RN Documentation Specialist: The Key to Improving Nursing Sensitive Indicators and Core Measures in Surgical Services

Purpose:
Improve and sustain patient outcomes and associated reimbursement through the implementation of an effectively designed initiative that reallocates human resources. Achieve Surgical Care Improvement Project (SCIP) compliance that correlates positively with Value Based Purchasing incentive goals.

Significance:
Delivering quality patient care has always been our top priority. Now, with VBP, quality care cannot be overstated. In an environment of decreasing reimbursement it is essential we provide cost effective quality care and receive appropriate reimbursement to remain viable and continue our ministry.

Strategy and Implementation:
In 2012 the interprofessional Best Care Executive Team set out to determine why compliance with SCIP measures was below national benchmarks. On its recommendation an RN Documentation Specialist was implemented. This RN identifies patients with a nurse sensitive SCIP measure and follows them through their hospital stay ensuring compliance with SCIP measures and appropriate documentation. She ensures the right antibiotic is ordered and given within one hour prior to surgery and follows up to ensure the antibiotic is discontinued within the specified 24hrs or 48hrs for cardiac surgery patients. Cardiac surgery patients are followed on POD1 and 2 for glucose measure compliance. Patients on beta blocker medications prior to surgery are followed on POD1 and 2. The RN ensures VTE prophylaxis is appropriately ordered and administered within the specified timeframe, urinary catheters removed and properly documented by POD2, doctors have timely orders, and assists nurses in following protocols.

Evaluation:
All SCIP measures now exhibit an upward trend of compliance. In 2009 SCIP1 was below 90% compliance. In the last 5 quarters compliance is at or near 100%. In the same period, SCIP9 was below 55%, now at or near 100% and SCIP VTE2 which was below 70% is now at or near 100% compliance since Sept 2012.

Implications for Practice:
Expand role to other areas where quality is measured. Choosing an RN with clinical experience in areas where SCIP and Core Measures are tracked and who has a developed a rapport with all stakeholders is the key to successfully maximizing patient care quality, compliance and incentive opportunities.