IHS Best of the Best Series: High Performing Groups - by JCAHO

Differences in the Higher-Performing Groups:

 high degree of goal sharing by staff throughout the organization
 substantial level of administrative support
 strong physician leadership
 high-quality data feedback

[Bradley, et al. A Qualitative Study of Increasing Beta-Blocker Use After Myocardial

Infarction: Why Do Some Hospitals Succeed? JAMA, May 23/30, 2001, Vol.285, No.20,
p.2604-2611]
• Sharing the data / information on how you are doing at the:
 Organization level
 Unit/department level
 Physician level (reprivileging data)
• Consider posting graphic pictures of performance data on staff / physician lounge bulletin
boards, put in physician newsletters and/or hospital’s intranet site, etc.
• Physician buy-in:
 Utilized physician champion
 Multidisciplinary team led by physicians developed care design systems for many
diagnoses
 Dedicated case manager
 Concurrent data collection
 Provide consistent regular feedback to all stakeholders in ANY venue available
 Make it as easy as possible to document the required documentation

• Tips for Physician Buy-in:

 Present at as many medical staff meetings as possible
 Post in hospital and obvious places
 Be sure physicians know how data is collected and is accurate
• Measures based on Evidence-Based Medicine
 Show the public website information so physicians know this is public now
 Use data in re-credentialing and reappointment process
 Core Measure Deficiency - MD
November 16, 2005

Dear Dr. X:
In our continuing endeavor to improve quality, the Medical Staff CQI
Committee has approved the sending of educational letters to physicians
when a patient meets the criteria for inclusion in a JCAHO or XMS ore
measure population but the core measure was not met. This letter will
be used as part of the re-credentialing process. The following
information pertains to a patient you treated during the last quarter:
Chart # CoreMeasureDeficiency Summary

1111 AMI6 – Beta blocker on arrival Beta blocker given 6 hours too late to comply
with measure, no reason documented
2222 CHF3 – ACEI for LVSD Patient did not get ACEI and no
contraindication indicated
3333 CHF2 – LVF assessment No assessment was done – no reason
documented

5555 PN5 – ABX within 4 hours of arrival Antibiotic was 45 minutes late

If you have any questions or concerns, please call _____________ or

the case manager who follows your patients. - 33 -

Core Measure Deficiency - Nursing

Nursing Quality/Chart Audit Memo
Date:________ To Manager:____________ Staff:_______________
From:____________ MR#______________ Rm#_______________
As part of our ongoing quality monitoring, the following indicators are reviewed
by Case Managers. Please note the deficiencies identified and recognize them
as an opportunity for improvement and to give our patients the quality of care
they deserve.
Indicator Yes No Comments
Antibiotic started within 4 hours of
admission of pneumonia
Smoking cessation counseling X Smoking cessation documentation was not found under
done for AMI, HF, pneumonia General PT. Education/smoking cessation in admission
database by nursing. (Needed for patients who are using
nicotine products or have quit in the last 12 months)
Immunization admission
database completed for
pneumococcol and/or flue
vaccine
Discharge instructions completed X A signed copy of the “HF Education”formwas not found in
for HF the patient’s medical record post discharge – as proof that
the J CAHO core measures requirements have been met. - 34 -