Heart Failure Heart Failure JCAHO Core Measure ProjectJCAHO Core Measure Project

Heart Failure Core Measure Team

Opportunity For ImprovementOpportunity For ImprovementJCAHO identified standardized, evidence based

performance measures “Core Measures” for adult patients admitted with a principal diagnosis of Heart Failure(HF).

The Core Measures support the HF Guidelines defined by the ACC/AHA.

Retroactive chart reviews indicated an opportunity for improvement in process and outcome for each of the HF Core Measures.

LUMC needed to establish a process to meet the JCAHO requirements for reporting quality data.

JCAHO HF Core MeasuresJCAHO HF Core Measures Discharge instructions regarding activity, diet, follow-up,

medications, symptoms worsening, and weight monitoring documented.

Left ventricular function assessment documented.

ACE inhibitor prescribed at discharge for LV systolic dysfunction if no documented contraindication.

Adult Smoking Cessation advice/counseling provided if patient has smoked in last 12 months.

Most Likely Causes for the Most Likely Causes for the Improvement OpportunityImprovement Opportunity

Inconsistent documentation of thought processes, findings, and education provided to patients

All physicians and nurses not aware of the HF guidelines

All physicians and nurses not aware of the resources available to them to assist in provision of and documentation of the highest standard of heart failure care.

Solutions ImplementedSolutions Implemented Task force was formed for strategic planning of data collection and

reporting of the core measures to JCAHO (2/03)

Graduate student piloted the data collection (3/03)

Telemetry/HTU/CCU nurses were educated about the project and need for their assistance. Use of the HF Discharge Instruction form was encouraged.

HF discharge progress note addendum was developed and implemented . (9/03)

Solutions ImplementedSolutions Implemented MIDAS data entry was presented to nursing staff as a clinical ladder

opportunity, and volunteers were trained.

Physicians were encouraged to utilize standardized HF admission orders available in EMR protocols. Physicians were asked to complete the HF discharge progress note addendum

Discharge Progress note addendum was revised to include use of ARB as potential contraindication to ACE Inhibitors

Patient list expanded based on ICD-9 HF codes from DRG 127 (1/04)

Consistent Use of the Heart Failure Discharge Instruction Form by Consistent Use of the Heart Failure Discharge Instruction Form by Nursing Staff Led to Improvement in Discharge InstructionsNursing Staff Led to Improvement in Discharge Instructions

LUHS Heart Failure Patients Receiving Discharge Specific Instructions Prior To DischargeRegarding Activity Level, Diet, Discharge Medications, Follow-up Appointment, Weight

Monitoring, and What to do if Symptoms Worsen

Date

Pilot 1

Sep-0

3(n=

28)

Oct-03

(n=4

8)

Nov-0

3(n=

38)

Dec-0

3(n=

47)

Jan-

04(n

=42)

Feb-0

4(n=

33)

0.0

0.2

0.4

0.6

0.8

1.0

UCL

Mean

LCL

Nu

rsin

g In

serv

ice

Pro

ges

s N

ote

Ad

den

du

m In

itia

ted

Incr

ease

Use

of

HF

Ord

er S

et

Pe

rce

nt

of

LU

HS

He

art

Fa

ilure

In

pa

tien

ts R

ece

ivin

g A

ll S

ix D

isch

arg

e I

nst

ruct

ion

s

LUHS Heart Failure Patients Receiving Discharge Specific Instructions Prior To DischargeRegarding Activity Level, Diet, Discharge Medications, Follow-up Appointment, Weight

Monitoring, and What to do if Symptoms Worsen

Pilot 1

Mar

-Apr

200

3(n=

26)

Sep-0

3(n=

28)

Oct-03

(n=4

8)

Nov-0

3(n=

38)

Dec-0

3(n=

47)

Jan-

04(n

=42)

Feb-0

4(n=

33)

0%

20%

40%

60%

80%

100%

UCL

LUHS Mean = 55%

LCL

Nu

rsin

g In

-ser

vice

Pro

gre

ss N

ote

Ad

den

du

m I

nit

iate

d

Incr

ease

Use

of

HF

Ord

er S

et

National Mean Q12003 = 31%

With Use of the Discharge Progress Note Addendum, Documentation of With Use of the Discharge Progress Note Addendum, Documentation of LVF Peaked to a Level of Excellence LVF Peaked to a Level of Excellence

