Using dedicated nurses to improve core measures compliance.

Area of Science:

• Healthcare Quality Improvement
• Nursing Administration
• Clinical Compliance

Background:

• The Joint Commission and Centers for Medicare and Medicaid Services (CMS) mandate specific core measures for healthcare quality.
• Ensuring consistent adherence to these core measures is crucial for hospital accreditation and reimbursement.
• University of Kentucky Health Care identified a need to enhance its performance on these critical quality indicators.

Purpose of the Study:

• To investigate and implement strategies for improving adherence to The Joint Commission and CMS core measures.
• To establish a sustainable model for monitoring and enhancing core measure performance within a healthcare system.

Main Methods:

• A team was formed, including six dedicated core measure nurses, to address performance gaps.
• Core measure nurses were responsible for patient identification, standardizing work processes, and concurrent review.
• Collaboration with bedside staff and an informaticist team was integral to the strategy.

Main Results:

• The implementation of core measure nurse roles led to improved compliance with core measures.
• Strong relationships between core measure nurses and bedside staff were critical for success.
• Pilot program results demonstrated sustained high compliance scores after the roles were made permanent.

Conclusions:

• A dedicated core measure nurse role is an effective strategy for improving and sustaining healthcare quality measure performance.
• Interdisciplinary collaboration and strong nurse-staff relationships are key components of successful quality improvement initiatives.
• The established roles were adopted by administration, indicating the program's value and sustainability.