1. Oversight and Systems Considerations to Aide in Meeting the Revised Performance Measures Nancy Albert, PhD, RN, CCNS, CCRN, NE-BC, FAHA, FCCM Senior Director Nursing Research and Innovation; CNS, Kaufman Center for Heart Failure May 2012

2. 2 Presenter Disclosure Information Nancy Albert, PhD, RN, CCNS, CCRN, NE-BC, FAHA, FCCM Oversight and Systems Considerations to Aide in Meeting the Revised Performance Measures 2 FINANCIAL DISCLOSURE: No relevant financial relationship exists

3. QUALITY Review Practice Profile Report Select Target Performance Measure Impact Opportunity Create Action Plan Cardiologists Nurses Administrative Support Staff Develop Solutions to Implementation Barriers Evaluate and Communicate Results to Team Implement Improvement Action Plan Improve Use of Evidence- Based Therapies Performance Improvement Process

4. Improvement in Hospital Quality of Care Using data to Drive Improvement (Quality Improvement Organization Warehouse [CMS/JC], QIO work with hospitals, collaborations) Making Data Public (Natl Hosp Voluntary Info; H-CAHPS Satisfaction Data) Linking Reimbursement to Quality (Medicare Modernization Act; Premier/CMS Project)

5. Participate in PROGRAMS to Improve Performance Measures Usually designed to enhance quality of patient care that promotes adoption of evidence- based, guideline-recommended therapies – Force a deeper look into actions and practices – Requires: – Leadership – Evidence-based clinical decision support (algorithms; pocket cards, customizable order sets...) – Patient education resources

6. REENGINEERING QUALITY Reengineering: – Starting over – Thinking outside of the box – Throwing out all the notions of how work was done and deciding how it can best be done now After identifying quality needs: – Design how it can best be done now – Design processes and aligning people to meet those needs

7. Reengineering aims at quantum gains on the order of 30-50% or more. QI programs stress incremental progress, striving for inch-by-inch gains again and again

8. MOVING FORWARD Consider how you are trying to meet the performance measure – Have you revised electronic documentation to show conformity to a performance measure? – Does the new system make a difference in quality care and patient outcomes? Consider who you ask to do work now – Are nurses who are already peaked out being asked to do more? – Do they have time to meet the request? SYSTEMS ISSUES? OVERSIGHT ISSUES?

9. Performance Measures Consider a positive deviance inquiry approach to problem solving: Premise: In every community there are certain individuals whose uncommon practices or behaviors enable them to find better solutions to problems than their neighbors who have access to the same resources

10. What enables some members of the community (the positive deviants) to find better solutions to pervasive problems than their neighbors who have access to the same resources? – Positive deviance focuses on PRACTICE (not knowledge) – Best understood through ACTION Its easier to ACT your way into a new way of THINKING, than to THINK your way into a new way of ACTING Performance Measures

11. Using Performance Measures to ACT Although there are multiple, complex rationale for problems that affect practice, performance measure programs promote solutions, now/today, before all the underlying causes are addressed Performance measure programs utilize the 6 Ds of positive deviance:

12. 1. Define the problem, its perceived causes and related current practices (situation analysis) – Define what a successful solution/outcome would look like (described as a behavioral or status outcome) 2. Determine if there are any individuals/entities who ALREADY exhibit desired behavior or status 3. Discover uncommon practices/behaviors enabling the individuals/entities to outperform/find better solutions to the problem (than others in their community) 6 Ds of Positive Deviance Approach:

13. 4. Design and implement activities enabling others to access and PRACTICE new behaviors (focus on doing rather than transfer of knowledge) 5. Discern the effectiveness of activities or project through ongoing monitoring and evaluation 6. Disseminate successful process to appropriate other (scaling up)

14. Use a Phases of Innovation Model Inspiration Ideation Implementation Observe & Inquire Tell Stories Synthesize Brainstorm Experiment Execute Spread

15. Innovation in Action What is the design challenge? What is the design challenge? What do we know about the challenge? What do we know about the challenge? What ideas might work? What ideas might work? How to test ideas? How to test ideas? How to implement? How to implement? Learning Organizing Building Deconstruct??

