TO DO IF HF SYMPTOMS WORSEN AFTER DC

6)WEIGHT MONITORING AFTER DC

Did the WRITTEN dc instructions (or other documentation of educational

materials) given to the patient/caregiver address…

Putting Our Heads Together

NursingAdministrationQualityCase ManagementMedical Staff

A Form is Born…

ALL PATIENTS WITH AN ADMITTING DIAGNOSIS OF HF OR ANY PATIENT THAT HAS HF

LISTED AS A CO-MORBIDITY

So…which patients get the form?

Safety Net

ALL patients sign & receive copies of:

Home Meds Reconciliation Discharge Report+

Discharge Assessment

Discharge Assessment Contains:

Discharge DietDischarge ActivityFollow-up Appointment(s)‘I should call my doctor if’ box

….combined with Med Reconciliation DC Report, meets all 6 elements of the discharge instruction standard.

Ongoing focus…

Concurrent reviews when possibleOne-on-one education as non-compliance is

noted Compliance posted in nursing departments

quarterlyCore measure education yearly at annual

skills/equipment workshopReport to physicians quarterly on “report card”Educate and collaborate with all new

physicians regarding core measure process

Contributing to our Success:

Engage ALL staff Utilize a collaborative/team approachImplement ideas/suggestions such as rewards

…most importantly…Change the culture

(and maintain the excellence)

…

Because it’s the RIGHT thing to do for the

Patient EVERY time