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Acute Myocardial Infarction	Medication Reconciliation (ADE)
Boards on Board	Pressure Ulcers
Catheter-Associated UTI	Rapid Response Teams
Central Line Infections	Surgical Complications
Congestive Heart Failure	Surgical Safety Checklist
High-Alert Medications	Surgical Site Infections
MRSA	Ventilator-Associated Pneumonia

Use this table to quickly find a mentor for improving Congestive Heart Failure care with demographics similar to your own, or use 'ctrl+f' in your web browser to search for specific key words on this page.

Baystate Medical Center – Springfield, MA
Availability Status: Available to answer requests
Licensed Beds: 636
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: January 2002
Mentor Contact Name: Jan Fitzgerald, RN
Mentor Contact Email: janice.fitzgerald@bhs.org
Mentor Contact Phone: 413-794-2531

Additional Information:

Keys to our success:

We developed reliable processes/systems/interventions to assess LVF, prescribe ACE/ARB, screen and provide all patients with smoking cessation counseling, DVT risk assessment and appropriate prophylaxis, review for ACEi/ARB and beta blocker use (or prompt documentation of omission rationale), and preventative strategies (immunization). 

Providing preliminary discharge instructions on admission as a starting point has pushed us to sustained high rates of compliance.

Capitalizing on our work flow and EMR have provided us interventions to get to near perfect care.  We now build all of our interventions using reliability principles as we recraft our models of care.

All patients have a system-generated admission assessment completed.  Part of the assessment is the education intake ("How do you learn best?" and "Who is your social/care support person?") as well as a high risk/risk for admission assessment completed which includes family/significant others and the role they play in the patient's life outside the hospital.

LVEF assessment: Focused interventions including ongoing education, 1:1 review and detailing, standardized care sets and developing a forcing function in our EMR to drive assessment or provide omission rationale based on approved NHQM criteria.  Since adoption of this, our rates have increased and been sustianed > 98% )

ACEi/ARB use has been driven by focused interventions including ongoing education, 1:1 review and detailing, standardized care sets and developing a forcing function in our EMR to drive prescribing of ACE/ARB or provide omission rationale based on approved NHQM criteria.  Since adoption of this, our rates have increased and been sustained > 98% )

Adult Smoking Cessation Advice/Counseling: All patients are screened on admission. If they have a history of active smoking, they receive cessation materials/advice.  Additionally, they are screened for possible entry into a formal smoking cessation program offered by Pulmonary Rehab department.  Smoking cessation materials are also part of the preliminary discharge instructions given on admisson to all adult patients.  Smoking cessation/counseling >95% since October 2005.

All patients receive preliminary discharge instructions given on admisson that include written instructions addressing activity level, diet, discharge medications, follow-up appointment, weight monitoring and what to do if symptoms worsen.  This is a starting point to begin the patient education process using "ask me three" and "teach back" models (current rates are sustained as  98-110% .

All patients screened for risk of VTE-appropriate prophylaxis applied >100% of HF patients. 
All patients screened and immunized (influenza and pneumococcal) rate is currently 93%.

Outpatient HF clinic launched after pilot demonstrated 1:1 work with clinicians helps patient self manage.

Since our work has begun, our perfect care score for heart faliure patients has improved from 78% to 95%.

Outcome measure:

Percent of Congestive Heart Failure Patient Discharges with Readmission within 30 Days is below the CMS national average (24%) and one of the lowest in the state of Massachusetts using the 3M Potentially Preventable Readmission Model.

All cause 30 day readmission rate was 18%.  HF related readmission rate = 6 - 8%.

Using our model of care, we have been able to target patients with the highest rates of readmissions, resulting in a decrease in 50-60 hospital visits for these difficult to manage patients.  This resulted in a light green savings of $374,000.

See graphs of their results.

Mentor designation - 3/13/07
Information updated - 2/24/10

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Blessing Hospital – Quincy, IL
Availability Status: Available to answer requests
Licensed Beds: 426
Teaching / Non-Teaching Status: Teaching
Setting: Rural
Start Date of Intervention Work: May 2008
Mentor Contact Name: Angie Hancox
Mentor Contact Email: ahancox@blessinghospital.com
Mentor Contact Phone: 217-223-1200

Additional Information:

Keys to success:

Evaluation of LVS function - When echocardiogram done at Blessing Hospital, the ejection fraction percent automatically flows to clinical summary in the electronic medical record (EMR) which is available every time a patient is admitted to hospital (April 08).

Adult Smoking Advice/Counseling - Nurse unable to close admission profile on the EMR without addressing the  advice/counseling questions if patient smokes or has smoked in the past 12 months (April 08).  This is considered a "hard stop" on the EMR.

Discharge Instructions - Nurse unable to complete the discharge flowsheet on EMR without providing patient/family with educational materials.  Another "hard stop."  The educational materials selection is automatically added to discharge flowsheet when CHF is added to plan of care (Sept. 08).

ACEI or ARB at Discharge - Implementation of CHF Discharge Sheet put on chart to remind physicians of need for ACEI or ARB if ejection fraction <40% (Oct. 08).

Email to specific physician who did not provide evidence-based care by Medical Director of Quality Management (Feb. 09).

Patient- and family-centered initiatives to improve your CHF care:

On Sept. 1st, 2009, Blessing initiated the HeartWorks program.  This program was developed to improve quality care to patients admitted with CHF and decrease readmissions.  We are providing all patients with a CHF "binder" with educational materials, log sheets for daily weights, and a magnet to hang up the "zone form."

