HEART FAILURE TEAM MEMBERSHIP CARDIOLOGY, CARDIOVASCULAR SURGERY, MEDICINE, NURSING, QRM, CCE, MEDICAL RECORDS PROJECT COORDINATORS CARMEN BARC, RN, BSN CAROL KEELER, RN, MS

Our goal is to achieve 100% compliance to these measures. Heart failure accounts for more hospital admissions than any other Medicare diagnosis. Research shows that the following care processes decrease morbidity and mortality rates for heart failure patients: Left ventricular systolic function assessment ACEI or ARB prescribed for LVSD (EF <40% or description of moderate/severe dysfunction) Smoking cessation counseling Written discharge instructions regarding activity, diet, follow-up, medications, symptoms worsening, and weight management Our goal is to achieve 100% compliance to these measures. Source: www.jcaho.org

OPPORTUNITY STATEMENT Concurrent patient care and retrospective chart review indicated an opportunity for improvement in process and outcome for each of the measures.

Cycle 1 PLAN Implement a Heart Failure Core Measures program in accordance with JCAHO/CMS guidelines DO •HF Task Force formed •Nursing clinical ladder opportunity offered for data collection and entry •Pilot study of core measure performance for DRG 127 P L A N D O S T U Y C PLAN DO STUDY ACT STUDY •Current processes not adequately fulfilling project requirements •Lack of house-wide awareness/understanding of HF Core Measures •Data variability identified ACT •Physician and nursing staff education •Develop HF-specific documentation forms •Decrease data variability

Cycle 2 PLAN DO ACT STUDY PLAN DO STUDY ACT •Capture HF patient population using ICD-9 codes rather than DRG coding •Dedicated FTEs for the Core Measures initiative •Revise HF Discharge Progress Note(DPN) addendum •Physician and nursing staff education DO •100% chart review based on ICD-9 diagnosis codes •Nursing Quality Specialist given responsibility for data collection and entry as well as education •DPN addendum revision to include documentation of ARB as potential contraindication to ACE inhibitor •Multidisciplinary education by in-services and point of service posters/ information P L A N D O S T U Y C PLAN DO STUDY ACT ACT •Attend nurse managers meeting to discuss National Hospital Quality Measures •Place HF packets – including standard order sets, discharge instructions, and discharge progress note addendum – in the ED, EP lab, and all patient care areas that treat the HF population STUDY •Improved documentation of D/C instructions •LV assessment documentation peaked to a level of excellence •Decreased data variability •Continuity of required documentation house-wide needs improvement

Cycle 3 PLAN DO ACT STUDY PLAN DO STUDY ACT •Focus on unit and nurse specific performance DO •Analyze and provide unit and nurse specific performance data to managers •Provide overall performance data to the HF task force P L A N D O S T U Y C PLAN DO STUDY ACT ACT •Surgical and non-cardiac unit-specific education •Agency and registry nurse education •Involve cardiac rehabilitation nurses, heart transplant case managers and nurse practitioners, as well as cardiovascular case managers and nurse practitioners STUDY •High volume cardiac units tend to perform well; however, there is still an opportunity for improvement •Surgical and non-cardiac units need further education regarding the HF measures •Staff nurses perform better than agency nurses

Heart Failure Patients Receiving Left Ventricular Systolic Function Assessment 106 104 UCL = 103.54 102 100 Mean = 98% 98 Percent 96 94 LCL = 92.98 92 90 Jan-04 (n=55) Feb-04 (n=56) Mar-04 (n=35) Apr-04 (n=58) May-04 (n=60) Jun-04 (n=47) Jul-04 (n=58) Aug-04 (n=55) Sep-04 (n=35) Oct-04 (n=57) Nov-04 (n=49) Dec-04 (n=50) Jan-05 (n=69) Feb-05 (n=53) Mar-05 (n=69) Apr-05 (n=57) May-05 (n=73) Jun-05 (n=52) Jul-05 (n=52) Aug-05 (n=58) Sep-05 (n=62) *Oct-05 (n=56) *Nov-05 (n=71) *Dec-05 (n=76) *Jan-06 (n=48) *Feb-06 (n=26) Month * Preliminary data for quality improvement purposes only

National Hospital Quality Measures Heart Failure Patients Receiving Complete Discharge Instructions Prior to Discharge 90 90 UCL = 83.62 UCL = 83.62 80 80 70 70 Mean = 63% Mean = 62.97 60 60 Distributed HF Packets to ED Percent Percent and units that treat HF population 50 50 LCL = 42.32 LCL = 42.32 40 40 Jan-04 (n=43) Jan-04 (n=43) Feb-04 (n=46) Feb-04 (n=46) Mar-04 (n=28) Mar-04 (n=28) Apr-04 (n=52) Apr-04 (n=52) May-04 (n=57) May-04 (n=57) Jun-04 (n=41) Jun-04 (n=41) Jul-04 (n=50) Jul-04 (n=50) Aug-04 (n=51) Aug-04 (n=51) Sep-04 (n=33) Sep-04 (n=33) Oct-04 (n=51) Oct-04 (n=51) Nov-04 (n=43) Nov-04 (n=43) Dec-04 (n=44) Dec-04 (n=44) Jan-05 (n=61) Jan-05 (n=61) Feb-05 (n=50) Feb-05 (n=50) Mar-05 (n=59) Mar-05 (n=59) Apr-05 (n=52) Apr-05 (n=52) May-05 (n=66) May-05 (n=66) Jun-05 (n=46) Jun-05 (n=46) Jul-05 (n=47) Jul-05 (n=47) Aug-05 (n=52) Aug-05 (n=52) Sep-05 (n=54) Sep-05 (n=54) *Oct-05 (n=49) *Oct-05 (n=49) *Nov-05 (n=65) *Nov-05 (n=65) *Dec-05 (n=70) *Dec-05 (n=70) *Jan-06 (n=44) *Jan-06 (n=44) *Feb-06 (n=26) *Feb-06 (n=26) Month Month * Preliminary data for quality improvement purposes only * Preliminary data for quality improvement purposes only

