Transcript Heart Failure JCAHO Core Measure Project

Heart Failure
JCAHO Core Measure Project
Heart Failure Core Measure Team
Opportunity For Improvement

JCAHO identified standardized, evidence based
performance measures “Core Measures” for adult patients
admitted with a principal diagnosis of Heart Failure(HF).
 The Core Measures support the HF Guidelines defined by
the ACC/AHA.
 Retroactive chart reviews indicated an opportunity for
improvement in process and outcome for each of the HF
Core Measures.
 LUMC needed to establish a process to meet the JCAHO
requirements for reporting quality data.
JCAHO HF Core Measures

Discharge instructions regarding activity, diet, follow-up,
medications, symptoms worsening, and weight monitoring
documented.

Left ventricular function assessment documented.

ACE inhibitor prescribed at discharge for LV systolic dysfunction
if no documented contraindication.

Adult Smoking Cessation advice/counseling provided if patient has
smoked in last 12 months.
Most Likely Causes for the
Improvement Opportunity

Inconsistent documentation of thought processes, findings,
and education provided to patients

All physicians and nurses not aware of the HF guidelines

All physicians and nurses not aware of the resources
available to them to assist in provision of and
documentation of the highest standard of heart failure
care.
Solutions Implemented

Task force was formed for strategic planning of data collection and
reporting of the core measures to JCAHO (2/03)

Graduate student piloted the data collection (3/03)

Telemetry/HTU/CCU nurses were educated about the project and
need for their assistance. Use of the HF Discharge Instruction
form was encouraged.

HF discharge progress note addendum was developed and
implemented . (9/03)
Solutions Implemented

MIDAS data entry was presented to nursing staff as a clinical ladder
opportunity, and volunteers were trained.

Physicians were encouraged to utilize standardized HF admission
orders available in EMR protocols. Physicians were asked to complete
the HF discharge progress note addendum

Discharge Progress note addendum was revised to include use of ARB
as potential contraindication to ACE Inhibitors

Patient list expanded based on ICD-9 HF codes from DRG 127 (1/04)
UCL
UCL
0.8
80%
0.6
60%
Mean
0.4
40%
National Mean
= 31%
Q12003
LCL
LCL
0.2
20%
LUHS Mean = 55%
Increase
Set
OrderSet
HFOrder
UseofofHF
IncreaseUse
1.0
100%
Initiated
Progess
Addendum Initiated
ProgressNote
Note Addendum
Regarding
Regarding
Activity Level,
Activity
Diet,
Level,
Discharge
Diet, Discharge
Medications,
Medications,
Follow-up
Follow-up
Appointment,
Appointment,
Weight Weight
Monitoring,
Monitoring,
and Whatand
to do
What
if Symptoms
to do if Symptoms
Worsen Worsen
Nursing
In-service
NursingInservice
Percent of LUHS Heart Failure Inpatients Receiving All Six Discharge Instructions
Consistent Use of the Heart Failure Discharge Instruction Form by
Nursing
Staff
Led
to
Improvement
in
Discharge
Instructions
LUHS Heart
LUHS
Failure
HeartPatients
Failure Receiving
Patients Receiving
Discharge
Discharge
Specific Instructions
Specific Instructions
Prior To Discharge
Prior To Discharge
0.00%
Date
With Use of the Discharge Progress Note Addendum, Documentation of
LVF Peaked to a Level of Excellence
1.00
100%
LUHS LUHS
Heart Failure
Heart Failure
Inpatients
Inpatients
Receiving
Receiving
Left Ventricular
Left Ventricular
Function
Function
Assessment
Assessment
UCL
0.98
98%
LUHS Mean = 96%
Mean
0.94
94%
0.92
92%
LCL
0.90
90%
0.88
88%
0.86
86%
0.84
84%
National Mean
Q12003 = 84%
Initiated
Addendum
Note
Progress
Initiated
Addendum
Note
Progess
LCL
Order
Use
Increase
SetSet
Order
HFHF
of of
Use
Increase
0.96
96%
In-service
Nursing
Inservice
Nursing
Assessment
LVFAssessment
ReceivingLVF
Rate of LUHS Heart Failure Inpatients Receiing
UCL
0.82
82%
0.80
80%
Date
Opportunity Exists in Smoking Cessation Counseling
LUHSLUHS
Heart Failure
Receiving
Smoking
Cessation
Counseling
HeartInpatient
FailureSmokers
Inpatient
Smokers
Receiving
Smoking
Cessation
UCL
0.8
80%
0.6
60%
Mean
LUHS Mean = 58%
Set
Order
HFHF
ofof
Use
Increase
Set
Order
Use
Increase
UCL
Nursing Inservice
Nursing In-service
Progess
Initiated
AddendumInitiated
NoteAddendum
ProgressNote
Counseling
Cessation
Smoking
Receiving
Smokers
Inpatient
HFHF
of LUHS
Rate
Counseling
Cessation
Smoking
Receiving
Smokers
Inpatient
of LUHS
Percent
1.0
100%
National Mean
Q12003 = 47%
0.4
40%
0.2
20%
LCL
LCL
0.0
0%
Date
Counseling
Opportunity Exists in Prescribing ACEI for LVSD
or for Better Documentation of Contraindications
Percent of HF Inpatients with LVSD Receiving ACEI Prescription at Discharge
LUHS Heart Failure Inpatients with Left Ventricular Systolic Dysfunction and No Known ACE
Inhibitor Contraindications Receiving ACE Inhibitor at Discharge
100%
80%
60%
40%
20%
0%
Further Study/Action

Encourage use of HF Discharge Instruction form, Progress
Note addendum and standardized HF admission orders.
– Continue improvement in discharge instructions
– Improve documentation of ACE Inhibitor contraindications to
improve reported outcomes.
– Continue exceptional Left Ventricular Function Assessment
performance.

Continue education of staff to improve performance,
process, and outcome.