The "zone form" uses the stoplight colors of Green, Yellow, and Red with descriptions in each colored zone to assist the patient in determining the zone they are in and when to call physician or 9-1-1.  Also each patient who will return home at the time of discharge receives a complimentary digital scale which is to be used while patient is in the hospital so weights are more accurate and consistent.  Patients going home also receive a phone call by a clinical pharmacist made within 1 to 3 days after discharge and a complimentary home care visit within 5 to 7 days.

Evaluation of LVS Function

96.22% CY 2007
96.28% CY 2008
99.28% CY 2009

ACEI or ARB at discharge for patients with LVSD

85.85% CY 2007
86.73% CY 2008
91.14% CY 2009

Adult Smoking Cessation Advice/Counseling

98.11% CY 2007
97.96% CY 2008
100%    CY 2009

Discharge Instructions: 

88.24% CY 2007
78.46% CY 2008
94.29% CY 2009

Percent of Congestive Heart Failure Patients Receiving Perfect Care

81.18% FY 07
78.03% FY 08
91.83% FY 09

Percent of Congestive Heart Failure Patient Discharges with Readmission within 30 Days: Not yet available

[12/21/09]

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Centra Health – Lynchburg, VA
Availability Status: Available to answer requests
Licensed Beds: 517
Teaching / Non-Teaching Status: Non-teaching
Setting: Urban
Start Date of Intervention Work: September 2005
Mentor Contact Name: Joan Deal, RN, MSN, MBA, Director of Cardiovascular Nursing; Dana Woody, RN, Heart Failure Nurse Coordinator
Mentor Contact Email: joan.deal@centrahealth.com; woodda3@centrahealth.com
Mentor Contact Phone: 434-200-2254 (Deal); 434-200-5821 (Woody)

Additional Information:

In the fall of 2008, our organization reviewed program management related to HF and a HF nurse coordinator was hired to facilitate these efforts.  As our measures were indicative of a process that supported quality care, we wanted to continue to maintain this area and explore more opportunities to ensure quality care. 

The HF program has blossomed over the last year and half with the establishment of a multidisciplinary HF team, a cost drill-down sub-committee for HF patients, and an education committee for the HF population.  The efforts of these teams have allowed our organization to appreciate an organized effort for this population and bring HF care to the front-lines as we look into cost savings, LOS, readmission rates, and quality care. 

Our mission to strengthen the utilization of ancillary services for our patients has proven to be most successful, from home health, to case management and palliative care.  The multidisciplinary support offered to this population has allowed for improvements in quality care and overall patient outcomes.  All of the above efforts have supported our core measure compliance as well as driven our administration to focus on this disease.

Our latest venture is building a dedicated disease management community-based clinic for the HF population to facilitate quality follow-up care, education, and foster greater self care and management adherence.  We are in the process of assessing community partners and resources to build this program.  Currently, our efforts are being considered by administration.  Our organization also received top cardiovascular care honors as being in the top 100 facilities for CV care.

In August of 2009, we devised a heart failure family education class offered twice a week to foster self care as well as to offer needed emotional support.  This class is taught by the HF coordinator.

Evaluation of LVS Function:
100% of CHF patients for reporting months of November 08, December 08, February 09, March 09, May 09, and September 09

ACEI or ARB at discharge for patients with LVSD:
100% of CHF patients for reporting months of November 08, December 08, February 09, March 09, May 09, and September 09

Adult Smoking Cessation Advice/Counseling:
100% of CHF patients for reporting months of November 08, December 08, February 09, March 09, May 09, and September 09

Discharge Instructions: 
100% of CHF patients with documentation in the hospital record of having received written discharge instructions or educational material given to patient or caregiver addressing activity level, diet, discharge medications, follow-up appointment, weight monitoring and what to do if symptoms worsen for reporting months of November 08, December 08, February 09, March 09, May 09, and September 09

Percent of Congestive Heart Failure Patient Discharges with Readmission within 30 Days:
24.4% (all cause HF readmissions) 13.5% (HF only December 2008 thru September 2009)

In order to consider financial implications for our organization related to HF, we established a cost drill-down sub-committee, which began in August 2009.  This committee is being showcased at the Advisory Board CV Roundtable in March 2010.  Our financial efforts which have included drilling down into the overusage of BNP, LOS, and readmissions, our organization cut HF cost by over $600,000 for calendar years 2008 and '09.

Mentor designation - 3/13/07
Information update - 3/16/10

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The Chester County Hospital – West Chester, PA
Availability Status: Available to answer requests
Licensed Beds: 220
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: April 2005
Mentor Contact Name: Sandra Garrison, BSN, MBA
Mentor Contact Email: sgarrison@cchosp.com
Mentor Contact Phone: 610-431-5059

Additional Information:

We have built a model for HF disease management in the acute care setting, using evidence-based HF quidelines as a springboard.  We currently have nursing FTEs dedicated to heart failure disease management.  Our program includes patient self-reporting via a telemonitoring program, HF education for inpatients that reinforces education provided in the outpatient setting, as well as real-time monitoring for core measure compliance.  We have had success in achieving physician buy-in as well as in engaging bedside nurses in the process.  Our current focus is on increasing patient participation in post-dischage self-monitoring as a means of reducing re-admissions.  We were awarded Joint Commission Disease-Specific Certification in June 2008.

We are currently working on a progam that encourages patients to keep their own I & O records while they are inpatients.  The goal is to get them comfortable with the process and answer any questions they may have prior to discharge.

