A Multidisciplinary, Standardized Approach to Improve Sepsis Care

Tool: Daily communication between the medical information management (MIM) and quality departments regarding concurrent known or suspected sepsis cases. Doing so, leverages MIM’s awareness of provider differential and assessment documentation. This approach is more comprehensive and less time consuming than quality running a daily EMR-based chief/primary patient problem report.

Problem: We are trying to capture our suspected and known septic/septic shock patients while they are admitted. After doing so, we can confirm that the patient truly meet the CMS sepsis definition, received appropriate sepsis care, or has provider documentation that sepsis has been ‘ruled out.’

Tool Selection: We know that communication is a primary root cause in healthcare events. If MIM and quality did not communicate daily regarding sepsis cases, our hospital would miss the ability to accurately know which patients may be in need of appropriate sepsis care. It is simplistic; but, highly effective.

Usage: MIM forwards a daily list to quality of inpatient cases that have a sepsis working DRG or a working DRG that is closely related to a potential sepsis dx (i.e.: CAP or UTI). Quality does a concurrent review, provides findings back to CDI/MIM and follows up with the patient’s care team.

Results: East hospital now exceed the national average for CMS’ sepsis measures. Consistently following the DMAIC process with respect to this project was key to our continued success. The primary project barrier is provider accountability regarding their sepsis documentation.

Senior Quality Manager
Senior Quality Manager – OSUWMC

Speaker Type: Poster Presentations On-Demand

  • Quality Review and Accountability IconQuality Review and Accountability
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