ACE Inhibitor or ARB Prescription at Discharge Heart Failure Patients With Left Ventricular Systolic Dysfunction Receiving ACE Inhibitor or ARB Prescription at Discharge 110 UCL = 104.88 100 Mean = 84% 90 Percent 80 70 LCL = 63.57 60 Jan-04 (n=25) Feb-04 (n=24) Mar-04 (n=14) Apr-04 (n=25) May-04 (n=25) Jun-04 (n=20) Jul-04 (n=24) Aug-04 (n=22) Sep-04 (n=15) Oct-04 (n=26) Nov-04 (n=24) Dec-04 (n=21) Jan-05 (n=40) Feb-05 (n=35) Mar-05 (n=34) Apr-05 (n=30) May-05 (n=43) Jun-05 (n=31) Jul-05 (n=27) Aug-05 (n=32) Sep-05 (n=31) *Oct-05 (n=30) *Nov-05 (n=47) *Dec-05 (n=45) *Jan-06 (n=26) *Feb-06 (n=13) Month * Preliminary data for quality improvement purposes only

Smokers Receiving Smoking Cessation Counseling for Heart Failure Patients 140 120 UCL = 117.84 100 Mean = 77% 80 Percent 60 40 LCL = 36.38 20 Jan-04 (n=7) Feb-04 (n=7) Mar-04 (n=6) Apr-04 (n=9) May-04 (n=11) Jun-04 (n=4) Jul-04 (n=10) Aug-04 (n=3) Sep-04 (n=4) Oct-04 (n=4) Nov-04 (n=7) Dec-04 (n=10) Jan-05 (n=14) Feb-05 (n=11) Mar-05 (n=10) Apr-05 (n=8) May-05 (n=18) Jun-05 (n=8) Jul-05 (n=9) Aug-05 (n=9) Sep-05 (n=15) *Oct-05 (n=15) *Nov-05 (n=15) *Dec-05 (n=21) *Jan-06 (n=8) *Feb-06 (n=6) Month * Preliminary data for quality improvement purposes only

ACE Inhibitor or ARB Prescription at Discharge Heart Failure Patients With Left Ventricular Systolic Dysfunction Receiving ACE Inhibitor or ARB Prescription at Discharge 120 110 100 90 Percent 80 70 Jan-04 Feb-04 Mar-04 Apr-04 May-04 Jun-04 Jul-04 Aug-04 Sep-04 Oct-04 Nov-04 Dec-04 Jan-05 Feb-05 Mar-05 Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05 *Oct-05 *Nov-05 *Dec-05 *Jan-06 *Feb-06 Month LUHS ACE Inhibitor or ARB for LVSD Rate UHC Academic Hospitals ACE Inhibitor or ARB for LVSD Rate National ACE Inhibitor or ARB for LVSD Rate * Preliminary data for quality improvement purposes only

LUHS Discharge Instruction Rate Heart Failure Patients Receiving Complete Discharge Instructions Prior to Discharge 120 110 100 90 80 70 Percent 60 50 40 Jan-04 Feb-04 Mar-04 Apr-04 May-04 Jun-04 Jul-04 Aug-04 Sep-04 Oct-04 Nov-04 Dec-04 Jan-05 Feb-05 Mar-05 Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05 *Oct-05 *Nov-05 *Dec-05 *Jan-06 *Feb-06 Month LUHS Discharge Instruction Rate UHC Academic Hospitals Discharge Instruction Rate National Discharge Instruction Rate * Preliminary data for quality improvement purposes only

Heart Failure Patients Receiving Left Ventricular Systolic Function Assessment 120 115 110 105 100 Percent 95 90 85 Jan-04 Feb-04 Mar-04 Apr-04 May-04 Jun-04 Jul-04 Aug-04 Sep-04 Oct-04 Nov-04 Dec-04 Jan-05 Feb-05 Mar-05 Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05 *Oct-05 *Nov-05 *Dec-05 *Jan-06 *Feb-06 Month LUHS Left Ventricular Function Rate UHC Academic Hospitals Left Ventricular Function Rate National Left Ventricular Function Rate * Preliminary data for quality improvement purposes only

Smokers Receiving Smoking Cessation Counseling for Heart Failure Patients 120 110 100 90 80 Percent 70 60 50 Jan-04 Feb-04 Mar-04 Apr-04 May-04 Jun-04 Jul-04 Aug-04 Sep-04 Oct-04 Nov-04 Dec-04 Jan-05 Feb-05 Mar-05 Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05 *Oct-05 *Nov-05 *Dec-05 *Jan-06 *Feb-06 Month LUHS Smoking Cessation Advice Rate UHC Academic Hospitals Smoking Cessation Advice Rate National Smoking Cessation Advice Rate * Preliminary data for quality improvement purposes only

NEXT STEPS Involve cardiac rehabilitation nurses as well as cardiovascular NPs in the NHQM initiatives Analysis of physician specific performance Computerize discharge processes Evaluate process/outcome improvement resulting from interventions Continue public reporting of performance measures