Core Measure Magic - Our Journey to Become the Happiest Place on Earth

•    Purpose for the program: As part of a three-hospital maternity service line, the demand of collecting data manually for core measure reporting was immense.  The purpose of this innovation was to standardize an automated data collection process for reporting the Perinatal Care measure set in advance of the 2014 mandatory Joint Commission deadline. 

•    Proposed change: Our proposed change took the form of a six- sigma work out that examined workflow in data collection at all three entities.  An agreement on best- practice standardized work became the template that our team used to design the new process that would introduce automation for reporting. 

•    Implementation, outcomes and evaluation: Previous to this plan, only minimal automation was used during core measure reporting; and with a fully implemented electronic medical record (EMR) system having been used for years, it was our belief that we were not fully utilizing the benefits of what was available. With the mandatory reporting requirements for 2014 looming, our team wanted to have our process hard-wired prior to the end of 2013.  The implementation process proved more challenging than originally thought.  As our team designed the process from start to finish, we came upon technical roadblocks within our database and documentation systems that needed to be addressed prior to further implementation.  With the assistance of physicians, nurses, data analysts, informaticists, report writers and researchers our team began to sculpt the outcome we envisioned.  With the assistance of several products already in use for data collection, our evaluation began by comparing their accuracy to our new process.  We found many discrepancies in our reports that forced our team to look at how we were inputting the data into our EMR.  In our evaluation, we realized that in the future we would need to design our clinical documentation to reflect specifically how the core measure question was asked; ensuring the data output is in the required format for reporting.

•    Implications for nursing practice: The implications for nursing practice are vast.  The mandatory requirement for Core Measure reporting has the potential to dictate how we will document in the future.  Standards of care and Core Measure criteria must be written into physician orders and clinical documentation so that data reporting is accurate.  Due to the immense data elements required, an automated process is the only viable solution for the future.

•    Keywords: Core Measures, Automation, Data collection, Electronic Medical Record