improving the quality of care of patients with heart failure francisco lopez-jimenez md, msc...
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Improving the Quality of Care of Patients with Heart Failure
Francisco Lopez-Jimenez MD, MSc
Director, Preventive Cardiology
Professor of Medicine, Mayo Medical School
Heart Failure
• Leading cause of hospitalizations
• High long-term mortality
• Prevalence is increasing
• Evidence-based interventions available
Heart Failure Core Quality Measures
• LVF assessment
• ACEI/ARB for LVSD
• Adult smoking cessation counseling
• Discharge Instructions » Activity
» Low Sodium Diet
» HF Signs of Symptoms Worsening
» List of Medications
» Weight Monitoring
» Follow up Care
Magnitude of the Problem
Magnitude of the Problem
Project Goal
• 95% of all hospitalized patients with a principal diagnosis of heart failure will receive ALL core quality measures established by CMS (Medicare/Medicaid)
Team and Methods»Physicians, nurses, pharmacists, experts in
quality improvement, an expert in systems and procedures, medical residents, and administrators.
»DMAIC
»Hybrid methods: Small Test of Change, Immediate Action, etc
Heart Failure Team
• Robert Bleimeyer
• Lisa Bohn
• Joe Furst MD
• Kim Gaines
• Rudy Haddad MD
• Luis Haro MD
• Ann Hiniker
• Barry Karon MD*
• Mark Klarich*
• Jeff Leland*
• Dorinda Leutink*
• Francisco Lopez-Jimenez MD*
• Dennis Manning MD*
• Ann McLaughlin
• Fred North MD
• Narith Ou
• Katherine Pearson
• Qi Qian MD
• Carrie Sanvick
• Barb Spurrier
• Karyl Tammel
Define Phase
• Pre-Specified Core Performance Measures
• All-or-None
Measure Phase• Active surveillance
system
• Patients with principal diagnosis of HF
• Biweekly report
Analyze Phase• Pareto chart
FEMA Failure Mode Effects Analysis
0
1
2
3
4
5
6
7
8
9
10
ACE / ARB: ContraindicationsNOT Documented
No Documentation of DismissalSummary Given
Pt. Education not Documented
.
ACE/ARB notGiven and no Docum.Of Contraindication
No Docum. That Dismissal Summarywas Given
Patient EducationNot Documented
Patients with Primary Diagnosis of Heart Failure
Patients with SecondaryDiagnosis of HF
Segment Diagnosis ofHeart Failure(HF) At Admission
Diagnosis ofHeart Failure(HF) Post Admission
Heart RhythmServicesPatients withHF Diagnosis
All OtherPatients with HF
# of Cases for 2005 646 559 240
?
All or NonePerformance(April 2006)
91% 80% 0% ?
Performance Goals for 2006
Goal: 95% Goal: 95% Goal: 95% TBD
Segmentation
Problems / Cause / Solutions
1. Problem: ACE ARB not given or Contraindications not Documented
Root Cause:
• Clinicians unaware of core measures• Some services not aware of pt having low EF• No space in the EMR to document
contraindications.
Solutions: • MD education package• Pharmacy screening: Low EF+ACE?
Problems / Cause / Solutions
2. Problem: Patient Receipt of Discharge Summary not Documented
Root Cause: No institutional policy/procedures for discharge summary process
Solutions: Create policy, education of providers.
Problems / Cause / Solutions
3. Problem: Provider does not Decide Patient has HF
Root Cause: • Clinicians uneasy diagnosing HF• Using different statements to say HF
Solutions: • Educate clinicians • Flag patients with a history of HF in the EMR• Dictation prompts• Stickers.
Problems / Cause / Solutions
4. Problem: No education elements in electrophysiology service
Root Cause: • Clinical service focused on advanced treatment
of arrhythmias
Solutions: • Created a template to be included in all
dismissal summaries of electrophysiology service
• Educate nurses
Other Interventions
• Concurrent review
• Feedback to consultants
• Simplification of patient educ. material
• Pocket reminders
• Use of EMR to record previous intolerance
• Creation of a CHF Pager
• Online education modules for consultants
RN Checklist For all Measures
Addition of “Receipt ofDismissal Summary”
To Nursing Educ Plan
Interventions
Nurse EducPocket Cards
Posters
127-12-CHFPager
Letters to MDs,Nurses
Implementationof dismissal Summary
In HRS
Dictation Prompts for HF
ACE/ARB drug classesAdded to allergy
Module
Shorthand Template
In CVIdentifying
Patients with Low EF
Online EducationModule
Performance on Core Quality Measures (% of Patients Receiving all quality measures)
Magnitude of the Problem
Current Status
Mayo Clinic Elements of Quality
• Patient-centered
• Effective» Evidence-based» Standardized» Outcomes-based» Benchmarked
• Timely
• Efficient
• Safe
• Equitable
CollaborativeCollaborative CompassionateCompassionate InnovativeInnovative SatisfyingSatisfying Service-orientedService-oriented Fiscally-sustainableFiscally-sustainable StructuredStructured