16. WHY REENGINEERING? Health care costs too much and achieves too little – It is inefficient Need for improved safety Too much fragmented services and systems Need better performance – Reprioritization of the healthcare providers day – More time for patients Need to reduce tensions Need better communication

17. REENGINEERING Work is NOT a series of separate tasks to be individually optimized Champy J, Greenspun H. Reengineering Healthcare. FT Press; 2010

18. REENGINEERING Work is groupings of interconnected processes to be reassessed and reinvented in total Champy J, Greenspun H. Reengineering Healthcare. FT Press; 2010 Bundling

19. 4 Words- Keys to Reengineering 1. Fundamental: How work is performed – Ask yourself and the team: – Are the underlying assumptions about the design of work still valid? – Have advances in science & technology allowed work to be carried out in new and more efficient ways? 2. Radical: Going beyond superficial changes in the way things are done – Are old structures and operating assumptions diminishing the quality and service being delivered? – Do you need to go back to your original roots and rethink how work should be done? Champy J, Greenspun H. Reengineering Healthcare. FT Press; 2010

20. 4 Words- Keys to Reengineering 1. Dramatic: NOT about marginal or incremental improvements – Not piecemeal change...need MORE – Is your efficacy threatened in a way that only wholesale change can fix? 2. Process: Group of activities – Uses 1 or more types of input to create an output customers will value – Expanding accessibility / improving care – Customer: patient, clinician, family or insurer paying for care Champy J, Greenspun H. Reengineering Healthcare. FT Press; 2010

21. Deconstruct

22. Often, we question the reliability of performance measures in specific settings – Documentation of patient education – Checking a box does not reflect delivery of quality care REENGINEERING 1. Koelling TM, et al. Circulation 2005;111:179-185. 2. Krumholz HM et al. JACC 2002;39:83-89. 1:1 RN-delivered comprehensive HF education during a 1-hour hospital session decreased 6- month days hospitalized or days dead 1 RN delivered, 1 hour, comprehensive hospital education + ongoing 1 year telephone-based support decreased 1-year hospital readmission rate and hospital costs 2

23. Van der Wal MH, et al. Eur Heart J 2010;31:1486-1493 Compliance with advice on weight monitoring, low sodium diet, fluid restriction and exercise *, P< 0.01; **P<0.05 COACH study: Death or HF Rehospitalization 0 20 40 60 % primary endpoint Total compliance score (0-4) 4321 or 0 25% 38% 36% 45% * ** *

24. The Work of Adherence to a Chronic HF Regimen Qualitative report: Both patients and providers described adherence to the HF regimen as "work" Both reported the same list of tasks and knowledge requirements as key components of the HF regimen, and both reported delegating their own regimen-related work to others Granger BB, et al. J Cardiovasc Nurs. 2009;24:308-315. ThemePatientsPhysicians Work complexity Adherence to the regimen is hard work Instructions are easy Perceive pts as non participatory Under- standing Do understand but need help in carrying out Not understanding; need more repetition of knowledge- based instructions About What How

25. Quality improvement OUTPATIENT process measure: Patients with HF will be provided with self-care education in 3 or more elements during 1 or more visits within a 12 month period Includes: Def of HF (linking disease, symptoms, and Tx) & HF cause Recognition of escalating symptoms & concrete plan for response to symptoms Indications & use of each medicat. Modify risks for HF progression Specific diet recommendations Individualized low-sodium diet Recommend for ETOH intake Specific act./exercise recommend. Importance of Tx adherence & behavioral strategies to promote Tx adherence Importance of monitoring weight daily at home

26. Nurses Knowledge About HF Albert NM, et al. Heart Lung 2002;31:102-112. Washburn SC, et al. J Cardiovasc Nurs 2005;20:215-220. Willette EW, Et al. Progress in Cardiovasc Nurs 2007;22:190-195. Kalowes P, et al. Heart Lung 2011;40:362. Delaney C, et al. Heart Lung 2011;40:285-292. N = 300 N = 55 N = 49 Mean score % Correct N = 157 N = 94

27. Nurse Education Systems Rationale: Based on research results: – 118 nurses from 3 sites participated in survey research on comfort and frequency in delivering HF patient education before hospital discharge – CC Main campus – 2 community hospitals – CC site – Valdosta, Georgia site – Survey created by investigators based on education themes from national guideline discharge education recommendations Albert NM, et al. Heart & Lung 2011;40:363.

