Merry Medisolving featuring Salem Regional Medical Center

When you’ve been measuring and monitoring eCQMs for as long as Salem Regional Medical Center (SRMC) has, you learn a thing or two. We asked members of SRMC’s CQI team to share with us the most valuable lessons they’ve learned over the last decade, on everything from managing fallouts to onboarding new staff. Our biggest takeaway: Turn your data into a daily interventional tool. But that’s only the beginning...

Name: Lyn Pethtel
Job Title: Director of Quality Improvement and Infection Control

Name: Janet Moore
Job Title: CQI Analyst

Name: Britney Baird
Job Title: CQI Analyst

When did SRMC launch its eCQM program?

Lyn: We jumped on it pretty much as soon as the voluntary reporting program was announced. We always like to tackle things before they become mandated. That way you have time to build the quality infrastructure you need so that, by the time public reporting or pay-for-performance rolls out, you’ve already established your numbers and know that they look good. That approach has always worked well for us.

Even with a head start, launching any eCQM program still requires a big culture shift. How did you make it work for your organization?

 Janet: It was a slow start. A big part of our success has been getting a CQI physician liaison, Dr. Maria Ryhal, on our team. She will intervene with the medical staff on our behalf regarding any issues. What we still see with some regularity is that physicians will put orders into their notes, so the intent is there, but then they don’t put in the actual order. She’s a huge help intervening in instances like that.

Lyn: The fact that we can pull up the dashboard in Medisolv has also been a big help. We take snapshots of how we’re doing and present those to the various hospital committees. It’s now a standing agenda item in our quality management meetings.

So, fast-forward to today: where do your numbers stand now?

Lyn: Our numbers look good, but we always treat it like a work in progress. We set a target a year ago to hit 95% compliance on all measures, and, as of today, we have met that goal for all but 2 of the measures. One of those is at 94% and the other is at 87%, so we’re very close.

Janet: And those two measures in particular have very low sample sizes, so it only takes 1 or 2 fallouts for our numbers to take a hit.

How do you manage fallouts when you see them?

 Janet: Our CQI department is very active in real-time analysis. We try to intervene if we see a measure isn’t performing so we can get it rectified as quickly as possible. It really helps that, with Medisolv, we can look at our numbers daily and react quickly.

When you say you intervene, can you give us a few examples of what you do?

Lyn: We have several tools. The first is that we have patient care rounds every day at 10 am. Each patient case is discussed. That gives us the opportunity to flag things, like ‘you haven’t gotten your VTE prophylaxis initiated on patient X yet.’ Then we round-robin back to see if the intervention we requested took place before the end of the day.

Britney: In addition to the verbal reminders, we have reminder cards that we fill out and give to the unit charge nurse or the nurse involved with the care. Then it’s on to telephone call reminders if we have to.

Janet: We also do educational letters to the medical staff. What’s most important about these is that we present them as educational letters, not punitive letters.

What do you mean by “educational” letters?

Britney: We’ll do a recap that includes the patient’s name and medical number, why the patient fell out of the measure, and what they can do to meet the measure next time. We close out by saying if they’d like to speak to us to learn more, we’re here. We stress that this is just for education only—they’re not being reprimanded.

Lyn: We always joke that if you send them enough reminder letters and phone calls—if you nag them enough—they’ll do whatever you want so you quit nagging them. [laughs]

Have you done any work on the new opioid or hybrid measures?

Lyn: Yes, just like with eCQMs, we’ve gotten a head start on both because we know eventually we have to do it. The hybrid measure is still very new to us internally; we’re getting ready ‘behind the scenes’ so to speak. Our opioid measure started off really strong, below 15%. But now we’re creeping up to the national average.

Do you have any insight as to what’s behind the rise in your opioid measure?

Janet: Not yet, because the creep just started. But we suspect that it’s related to our patient population. It’s unique in that it’s not your normal base of med-surg patients. It’s a lot of higher acuity patients.

Britney, even though you’ve been with SRMC for 7 years, you’ve only been part of the CQI team since July. Any advice for quality newbies?

Britney: The educational resources that Medisolv offers are huge. Take advantage of them. When I first started, there were so many 3-letter codes and steps; it was a lot to take in. Medisolv breaks it all down for you.

Lyn: I will add that Britney is our second new analyst this year. When we have a changeover in staff, Medisolv’s educational programs are essential to onboarding a new analyst. I’m not in the system every day, so I wouldn’t be the best trainer. But with Medisolv we can jumpstart getting an analyst on our team when needed.

Janet and Lyn, as seasoned eCQM pros, what would you say are some of the secrets to your success?

Janet: Looking at the data every day and doing concurrent reviews. Way back when, we’d typically look at a case when it was time to sit down and abstract it—after it was coded, after it fell in or out of the measure. By that point, there’s nothing you can do but learn how to handle things better the next time. Now, we stay on top of the patient right when they hit. We’re looking at the patient that day and adjusting by the next morning.

Lyn: I’m very proud of the level of awareness that we’ve raised across our entire staff. I pushed for more concurrent intervention for patient safety and with the support of Medisolv we can react in real time. Maybe not everyone on the line staff can articulate what an eCQM is, but everyone here can articulate that there are quality measures that we’re accountable to. At the same time, we’re not blinded by it. When we ask someone to fix something, the first thing that our Medical Staff CQI liaison, Dr. Ryhal, says is "put the patient first." In other words, don’t stress about the measure. Don’t teach to the test. Always do what’s right for the patient first.