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Creating a Standardized Process to Meet Core Measure Compliance

Kwan, Sarah MSN, RN, CCRN, ACNS-BC; Daniels, Melodie MSN, RN, CNS, RNP; Ryan, Lindsey MSN, RN, CCRN-K, ACNS-BC; Fields, Willa DNSc, RN

doi: 10.1097/NCQ.0000000000000148

A standardized process to improve compliance with venous thromboembolism prophylaxis and hospital-based inpatient psychiatric services Core Measures was developed, implemented, and evaluated by a clinical nurse specialist team. The use of a 1-page tool with the requirements and supporting evidence, combined with concurrent data and feedback, ensured success of improving compliance. The initial robust process of education and concurrent and retrospective review follow-up allowed for this process to be successful.

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Sharp Grossmont Hospital, La Mesa, California (Mss Kwan, Daniels, and Ryan, and Dr Fields), and San Diego State University, San Diego, California (Dr Fields).

Correspondence: Sarah Kwan, MSN, RN, CCRN, ACNS-BC, 5555 Grossmont Center Dr, La Mesa, CA 91942 (

We thank Ana Maria Gallo, PhD, CNS, RNC, and Donna Flynt, MSN, RN, for their support.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (

Accepted for publication: June 7, 2015

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