We have just implemented a system for real time electronic tracking of compliance with daily weights in the inpatient setting.  This is a collaborative initiative involving IT, quality management and the nursing departments.  In conjunction with nursing education about the importance of weights, the goal is to increase the number of HF patients who are weighed daily while hospitalized and to have weight issues addressed prior to discharge.

Evaluation of LVS Function (% of CHF patients):

	2005	2006	2007	2008	2009
Q1	89.3	95.4	100	100	98.9
Q2	92	94.2	98.1	100	98.5
Q3	98.2	98.1	97.3	100	97.2
Q4	93.7	98.2	98.8	98.8

ACEI or ARB at discharge for patients with LVSD (% of CHF patients):

	2005	2006	2007	2008	2009
Q1	80.6	63.4	78	89.7	92.3
Q2	74.5	68.4	100	88	100
Q3	62.2	80	93.3	92.3	95.7
Q4	83.3	73.5	85.2	92.9

Adult smoking cessation advice/counseling (% of CHF patients):

	2005	2006	2007	2008	2009
Q1	70	85.7	100	100	100
Q2	75	94.1	100	94.1	100
Q3	80	93.8	100	100	100
Q4	70	100	100	100

Percent of CHF patients receiving Perfect Care:

	2005	2006	2007	2008	2009
Q1	41	70	76	84	86
Q2	46	68	78	82	86
Q3	41	65	78	85	94
Q4	51	73	72	85

Readmissions within 30 days for any reason %:

	2005	2006	2007	2008	2009
Q1	27	24	28	21	19
Q2	21	22	19	19	20
Q3	27	17	21	21	20
Q4	23	24	21	18

Written discharge instructions %:

	2005	2006	2007	2008	2009
Q1	26.7	75.4	78.2	78.6	84.9
Q2	42.2	77.5	76.8	81.3	83.3
Q3	29.9	67.5	75.9	82.7	98.3
Q4	44.3	75.8	71.4	84.8

Mentor designation - 8/13/07
Information updated - 3/3/10

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Christiana Care Health Systems – Newark, DE
Availability Status: Available to answer requests
Licensed Beds: 675
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: June 2007
Mentor Contact Name: Maria Albert, MSN, RN, PI Program Manager
Mentor Contact Email: malbert@christianacare.org
Mentor Contact Phone: 302-733-5417

Additional Information:

Christiana Care has a comprehensive heart failure program with designated heart failure units, outpatient clinics and provides a continuum of care with care navigators and home care services.  To improve core measure compliance, we developed process improvements to improve documentation which includes: guideline therapy prompts in pre-printed orders; created discharge instruction binders; instituted clinical documentation specialists’ concurrent chart review with physician notification process; posted publicly reported measures scores on the hospital web-site; weekly multidisciplinary rounds; and continuous staff education.  Despite organized and substantial process improvements in place, institution-wide initiatives in this large community hospital to address core measures remain challenging.

In 2008, our heart failure performance improvement team reconvened to survey current practice for each core measure and used data from outcomes reporting to better identify reasons why measures were still being missed.  As a result, the team created "Accountability Letters for Heart Failure Care."  Every time a core measure was missed, an individualized accountability letter was sent to the physician/nurse involved in the patient’s care.  These letters explain why we are reviewing the chart, what was documented in the chart, and ask the physician/nurse for any insight he/she may be able to lend.  To date, accountability letters have been sent to over 100 hospital staff members (i.e., cardiologists, hospitalists, residents, physician assistants, nurse practitioners, nurse managers, and bedside nurses). 

This effort to enhance patient safety has the leadership, support, and guidance of our heart failure program medical director.  In 2009, Christiana Care was able to roll out this initiative hospital wide and with very good results and was recognized by AHA's Get with the Guidelines program with a performance achievement (Silver) award.

By the end of 2009, the team reconvened to address opportunities to further improve care, patient and family experience as well as reduce readmission rates.  As a result, in early 2010 the program implemented Heart Failure Care Navigator nurses whose role is to be an advocate for each patient admitted with Heart Failure.  The Care Navigator provides daily, individualized patient/family education regarding heart failure, signs and symptoms, diet and fluid restrictions, weight monitoring, medication instructions, activity recommendations and when to call MD for worsening symptoms.  The Care Navigator facilitates access to services, and coordinates care between all consultants, as well as Case Management and Social Work.  A Heart Failure Clinical Pathway is followed, and goals of therapy are monitored closely.  The Care Navigator confirms every heart failure patient has a follow-up appointment scheduled within one week of discharge.  The Navigator calls all discharged patients in 3 days, to assure a smooth transition to home (i.e., patient got all prescriptions filled, is asymptomatic, is checking weights, is aware of follow-up appointment dates, etc).  A second follow-up phone call is placed 3 weeks post discharge to assess patient, and to inform physician of any issues that potentially could result in decompensation and re-admission.

FY10 December 09 Data

100% compliance in Evaluation of LVS Function compared to 99% (FY09) and 97% (FY08).

89% compliance in ACEI or ARB for LVSD compared to 89% (FY09) and 86% (FY08).

100% compliance in Adult Smoking Cessation Advice/Counseling compared to 100% (FY09) and 94% (FY08).

89% compliance in complete Discharge Instructions measure compared to 86% (FY09) and 76% (FY08).

87% Percent of Congestive Heart Failure Patients Receiving Perfect Care compared to 86% (FY09) and 76% (FY08).

7.2% Percent of Congestive Heart Failure Patient Discharges with Readmission within 30 Days compared to 7.7 (FY09).

