Visits, Themes, Lessons Learned

1. Visits, Themes, Lessons Learned Maine Quality Forum Heart Failure Summit March 30,2010 Deb Mattin, R.N.

2. Background • Explore the rate of readmissions in heart failure population • CMS reported HF readmission rate : 24.5% • Maine HF readmission rate: 21.2 – 27.2 % • Explore Care Transitions Measures (CTM) • One year of data on patient’s perception of preparation for discharge • Explore CMS Heart Failure Discharge Instruction Measure performance • Ask the question – is there any correlation between performance on the HF-1 measure, the CTM, and HF readmission rates?

3. HF-1 Measure Background • One of Medicare’s quality measures for patients hospitalized with heart failure (HF) • There are 4 measures: • HF-2: Left ventricular function assessment • HF-3: Left ventricular dysfunction ( based on LVEF <40% or qualitatively moderate/severe) treated with either ACE or ARB • HF-4: Smoking cessation counseling for smokers (year PTA) • HF-1: Written documentation of HF-specific instructions given to patient that include all of the following: • Meds, diet, activity, follow-up, weight monitoring and management of worsening symptoms (HF-1)

4. More information needed! • Data only tells part of story • Needed to know: • How does discharge process work? • How are HF patients identified? • Are Care Transitions Measure data useful for improvement? • Is hospital readmission rate used for improvement? • What strategies are successful in reducing readmission, improving performance on HF-1, and improving patient’s perception of preparation for discharge (Care Transitions Measures)?

5. Visits • Hospitals selected for on-site visit to help us understand: • How discharge process works in general • How discharge process works for HF patients • How data (HF-1, CTM, Readmission rates) are useful for improvement • What resources are available for improvement • What are barriers to improvement

6. What we did • Asked hospitals to complete a pre-visit questionnaire aimed at learning more about how care works at their facility • Is there a team approach to HF improvement • Is there a team approach to improving care at discharge for all patients • Who is on these teams • What tools used for HF care • Do you know how often these tools are used • Who is responsible for selecting/writing the discharge instructions

7. What we did, continued • More questions: • Is concurrent monitoring part of your process • What part of the HF-1 measure is most problematic • What challenges/ barriers have you identified • What successes have you had in improving HF discharge care

8. Good work is happening in Maine ! • Most hospitals report success with HF-1 in patients with diagnosis of HF on admission. • Process geared to “kick-off” by admission diagnosis ( standardized orders, teaching plan, discharge instruction selection) • Significant resources devoted to improvement • Electronic record • Improvement teams • Tool/program development • Care Management programs (inpatient/outpatient)

9. More good work • Most hospitals have: • Robust HF teaching programs • Standardized instructions for HF patients that include all the elements of the HF-1 measure • Teams with physician champions • Evidence –based protocols for HF • Most hospitals are actively working to reduce readmission rates in the HF population.

10. Recurring themes If there is an admitting diagnosis of heart failure, the patient usually receives the appropriate HF instructions. Patients with a diagnosis other than HF on admission are most likely not to receive HF specific instructions. Many hospitals use concurrent monitoring to remind care givers of HF measure elements and prompt for appropriate instructions. There are specific sections of the HF-1 measure that are challenging. Data not always “mined” for improvement opportunities

11. Recurring Theme Number 1Patients admitted with diagnosis of heart failure are likely to receive appropriate HF instructions • Admitting diagnosis is entry point into HF care • Kicks off use of standardized orders, care paths, involvement of HF teaching team, and use of HF specific discharge instructions. • Most patients with stay coded as HF have HF as admitting diagnosis • Majority of HF cases in this category

12. Lessons learned • Reliable process that captures most HF cases • Admission diagnosis ensures that the plan for this patient is evidence-based HF care that includes appropriate testing, medications, teaching and follow-up. • Admitting diagnosis kicks-off use of standardized orders, HF care management, HF specific instructions

