Process-of-care measures help hospital stand out nationally

Western Baptist Hospital in Paducah, Ky., scores in the top 3 percent in a composite of seven pneumonia process-of-care or core measures among more than 2,800 hospitals with 50 or more beds. Western Baptist Hospital: Problem-Solving with Pneumonia Care Performance Improvement Teams, a new case study by the Commonwealth Fund, details the strategies the hospital used to achieve this distinction.

One key: Western Baptist has multidisciplinary performance improvement teams for each core measure set, and every team has a physician champion with a formalized, compensated role. "The hospital contracts with physicians to: 1) provide reports and updates at medical staff meetings on core measure performance and proposed quality improvement initiatives; 2) review core measure performance data and instances of noncompliance; and 3) meet one-on-one with the physicians involved in cases that fall out of compli­ance," says the report.

Action steps taken by the hospital include conducting a vaccination assessment screening for all patients upon admission. "When the hospital implemented the policy, many of the community physicians expressed concerns that they would have no way of knowing whether their patients had been vaccinated. Physician champions from the pneumonia performance improvement team spoke at medical staff committee meetings about the issue," says the report. "Eventually, Western Baptist created a vaccination database and agreed to notify physicians each time a patient received a vaccination at the hospital. To do so, the hospital sends a letter to community physicians and scans the letter into the patient's electronic medical record. Physicians and other clinical staff have access to these electronic records from remote locations."

Western Baptist also added vaccination reminders to pneumonia preprinted order sets; set up a system for discharge expeditors to track vaccinations on a dry-erase board behind the nursing station; and allowed nurses to administer pneumo­coccal and influenza vaccinations using a preprinted protocol without a physician's order.

To learn more about the hospital's path to success:
- read the case study