Purpose: Healthcare teams enhanced the quality and safety of care by using a data-driven approach to improve timely documentation of weights and vital signs upon admission.

Background: Centers for Medicare & Medicaid Services (CMS) mandates require hospitals to submit electronic health record (EHR) data for inpatients’ weight and vital signs. This highlights the importance of prompt clinical documentation to determine medication doses and monitoring changes in health over time.

Methods/project milestones: In May 2023, Hartford HealthCare (HHC) received feedback from CMS which identified system-wide opportunities to improve timely documentation of weights and vital signs upon admission. Review of CMS hybrid readmission measurements began via Epic-released reports that were shared with quality leaders. In November 2023, HHC established a multidisciplinary work group to analyze data and develop strategies to increase data completeness. In January 2024, the quality team engaged with executive nursing leadership to disseminate hospital and unit-specific performance reports, initially sharing monthly data then increasing the frequency to biweekly distributions. Nursing leadership rounding addressed equipment and clinical workflow challenges. A revised policy was issued to align with requirements and workflows for weight and vital signs documentation.

In February 2024, HHC established a nursing subgroup, and best practice advisories (BPAs) were implemented to support timely EHR documentation. The subgroup monitored BPA metrics and adjusted criteria during the silent period in which BPAs did not appear to clinical end users. This allowed the subgroup to capture data and optimize BPAs accordingly. Effective March 18, 2024, BPAs displayed to nurses and patient care technicians (PCTs). Weekly monitoring of BPA performance and end user feedback were drivers to plan, do, study, and adjust.

Conclusion: CMS requirements were a catalyst to overcome logistical and technical challenges associated with obtaining weight and vital signs upon admission for all inpatients ≥18 years old. Continuous improvement was achieved at all seven acute care hospitals, with ≥90% data completeness noted. Leveraging a system approach, data, and feedback were crucial in developing sustainable solutions that meet regulatory demands while supporting quality and safe care and without compromising workflow efficiencies.

Kaysie Lloyd BSN, RN

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