13. Recurring Theme 2,3Patients without an admitting diagnosis of HF are less to receive HF specific instructions. 1 http://www.qualitynet.org/ • Cases are included in the HF measure based on the principle diagnosis code assigned after discharge. 1 • Most hospitals report that these are the cases that most often fail the HF 1 measure • Aggressive strategies to capture these cases: • Concurrent review of all records

14. Lessons learned • Identifying appropriate cases for the HF measure can be complicated. • Many hospitals using labor intensive, case-by-case record review both to find cases and provide reminder prompts for care. • This level of case review may not be sustainable as more categories of patients needing review are added • “Failures” when review not available – weekends, holidays, etc. • Does not address system –wide improvement

15. Lessons learned Reliability improvement from IHI • Chaotic process: Failure in greater than 20% of opportunities • 10-1: 80 or 90 percent success. 1 or 2 failures out of 10 opportunities • 10-2: 5 failures or less out of 100 opportunities • 10-3: 5 failures or less out of 1000 opportunities • 10-4: 5 failures or less out of 10,000opportunities (These are IHI definitions and are not meant to be the true mathematical equivalent)

16. Improvement Concepts Associated with 10-2 Performance (Uses human factors and reliability science to design sophisticated failure prevention, failure identification, and mitigation) Decision aids and reminders built into the system Desired action the default (based on scientific evidence) Redundant processes utilized Scheduling used in design development Habits and patterns known and taken advantage of in the design Standardization of process based on clear specification and articulation is the norm

17. Improvement Concepts Associated with 10-1 Performance (Primarily can be described as intent, vigilance, and hard work) Common equipment, standard order sheets, multiple choice protocols, and written policies/procedures Personal check lists Feedback of information on compliance Suggestions of working harder next time Awareness and training

18. Opportunities for improvement in HF case finding • Add discussion with physicians to improvement team work • How to clarify /improve communication about diagnosis and emphasize it’s importance • Consider working with EHR, pharmacy, lab to identify reports that could identify HF patients and eliminate need for record review. • Key words in EHR, medications dispensed, lab studies,etc. • Include coders in improvement team • Consider a targeted review of the cases without an admitting diagnosis of HF to identify any common themes ( ED admits, admitting physician, weekend admits, etc.)

19. Recurring theme 4There are specific sections of the HF-1 measure that are challenging. • HF-1 measure – patient receives written instructions in 6 areas: • Meds, diet, activity, follow-up, weight monitoring, and management of worsening symptoms • Most standardized instruction forms address all but the last 2 – weight management and management of worsening symptoms. HF-specific instructions contain these additional elements. • Identifying HF patients is crucial to ensure that patients receive the appropriate instructions

20. Recurring theme 4, continued • Medications - many hospitals report that med reconciliation programs have helped improve the accuracy of discharge medication lists. • Some hospitals have reported success in process changes for dictation systems for discharge meds/discharge summary • One system only requires the physician to dictate the list of meds once and it populates both the discharge med list and the discharge summary (effectively ensuring that they match). • Others have physically changed where the discharge med list is located in the paper record so the physician can easily locate it to use when dictating the discharge summary.

21. Recurring theme 5Data not always “mined” for improvement opportunities • Finding common cause for case “failures” can identify gaps in process and focus improvement activities. • Example: Are case failures due to day of week, time of day, hospital unit, lack of use of evidence-based protocols, etc. • Not knowing your own population can lead to changing process to fix a problem that doesn’t exist and overlooking one that does • No “one-size fits all” solution in healthcare (or jeans!) • Care Transitions Measures data often not included in HF improvement work • New data set, similar to HCAHPS, so may not be seeing relevance

22. Best practices – No magic bullet, no one-size fits all improvement strategy! • Multidisciplinary team approach to improvement • Includes physicians, nurses (staff and leadership), quality improvement, coding, pharmacy, case management • Aggressive analysis of data to identify process success and failures • Multidisciplinary team rounds • Case identification, promotes team accountability, review of guidelines vs. actual care delivery • Ability to make rapid tests of change

23. Questions?