28. HF Hospital Nurses Need HELP (Health Education and Logical Planning) to Educate Patients Frequency, % 43.5% Albert NM, et al. Heart & Lung 2011;40:363. 0% 10% 20% 30% 40% 0<1 to <33 to <55 to <1010 to <15 15 to < 30 30 or more Time, minutes Time spent delivering HF discharge education: N=118 RNs

29. Comfort Factor* nMean (SD) Frequency Factor** nMean (SD) Overall11881.4 (11.3)Overall11857.7 (24.4) Weight monitoring11790.0 (12.0)S/S worsen cond.11671.5 (29.0) S/S worsen cond.11788.8 (11.8)S/S fluid overload11670.1 (30.5) S/S fluid overload11688.5 (12.2)Weight monitoring11769.8 (29.8) Fluid restriction11788.3 (12.7)Fluid restriction11668.5 (29.2) HF Beliefs11783.2 (14.9)HF Beliefs11759.9 (29.4) Low Na+ Diet11780.0 (14.5)Medications11656.8 (25.5) Medications11778.0 (13.8)Low Na+ Diet11748.0 (29.2) Activity/Exercise11773.0 (19.3)Activity/Exercise11742.7 (29.4) Albert NM, et al. Heart & Lung 2011;40:363. HF Hospital Nurses Need HELP (Health Education and Logical Planning) to Educate Patients *, Comfortable/very comfortable **, Deliver education 70-100% of time

30. Educating Patients about Medications 2011 © Nancy M. Albert

31. Weight Monitoring If you gain 3 or more pounds in a day or 5 or more pounds in a week call me / do something AHA/ACC and HFSA guidelines include weight monitoring as a component of education – But, guidelines do NOT include specific wording about how to do it Does this recommendation really work in your setting?

32. Weight Change Patterns Pre-Hosp. Daily weight changes before hospitalization; P < 0.001 Chaudhry SI, et al. Circulation 2007;116:1549-54. Days 454035302520151050 -5 -4 -3 -2 0 1 2 3 4 5 Daily Weight Change, Mean Controls Cases

33. Conditional Logistic Regression Models of HF Hospitalization (N=240) Weight Gain, Lbs Case Pts, n (%) Control Pts, n (%) Matched Unadjusted OR (95% CI) Matched Adjusted OR (95% CI) Adj. P < 2 65 (54)92 (77)Reference---- >2 - <5 21 (18)16 (13)2.40 (1.05–5.45)2.77 (1.13–6.80)0.026 >5 - <10 17 (14)8 (7)3.81 (1.35–10.77)4.46 (1.45-13.75)0.009 > 10 17 (14)4 (3)5.65 (1.81–17.65)7.65 (2.22–26.39)0.001 Chaudhry SI, et al. Circulation 2007;116:1549-54.

34. Weight Monitoring Blair JE et al. European Heart J. 2009;30:1666–1673. HF Hospitalization 60 days 120 days 180 days Time Post Discharge P<0.0001 (no event vs. visit prior to event groups) 2.5 2 1.5 1 0.5 0 3169 184 401 2941 411 635 2780 411 635 Change, Body Weight; Kg 4133 Pts w HF-REF; EVEREST Trial *, Time from remote monitor to event: 32/44/56 days; time from clinic visit to event: 9/12/14 days No event Remote monitor before event* Clinic visit before event*

35. OVERSIGHT & SYSTEMS CONSIDERATIONS Patient Education in Self Care Knowledgeable educators – Medications, Diet, Exercise Educators need time to educate Select EBP daily weight reporting criteria Medication reconciliation Medication understanding Across continuum: hosp. to home; hosp. to SNF; hosp. to home care program

36. Reengineering - Bundled Initiatives FocusChanges Patient Revised HF handbook & Quick Sheet; New focus; pages; reorgan. Revised weight monitoring criteria Revised Epic template to include weight expectations Nurses1 hour HF education; take session yearly OPD: Document new weight protocol in Epic Hosp: Revised HF edu. Documentation system TeamHosp: PharmD provide pharmacy edu. & reconciliation x 2 APN assigned to SNFs; visit within 48 hrs. CNS Care Coordinators at community hospitals All educators: Teachback Home care at home program w telemonitoring Phone calls to pts 48 hrs and 10 days post discharge

37. Are All Readmissions Bad Readmissions? 3857 hospitals in the CMS Hospital Compare public reporting database without missing data Higher occurrence of readmissions after index admissions for HF was associated with lower risk-adjusted 30- day mortality Readmissions could be adversely affected by competing risk of death Gorodeski EZ, et al. NEJM 2010;363(3):297. Risk-Adjusted 30-Day Readmission Rate (%) 01820 22 2426283032 0.0 10.0 10.5 11.0 11.5 Risk-Adjusted 30-Day Mortality Rate (%)