Opportunities for Improvement
Monitoring core measure data allows our caregivers to quickly respond when the data deviates from best practice. Feedback is given to doctors and staff so that changes can be made to processes and practice.
What is the problem? The admitting physician must determine if the patient meets the criteria for a pneumonia vaccine and then whether the patient has already received the vaccine in the past year. If the patient meets the criteria, the physician may be hesitant to approve the vaccine due to uncertainty about if or when it was last administered. Often the patient does not remember and the doctor does not have the patient’s non-hospital record at his or her fingertips.
How are we fixing it? We are working on a process involving our Pharmacy Department. The patient’s nurse will do the preliminary screening to determine if the patient meets the vaccine criteria. If the patient meets the criteria, the pharmacist will research hospital records and, if necessary, contact the doctor’s office to determine vaccine date. The pharmacy will then enter the order for the vaccine.