HEART FAILURE TEAM MEMBERSHIP DEPARTMENTS OF CARDIOLOGY, CARDIOVASCULAR SURGERY, MEDICINE, NURSING, QUALITY AND RESOURCE MANAGEMENT, THE CENTER FOR CLINICAL EFFECTIVENESS, MEDICAL RECORDS, INFORMATION TECHNOLOGIES, EPIC PROJECT COORDINATORS CARMEN BARC, RN, BSN SARAH BORN, RN, BSN Confidential: For Quality Improvement Purposes Only

OPPORTUNITY STATEMENT Improve the quality of care for heart failure patients by providing evidence-based treatment as outlined in the Heart Failure Core Measures Confidential: For Quality Improvement Purposes Only

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 (LVSF) assessment Angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) prescribed for left ventricular systolic dysfunction (LVSD). Ejection fraction (EF) <40% or description of moderate/severe dysfunction. Written discharge instructions regarding activity, diet, follow-up, medications, symptoms worsening, and weight management Smoking cessation counseling Our goal is to achieve 100% compliance to these measures. Confidential: For Quality Improvement Purposes Only

FORCES OF MAGNETISM Force 6: Quality of Care Force 7: Quality Improvement Force 9: Autonomy Force 11: Nurses as Teachers Force 13: Interdisciplinary Relationships Confidential: For Quality Improvement Purposes Only

Cycle 1 PLAN DO STUDY ACT PLAN DO STUDY ACT Implement a Heart Failure (HF) 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 Confidential: For Quality Improvement Purposes Only

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 Cycle 2 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 discharge instructions •LV assessment documentation peaked to a level of excellence •Decreased data variability •Continuity of required documentation house-wide needs improvement Confidential: For Quality Improvement Purposes Only

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 Confidential: For Quality Improvement Purposes Only

Cycle 4 PLAN DO ACT STUDY PLAN DO STUDY ACT Incorporate HF measures into the electronic medical record DO ●Develop a HF admission order set ●Develop a medicine discharge order set to include a HF assessment, HF specific discharge instructions, and smoking cessation counseling ●Include respiratory therapy in smoking cessation counseling P L A N D O S T U Y C PLAN DO STUDY ACT ACT ●Develop a CV Surgery discharge order set to include a HF assessment, HF specific discharge instructions, and smoking cessation counseling ●Analyze physician compliance with electronic medical record documentation STUDY ●Improved documentation of LVSF assessment and contraindications to prescribing ACEI and ARB for patients with LVSD ●Improved documentation of smoking cessation counseling ●Identified that surgical heart failure patients were not being included in the current electronic workflow pathways Confidential: For Quality Improvement Purposes Only

Cycle 5 PLAN DO STUDY ACT PLAN DO STUDY ACT Improve CV Surgery documentation regarding HF guidelines DO ●Develop a CV Surgery discharge order set to include HF assessment and HF specific discharge instructions P L A N D O S T U Y C PLAN DO STUDY ACT STUDY ●Improved documentation of LVSF assessment and contraindications to prescribing ACEI and ARB for CV surgical patients with LVSD ●Identified the need for cardiac rehab documentation to be part of the EMR ●Inconsistent RN documentation of patient HF education and patient clinical trial participation ACT ●Incorporate cardiac rehab documentation in the EMR ●Include research nurses in the HF initiatives Confidential: For Quality Improvement Purposes Only

Percent Core Measures Heart Failure Patients Receiving Left Ventricular Systolic Function Assessment Month UCL = 102.4 Mean = 99.5 LCL = 96.6 Jan 2006 (n=52) Feb 2006 (n=73) Mar 2006 (n=64) Apr 2006 (n=65) May 2006 (n=64) Jun 2006 (n=55) Jul 2006 (n=49) Aug 2006 (n=68) Sep 2006 (n=62) Oct 2006 (n=57) Nov 2006 (n=49) Dec 2006 (n=86) Jan 2007 (n=68) Feb 2007 (n=63) Mar 2007 (n=64) Apr 2007 (n=63) May 2007 (n=56) Jun 2007 (n=51) Jul 2007 (n=43) Aug 2007 (n=61) Sep 2007 (n=40) Oct 2007 (n=47) Nov 2007 (n=41) Dec 2007 (n=54) Jan 2008 (n=64) Feb 2008 (n=49) Mar 2008 (n=12) 90 92 94 96 98 100 102 104 106 Confidential: For Quality Improvement Purposes Only Definition: HF patients with documentation in the hospital record that left ventricular function (LVF) was assessed before arrival, during hospitalization, or is planned for after discharge / All HF Patients. Datasource: Original data extracted from LUMC charts by RNs. Analysis: LUMC performance has been above 97% since January 2006.

