In 2010 The Joint Commission (TJC) developed Perinatal Core Measures.  One measure is Exclusive Breast Milk Feeding (EBMF). No national benchmarking systems existed for gathering or comparing institutional data. The purpose of the project was to demonstrate how the electric medical record (EMR) can be used for data collection, quality improvement, and benchmarking this nurse sensitive indicator.  While other initiatives were used to meet the core measure, the focus of this project was the EMR and data collection.

Proposed change:

This 550 bed tertiary care teaching hospital with 3100 births per year had adopted the EMR when the EBMF measure was proposed. Instead of using a manual process to collect data for this new core measure, we saw the benefit of using the EMR to automate this process. A multidisciplinary group with Information Technology (IT), nurse managers, and staff from all areas of the family care unit formed and met routinely to design EMR documentation and reports that supports data extraction needed for monitoring Perinatal Core Measures.

Implementation, outcomes and evaluation:

First all EMR documentation was reviewed for L&D, PACU, and postpartum care to determine existing data points in the mother’s and the baby’s record.  Data points needed for the reports were identified, such as needing a “time stamp” within the maternal chart for feeding initiation.  Document flow sheet rows were created in the L&D PACU Record to fill identified gaps.  Staff was educated on the core measure and the need for precise documentation in the EMR for accurate data collection.  Reports were created and validated in the test environment of the EMR.  Gaps in collection were noted and corrected.  Validation steps were completed to ensure the quality of the tools.  Reports are run monthly and results evaluated to improve compliance with the evidence based TJC core measure.  Over the course of 6 months, we were able to complete this project. Now confident in our reports, we can focus on interventions to increase our EBMF rate to reach our initiation rate of 83%.

Implications for nursing practice:

Nurses collaborating with IT can develop innovative tools to easily extract data for determining outcomes.  This can ignite the movement for benchmarking within an institution and perhaps regionally.  Currently Perinatal Core Measures are not reported through NDNQI.  Perhaps this could be the first steps towards national benchmarks for the Perinatal Community.

Keywords:

Electronic Medical Record, Data Collection