HF in-hospital mortality: 2.5% (FY09) compared to 3.5% (FY08)

Mentor designation - 3/8/10

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Cleveland Regional Medical Center – Shelby, NC
Availability Status: Available to answer requests
Licensed Beds: 241
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: 2004
Mentor Contact Name: Cindy Proctor, Director of Quality Management
Mentor Contact Email: cynthia.proctor@carolinashealthcare.org
Mentor Contact Phone: 980-487-3721

Additional Information:

CRMC implemented a concurrent chart review and intervention process.  This process includes active intervention and follow up among the Quality Management staff and direct care givers.  Weekly monitoring of our processes as well as "All or none/ perfect process" indicators have improved mortality as well as process indicator compliance.

Readmission rate reduction from greater than 25% in 2002 to 8.9% in 2005; process work started at the 12.09% rate in 2003.
Mortality reduction from 2003 4.8% to 3.1 in 2005.
Perfect process compliance is greater than 95% for 2 years.
Process compliance for all indicators is 95% or higher for 2 years (2005-2006).  Discharge instructions, smoking cessation counseling, LVF assessment, and ACEI or ARB have been 100% for over a year and 6 months.

[3/13/07]

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Columbus Regional Hospital – Columbus, IN
Availability Status: Available to answer requests
Licensed Beds: 325
Teaching / Non-Teaching Status: Non-teaching
Setting: Rural
Start Date of Intervention Work: January 2003
Mentor Contact Name: Barb Hull
Mentor Contact Email: bhull@crh.org
Mentor Contact Phone: 812-375-3443

Additional Information:

Developed a process for automated old echocardiogram retrieval.
Developed a house-wide discharge tool "Tips for Heatlhy Living" that includes all discharge elements.
Developed a house-wide smoking cessation protocol focused on education and counseling.
Developed a standing order and automated process for the administration of pneumococcal and influenza vaccine.
Added bundle scores to leadership score cards and bundle composites to medical staff score cards.  Quarterly board reports include scores. 

Patient- and family-centered initiatives to improve CHF care:
• A CHF specilized nurse provides call-back to every CHF patient discharged within 72 hours.
• Data is analyzed to determine perpetual patients (who may require high use of hospital services) and these patients are extensively telemanaged.
• This nurse is alligned with key physicians in the community to have direct access to a phyisician if a medical problem arises and is able to document in their records to assure the most accurate medical record for the patient.

CHF discharge instructions including signs/symptoms, daily weight, activity, medications, follow-up, and diet: 91% (Decreased to 70% related to medication reconcilliation errors.)
LVF assessment: 98%
ACEI or ARB prescribed at discharge: 95%
Smoking cessation education: 100%
Pneumococcal Vaccination: 89%
Influenza Vaccination: 83%
Anticoagulant at Discharge for HF Patients with Atrial Fibrillation: 97%
Percent of Congestive Heart Failure Patient Discharges with Readmission within 30 Days: 16% statistically significantly lower than national rates
Percent of Congestive Heart Failure Patients Receiving Perfect Care: 68%

Mentor designation - 3/13/07
Information updated - 2/10/10

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Geisinger Medical Center – Danville, PA
Availability Status: Available to answer requests
Staffed Beds: 397
Teaching / Non-Teaching Status: Teaching
Setting: Rural
Start Date of Intervention Work: January 2007
Mentor Contact Name: John B. Bulger, DO
Mentor Contact Email: jbulger@geisinger.edu
Mentor Contact Phone: 570-214-9585

Additional Information:

Prior to January of 2007, attempts were made to improve care of CHF patients as measured by compliance with Medicare core measures.  These efforts, while substantial, were not organized and did not include a multidisciplinary team of hospital leaders.

• Reviewed the current literature for best practices.
• Surveyed current practice for each component of the Medicare core measures.
• Analyzed baseline data with attention to specific characteristics:  Admission source, treating service & hospital location of care.
• Educated the CHF performance improvement team on reliability theory.
• Tested compliance with measures within existing microsystems.
• Changed the rapidity of chart review and compliance feedback for CHF patients.
• Implemented discharge instructions prompts on targeted floors.
• Removed discharge instruction forms from all charts on targeted floors so that only prompts were in charts.
• Surveyed all nursing units to ascertain existence of CHF patient instruction booklets.
• Standardized CHF discharge instruction booklets to include all necessary components of discharge instruction and advice not to smoke.
* Placed new CHF discharge instruction booklets on all floors.
• Revised patient discharge instruction forms to include all necessary discharge instruction components as well as prompts for angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) use, smoking cessation instructions and documentation of left ventricular systolic function (LVSF).
• Included definitive instruction to not smoke on all patient discharge instructions.
• Revised nursing admission data base in the electronic health record (EHR) to reflect changes in the Medicare definition of smoking status from current use of tobacco products to use of tobacco products within the last 12 months.
• Developed nursing education forms to streamline documentation of receipt of CHF instructions.
• Added documentation of performance of CHF education to the CHF nursing care maps.
• Updated the patient discharge instruction form, at the request of treating physicians, after a possible patient safety issue surfaced.
• Included review by inpatient documentation specialists for smoking cessation and use of ACEI/ARB in patient with decreased LVSF.
• Initiated inpatient documentation specialist notification of the treating team when a chart documentation manifests CHF as the billing diagnosis.
• Recruited and trained documentation specialists with real-time chart review and notification of treatment lapses.
• Educated internal medicine residents, emergency medicine residents, cardiology fellows, internal medicine and cardiology faculty on core measures.
• Provided prompt feedback to physicians with regard to patients who did not receive perfect care.

