Heart Failure JCAHO Core Measure Project

1. Heart Failure JCAHO Core Measure Project Heart Failure Core Measure Team

2. 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.

3. 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.

4. 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.

5. 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)

6. 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)

7. Consistent Use of the Heart Failure Discharge Instruction Form by Nursing Staff Led to Improvement in Discharge Instructions LUHS Heart Failure Patients Receiving Discharge Specific Instructions Prior To Discharge LUHS Heart Failure Patients Receiving Discharge Specific Instructions Prior To Discharge Regarding Activity Level, Diet, Discharge Medications, Follow-up Appointment, Weight Regarding Activity Level, Diet, Discharge Medications, Follow-up Appointment, Weight Monitoring, and What to do if Symptoms Worsen Monitoring, and What to do if Symptoms Worsen 100% 1.0 UCL UCL Progress Note Addendum Initiated 80% 0.8 Progess Note Addendum Initiated Nursing In-service Nursing Inservice 0.6 60% LUHS Mean = 55% Mean Percent of LUHS Heart Failure Inpatients Receiving All Six Discharge Instructions 0.4 40% National Mean Q12003 = 31% Increase Use of HF Order Set LCL LCL Increase Use of HF Order Set 0.2 20% 0.0 0% Pilot 1 Pilot 1 Oct-03(n=48) Jan-04(n=42) Feb-04(n=33) Sep-03(n=28) Nov-03(n=38) Dec-03(n=47) Mar-Apr 2003(n=26) Oct-03(n=48) Jan-04(n=42) Feb-04(n=33) Sep-03(n=28) Nov-03(n=38) Dec-03(n=47) Date

8. With Use of the Discharge Progress Note Addendum, Documentation of LVF Peaked to a Level of Excellence LUHS Heart Failure Inpatients Receiving Left Ventricular Function Assessment LUHS Heart Failure Inpatients Receiving Left Ventricular Function Assessment 100% 1.00 UCL UCL 98% 0.98 LUHS Mean = 96% Mean 0.96 96% 0.94 94% LCL LCL 92% 0.92 Increase Use of HF Order Set Increase Use of HF Order Set Nursing Inservice 90% 0.90 Nursing In-service 0.88 88% Progess Note Addendum Initiated Rate of LUHS Heart Failure Inpatients Receiving LVF Assessment Rate of LUHS Heart Failure Inpatients Receiing LVF Assessment Progress Note Addendum Initiated 0.86 86% National Mean Q12003 = 84% 0.84 84% 0.82 82% 80% 0.80 Pilot 1 Pilot 1 Oct-03(n=48) Jan-04(n=53) Sep-03(n=31) Nov-03(n=44) Dec-03(n=55) Feb-04(n=42) Oct-03(n=48) Jan-04(n=53) Sep-03(n=31) Nov-03(n=44) Dec-03(n=55) Feb-04(n=42) Mar-Apr 2003(n=29) Mar-Apr 2003(n=29) Date

9. Opportunity Exists in Smoking Cessation Counseling LUHS Heart Failure Inpatient Smokers Receiving Smoking Cessation Counseling LUHS Heart Failure Inpatient Smokers Receiving Smoking Cessation Counseling 100% 1.0 UCL UCL 0.8 80% Increase Use of HF Order Set Progress Note Addendum Initiated Progess Note Addendum Initiated Increase Use of HF Order Set Rate of LUHS HF Inpatient Smokers Receiving Smoking Cessation Counseling Nursing In-service Nursing Inservice LUHS Mean = 58% 0.6 60% Mean National Mean Q12003 = 47% Percent of LUHS HF Inpatient Smokers Receiving Smoking Cessation Counseling 0.4 40% 0.2 20% LCL LCL 0.0 0% Pilot 1 Pilot 1 Jan-04(n=7) Sep-03(n=6) Nov-03(n=4) Feb-04(n=7) Oct-03(n=10) Dec-03(n=10) Mar-Apr 2003(n=4) Jan-04(n=7) Sep-03(n=6) Nov-03(n=4) Feb-04(n=7) Oct-03(n=10) Dec-03(n=10) Mar-Apr 2003(n=4) Date

10. Opportunity Exists in Prescribing ACEI for LVSDor for Better Documentation of Contraindications LUHS Heart Failure Inpatients with Left Ventricular Systolic Dysfunction and No Known ACE Inhibitor Contraindications Receiving ACE Inhibitor at Discharge 100% 80% 60% Percent of HF Inpatients with LVSD Receiving ACEI Prescription at Discharge 40% 20% 0% January-04 February-04

11. 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.