Franciscan St. Anthony Health Michigan City, IN

1. Franciscan St. Anthony Health Michigan City, IN

2. St. Margaret Health Hammond St. Anthony Health Michigan City 80 80 90 90 St. Anthony Health Crown Point 65 St. Francis Health Indianapolis 65 Franciscan Health Services, Inc. Franciscan Alliance Corporate Office St. James Health Olympia Fields Mishawaka 90 St. James Health Chicago Heights St. Margaret Health Dyer St. Elizabeth Health Lafayette St. Elizabeth Health Crawfordsville St. Francis Health Beech Grove St. Francis Health Mooresville

3. Franciscan Alliance

4. Mission Driven Quality Goals • Adherence to the CMS Core Measures is rooted in the Franciscan Alliance culture at the facility, regional, and corporate level which is accomplished through continuous process improvement and focus on CMS best practice standards with robust communication at all levels, as well as through results reporting on the Franciscan Alliance Corporate Report. The color green on this report is associated with achieving results in line with the top 10% of hospitals in the nation. FSAH used this cultural norm to launch the Quality Rounding Program with the slogan: It Takes a Team to Go Green!

5. Purpose and Goal Purpose: • Assist the facility in compliance with the CMS quality initiatives, and to move our results on the Franciscan Alliance Corporate Report from red or yellow to green. • Prepare FSAH to compete as healthcare reimbursement moves to Value-Based Purchasing. Goal: • The broad goal of the Quality Rounding Program is to assist FSAH in elevating the quality and consistency of patient care delivery through improvement with compliance to the CMS Core Measure Standards through a collective experience of teamwork, communication and accountability. Franciscan Alliance Corporate Report – CMS Quality Measures

6. In 2010 VBP became required by the Affordable Care Act to provide value-based incentive payments to hospitals beginning in FY 2013 for two domains: Clinical Process Measures and HCAHPS. CMS has outlined proposals for the VBP Program and views it a vital link to moving increasingly toward rewarding better value, outcomes and innovations instead of volume. FY 2013 payment determination will be based upon comparing a hospital’s performance of the chosen measures during a performance period (7/1/2011 – 3/31/2012) to a baseline period (7/1/2009 – 3/31/ 2010). FY 2014 payment determination will include mortality measures, as well as certain hospital-acquired conditions and patient safety/inpatient quality indicators. At risk is a 1% reduction of FY 2013 base operating DRG payments, with a .25% added reduction per year. Value-Based Purchasing (VBP)

7. VBP Scoring • Total Performance Score: • 70% Clinical Process Measures • 30% HCAHPS • Two scores will be awarded for each measure: Achievement and Improvement, with the higher score used • Attainment • 0 to 10 points awarded for achievement based on where the hospital’s performance for the measure falls relative to an achievement threshold (proposed to be at the 50th percentile during the baseline period) and the benchmark (proposed to be at the mean of the top decile). • Improvement • 0 to 9 points scored relative to a hospital’s performance during the performance period compared to its own performance during the baseline period. • For HCAPHS, up to an additional 20 consistency points are possible to obtained • CMS feels that consistency points encourage hospitals to meet or exceed the achievement threshold. • If all HCAHPS scores are > the achievement threshold than all 20 points will be awarded.

8. Value-Based Purchasing Achieving and sustaining top box scores will be vital to survival!

9. Goal Attainment Through Focused Objectives • During Quality Rounding the Quality Services team focuses on the following objectives: • Performing concurrent review and abstraction • Capturing CMS documentation compliance prior to discharge • Providing “just-in-time” education and support for staff and physicians • Ensuring timely feedback of results for accountability • Identifying and improving processes to eliminate barriers to compliance through teamwork

10. Key to Success: Multidisciplinary Approach Patient

11. Quality Rounding Process Flow

12. Day in the Life of a Quality Rounder • Run daily census report and surgery schedule • Log onto physician portal and review: • Test results • Labs (cardiac enzymes, BNP level, blood cultures & lipid panel performed) • Chest Xray/CT (congestion, edema, infiltrates, consolidation, etc.) • Abdominal Xray/CT (obstruction, free air, ileus, infarcted bowel, perforation, etc.) • Other Xray/CT/Angiography (fractures, occlusion, aneurysm, etc.) • EKGs, Stress Tests, Echocardiograms • Admission History • Current smoker or quit within last 12 months • Vaccination status • Past medical history (i.e., CHF) • Home medication list • Close attention to ACE/ARB, Beta-Blocker, Coumadin, Aspirin, Statin, Antiboitics, Immunosuppressives • Dictated H&Ps/Consults/Operative Reports • Electronic Nursing Charting • Pre-op/Intraop/PACU charting • Narrative notes • Clinical documentation (I&O, ADLs, etc)

