Don't "Fallout" of Love With Stroke Core Measures

Methodist Hospital (San Antonio, Texas)

CSI Summary

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Project Topic:

Improving stroke core measures documentation

Hospital Unit:


CSI Participants:

  • McKenzie Boening, BSN, RN
  • Lyndsay Medina, BSN, RN
  • Lauren Watson, BSN, RN

Project Goals/Objectives:

  1. Decrease the total number of stroke core measure “fallouts” (stroke orders not being completed) on the Neuro-Telemetry unit
  2. Increase current and new staff compliance with documenting stroke core measures
  3. Increase staff knowledge on locating, documenting and advocating for the stroke core measures through additional education

Project Outcomes:

  1. Decreased stroke documentation fallout
  2. Increased staff use of door signs to aide in documentation of certain stroke core measures
  3. Increased staff knowledge and awareness of stroke core measures

Project Overview:

Methodist Hospital is accredited by The Joint Commission (TJC) in stroke care. We have stroke core measures in place to support this accreditation by documenting how quality measures are followed. The quality measures involve advocating for and emphasizing certain actions and medications that are instrumental in pre- and post-stroke care.

Our CSI team was aware that our Neuro-Telemetry unit was experiencing an increase in fallouts, or lapses in stroke core measures being completed and documented. Fallouts could result in negative effects on a patient’s stroke care and on our TJC accreditation. We launched an innovation project to improve completion and documentation rates of stroke core measures.

As our first step, the team developed a “help sheet” describing how to complete and document the stroke core measures. After implementing the sheet, we realized it was rather long for staff to easily read and follow, so we created additional materials. We produced and implemented door signs and resource folders to increase awareness and documentation of stroke core measures. Over the next several months, our team educated current and new staff about the importance of completing required documentation.

While the overall results of the door hangers have been positive, we’ve also encountered an unexpected challenge. The most successful impact of the door signs has been an increase in completion and documentation in stroke core measures ― our primary goal. However, the door hangers are also being used to document other kinds of data that prevent collection of stroke core measure information.

Even though our CSI program has concluded, we plan to continue and expand our efforts through:

  • Inclusion of stroke core measures and help sheet during staff orientation
  • Advocating for core measures during case management huddles
  • Continued use of the help sheet and door signs
  • Providing our resource folder to other telemetry units

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The AACN CSI Academy program supports change projects based on quality improvement methods. Although CSI teams seek to ensure linkage between their project and clinical/fiscal outcomes, data cannot be solely attributed to the project and are estimations of impact.