We implemented CPOE and physician documentation in our EHR through September and October of 2007.  Many paper processes were converted into the EHR.  Some processes needed to be modified. We continued to use PDSA cycles and rapid feedback to achieve our goals.  We are now working on using computer-aided decision support to embed best practice into our systems.

Our goal is 100% bundle compliance.  We began in January of 2007 at 46%.  By July of 2007, we achieved 96% compliance.  This has been sustainable with the exception of September and October of 2007.  At this time we implemented both CPOE and physician documentation in our EHR.  November and December of 2007 were both over 95% and in January 2008 we have achieved 100% compliance will all CHF measures.

Geisinger's 30-day readmission rate for CHF patients was 23% in the first quarter of 2007.  This corresponded to the 81%ile nationally in the MIDAS database of 466 sites (mean is 18.55%).  As core measure processes improved, so has the readmission rate.  This dropped to 17% (34%ile) in the second quarter and 14% (19%ile) in the third quarter.  The represents a change from the lowest to the highest quintile in the MIDAS database.

[3/20/08]

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Hazleton General Hospital – Hazleton, PA
Availability Status: Available to answer requests
Licensed Beds: 150
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: January 2006
Mentor Contact Name: Andrea Andrews, RN, Director of Quality/Case Management
Mentor Contact Email: aandrews@ghha.org
Mentor Contact Phone: 570-501-4744

Additional Information:

Keys to success:

Hazleton General's CHF team was part of the Accelerating Best Care (ABC) in Pennsylvania program funded by our state legislature.  The team is comprised of physicians, nursing staff, unit secretaries, and quality/case management staff and initially met weekly.  We identified high-leverage points to address, including discharge instructions.

Utilizing a rapid cycle response methodology, the team analyzed roadblocks to success and implemented interventions in HF discharge instructions.

The mulitidisciplinary team approach to CHF care has all the needed disciplines involved in the patient's care from admission through discharge.

The patient is cared for utilizing evidence-based standards of care, so we proide the best care to all our HF patients - every time, all the time.

We have received our HF Gold Award from Get With The Guidelines AHA on 9-30-09 - for two years of HF data at 85% compliance or better.

We have restructured our Quality/Case Management Department - placing a clinical quality data RN specialist on the clinical units - monitoring the care our CHF patients receive.

We have submitted our CHF discharge instruction forms and CHF order sets to the American Heart Association, and after extensive review of all the heart failure tools submitted to them, were chosen to have our CHF tools posted in their GWTG Tool Library.

An article, showcasing our Heart Failure Tools, has been selected to appear in an upcoming edition of the journal entitled - Critical Pathways in Cardiology.

Our home health agency has home telehealth monitors that are placed in the home for CHF patients who request our agency and who meet criteria for these monitors.  The monitors assess weight, blood pressure, O2 sats, and pulse, along with a set of questions individually selected for each patient regarding edema, shortness of breath, meds, etc.  These monitors are set up to be checked daily.  The information is then sent to a secure website, which our home health nurses check on a daily basis (Monday through Friday) and identify any real or potential problems.  If a problem is identified, the home health nurse calls the patient for more information and then either calls the physician or sends a nurse out to evaluate.  Our home health agency tracks all home health patients readmitted to the hospital during a home health episode, along with the number of patients on monitors readmitted to the hospital.  These results are compared to total hospital readmissions for CHF (whether home health or not) and also to the state and national averages for home health.  Of 27 placements of monitors, we have had only two readmissions to the hospital -and neither were for a CHF diagnosis.  This data was from the period of 2/24/09 through 10/16/09.

Pre-implementation/baseline data from 2004:

Evaluation of LVS Function - 67% compliance
An ACE or ARB for LVSD - 48% compliance
Adult Smoking Cessation - 19% compliance
Discharge Instructions - 14% compliance

Our discharge instruction compliance rate for the second quarter of 2009 is 98%.
Our readmission rate for HF shows we are significantly lower than expected compared to the statewide and national averages (utilizing PHC4 data of discharges from 10-1-07 through 9-30-08).  Our internal data for HF readmits also shows us to be at 4.4% for the first half of 2009 - showing further improvement from 7.7% in 2007.

We continue to meet monthly and have maintained compliance in all process measures:

Evaluation of LVS Function:  Q1 2009 - 97% compliance; Q2 2009 - 100% compliance
An ACE or ARB for LVSD:  Q1 2009 - 83% compliance; Q2 2009 - 100% compliance
Adult Smoking Cessation:  Q1 2009 - 100% compliance; Q2 2009 - 100% compliance
Discharge Instructions:  Q1 2009 - 93% compliance; Q2 2009 - 98% compliance

Our outcome measure for HF patients being readmitted within 31 days per PHC4 data for discharges from 10-1-07 through 9-30-08 shows our CHF readmission rate is much lower than the statewide and national averages.  For the first six months of 2009, we had a 4.4% readmit rate - when looking at our Atlas data internally.  In comparison to June of 2007, where our readmit rate was 7.7%, we definitely continue to show improvement in our readmit HF outcome data.  The benchmark from MedPro remains 14.7% - which we continue to utilize as our benchmark when looking at our HF readmits.

The percentage of CHF patients receiving appropriate/perfect care for the first quarter of 2009 was 91%, and for the second quarter of 2009 - went to 99%.