13. Day in the Life of a Quality Rounder • Round on Units - Interventions Include: • Review Emergency Department documentation • Read physician progress notes/physicians orders • Confer with documentation specialist • If patient has a history of HF, an automatic education referral will be ordered • Talk one-to-one with physicians and/or nurses • Leave rounding notes on chart for physicians and/or nurses • Follow up on previous day’s active patient records

14. Core Measure Focus • Heart Failure Measures • LV Assessment: • Appropriate testing ordered • LV function/EF documentation within physician documentation • Reason for not assessing documented • ACE/ARB for LVSD • ACE/ARB ordered • Contraindication documented within physician documentation If the answer is always no, note left for physician to ensure measure compliance • Smoking Cessation • Current smoker and/or quit within last 12 months • Education refusal documented / Smoking cessation education ordered • Education completed If near discharge and the education not completed, contact Cardiac Services and/or inform patient’s nurse that education has not been done • HF Discharge Instructions • Admission origin • HF discharge education ordered • Education completed • Discharge medications & Discharge summary match If near discharge and the education not completed, contact Cardiac Services and/or inform patient’s nurse that education has not been done If discharge summary is missing a medication that physician ordered/patient went home on, meet with physician to review case. Physician can dictate an addendum within 30 days, if appropriate.

15. Core Measure Focus • AMI Measures • Aspirin on arrival • Aspirin given within 24 hours prior to arrival or administer within 24 hours after arrival • Contraindication documented within physician documentation • EKG positive & Angioplasty performed • Balloon/Stent inflated/deployed within 90 minutes • Reason for delay documented • ACE/ARB for LVSD ordered • ACE/ARB ordered • Contraindication documented within physician documentation • Aspirin at discharge • Aspirin ordered • Contraindication documented within physician documentation If the answer is always no, note left for physician to ensure measure compliance

16. Core Measure Focus • AMI Measures (cont) • Beta-Blocker at discharge • Beta-Blocker ordered • Contraindication documented within physician documentation • Statin at discharge • Statin ordered • Contraindication documented within physician documentation If the answer is always no, note left for physician to ensure measure compliance • Smoking Cessation • Current smoker and/or quit within last 12 months • Education refusal documented / Smoking cessation education ordered • Education completed If near discharge and the education not completed, contact Cardiac Services and/or inform patient’s nurse that education has not been done

17. Core Measure Focus • Pneumonia Measures • Antibiotic given within 6 hours of arrival • Appropriate antibiotic given • Blood Culture collected before antibiotic The above measures do not allow for a yes/no answer…it is what it is! • Smoking Cessation • Current smoker and/or quit within last 12 months • Education refusal documented / Smoking cessation education ordered • Education completed If near discharge and the education not completed, contact Cardiac Services and/or inform patient’s nurse that education has not been done • Pneumococcal / Influenza vaccinations • Patient up-to-date with vaccines • Contraindication documented • Vaccine administered Note left for nursing staff on patient’s Kardex as a reminder that patient qualifies and vaccine(s) need to be given before discharge or document contraindication…daily re-checks and calls to nurse until vaccine given

18. Core Measure Focus • SCIP Measures • Beta-Blocker within appropriate timeframe • Beta-Blocker given / taken prior to surgery • Contraindication documented within physician documentation If the answer is always no, note left for physician to ensure measure compliance If patient’s nurse failed to document date & time of last home dose, the nurse to re-interview patient to obtain information. • VTE prophylaxis ordered • Appropriate mechanical/pharmacological VTE prophylaxis ordered • Contraindication documented within physician documentation • Foley discontinued by POD 2 • Foley discontinued • ICU patient and receiving IV Lasix • Reason to keep documented • Antibiotic stopped within 24 hours of anesthesia end time • Appropriate post-op antibiotics ordered (Q8 X 2 doses, Q12 X 1 dose) • Post-op infection documented If the answer is always no, note left for physician to ensure measure compliance

