Quality & Patient Safety

Implementing the CMS sepsis bundle

Briefings on Accreditation and Quality, July 1, 2016

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Editor's note: The following is an edited excerpt from an interview with Sheri Campion, BSN, RN, and Andrew L. Masica, MD, MSCI, of Baylor Scott & White Health (BSWH) in Dallas. Campion is a senior healthcare improvement consultant at BSWH, while Masica is the chief clinical effectiveness officer; both have been part of the effort to implement the sepsis bundle at their facilities.

BOAQ: What are some of the key takeaways from the bundle for accreditation specialists?

Sheri Campion: One of the primary purposes of engaging in clinical quality measurements is to use the data to evaluate the care you're providing and drive care improvement. The challenge with the bundle is that it's designed as an "all or none" bundle and not as seven individual processes of care.

The way that the measure is designed, you go through the collection of processes of care and if at any point if you fail to provide one process, you stop. So we're getting incomplete data, number one, on every patient we're measuring.

Number two, the measure's design doesn't tell us where our opportunities for improvement are, where can we focus in on improvements, or where are the gaps in our processes.

One of the things we've had to do is try and find an alternate way of collecting the data that will give us the information that we need to actually improve care.

So we can actually find out if it's because we're not getting a repeat lactate in a timely fashion, or we're not blow-drying our cultures prior to antibiotics, or we failed to give the full 30 ml per kg of fluid. The bundle doesn't tell us that, so we've had to create and spend quite a lot of resources in developing a way of measuring that.

In our case we're trying to electronically mine the data from our electronic health record, that will give us the supplemental information we need in order to actually improve the care.

Andrew Masica: The methodology of the bundle uses a sampling approach and focuses on an aggregate performance. Historically, we had an approach that looked at individual care processes and also looked at the overall bundle compliance. We'd used that as a quality improvement tool for the past several years and when we moved to a different specification on the sepsis measure, the feedback from our staff was that they missed that granularity of that historical report.

So we've decided to supplement the step 1 bundle reports with their internal reports derived from their health record data. We use specifications that, as best we can, match the specifications of the CMS core measures.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on Accreditation and Quality.

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