Medical Center Hospital Women and Infant wing built in 2012
Odessa, Texas
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Medical Center Hospital 402 bed level II trauma Center Center
For Women and Infant L&D, Postpartum, Nursery, NICU Close to
2,000 deliveries a year All Private Rooms 12 LDRs, 30 Postpartum,
30 NICU Used CPN for over 15 years, currently at version
6.94.5
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The content of this presentation represents the views of the
author and presenter. GE, the GE Monogram, Centricity and
Imagination at Work are trademarks of General Electric Company. The
faculty and planning committee have declared no conflict of
interest. Disclosures:
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Objectives: At the end of the presentation, the participants
will: Describe the requirements for compliance of Exclusive
Breastmilk Feeding Core Measure. Recognize what charting elements
are required to pass PC05 core measure. Explain how to build
charting elements required to comply with requirements of the PC05
Core Measure. Identify how the Data Reporting Module supports data
collection for core measure reporting. Criteria for successful
completion include attending the entire session and turning in an
evaluation form.
Slide 6
Perinatal Core Abstractions Whos doing it? Who are we reporting
to?
Slide 7
How is breastmilk defined? The Joint Commission defines
exclusive breast milk feeding as a newborn receiving only breast
milk and no other liquids except for drops or syrups consisting of
vitamins, minerals, or medicines
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What are the Allowable Values For PC05? AV1- There is
documentation of a reason for not exclusively feeding breast milk
during the infants stay due to a maternal medical condition with
which breastmilk should be avoided. AV2- There is documentation
that the newborns mother chose to not exclusively breastfeed breast
milk upon admission AV3 (FAIL) There is no documentation in the
record for not exclusively breastfeeding, including UTD.
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Allowable values for not exclusively breast feeding Maternal
Conditions Maternal Initial Feeding Plan Undetermined
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Breastfeeding Discussion Requirement The initial feeding plan
discussion prior to first feeding must appear in newborns record
IBCLC or CLC/physician must validate information given RN
documentation requires additional validation (more than just a
check box) Mothers record cannot be used if linked via EHRs
(Mother-Baby Link) Must read formula Discussion prior to admission
is acceptable as long as it appears in newborns record
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What if they change their minds? If the mother choses to
breast/formula feed on admission as a mothers choice, a lactation
discussion must be performed before the initial feeding for this
measure to count.
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Where can abstractors find this information? Discharge Summary
Feeding flow sheets Individual treatment plans Intake and output
sheets Nursing notes Physician progress notes
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Workflow Mother states Breast Mother states Breast/Formula
Mother states Formula The nurse admitting the newborn will initiate
a lactation discussion Reason must be entered
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All lactation discussions must be verified! If there is no
documentation in the chart that a lactation discussion or
verification took place, AV2 cannot be used. NOTE!!
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Challenges with Core Measure Compliance Charting Challenges
finding needed information after charting was done Nurse resistance
to change Evolving core measure Understanding the core measure
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THE BUILD
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Definition and description of the core measure was confusing.
Build and rebuild forms and workflows dependent on interpretation
of core measure. Challenges with the Build
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Changed verbiage from Breast, Bottle, Both, and Undecided.
Perinatal View/LD View
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All other documentation on lactation needs to be done on the
babys chart.
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Nurses were not going to the flowsheet to document on necessary
lactation items. Nurses were not completing intake and output
complexity with creating intake and output elements. Other Issues
Identified Fix: Created a new Intake and Output form that was more
user friendly and incorporated charting elements for
lactation.
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Replaced Intake and Output Form
Slide 23
Physician Discharge Summary Review chart provides information
on feedings during hospital stay. Physician also has to complete
documentation if infant is not exclusively breastfeeding.
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Newborn Flowsheet Addendum Contains lactation documentation
from floor RN, lactation consultant and Pediatrician in one chart.
Makes it easier for doing manual chart audits
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DRM Report
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Not able to automate report through DRM.
Slide 27
References The Joint Commission. (n.d.) Retrieved from Core
Measure Sets:
http://www.jointcommssion.org/assests/1/6PC-05a_Clarification.pdf
The Joint Commission. (2013, November). Core Measure Sets. Joint
Commission Perspective, 33(11), 12-14. Retrieved from the Joint
Commission:
http://www.jointcommission.org/assets/1/6/S11.pdf.http://www.jointcommission.org/assets/1/6/S11.pdf
CPN 6.94.3 Clinical Configuration Manual CPN 6.94.3 Options
Configuration Manual