Automated data acquisition and scoring for JCAHO ICU core measures

Abstract

The Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) has recently established six Core Measures as indicators of quality in the delivery of care to adult Intensive Care Unit (ICU) patients. These Core Measures are demanding in terms of the amount of physiologic, medication, treatment and observational data required for measurement. At Cedars-Sinai Medical Center (CSMC), a Clinical Information System (CIS) gathers data for all ICU patients. For 72 beds in eight adult ICUs, the CIS was configured to ensure automated and easy charting of Core Measure observations. Severity of illness is automatically calculated from physiologic and admission data. All data is automatically transferred to a relational database daily. A Core Measure scoring program was devised to produce weekly and monthly run charts of JCAHO ICU Core Measure performance for each ICU. Internal publication of results and refinement of care processes led to progressive improvement in compliance with Core Measure treatments.

Figure 1

CIS Core Measure Review Flowsheet

Figure 2

CIS Physician Central Line Insertion Procedure Note

Figure 3

Stress Ulcer Disease Prophylaxis (SUD) ICU-2 Scoring Algorithm

Figure 4

Ventilator Bundle Compliance (VAP Prevention, DVT and SUD prophylaxis daily)