Transcript Franciscan Health Services, Inc. presentation
Franciscan St. Anthony Health Michigan City, IN
Franciscan Health Services, Inc
.
St. Margaret Health Hammond St. Anthony Health Michigan City St. James Health Olympia Fields 80 90 90 St. James Health Chicago Heights Franciscan Alliance Corporate Office Mishawaka 80 90 St. Anthony Health Crown Point 65 St. Margaret Health Dyer St. Elizabeth Health Lafayette St. Elizabeth Health Crawfordsville St. Francis Health Beech Grove St. Francis Health Mooresville St. Francis Health Indianapolis 65
Franciscan Alliance
Mission Driven Quality Goals
• Adherence to the CMS Core Measures is rooted in the Franciscan Alliance culture at the facility, regional, and corporate level which is accomplished through continuous process improvement and focus on CMS best practice standards with robust communication at all levels, as well as through results reporting on the Franciscan Alliance Corporate Report. The color green on this report is associated with achieving results in line with the top 10% of hospitals in the nation. FSAH used this cultural norm to launch the Quality Rounding Program with the slogan:
It Takes a Team to Go Green !
Purpose and Goal
Purpose
: • Assist the facility in compliance with the CMS quality initiatives, and to move our results on the Franciscan Alliance Corporate Report from red or yellow to green.
• Prepare FSAH to compete as healthcare reimbursement moves to Value-Based Purchasing.
Goal:
• The broad goal of the Quality Rounding Program is to assist FSAH in elevating the quality and consistency of patient care delivery through improvement with compliance to the CMS Core Measure Standards through a collective experience of teamwork, communication and accountability.
Franciscan Alliance Corporate Report – CMS Quality Measures
Action Plan Caution Zone Way to Go!
Value-Based Purchasing (VBP)
• In 2010 VBP became required by the Affordable Care Act to provide value-based incentive payments to hospitals beginning in FY 2013 for two domains:
Clinical Process Measures
and
HCAHPS.
• CMS has outlined proposals for the VBP Program and views it a vital link to moving increasingly toward rewarding better value, outcomes and innovations instead of volume. • FY 2013 payment determination will be based upon comparing a hospital’s performance of the chosen measures during a performance period (7/1/2011 – 3/31/2012) to a baseline period (7/1/2009 – 3/31/ 2010). • FY 2014 payment determination will include mortality measures, as well as certain hospital-acquired conditions and patient safety/inpatient quality indicators.
• At risk is a 1% reduction of FY 2013 base operating DRG payments, with a .25% added reduction per year.
VBP Scoring
• Total Performance Score: – 70% Clinical Process Measures – 30% HCAHPS • Two scores will be awarded for each measure:
Achievement Improvement
, with the higher score used and – Attainment • 0 to 10 points awarded for achievement based on where the hospital’s performance for the measure falls relative to an achievement threshold (proposed to be at the 50 – Improvement period.
th percentile during the baseline period) and the benchmark (proposed to be at the mean of the top decile).
• 0 to 9 points scored relative to a hospital’s performance during the performance period compared to its own performance during the baseline • For HCAPHS, up to an additional 20 consistency points are possible to obtained • CMS feels that consistency points encourage hospitals to meet or exceed the achievement threshold.
• If all HCAHPS scores are > the achievement threshold than all 20 points will be awarded.
Value-Based Purchasing
HCAHPS 30% CMS Core Measures 70%
Achieving and sustaining top box scores will be vital to survival!
Goal Attainment Through Focused Objectives • During
Quality Rounding
the Quality Services team focuses on the following objectives:
– – – – – Performing concurrent review and abstraction Capturing CMS documentation compliance prior to discharge Providing “just-in-time” education and support for staff and physicians Ensuring timely feedback of results for accountability Identifying and improving processes to eliminate barriers to compliance through teamwork
Medical Staff
Key to Success: Multidisciplinary Approach
Quality Services Pharmacy Staff Patient Documentation Specialist Patient Care Staff Case Management Informatics Staff
Quality Rounding Process Flow
Obtain Reports
Census Report Surgery Schedule Pneumo/Flu Status Reports
Review Portal
Test Results Admission Hx Home Med List H&P/Dicated Consults
Round on Floors
Read MD Notes Talk w/ MD/Nursing Staff Leave Rounding Notes Follow Up RN Documentation Issue Yes NO Discuss w/ RN or Leave Note on Chart NO Issue Resolved Yes Record Information on Abstraction Tool Abstract Record as Usual NO MD Documentation Issue Yes Discuss w/ MD or Leave Note on Chart Issue Resolved Yes NO
•
Day in the Life of a Quality Rounder
Run daily census report and surgery schedule • Log onto physician portal and review: – Test results • Labs (cardiac enzymes, BNP level, blood cultures & lipid panel performed) • Chest Xray/CT – Admission History (congestion, edema, infiltrates, consolidation, etc.) • Abdominal Xray/CT • Vaccination status • Past medical history (obstruction, free air, ileus, infarcted bowel, perforation, etc.) • Other Xray/CT/Angiography (fractures, occlusion, aneurysm, etc.) • EKGs, Stress Tests, Echocardiograms • Current smoker or quit within last 12 months (i.e., CHF) – Home medication list • Close attention to ACE/ARB, Beta-Blocker, Coumadin, Aspirin, Statin, Antiboitics, Immunosuppressives – Dictated H&Ps/Consults/Operative Reports – Electronic Nursing Charting • Pre-op/Intraop/PACU charting • Narrative notes • Clinical documentation (I&O, ADLs, etc)
Day in the Life of a Quality Rounder
• Round on Units - Interventions Include: – Review Emergency Department documentation – Read physician progress notes/physicians orders – Confer with documentation specialist – If patient has a history of HF, an automatic education referral will be ordered – Talk one-to-one with physicians and/or nurses – Leave
rounding notes
on chart for physicians and/or nurses – Follow up on previous day’s active patient records
Core Measure Focus
•
Heart Failure Measures
– LV Assessment: ?
