Maine Quality ForumHeart Failure Summit

March 30,2010Deb Mattin, R.N.

Explore the rate of readmissions in heart failure population

CMS reported HF readmission rate : 24.5% Maine HF readmission rate: 21.2 – 27.2 %

Explore Care Transitions Measures (CTM)One year of data on patient’s perception of

preparation for dischargeExplore CMS Heart Failure Discharge

Instruction Measure performanceAsk the question – is there any correlation

between performance on the HF-1 measure, the CTM, and HF readmission rates?

One of Medicare’s quality measures for patients hospitalized with heart failure (HF)

There are 4 measures:HF-2: Left ventricular function assessmentHF-3: Left ventricular dysfunction ( based on LVEF

<40% or qualitatively moderate/severe) treated with either ACE or ARB

HF-4: Smoking cessation counseling for smokers (year PTA)

HF-1: Written documentation of HF-specific instructions given to patient that include all of the following: Meds, diet, activity, follow-up, weight monitoring

and management of worsening symptoms (HF-1)

Data only tells part of story Needed to know:

How does discharge process work?How are HF patients identified?Are Care Transitions Measure data useful for

improvement?Is hospital readmission rate used for

improvement?What strategies are successful in reducing

readmission, improving performance on HF-1, and improving patient’s perception of preparation for discharge (Care Transitions Measures)?

Hospitals selected for on-site visit to help us understand:How discharge process works in generalHow discharge process works for HF patientsHow data (HF-1, CTM, Readmission rates) are

useful for improvement What resources are available for improvementWhat are barriers to improvement

Asked hospitals to complete a pre-visit questionnaire aimed at learning more about how care works at their facility

Is there a team approach to HF improvement Is there a team approach to improving care at

discharge for all patients Who is on these teams What tools used for HF care

Do you know how often these tools are used

Who is responsible for selecting/writing the discharge instructions

More questions:Is concurrent monitoring part of your processWhat part of the HF-1 measure is most

problematicWhat challenges/ barriers have you identifiedWhat successes have you had in improving

HF discharge care

Most hospitals report success with HF-1 in patients with diagnosis of HF on admission.Process geared to “kick-off” by admission

diagnosis ( standardized orders, teaching plan, discharge instruction selection)

Significant resources devoted to improvementElectronic recordImprovement teamsTool/program developmentCare Management programs (inpatient/outpatient)

Most hospitals have:Robust HF teaching programs Standardized instructions for HF patients that

include all the elements of the HF-1 measureTeams with physician champions Evidence –based protocols for HF

Most hospitals are actively working to reduce readmission rates in the HF population.

If there is an admitting diagnosis of heart failure, the patient usually receives the appropriate HF instructions.

Patients with a diagnosis other than HF on admission are most likely not to receive HF specific instructions.

Many hospitals use concurrent monitoring to remind care givers of HF measure elements and prompt for appropriate instructions.

There are specific sections of the HF-1 measure that are challenging.

Data not always “mined” for improvement opportunities

Admitting diagnosis is entry point into HF careKicks off use of standardized orders, care paths,

involvement of HF teaching team, and use of HF specific discharge instructions.

Most patients with stay coded as HF have HF as admitting diagnosisMajority of HF cases in this category

Reliable process that captures most HF cases

Admission diagnosis ensures that the plan for this patient is evidence-based HF care that includes appropriate testing, medications, teaching and follow-up.Admitting diagnosis kicks-off use of

standardized orders, HF care management, HF specific instructions

Cases are included in the HF measure based on the principle diagnosis code assigned after discharge. 1

Most hospitals report that these are the cases that most often fail the HF 1 measure

Aggressive strategies to capture these cases:Concurrent review of all records

1 http://www.qualitynet.org/

Identifying appropriate cases for the HF measure can be complicated.

Many hospitals using labor intensive, case-by-case record review both to find cases and provide reminder prompts for care.This level of case review may not be sustainable as

more categories of patients needing review are added

“Failures” when review not available – weekends, holidays, etc.

Does not address system –wide improvement

Reliability improvement from IHI Chaotic process: Failure in greater than 20% of

opportunities

10-1: 80 or 90 percent success. 1 or 2 failures out of 10 opportunities

10-2: 5 failures or less out of 100 opportunities

10-3: 5 failures or less out of 1000 opportunities

10-4: 5 failures or less out of 10,000 opportunities

(These are IHI definitions and are not meant to be the true mathematical equivalent)

(Uses human factors and reliability science to design sophisticated failure prevention, failure identification, and mitigation)

Decision aids and reminders built into the system

Desired action the default (based on scientific evidence)

Redundant processes utilized

Scheduling used in design development

Habits and patterns known and taken advantage of in the design

Standardization of process based on clear specification and articulation is the norm

(Primarily can be described as intent, vigilance, and hard work)

Common equipment, standard order sheets, multiple choice protocols, and written policies/procedures

Personal check lists

Feedback of information on compliance

Suggestions of working harder next time

Awareness and training

Add discussion with physicians to improvement team workHow to clarify /improve communication about diagnosis

and emphasize it’s importanceConsider working with EHR, pharmacy, lab to

identify reports that could identify HF patients and eliminate need for record review.

Key words in EHR, medications dispensed, lab studies,etc. Include coders in improvement team Consider a targeted review of the cases without

an admitting diagnosis of HF to identify any common themes

( ED admits, admitting physician, weekend admits, etc.)

HF-1 measure – patient receives written instructions in 6 areas:Meds, diet, activity, follow-up, weight monitoring,

and management of worsening symptoms Most standardized instruction forms address all but

the last 2 – weight management and management of worsening symptoms. HF-specific instructions contain these additional elements.Identifying HF patients is crucial to ensure that

patients receive the appropriate instructions

Medications - many hospitals report that med reconciliation programs have helped improve the accuracy of discharge medication lists.Some hospitals have reported success in

process changes for dictation systems for discharge meds/discharge summary One system only requires the physician to dictate

the list of meds once and it populates both the discharge med list and the discharge summary (effectively ensuring that they match).

Others have physically changed where the discharge med list is located in the paper record so the physician can easily locate it to use when dictating the discharge summary.

Finding common cause for case “failures” can identify gaps in process and focus improvement activities. Example: Are case failures due to day of week, time of

day, hospital unit, lack of use of evidence-based protocols, etc.

Not knowing your own population can lead to changing process to fix a problem that doesn’t exist and overlooking one that does

No “one-size fits all” solution in healthcare (or jeans!)

Care Transitions Measures data often not included in HF improvement work New data set, similar to HCAHPS, so may not be

seeing relevance

Multidisciplinary team approach to improvementIncludes physicians, nurses (staff and leadership),

quality improvement, coding, pharmacy, case management

Aggressive analysis of data to identify process success and failures

Multidisciplinary team roundsCase identification, promotes team accountability,

review of guidelines vs. actual care delivery Ability to make rapid tests of change