Transcript HF - ACHPE

Improving the Quality of Care of Patients
with Heart Failure
Francisco Lopez-Jimenez MD, MSc
Director, Preventive Cardiology
Professor of Medicine, Mayo Medical School
Heart Failure
• Leading cause of hospitalizations
• High long-term mortality
• Prevalence is increasing
• Evidence-based interventions
available
Heart Failure Core Quality Measures
• LVF assessment
• ACEI/ARB for LVSD
• Adult smoking cessation counseling
• Discharge Instructions
» Activity
» Low Sodium Diet
» HF Signs of Symptoms Worsening
» List of Medications
» Weight Monitoring
» Follow up Care
Magnitude of the Problem
Magnitude of the Problem
Project Goal
• 95% of all hospitalized patients with a
principal diagnosis of heart failure will receive
ALL core quality measures established by
CMS (Medicare/Medicaid)
Team and Methods
»Physicians, nurses, pharmacists, experts in
quality improvement, an expert in systems
and procedures, medical residents, and
administrators.
»DMAIC
»Hybrid methods: Small Test of Change,
Immediate Action, etc
Heart Failure Team
•
Robert Bleimeyer
•
Dorinda Leutink*
•
Lisa Bohn
•
Francisco Lopez-Jimenez MD*
•
Joe Furst MD
•
Dennis Manning MD*
•
Kim Gaines
•
Ann McLaughlin
•
Rudy Haddad MD
•
Fred North MD
•
Luis Haro MD
•
Narith Ou
•
Ann Hiniker
•
Katherine Pearson
•
Barry Karon MD*
•
Qi Qian MD
•
Mark Klarich*
•
Carrie Sanvick
•
Jeff Leland*
•
Barb Spurrier
•
Karyl Tammel
Define Phase
• Pre-Specified Core
Performance Measures
• All-or-None
Measure Phase
• Active surveillance
system
• Patients with principal
diagnosis of HF
• Biweekly report
120%
500
100%
400
80%
300
60%
200
40%
100
20%
CAR Cardiology
CVM Cardiovasc. Med
Med General Med
PCM
HIM
INT Internal Med
Family Med
CCS Critical Car SV
CAS Cardiovasc. Sur
Thoracic
Hematology
Kidney Transplant
PCC Peds Critical
Neurology
GAS Gastroent
LIV Liver Transplt
Ophthamalogy
0%
0
% of Total Cases
600
Cases
Analyze Phase
• Pareto chart
Hospital Cases with Admitting Diagnosis of Heart Failure
FEMA
Failure Mode Effects Analysis
10
9
8
7
6
5
4
3
2
1
0
ACE / ARB: Contraindications
ACE/ARB
not
NOT Documented
Given and no Docum.
Of Contraindication
.
No Documentation of Dismissal
Summary Given
Pt. Education not Documented
No Docum. That
Patient Education
Dismissal Summary Not Documented
was Given
Segmentation
Patients with
Secondary
Diagnosis of HF
Patients with
Primary Diagnosis of Heart Failure
Segment
# of Cases for
2005
All or None
Performance
(April 2006)
Performance
Goals for 2006
Diagnosis of
Heart Failure
(HF)
At Admission
Diagnosis of
Heart Failure
(HF)
Post Admission
Heart Rhythm
Services
Patients with
HF Diagnosis
All Other
Patients with HF
?
646
559
240
91%
80%
0%
Goal: 95%
Goal: 95%
Goal: 95%
?
TBD
Problems / Cause / Solutions
1. Problem: ACE ARB not given or
Contraindications not Documented
Root Cause:
• Clinicians unaware of core measures
• Some services not aware of pt having low EF
• No space in the EMR to document
contraindications.
Solutions:
• MD education package
• Pharmacy screening: Low EF+ACE?
Problems / Cause / Solutions
2. Problem: Patient Receipt of Discharge
Summary not Documented
Root Cause: No institutional
policy/procedures for discharge summary
process
Solutions: Create policy, education of
providers.
Problems / Cause / Solutions
3. Problem: Provider does not Decide
Patient has HF
Root Cause:
• Clinicians uneasy diagnosing HF
• Using different statements to say HF
Solutions:
• Educate clinicians
• Flag patients with a history of HF in the EMR
• Dictation prompts
• Stickers.
Problems / Cause / Solutions
4. Problem: No education elements in
electrophysiology service
Root Cause:
• Clinical service focused on advanced
treatment of arrhythmias
Solutions:
• Created a template to be included in all
dismissal summaries of electrophysiology
service
• Educate nurses
Other Interventions
• Concurrent review
• Feedback to consultants
• Simplification of patient educ. material
• Pocket reminders
• Use of EMR to record previous intolerance
• Creation of a CHF Pager
• Online education modules for consultants
Interventions
127-12-CHF
Pager
Nurse Educ
Pocket Cards
Posters
Letters to MDs,
Nurses
Addition of “Receipt of
Dismissal Summary”
To Nursing Educ Plan
Implementation
of dismissal Summary
In HRS
Dictation
Prompts for HF
Online Education
Module
Shorthand
Template
In CV
Identifying
Patients with
Low EF
ACE/ARB drug classes
Added to allergy
Module
RN Checklist
For all Measures
Performance on Core Quality Measures
(% of Patients Receiving all quality measures)
Magnitude of the Problem
Current Status
Mayo Clinic Elements of Quality
• Patient-centered

Collaborative
• Effective

Compassionate

Innovative

Satisfying

Service-oriented

Fiscally-sustainable

Structured
»
»
»
»
Evidence-based
Standardized
Outcomes-based
Benchmarked
• Timely
• Efficient
• Safe
• Equitable
Gracias!
[email protected]
@CVDprevention