HEART FAILURE TEAM MEMBERSHIP DEPARTMENTS OF CARDIOLOGY CARDIOVASCULAR

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 CAROL KEELER, RN, MS

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

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. Smoking cessation counseling Written discharge instructions regarding activity, diet, follow-up, medications, symptoms worsening, and weight management Our goal is to achieve 100% compliance to these measures.

PLAN Implement a Heart Failure (HF) Core Measures program in accordance with JCAHO/CMS guidelines Cycle 1 L A N P PLAN A DO C STUDY T ACT • Physician and nursing staff education • Develop HF-specific documentation forms • Decrease data variability D O ACT S T U D Y DO • HF Task Force formed • Nursing clinical ladder opportunity offered for data collection and entry • Pilot study of core measure performance for DRG 127 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 A Progress Note(DPN) C addendum T • Physician and nursing staff 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 Cycle 2 L A DO N PLAN D DO O STUDY ACT S T U D Y • 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 PLAN A DO C STUDY T O ACT • Surgical and non-cardiac unitspecific 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 D S T U D Y • 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 DO N P PLAN A DO C STUDY T 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 D O ACT S T U D ●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 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

NEXT STEPS Analyze physician compliance with electronic medical record documentation Computerize nursing documentation Ongoing staff education