Transcript Slide 1

HEART FAILURE
TEAM 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
Cycle 1
PLAN
Implement a Heart
Failure (HF) Core
Measures program in
accordance with
JCAHO/CMS guidelines
L
•Physician and nursing staff
education
•Develop HF-specific
documentation forms
•Decrease data variability
Confidential: For Quality Improvement Purposes Only
N
P
PLAN
A
DO
C
STUDY
T
ACT
A
DO
D
O
ACT
S T
•HF Task Force formed
•Nursing clinical ladder
opportunity offered for data
collection and entry
•Pilot study of core measure
performance for DRG 127
Y
U
D
STUDY
•Current processes not
adequately fulfilling project
requirements
•Lack of house-wide
awareness/understanding of
HF Core Measures
•Data variability identified
PLAN
•Capture HF patient
population using ICD-9 codes
rather than DRG coding
P
•Dedicated FTEs for the Core
Measures initiative
•Revise HF Discharge
Progress Note(DPN)
A
addendum
C
•Physician and nursing staff
T
education
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
Confidential: For Quality Improvement Purposes Only
Cycle 2
L
A
DO
N
PLAN
D
DO
O
STUDY
ACT
S T
Y
U
D
•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 housewide needs improvement
Cycle 3
PLAN
•Focus on unit and
nurse specific
performance
L
A
DO
N
P
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
Confidential: For Quality Improvement Purposes Only
PLAN
A
DO
C
STUDY
T
D
O
ACT
S T
Y
U
D
•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
Cycle 4
PLAN
Incorporate HF
measures into the
electronic medical
record
L
A
N
P
PLAN
ACT
A
DO
C
STUDY
T
●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
Confidential: For Quality Improvement Purposes Only
DO
D
O
ACT
S T
●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
Y
U
D
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
Cycle 5
PLAN
Improve CV Surgery
documentation
regarding HF
guidelines
L
A
●Develop a CV Surgery
discharge order set to include
HF assessment and HF specific
discharge instructions
N
P
PLAN
A
DO
C
T
STUDY
D
O
ACT
ACT
●Incorporate cardiac rehab
documentation in the EMR
●Include research nurses in
the HF initiatives
Confidential: For Quality Improvement Purposes Only
DO
S T
Y
U
D
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
Core Measures
Heart Failure Patients Receiving Left Ventricular Systolic Function Assessment
106
104
UCL = 102.4
102
Percent
100
Mean = 99.5
98
LCL = 96.6
96
94
92
Confidential: For Quality Improvement Purposes Only
90
Month
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.
Core Measures
Heart Failure Patients With Left Ventricular Systolic Dysfunction Receiving
ACE Inhibitor or ARB Prescription at Discharge
115
110
UCL = 107.2
105
Percent
100
95
Mean = 95.6
90
85
LCL = 84.0
80
75
Confidential: For Quality Improvement Purposes Only
Month
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.
Core Measures
Heart Failure Patients Receiving Complete Discharge Instructions Prior to Discharge
110
100
UCL = 90.5
90
80
Mean = 71.6
Percent
70
60
LCL = 52.7
50
40
30
Epic programming
issue
Confidential: For Quality Improvement Purposes Only
Epic
discharge
process
revised
Month
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.
Core Measures
Smokers Receiving Smoking Cessation Advice for Heart Failure Patients
120
UCL = 111.9
110
Percent
100
Mean = 97.8
90
LCL = 83.6
Discharge form
updated to include
smoking cessation
recommendations
80
Confidential: For Quality Improvement Purposes Only
Month
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.
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