19. Core Measure Focus • SCIP Measures (cont) • VTE prophylaxis given / on • Ordered VTE prophylaxis given / status documented Nurse contacted and reminded thatthe medication needs to be given by X time and/or mechanical prophylaxis needs to be documented on. • Antibiotic prior to incision • Pre-op infection • Pre-op antibiotic given and documented Contact Anesthesia Medical Director to review and follow up • Perioperative temperature management • Forced air warming unit documented as on patient during surgery • 1st post-op temperature documented • Hair Removal • Hair removal method documented Contact Surgery / PACU Manager to review and follow up

20. Measure Awareness • Ensuring that all are aware of the CMS measures, this document is laminated on bright yellow paper and placed in nursing staff and physician areas of the hospital (i.e., break rooms, lounges).

21. CMS Tri-fold Pocket Guide • In keeping with our facility motto…It takes a Team to go GREEN, a pocket sized education tool was developed. • These guides will be provided to our physicians and nursing staff • A small but great reminder of SAM’s commitment to the CMS quality measures

22. Educational Tools Appropriate antibiotic selection tables posted in the physician dictation areas within Surgery, Outpatient Surgery, ICU and the medical/surgical inpatient units.

23. Request for Documentation • Below is the documentation request that is left for the physicians when there is a potential measure non-compliance. • Contact with the individual physician/surgeon occurs when note is not addressed.

24. Variances • When a variance is identified, the Quality Rounders update a spreadsheet and issue a letter of non-compliance. • Real-time information is available to department director and vice president.

25. Results

26. Improvement in ACM Scores • Source: SSFHS Quality Improvement CMS BIS Report-AMC Scores. Retrieved: 4/18/2011

27. CMS Quality MeasuresIt takes a Team to go GREEN! Celebrate the Green!!

28. CMS Quality MeasuresIt takes a Team to go GREEN! Continually work on opportunities

29. Continuous Improvement

30. Continuous Improvement Quality Rounders work with physicians to educate regarding thorough documentation for compliance

31. Continuous Improvement Action: Quality Rounding continually educated Nursing staff on documenting date & time of patient’s last home dose. Attended Nursing and Physician Department meetings to review measure and results. Anesthesia pre-op assessment form revised to ensure compliance.

32. Continuous Improvement

33. Continuous Improvement

34. Continuous Improvement

35. Continuous Improvement

36. Quality Rounding (QR) • Highlights of our teamwork…

37. Rounding SuccessesVariances Corrected Prior to Discharge

38. Objectives Met: • Performing concurrent review and abstraction • QR uses the daily census report and surgery schedule • Specific admission reports • Daily discussions w/ charge nurse, and the clinical documentation specialist for identification for chart review.

39. Objectives Met: • Capturing CMS documentation compliance prior to discharge • QR identifies standard compliance opportunities and discusses individual cases w/ nurses and MD’s • Calls MD’s directly, or leaves rounding notes • Emails clinical mgrs and supervisors w/ open cases • The QR team also works with the EBOS Facilitator to ensure CMS compliance

40. Objectives Met: • Providing “just-in-time” education and support for staff and physicians • The success of this program is relationship driven • QR has developed a good report with physicians and staff through continual communication offering daily support while rounding on the units • The QR team has developed a one page Core Measure Fact Sheet and CMS Pocket Guide • Quality Services page on the Intranet which includes CMS data definitions.

41. Objectives Met: • Ensuring timely feedback of results for accountability • Provides daily feedback via: • rounding • staff meetings • email alerts • variance reporting through letters to physicians and clinical managers • reporting variances at medical staff meetings

42. Objectives Met: • Identifying and improve processes to eliminate barriers to compliance • When trends are identified while rounding, the QR team brings stakeholders together more timely to work on processes.

43. Overall Impact: Improved teamwork, awareness, and accountability through relationship building and ongoing and timely communication among Quality Services, Medical Staff, Nursing and Ancillary Staff resulting in increased quality of care delivery, consistency in practice and compliance to standards as evidenced by our results!

44. Questions? Amy Baker, AD CMS Data Analyst amy.baker@franciscanalliance.org Deborah Kelley, LPN Clinical Data Coordinator deborah.kelley@franciscanalliance.org Genevieve Koehler, RN, CPHQ Director of Quality genevieve.koehler@franciscanalliance.org