When providing optimal CHF care, you benefit in many ways:
- LOS is decreased
- utilization of resources is decreased
- most importantly, patient satisfaction is increased

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Mercy Medical Center – Nampa, ID
Availability Status: Available to answer requests
Licensed Beds: 152
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: 2003
Mentor Contact Name: Crystal Harris
Mentor Contact Email: crystalharris@chiwest.com
Mentor Contact Phone: 208-463-5888

Additional Information:

Mercy Medical Center is licensed for 152 beds with an average daily census of 57 beds and an average 10 HF patients per month.

Mercy Medical Center attributes our success with providing highly-reliable CHF care to many factors including: our concurrent coding process, identifying patients for intervention while they are in-house, reviewing missed opportunities with direct care givers, automation of key processes including CHF discharge instructions and smoking cessation, and using more than one strategy to increase compliance (e.g., including smoking cessation statement on discharge instruction sheet as well as automated process for education brochure.)

Concurrent Coding Process:
• Each patient is concurrently coded within 2 days of admission.
• A designated coder reviews the patient’s chart and assigns a working principal diagnosis.  Coding and case managers collaborate daily to determine appropriate codes.
• Principal diagnosis codes drive worklist for PN, HF, and AMI.  Case managers utilize PN, HF, and AMI worklists to collect data concurrently.  At daily multidisciplinary meetings, case managers flag every patient with HF diagnosis for study and make sure all recommended interventions are in place.
• Staff and physicians receive a quality reminder (verbally or written) on the indicators that are not found in the current documentation.
• Before the abstraction is completed, case managers follow-up to ensure that all documentation is completed.

Within a month of discharge, missed opportunities are reviewed with case managers, physician, director of unit.

Mercy Medical Center also works hard to communicate the results of our efforts to improve HF care. With physicians, we use individualized report cards, presentations at MEC & individual department meetings and memos regarding changes or reminders.  With senior leadership, we use hospital report cards, annual PI evaluations, and quarterly presentations.  With clinical directors, we use hospital report cards by department, provide immediate notification (using Midas Smart track worklists) to managers/directors when something is missed, study variances for common causes, and give quarterly presentations to the Performance Improvement Steering Committee.  To keep the clinical staff informed, we post results on the communication boards throughout the facility, give presentations at department meetings, and use newsletters, e-mails, and internet postings.

As a smaller hospital, we face the challenge of limited resources.  However, our size also means we can implement performance improvement changes relatively quickly.  We also have a culture of excellence and leadership that challenges our team to keep improving.

Mercy Medical Center has provided every CHF patient with "Perfect Care" for the past 19 months.

05 unplanned readmissions = 1.70 per 100 discharges
06 unplanned readmissions = 3.18 per 100 discharges
07 unplanned readmissions = .69 per 100 discharges

[1/10/07]

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Monmouth Medical Center – Long Branch, NJ
Availability Status: Available to answer requests
Licensed Beds: 528
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: January 2008
Mentor Contact Name: Sharon Holden
Mentor Contact Email: SHolden@sbhcs.com
Mentor Contact Phone: 732-923-6594

Additional Information:

Key initiatives contributing to the success of Monmouth Medical Center's (MMC) Heart Failure (HF) program are:

• Organized multidisciplinary team to meets weekly and analyzes data for ALOS, number of HF patients in ICU and recidivism.
• Researched evidence based quidelines for standardization of HF order set and 4 day care map.
• Worked with Performance Improvement (PI) to create a daily computerized monitoring tool for early notification of HF patients to be seen.
• Concurrent chart review by PI to ensure compliance with Core Measures. 
• Provided house-wide education including attendings and residents regarding goals for HF initiative.
• Designated one patient/family educational tool to be used across the continuum to ensure standardized care.
• Collaborated with VNA for Telehealth in home clinical monitoring to evalute daily weights, blood pressure, pulse ox and glucose monitoring.  Results: 2008 30-day recidivism rate for patients enrolled in Telehealth program = 6% vs. non-Teleheath patients = 33% and same trend replicated for 2009: 6% recidivism rate for Teleheath patients compared with 30% for non-Teleheath patients.
• Worked with both Skilled Nursing and Long Term Care Facilities to create standing order sets and care maps so continuum of care is maintained and readmissions are avoided.
• Standardized education tool for patient and family so teaching is consistenly reinforced from admission to discharge and worked with VNA to adapt same tool.
• Prior to discharge, case managers inquire as to whether or not patient has a scale and will provide one if the patient cannot afford one.
• As part of the NJHA and CMS collaborative, patients receive a follow up phone call on day 3 and day 14 post discharge to evaluate their clinical progress.

Evaluation of LVS Function:

2008 - 100% compliance
2009 - 100% compliance

ACEI or ARB at discharge for patients with LVSD:

2008 - 98.2% compliance
2009 - 100%  compliance

Adult Smoking Cessation Advice/Counseling:

2008 - 100% compliance
2009 - 100% compliance

Discharge Instructions: 

2008 - 100% compliance
2009 - 100% compliance

Percent of Congestive Heart Failure Patients Receiving Perfect Care:

Outcome measure: 100% 4th quarter 2009

As of January 2010 = 5.08
2009 ALOS = 5.47
2008 ALOS = 5.28
2007 ALOS = 5.80
2006 ALOS = 5.88

Mentor designation - 3/9/10

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Reading Hospital and Medical Center – Reading, PA
Availability Status: Available to answer requests
Staffed Beds: 743
Teaching / Non-Teaching Status: Teaching
Setting: Rural
Start Date of Intervention Work: May 2005
Mentor Contact Name: Maureen Miller RN, BSN, CEN Heart Failure Program Coordinator
Mentor Contact Email: millerm@readinghospital.org
Mentor Contact Phone: 610-988-5272

Additional Information:

Reading Hospital and Medical Center decided to focus on patients admitted to their hospital with a diagnosis of heart failure because heart failure represented the leading "medical" volume DRG and the 2nd highest volume DRG for readmission.  A review of available data demonstrated that there were multiple processes of care that were ripe for improvement, including improvement in the core measures, reducing length of stay, decreasing readmissions, and providing cardiac nurses with more explicit education and training about heart failure.

