HEART FAILURETEAM MEMBERSHIP

DEPARTMENTS OF CARDIOLOGY, CARDIOVASCULAR SURGERY, MEDICINE, NURSING, QUALITY AND RESOURCE

MANAGEMENT, THE CENTER FOR CLINICAL EFFECTIVENESS, MEDICAL RECORDS, INFORMATION

TECHNOLOGIES, EPIC

PROJECT COORDINATORS

CARMEN BARC, RN, BSN

SARAH BORN, RN, BSN

Confidential: For Quality Improvement Purposes Only

OPPORTUNITY STATEMENT

Improve the quality of care for heart failure patients by providing evidence-based treatment as outlined in the Heart Failure Core Measures

Confidential: For Quality Improvement Purposes Only

Heart failure accounts for more hospital admissions than any other Medicare diagnosis. Research shows that the following care processes decrease morbidity and mortality rates for heart failure patients:

Left ventricular systolic function (LVSF) assessment

Angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) prescribed for left ventricular systolic dysfunction (LVSD). Ejection fraction (EF) <40% or description of moderate/severe dysfunction.

Written discharge instructions regarding activity, diet,

follow-up, medications, symptoms worsening, and weight management

Smoking cessation counseling

Our goal is to achieve 100% compliance to these measures.

Confidential: For Quality Improvement Purposes Only

FORCES OF MAGNETISM

Force 6: Quality of Care

Force 7: Quality Improvement

Force 9: Autonomy

Force 11: Nurses as Teachers

Force 13: Interdisciplinary Relationships

Confidential: For Quality Improvement Purposes Only

PLANImplement a Heart Failure (HF) Core Measures program in accordance with JCAHO/CMS guidelines

DO•HF Task Force formed

•Nursing clinical ladder opportunity offered for data collection and entry

•Pilot study of core measure performance for DRG 127

ACT•Physician and nursing staff education

•Develop HF-specific documentation forms

•Decrease data variability

STUDY•Current processes not adequately fulfilling project requirements

•Lack of house-wide awareness/understanding of HF Core Measures

•Data variability identified

Cycle 1Cycle 1

PL A N

D

O

S TU

DY

A

C

T

PLAN

DO

STUDY

ACT

Confidential: For Quality Improvement Purposes Only

Cycle 2Cycle 2PLAN•Capture HF patient population using ICD-9 codes rather than DRG coding

•Dedicated FTEs for the Core Measures initiative

•Revise HF Discharge Progress Note(DPN) addendum

•Physician and nursing staff education

DO•100% chart review based on ICD-9 diagnosis codes

•Nursing Quality Specialist given responsibility for data collection and entry as well as education

•DPN addendum revision to include documentation of ARB as potential contraindication to ACE inhibitor

•Multidisciplinary education by in-services and point of service posters/ information

STUDY•Improved documentation of discharge instructions

•LV assessment documentation peaked to a level of excellence

•Decreased data variability

•Continuity of required documentation house-wide needs improvement

ACT•Attend nurse managers meeting to discuss National Hospital Quality Measures

•Place HF packets – including standard order sets, discharge instructions, and discharge progress note addendum – in the ED, EP lab, and all patient care areas that treat the HF population

PL A N

D

O

S TU

DY

A

C

T

PLAN

DO

STUDY

ACT

Confidential: For Quality Improvement Purposes Only

Cycle 3Cycle 3PLAN•Focus on unit and nurse specific performance

DO•Analyze and provide unit and nurse specific performance data to managers

•Provide overall performance data to the HF task force

STUDY•High volume cardiac units tend to perform well; however, there is still an opportunity for improvement

•Surgical and non-cardiac units need further education regarding the HF measures

•Staff nurses perform better than agency nurses

ACT•Surgical and non-cardiac unit-specific education

•Agency and registry nurse education

•Involve cardiac rehabilitation nurses, heart transplant case managers and nurse practitioners, as well as cardiovascular case managers and nurse practitioners

PL A N

D

O

S TU

DY

A

C

T

PLAN

DO

STUDY

ACT

Confidential: For Quality Improvement Purposes Only

Cycle 4Cycle 4PLANIncorporate HF measures into the electronic medical record

DO●Develop a HF admission order set

●Develop a medicine discharge order set to include a HF assessment, HF specific discharge instructions, and smoking cessation counseling

