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

2. 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:

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

4. 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

5. 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

6. 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

7. Heart Failure Patients Receiving Left Ventricular Systolic Function Assessment
106
104
UCL =
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

8. 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

9. 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 =
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

10. Smokers Receiving Smoking Cessation Counseling for Heart Failure Patients
140
120
UCL =
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

11. 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

12. 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

13. 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

14. 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

15. 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