• Created a Heart Failure unit staffed by all RNs and co-directed by a a cardiologist and hospitalist.  The unit includes a dedicated case manager, social worker, physical and occupational therapist, and nutritionist.  Daily interdisciplinary team meetings are held, which promotes improved care coordination and discharge planning.  Created a unit-based heart failure program coordinator who ensures appropriate placement of patients on the unit and adherence to standard guidelines.
• Implemented “Get with the Guidelines” database to drive improvement efforts and which also allows for Reading Hospital and Medical Center to monitor adherence to other important standards of care for heart failure patients.

LESSONS LEARNED
• Gain and maintain administration’s support by demonstrating objective and positive results.
• Have a true daily champion(s) who owns the process and is dedicated to its success.
• Invite persons responsible for heart failure data collection to be part of the team. This allows for collective understanding on how to improve documentation and communication.
• Place heart failure patients on the same unit to promote consistency and allow for early adoption of innovation as heart failure treatment changes.
• "Blend" roles among the different disciplines on the team to promote patient-centered care.
• Decreased average length of stay for heart failure patients from 6.8 days to 5.3 days and readmission rate within 30 days of discharge from 8 percent to 3.9 percent over the past 2 years.

Percent of heart failure patients currently receiving recommended care for the following measures (if available):

Evaluation of LVS Function - 99.7% for 2007; 99.3% for Q1 2008; 99.5% (prelim) Q2 2008
ACEI or ARB for LVSD - 95.3% for 2007; 100% for Q1 2008; 97.9% (prelim) Q2 2008
Adult Smoking Cessation Advice/Counseling - 100% for 2007; 100% for Q1 2008; 100% (prelim) for Q2 2008
Discharge Instructions - average 87.8% for 2007; 85.4% for Q1 2008; 89.6% (prelim) for Q2 2008
Percent of Congestive Heart Failure Patients Receiving "Perfect Care" - 95.69% for 2007;
95.95% for Q1 2008; 96.725 (prelim) for Q2 2008

[9/19/08]

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St. Luke’s Hospital – Cedar Rapids, IA
Availability Status: Available to answer requests
Licensed Beds: 560
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: May 2006
Mentor Contact Name: Peg Bradke
Mentor Contact Email: BradkeMM@crstlukes.com
Mentor Contact Phone: 319-369-7269

Additional Information:

Keys to St. Luke's success:

• Cross Continuum Team to evaluate processes and ideal transition to home.  (In addition to hospital representation, membership includes LTC/SNF, Home Health, and Clinic RNs.)

• Include patient and family input through Med/Surg Patient and Family Advisory Council.  This council is very engaged and helps in our work to achieve the ideal transition to home.

• Standardized care through order sets

• Teaching and learning enhancements
   - Utilize universal health literacy concepts in teaching and written material
   - Enhanced teaching materials to make them more patient friendly
                   Emergency Plan Magnet to place near scale
                   Red Yellow Green Zone reference for warning signs
                   Calendar highlighting information patient needs to know
                   General information on heart failure
                   Eating plan which specifies "choose this not that"
                   Utilize Teachback with teaching across the continuum
     - Recently produced an educational DVD that highlights and demostrates the Teachback method with three patient interactions.  Utilized in orientation and for educational purposes.  Video ends with the patient's reaction to the Teachback through personal testimonies.
     - Tested information with focus group of heart failure patients and family members prior to implementation.

• Touchpoints after discharge
   Home care visits 24 to 48 hours after discharge (began January 2007)
                   Follow up appointment with care provider 3-5 days after discharge
                   Follow up phone call 7 days after discharge
                   Outpatient heart failure class
                   Collaborate with clinic-based heart failure clinics

2009 Data:

Evaluation of LVS Function: Q3 2009 = 100% (Compared to Q1 2006 = 93%; Q2 2006 = 95%; Q3 2006 = 93%)
ACEI or ARB: Q3 2009 100% (Compared to Q1 2006 = 83%; Q2 2006 = 84%; Q3 2006 = 77%)
Smoking Cessation Counseling: Q3 2009 = 100% (Compared to Q1 2006 = 67%; Q2 2006 = 100% ; Q3 2006 = 100%)
Successful Teachback rate to Warning signs and symptoms of HF = 83%
Readmission Rate (All Cause 30 day) = 17% (down from 29% in 2006)
Patient satisfaction with education material is at 90% or better
Discharge Instructions: Q3 2009 = 92%

Mentor designation - 4/19/07
Information updated - 3/10/10

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Sentara HealthCare/Sentara Norfolk General Hospital – Norfolk, VA
Availability Status: Available to answer requests
Licensed Beds: 649
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: 2004
Mentor Contact Name: Betty C. Crandall
Mentor Contact Email: bccranda@sentara.com
Mentor Contact Phone: 757-388-8071

Additional Information:

Keys to the success of our efforts to improve CHF care:

• We have worked as a system of 7 hospitals to make improvements and share strategies across the hospitals.
• We identified champions at each of our hospitals and at Sentara Norfolk General Hospital (SNGH), the tertiary hospital, a champion in Medicine and one in Cardiac. 
• Champions met monthly, then quarterly, to now, on an as needed basis, to share successes, problem solve, and develop strategies.  To facilitate participation, meetings were held by conference call.
• Developed patient education tools which would capture all of the discharge instructions which needed to be provided on a one-page handout.
• Simplified documentation so it was easy for nurses to document having provided all the discharge education.
• Provided education for physicians and reminders to prescribe an ACE or ARB or to document the reasons why these were not appropriate for the patient.
• Involved the hospital executive team in reviewing outcomes and assisting with removal of barriers.