Rat

e of

LU

HS

Hea

rt F

ailu

re In

patie

nts

Rec

eiin

g LV

F A

sses

smen

t

LUHS Heart Failure Inpatients Receiving Left Ventricular Function Assessment

Date

Pilot 1

Mar

-Apr

200

3(n=

29)

Sep-0

3(n=

31)

Oct-03

(n=4

8)

Nov-0

3(n=

44)

Dec-0

3(n=

55)

Jan-

04(n

=53)

Feb-0

4(n=

42)

0.80

0.82

0.84

0.86

0.88

0.90

0.92

0.94

0.96

0.98

1.00 UCL

Mean

LCL

Incr

ease

Use

of

HF

Ord

er S

et

Nu

rsin

g In

serv

ice

Pro

ges

s N

ote

Ad

den

du

m In

itia

ted

Rat

e of

LU

HS

Hea

rt F

ailu

re In

patie

nts

Rec

eivi

ng L

VF

Ass

essm

ent

LUHS Heart Failure Inpatients Receiving Left Ventricular Function Assessment

Pilot 1

Mar

-Apr

200

3(n=

29)

Sep-0

3(n=

31)

Oct-03

(n=4

8)

Nov-0

3(n=

44)

Dec-0

3(n=

55)

Jan-

04(n

=53)

Feb-0

4(n=

42)

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%UCL

LUHS Mean = 96%

LCL

Incr

ease

Use

of

HF

Ord

er S

et

Nu

rsin

g In

-ser

vice

Pro

gre

ss N

ote

Ad

den

du

m In

itia

ted

National Mean Q12003 = 84%

Opportunity Exists in Smoking Cessation CounselingOpportunity Exists in Smoking Cessation CounselingR

ate

of

LU

HS

HF

In

pa

tien

t S

mo

kers

Re

ceiv

ing

Sm

oki

ng

Ce

ssa

tion

Co

un

selin

g

LUHS Heart Failure Inpatient Smokers Receiving Smoking Cessation Counseling

Date

Pilot 1

Mar

-Apr

200

3(n=

4)

Sep-0

3(n=

6)

Oct-03

(n=1

0)

Nov-0

3(n=

4)

Dec-0

3(n=

10)

Jan-

04(n

=7)

Feb-0

4(n=

7)

0.0

0.2

0.4

0.6

0.8

1.0 UCL

Mean

LCL

Nu

rsin

g In

serv

ice

Pro

ges

s N

ote

Ad

den

du

m In

itia

ted

Incr

ease

Use

of

HF

Ord

er S

et

Pe

rce

nt

of

LU

HS

HF

In

pa

tien

t S

mo

kers

Re

ceiv

ing

Sm

oki

ng

Ce

ssa

tion

Co

un

selin

g

LUHS Heart Failure Inpatient Smokers Receiving Smoking Cessation Counseling

Pilot 1

Mar

-Apr

200

3(n=

4)

Sep-0

3(n=

6)

Oct-03

(n=1

0)

Nov-0

3(n=

4)

Dec-0

3(n=

10)

Jan-

04(n

=7)

Feb-0

4(n=

7)0%

20%

40%

60%

80%

100%UCL

LUHS Mean = 58%

LCL

Nu

rsin

g In

-ser

vice

Pro

gre

ss N

ote

Ad

den

du

m In

itia

ted

Incr

ease

Use

of

HF

Ord

er S

et

National Mean Q12003 = 47%

Opportunity Exists in Prescribing ACEI for LVSDOpportunity Exists in Prescribing ACEI for LVSDor for Better Documentation of Contraindications or for Better Documentation of Contraindications

Pe

rce

nt

of

HF

In

pa

tien

ts w

ith L

VS

D R

ece

ivin

g A

CE

I P

resc

riptio

n a

t D

isch

arg

e

LUHS Heart Failure Inpatients with Left Ventricular Systolic Dysfunction and No Known ACE Inhibitor Contraindications Receiving ACE Inhibitor at Discharge

Janu

ary-

04

Febru

ary-

04

0%

20%

40%

60%

80%

100%

Further Study/ActionFurther Study/ActionEncourage use of HF Discharge Instruction form, Progress

Note addendum and standardized HF admission orders. – Continue improvement in discharge instructions– Improve documentation of ACE Inhibitor contraindications to

improve reported outcomes.– Continue exceptional Left Ventricular Function Assessment

performance.

Continue education of staff to improve performance, process, and outcome.