1. Congestive Heart Failure Core Measure Failure Mode Effects Analysis for CHF core measure quality indicators By: Daidreanna Whiteman, RN-C Columbus State University School of Nursing NUR 3192 Professional Nursing Perspectives Spring 2014

2. Congestive Heart Failure Team Members Executive Sponsor: Laura Drew Quality Management Freya Gilbert Team Leader: Daidre Whiteman Pharmacy: Mandy Mock Education: Gwen Pugh Smith Nursing: Magelie Devera Vidal Rodriguez Archie Person June Spivey

3. What are core measure? Core measures are nationally mandated quality measures from The Joint Commission (TJC) and Centers for Medicare and Medicaid Services (CMS) that help monitor specific hospital processes and how well the hospitals provide care as well as patient outcomes for specific diagnosis(TJC, 2014).

4. Congestive Heart Failure The heart failure set of core measures was introduced by TJC in May of 2001 with four initial core measures indicators for hospitals that help measure the quality of care for heart failure patients and AMI patients. There are currently only 3 measures that are now monitored by CMS and TJC (TJC, 2014).

5. CHF CORE MEASURE INDICATORS HF-1: Discharge instructions to include: Activity Level Diet Discharge Medications Follow-up Appointment Weight Monitoring Symptoms worsening HF-2: Evaluation of left ventricular systolic (LVS) Function from and Echocardiogram HF-3: Angiotensin Enzyme Inhibitor (ACEI) or Angiotensin Receptor Blocker (ARB) for left ventricular systolic dysfunction LVSD Prescribed at Discharge (TJC,2014)

6. Failure Mode Effects Analysis (FMEA) Failure Mode Effects Analysis is a systemized approach to recognizing and evaluating current processes and the potential for failure in these processes. FMEA uses scoring guidelines to score the possibilities of failure and how catastrophic the failure could be.

8. Failure Mode Effects Analysis (FMEA) The team first looked at where in the process the failures were occurring. Next we walked the process of CHF patients from admission to discharge and looked for the potential failures. Then we looked at what the proposed action was to correct the potential failure. We redesigned the process to correct the issues. We now monitor progress through concurrent chart reviews in house from the quality department.

9. Failure Mode Effects Analysis (FMEA) Biggest concern from the team was that the process was a one man process of the CHF nurse. We continued to send patients home without proper instructions or documentation of the required instructions on the chart when the CHF nurse was not present to assist with discharge. The team also found that the nurses needed more education about the core measure requirements and expectations.

10. Plan of Action Redesigned the process to involve the nurses caring for the patient. Reeducated and reinforced the information to the primary care nurses. Created a checklist that started at admission and walked the staff through inpatient and discharge to ensure all measures were met. Added education to out electronic medical record (EMR) system to include discharge instructions that was a hardstop for the nurses to ensure that they addressed CHF discharge instructions for all patients with CHF.

11. CHF Admission & Discharge Checklist

12. SOARIAN DISCHARGE EDUCATION

13. Results In the first month we saved 3 charts from failures on discharge instructions with the addition in the EMR of discharge instructions. We saved 2 failures of no documentation from the physician on LVS and patient being discharged on an ACE or an ARB. 5 months running without failure.

14. Final Results Target Measures Avg90th%Jan-13Feb-13Mar-13Apr-13May-13Jun-13Jul-13Aug-13Sep-13Oct-13Nov-13 HF-1 Discharge Instruction s 93.0%100.0%100.00%0 0 0 0 088.24%2100.00%0 0 0 0 0 HF-2 Evaluation of LVS Function 99.0%100.0%100.00%0 0 0 0 0 0 0 0 0 0 0 HF-3 ACEI or ARB for LVSD 96.0%100.0%100.00%083.33%2100.00%086.67%2100.00%0 0 0 0 0 0 0

15. References: The Joint Commission, 2014. Core Measure Sets. Retrieved from:http://www.jointcommission.org/core_measure_sets.aspx United States Department of Veterans Affairs, 2013. Failure Mode Effects Analysis. Retrieved from: http://www.patientsafety.va.gov/SafetyTopics/HFMEA/FMEA2.pdf#top