●Include respiratory therapy in smoking cessation counseling

STUDY●Improved documentation of LVSF

assessment and contraindications to prescribing ACEI and ARB for patients with LVSD

●Improved documentation of smoking cessation counseling

●Identified that surgical heart failure patients were not being included in the current electronic workflow pathways

ACT●Develop a CV Surgery discharge order set to include a HF assessment, HF specific discharge instructions, and smoking cessation counseling

●Analyze physician compliance with electronic medical record documentation

PL A N

D

O

S TU

DY

A

C

T

PLAN

DO

STUDY

ACT

Confidential: For Quality Improvement Purposes Only

Cycle 5Cycle 5PLANImprove CV Surgery documentation regarding HF guidelines

DO●Develop a CV Surgery discharge order set to include HF assessment and HF specific discharge instructions

STUDY●Improved documentation of LVSF

assessment and contraindications to prescribing ACEI and ARB for CV surgical patients with LVSD

●Identified the need for cardiac rehab documentation to be part of the EMR

●Inconsistent RN documentation of patient HF education and patient clinical trial participation

ACT●Incorporate cardiac rehab documentation in the EMR

●Include research nurses in the HF initiatives

PL A N

D

O

S T UD

Y

A

C

T

PLAN

DO

STUDY

ACT

Confidential: For Quality Improvement Purposes Only

Per

cen

tCore Measures

Heart Failure Patients Receiving Left Ventricular Systolic Function Assessment

Month

UCL = 102.4

Mean = 99.5

LCL = 96.6

Jan 2

006

(n=5

2)

Feb 2

006

(n=7

3)

Mar

200

6 (n

=64)

Apr 200

6 (n

=65)

May

200

6 (n

=64)

Jun 2

006

(n=5

5)

Jul 2

006

(n=4

9)

Aug 200

6 (n

=68)

Sep 2

006

(n=6

2)

Oct 2

006

(n=5

7)

Nov 20

06 (n

=49)

Dec 2

006

(n=8

6)

Jan 2

007

(n=6

8)

Feb 2

007

(n=6

3)

Mar

200

7 (n

=64)

Apr 200

7 (n

=63)

May

200

7 (n

=56)

Jun 2

007

(n=5

1)

Jul 2

007

(n=4

3)

Aug 200

7 (n

=61)

Sep 2

007

(n=4

0)

Oct 2

007

(n=4

7)

Nov 20

07 (n

=41)

Dec 2

007

(n=5

4)

Jan 2

008

(n=6

4)

Feb 2

008

(n=4

9)

Mar

200

8 (n

=12)

90

92

94

96

98

100

102

104

106

Definition: HF patients with documentation in the hospital record that left ventricular function (LVF) was assessed before arrival, during hospitalization, or is planned for after discharge / All HF Patients.

Datasource: Original data extracted from LUMC charts by RNs.

Analysis: LUMC performance has been above 97% since January 2006.

Confidential: For Quality Improvement Purposes Only

Per

cen

tCore Measures

Heart Failure Patients With Left Ventricular Systolic Dysfunction ReceivingACE Inhibitor or ARB Prescription at Discharge

Month

UCL = 107.2

Mean = 95.6

LCL = 84.0

Jan 2

006

(n=2

8)

Feb 2

006

(n=3

6)

Mar

200

6 (n

=35)

Apr 200

6 (n

=37)

May

200

6 (n

=25)

Jun 2

006

(n=3

2)

Jul 2

006

(n=2

3)

Aug 200

6 (n

=31)

Sep 2

006

(n=3

9)

Oct 2

006

(n=2

8)

Nov 20

06 (n

=27)

Dec 2

006

(n=4

3)

Jan 2

007

(n=2

9)

Feb 2

007

(n=3

4)

Mar

200

7 (n

=36)

Apr 200

7 (n

=24)

May

200

7 (n

=25)

Jun 2

007

(n=2

1)

Jul 2

007

(n=1

5)

Aug 200

7 (n

=34)

Sep 2

007

(n=2

2)

Oct 2

007

(n=1

9)

Nov 20

07 (n

=24)

Dec 2

007

(n=2

8)

Jan 2

008

(n=2

9)

Feb 2

008

(n=2

3)

Mar

200

8 (n

=8)

75

80

85

90

95

100

105

110

115

Definition: Heart Failure patients who are prescribed an angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) at hospital discharge / HF patients with LVSD and without contraindications. LVSD is defined as chart documentation of a left ventricular ejection fraction less than 40% or a narrative description of left ventricular function consistent with moderate or severe systolic dysfunction. Prior to 2005, ARBs were not recognized in compliance with this measure.

