1. Improving the Quality of Care of Patients with Heart Failure Francisco Lopez-Jimenez MD, MSc Director, Preventive Cardiology Professor of Medicine, Mayo Medical School

2. Heart Failure Leading cause of hospitalizations High long-term mortality Prevalence is increasing Evidence-based interventions available

3. Heart Failure Core Quality Measures LVF assessment ACEI/ARB for LVSD Adult smoking cessation counseling Discharge Instructions »Activity »Low Sodium Diet »HF Signs of Symptoms Worsening »List of Medications »Weight Monitoring »Follow up Care

4. Magnitude of the Problem

7. Project Goal 95% of all hospitalized patients with a principal diagnosis of heart failure will receive ALL core quality measures established by CMS (Medicare/Medicaid)

8. Team and Methods »Physicians, nurses, pharmacists, experts in quality improvement, an expert in systems and procedures, medical residents, and administrators. »DMAIC »Hybrid methods: Small Test of Change, Immediate Action, etc

9. Heart Failure Team Robert Bleimeyer Lisa Bohn Joe Furst MD Kim Gaines Rudy Haddad MD Luis Haro MD Ann Hiniker Barry Karon MD* Mark Klarich* Jeff Leland* Dorinda Leutink* Francisco Lopez-Jimenez MD* Dennis Manning MD* Ann McLaughlin Fred North MD Narith Ou Katherine Pearson Qi Qian MD Carrie Sanvick Barb Spurrier Karyl Tammel

11. Define Phase Pre-Specified Core Performance Measures All-or-None

12. Measure Phase Active surveillance system Patients with principal diagnosis of HF Biweekly report

13. Analyze Phase Pareto chart

14. FEMA Failure Mode Effects Analysis ACE/ARB not Given and no Docum. Of Contraindication No Docum. That Dismissal Summary was Given Patient Education Not Documented

15. Patients with Primary Diagnosis of Heart Failure Patients with Secondary Diagnosis of HF Segment Diagnosis of Heart Failure (HF) At Admission Diagnosis of Heart Failure (HF) Post Admission Heart Rhythm Services Patients with HF Diagnosis All Other Patients with HF # of Cases for 2005646559240 ? All or None Performance (April 2006) 91%80%0%? Performance Goals for 2006 Goal: 95% TBD Segmentation

16. Problems / Cause / Solutions 1.Problem: ACE ARB not given or Contraindications not Documented Root Cause: Clinicians unaware of core measures Some services not aware of pt having low EF No space in the EMR to document contraindications. Solutions: MD education package Pharmacy screening: Low EF+ACE?

17. Problems / Cause / Solutions 2.Problem: Patient Receipt of Discharge Summary not Documented Root Cause: No institutional policy/procedures for discharge summary process Solutions: Create policy, education of providers.

18. Problems / Cause / Solutions 3. Problem: Provider does not Decide Patient has HF Root Cause: Clinicians uneasy diagnosing HF Using different statements to say HF Solutions: Educate clinicians Flag patients with a history of HF in the EMR Dictation prompts Stickers.

19. Problems / Cause / Solutions 4. Problem: No education elements in electrophysiology service Root Cause: Clinical service focused on advanced treatment of arrhythmias Solutions: Created a template to be included in all dismissal summaries of electrophysiology service Educate nurses

20. Other Interventions Concurrent review Feedback to consultants Simplification of patient educ. material Pocket reminders Use of EMR to record previous intolerance Creation of a CHF Pager Online education modules for consultants

21. RN Checklist For all Measures Addition of “Receipt of Dismissal Summary” To Nursing Educ Plan Interventions Nurse Educ Pocket Cards Posters 127-12-CHF Pager Letters to MDs, Nurses Implementation of dismissal Summary In HRS Dictation Prompts for HF ACE/ARB drug classes Added to allergy Module Shorthand Template In CV Identifying Patients with Low EF Online Education Module

22. Performance on Core Quality Measures (% of Patients Receiving all quality measures)

23. Magnitude of the Problem

24. Current Status

25. Mayo Clinic Elements of Quality Patient-centered Effective »Evidence-based »Standardized »Outcomes-based »Benchmarked Timely Efficient Safe Equitable Collaborative Collaborative Compassionate Compassionate Innovative Innovative Satisfying Satisfying Service-oriented Service-oriented Fiscally-sustainable Fiscally-sustainable Structured Structured

26. Gracias! lopez@mayo.edu @CVDprevention