Over the past two years, the most significant improvements have occurred since implementation of the EMR.  That has resulted in all hospitals reaching the goals for discharge instructions consistently.  The electronic process for discharge has hardwired our results.

Data (% of CHF patients)

Evaluation of LVS Function: 100%
This has been a metric on which we have done well for many years.  Physicians document this consistently and we have not had to implement strategies for improvement on this measure.

ACEI or ARB at discharge for patients with LVSD: 98%
This required some focus several years ago but for the last several years, there has been good documentation of ACEI or ARB prescribed at discharge or clear documentation as to the reasons not prescribed.

Adult Smoking Cessation Advice/Counseling: 100%
This is a measure on which we have performed well for several years.  We have focused on smoking cessation education for all patients so that nursing staff don't look at the patient's diagnosis; they provide education for smoking cessation at any time that a patient is identified as a smoker.  Reports from our EMR allow us to track patients on each unit who indicate on admission that they are smokers.

Discharge Instructions: 87%
We struggled with meeting this measure until 2009.  With implementation of our EMR, this measure improved dramatically with the last several months of the year being consistently over 90%.

Percent of Congestive Heart Failure Patients Receiving Perfect Care: 88%

2009 Readmissions Data:

For Sentara Healthcare for DRG 291, the rate was 0.18.  For the same DRG, for Sentara Norfolk General Hospital (SNGH), rate was 0.22.

For DRG 292, Sentara Healthcare (all hospitals) was 0.18 and SNGH was 0.20.

For DRG 293, Sentara Healthcare 0.13 and SNGH 0.12.

Performance on the CHF Measures for SNGH and then for Sentara Hospitals in aggregate is shown below:

		2004	2005	2006	2008	2009
ACE/ARB at discharge	Sentara Hospitals	90%	83%	97%	96%	97%
	SNGH	75%	83%	97%	100%	98%
Documentation of EF	Sentara Hospitals	96%	98%	99%	99%	100%
	SNGH	96%	98%	100%	100%	100%
Smoking Cessation	Sentara Hospitals	92%	91%	98%	99%	100%
	SNGH	86%	87%	100%	100%	100%
Daily Wt Monitoring	Sentara Hospitals	80%	81%	85%
	SNGH	75%	74%	83%
Discharge Instructions	Sentara Hospitals	61%	64%	72%	77%	90%
	SNGH	57%	61%	76%	72%	87%
VTE Prophylaxis	Sentara Hospitals		94%	97%	99%	99%
	SNGH		94%	97%	99%	99%
CHF Composite Quality Score	Sentara Hospitals		63%	74%	78%	90%
	SNGH		56%	77%	74%	88%

Mentor Designation - 3/13/07
Information updated - 2/19/10

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United Hospital Center – Clarksburg, WV
Availability Status: Available to answer requests
Licensed Beds: 318
Teaching / Non-Teaching Status: Teaching
Setting: Rural
Start Date of Intervention Work: July 2003
Mentor Contact Name: Mark Povroznik, PharmD – Director, Quality Initiatives
Mentor Contact Email: povroznikm@uhcwv.org
Mentor Contact Phone: 304-624-2088

Additional Information:

Over the past four years, UHC has gone from a predominantly manual process to a more streamlined electronic abstraction process.  The first step in our success was the implementation of Horizon Patient Folder.  This system allows abstractors to review charts that are electronically triggered for review seven days after discharge.  This allows official data to be available quicker and provide more timely feedback to providers on specific cases that have missed opportunities.

UHC's success specifically related with CHF is largely attributed to building redundancies into the patient care processes.  Smoking cessation is incorporated both on the admission assessment, as well as on the Respiratory Therapy assessment.  Pre-printed orders automatically list all components of the discharge instructions.  The Patient Discharge Instructions were also revised to include ACEI/ARB, Smoking Cessation, and all elements of the discharge instructions.  Recent implementation of a computerized nursing documentation system has also greatly increased compliance by building the required data elements into the system.

UHC's success has been increasing steadily over the past several years with the Heart Failure outcomes data.

Discharge Instructions
2003 - 8.2%, 2004 - 67.7%, 2005 - 87.3%, 2006 - 100%

Evaluation of LVS Function
2003 - 67.7%, 2004 - 84.3%, 2005 - 95.9%, 2006 - 99.5%

Ace/ARB for LVSD
2003 - 44.2%, 2004 - 82.1%, 2005 - 93.3%, 2006 - 100%

Smoking Cessation/Counseling
2003 - 23.7%, 2004 - 76.9%, 2005 - 95.6%, 2006 - 100%

Readmissions within 30 Days of Discharge (all payors)
2003 - 25.1%, 2004 - 25.2%, 2005 - 18.7%, 2006 - 27.1% (Heart Failure readmissions are on target for 2008 formal Performance Improvement review)

[12/6/07]