Datasource: Original data extracted from LUMC charts by RNs.

Analysis: LUMC performance has been at 100% since May 2007.

Confidential: For Quality Improvement Purposes Only

Per

cen

tCore Measures

Heart Failure Patients Receiving Complete Discharge Instructions Prior to Discharge

Month

UCL = 90.5

Mean = 71.6

LCL = 52.7

Jan 2

006

(n=4

6)

Feb 2

006

(n=6

9)

Mar

200

6 (n

=58)

Apr 200

6 (n

=59)

May

200

6 (n

=61)

Jun 2

006

(n=5

0)

Jul 2

006

(n=4

5)

Aug 200

6 (n

=62)

Sep 2

006

(n=6

0)

Oct 2

006

(n=4

6)

Nov 20

06 (n

=45)

Dec 2

006

(n=7

9)

Jan 2

007

(n=5

6)

Feb 2

007

(n=5

7)

Mar

200

7 (n

=59)

Apr 200

7 (n

=59)

May

200

7 (n

=52)

Jun 2

007

(n=4

6)

Jul 2

007

(n=4

0)

Aug 200

7 (n

=55)

Sep 2

007

(n=3

4)

Oct 2

007

(n=4

0)

Nov 20

07 (n

=39)

Dec 2

007

(n=5

1)

Jan 2

008

(n=6

0)

Feb 2

008

(n=4

3)

Mar

200

8 (n

=11)

30

40

50

60

70

80

90

100

110

Definition: HF patients with documentation that they or a caregiver received discharge instructions (weight monitoring, what to do if symptoms worsen, diet, medications, activity level, follow-up appointment) prior to hospital discharge / HF patients discharged to home.

Data Source: Original data extracted from LUMC charts by RNs.

Analysis: A technical issue with the electronic medical record lead to a decline in this measure. This was resolved starting with January 2007 discharges, and performance has improved significantly.

Epic programming issue

Epic discharge process revised

Confidential: For Quality Improvement Purposes Only

Per

cen

tCore Measures

Smokers Receiving Smoking Cessation Advice for Heart Failure Patients

Month

UCL = 111.9

Mean = 97.8

LCL = 83.6

Jan 2

006

(n=9

)

Feb 2

006

(n=1

5)

Mar

200

6 (n

=19)

Apr 200

6 (n

=10)

May

200

6 (n

=10)

Jun 2

006

(n=1

4)

Jul 2

006

(n=9

)

Aug 200

6 (n

=6)

Sep 2

006

(n=1

2)

Oct 2

006

(n=1

0)

Nov 20

06 (n

=7)

Dec 2

006

(n=1

1)

Jan 2

007

(n=1

3)

Feb 2

007

(n=1

2)

Mar

200

7 (n

=7)

Apr 200

7 (n

=7)

May

200

7 (n

=9)

Jun 2

007

(n=9

)

Jul 2

007

(n=7

)

Aug 200

7 (n

=9)

Sep 2

007

(n=7

)

Oct 2

007

(n=1

0)

Nov 20

07 (n

=6)

Dec 2

007

(n=1

1)

Jan 2

008

(n=1

5)

Feb 2

008

(n=9

)

Mar

200

8 (n

=4)

80

90

100

110

120

Definition: Smokers receiving smoking cessation counseling / HF Patients who have smoked cigarettes at any time in the 12 months prior to hospital arrival.

Data Source: Original data extracted from LUMC charts by RNs.

Analysis: LUMC performance has been nearly perfect since March 2006.

Discharge form updated to include smoking cessation recommendations

Confidential: For Quality Improvement Purposes Only

NEXT STEPS

Develop a cardiac rehab documentation tool in the EMR

Include cardiac research nurses in the HF initiatives

Ongoing staff education and feedback

Incorporate new abstraction guidelines

Confidential: For Quality Improvement Purposes Only