Percent Core Measures Heart Failure Patients With Left Ventricular Systolic Dysfunction Receiving ACE Inhibitor or ARB Prescription at Discharge Month UCL = 107.2 Mean = 95.6 LCL = 84.0 Jan 2006 (n=28) Feb 2006 (n=36) Mar 2006 (n=35) Apr 2006 (n=37) May 2006 (n=25) Jun 2006 (n=32) Jul 2006 (n=23) Aug 2006 (n=31) Sep 2006 (n=39) Oct 2006 (n=28) Nov 2006 (n=27) Dec 2006 (n=43) Jan 2007 (n=29) Feb 2007 (n=34) Mar 2007 (n=36) Apr 2007 (n=24) May 2007 (n=25) Jun 2007 (n=21) Jul 2007 (n=15) Aug 2007 (n=34) Sep 2007 (n=22) Oct 2007 (n=19) Nov 2007 (n=24) Dec 2007 (n=28) Jan 2008 (n=29) Feb 2008 (n=23) Mar 2008 (n=8) 75 80 85 90 95 100 105 110 115 Confidential: For Quality Improvement Purposes Only Definition: Heart Failure patients who are prescribed an angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) at hospital discharge / HF patients with LVSD and without contraindications. LVSD is defined as chart documentation of a left ventricular ejection fraction less than 40% or a narrative description of left ventricular function consistent with moderate or severe systolic dysfunction. Prior to 2005, ARBs were not recognized in compliance with this measure. Datasource: Original data extracted from LUMC charts by RNs. Analysis: LUMC performance has been at 100% since May 2007.

Percent Core Measures Heart Failure Patients Receiving Complete Discharge Instructions Prior to Discharge Month UCL = 90.5 Mean = 71.6 LCL = 52.7 Jan 2006 (n=46) Feb 2006 (n=69) Mar 2006 (n=58) Apr 2006 (n=59) May 2006 (n=61) Jun 2006 (n=50) Jul 2006 (n=45) Aug 2006 (n=62) Sep 2006 (n=60) Oct 2006 (n=46) Nov 2006 (n=45) Dec 2006 (n=79) Jan 2007 (n=56) Feb 2007 (n=57) Mar 2007 (n=59) Apr 2007 (n=59) May 2007 (n=52) Jun 2007 (n=46) Jul 2007 (n=40) Aug 2007 (n=55) Sep 2007 (n=34) Oct 2007 (n=40) Nov 2007 (n=39) Dec 2007 (n=51) Jan 2008 (n=60) Feb 2008 (n=43) Mar 2008 (n=11) 30 40 50 60 70 80 90 100 110 Epic programming issue Epic discharge process revised Confidential: For Quality Improvement Purposes Only Definition: HF patients with documentation that they or a caregiver received discharge instructions (weight monitoring, what to do if symptoms worsen, diet, medications, activity level, follow-up appointment) prior to hospital discharge / HF patients discharged to home. Data Source: Original data extracted from LUMC charts by RNs. Analysis: A technical issue with the electronic medical record lead to a decline in this measure. This was resolved starting with January 2007 discharges, and performance has improved significantly.

Percent Core Measures Smokers Receiving Smoking Cessation Advice for Heart Failure Patients Month UCL = 111.9 Mean = 97.8 LCL = 83.6 Jan 2006 (n=9) Feb 2006 (n=15) Mar 2006 (n=19) Apr 2006 (n=10) May 2006 (n=10) Jun 2006 (n=14) Jul 2006 (n=9) Aug 2006 (n=6) Sep 2006 (n=12) Oct 2006 (n=10) Nov 2006 (n=7) Dec 2006 (n=11) Jan 2007 (n=13) Feb 2007 (n=12) Mar 2007 (n=7) Apr 2007 (n=7) May 2007 (n=9) Jun 2007 (n=9) Jul 2007 (n=7) Aug 2007 (n=9) Sep 2007 (n=7) Oct 2007 (n=10) Nov 2007 (n=6) Dec 2007 (n=11) Jan 2008 (n=15) Feb 2008 (n=9) Mar 2008 (n=4) 80 90 100 110 120 Discharge form updated to include smoking cessation recommendations Confidential: For Quality Improvement Purposes Only Definition: Smokers receiving smoking cessation counseling / HF Patients who have smoked cigarettes at any time in the 12 months prior to hospital arrival. Data Source: Original data extracted from LUMC charts by RNs. Analysis: LUMC performance has been nearly perfect since March 2006.

NEXT STEPS Develop a cardiac rehab documentation tool in the EMR Include cardiac research nurses in the HF initiatives Ongoing staff education and feedback Incorporate new abstraction guidelines Confidential: For Quality Improvement Purposes Only