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

3. 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

4. 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

5. 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

6. 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.

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

8. Acute Myocardial Infarction ACEI or ARB for LVSD at Discharge

9. 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.

10. Core Measure Checklist Acute MI

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