St. Mary’s Health Care System, Inc. Joint Commission Disease Specific Certifications Advanced Primary Stroke (2004) Heart Failure (2007) Total Knee Replacement (2008)

St. Mary’s Health Care System, Inc. Achieving Excellence in Patient Care Presenters: Darlene Morocco, RN, BSN, NE-BC Director, IMCU Chair, Heart Failure Program Dina Hewett, Ph.D., RN, CCRN, NEA-BC Director, ICU

A Team Approach! Senior Leadership Staff Physicians Medical Records Quality Department Heart Failure Team Senior Leadership – especially CNO and CMO Medical Records – notification of charts coded out as heart failure Quality Department – Weekly spreadsheets with indicators needing follow up; especially with MDs 30 day window for MD addendum if applicable

Performance Improvement Identifying the HF patient with primary and/or secondary diagnosis Standardized Order Sets and Pathways Core Measure Checklist Concurrent Chart Audits Daily Reports of Hospital Census Discharge Medication Reconciliation ID patient – initially the biggest problem; especially the secondary diagnosis that would code out as HF Standardized order sets – include the ACE/ARB, Echo, EF Core Measure check list – monitored by team leaders and directors Daily Reports: BNP, EF and census capturing patients with history of Med-Rec requires double signature by nurses

Education Staff Physicians Monthly Heart Failure Inservices Monthly Educational Bulletin Board (HF) PharmD students (UGA) provide inservices Physicians Attend office staff meetings Hospitalists and Cardiologists Physician and staff accountability – letters sent to MD and nurses when measure missed. Staff Recognition – celebrating success! Thank you letters and notes for files.

Heart Failure ACEI or ARB for LVSD at Discharge July 2010 – only 7 cases and missed 1 or 2 measures (volume related)

Acute Myocardial Infarction ACEI or ARB for LVSD at Discharge

Core Measure Checklist Heart Failure Also includes follow up phone calls at 7, 14 and 21 days. Nurse and MDs and is on chart. Serves as a reminder to meet measures before discharge.

Core Measure Checklist Acute MI

Keys to Success Daily monitoring!! On-going Education Collaboration and Networking