Appropriate testing ordered ?
LV function/EF documentation within physician documentation ?
Reason for not assessing documented – ACE/ARB for LVSD ?
?
ACE/ARB ordered Contraindication documented within physician documentation
If the answer is always no, note left for physician to ensure measure compliance
– Smoking Cessation ?
Current smoker and/or quit within last 12 months ?
?
Education refusal documented / Smoking cessation education ordered Education completed
If near discharge and the education not completed, contact Cardiac Services and/or inform patient’s nurse that education has not been done
– HF Discharge Instructions ?
?
?
?
Admission origin HF discharge education ordered Education completed Discharge medications & Discharge summary match
If near discharge and the education not completed, contact Cardiac Services and/or inform patient’s nurse that education has not been done If discharge summary is missing a medication that physician ordered/patient went home on, meet with physician to review case. Physician can dictate an addendum within 30 days, if appropriate.
Core Measure Focus
•
AMI Measures
– Aspirin on arrival ? Aspirin given within 24 hours prior to arrival or administer within 24 hours after arrival ? Contraindication documented within physician documentation – EKG positive & Angioplasty performed ? Balloon/Stent inflated/deployed within 90 minutes ? Reason for delay documented – ACE/ARB for LVSD ordered ? ACE/ARB ordered ? Contraindication documented within physician documentation – Aspirin at discharge ? Aspirin ordered ? Contraindication documented within physician documentation
If the answer is always no, note left for physician to ensure measure compliance
•
Core Measure Focus
AMI Measures (cont)
– Beta-Blocker at discharge ? Beta-Blocker ordered ? Contraindication documented within physician documentation – Statin at discharge ? Statin ordered ? Contraindication documented within physician documentation
If the answer is always no, note left for physician to ensure measure compliance
– Smoking Cessation ? Current smoker and/or quit within last 12 months ? Education refusal documented / Smoking cessation education ordered ? Education completed
If near discharge and the education not completed, contact Cardiac Services and/or inform patient’s nurse that education has not been done
•
Core Measure Focus
Pneumonia Measures
– Antibiotic given within 6 hours of arrival – Appropriate antibiotic given – Blood Culture collected before antibiotic
The above measures do not allow for a yes/no answer…it is what it is!
– Smoking Cessation ? Current smoker and/or quit within last 12 months ? Education refusal documented / Smoking cessation education ordered ? Education completed
If near discharge and the education not completed, contact Cardiac Services and/or inform patient’s nurse that education has not been done
– Pneumococcal / Influenza vaccinations ? Patient up-to-date with vaccines ? Contraindication documented ? Vaccine administered
Note left for nursing staff on patient’s Kardex as a reminder that patient qualifies and vaccine(s) need to be given before discharge or document contraindication…daily re-checks and calls to nurse until vaccine given
•
Core Measure Focus
SCIP Measures
– Beta-Blocker within appropriate timeframe ? Beta-Blocker given / taken prior to surgery ? Contraindication documented within physician documentation
If the answer is always no, note left for physician to ensure measure compliance If patient’s nurse failed to document date & time of last home dose, the nurse to re interview patient to obtain information
.
– VTE prophylaxis ordered ? Appropriate mechanical/pharmacological VTE prophylaxis ordered ? Contraindication documented within physician documentation – Foley discontinued by POD 2 • Foley discontinued • ICU patient and receiving IV Lasix • Reason to keep documented – Antibiotic stopped within 24 hours of anesthesia end time ? Appropriate post-op antibiotics ordered (Q8 X 2 doses, Q12 X 1 dose) ? Post-op infection documented
If the answer is always no, note left for physician to ensure measure compliance
Core Measure Focus
•
SCIP Measures (cont)
– VTE prophylaxis given / on ? Ordered VTE prophylaxis given / status documented
Nurse contacted and reminded that the medication needs to be given by X time and/or mechanical prophylaxis needs to be documented on.
– Antibiotic prior to incision ? Pre-op infection ? Pre-op antibiotic given and documented
Contact Anesthesia Medical Director to review and follow up
– Perioperative temperature management ? Forced air warming unit documented as on patient during surgery ? 1 st post-op temperature documented – Hair Removal ? Hair removal method documented
Contact Surgery / PACU Manager to review and follow up
Measure Awareness
• Ensuring that all are aware of the CMS measures, this document is laminated on bright yellow paper and placed in nursing staff and physician areas of the hospital (i.e., break rooms, lounges).
CMS QUALITY INITIATIVES
REVISED 9/22/2010
HOSPITAL QUALITY ALLIANCE (INPATIENT)
Acute Myocardial Infarction Patients • Aspirin on arrival • Aspirin prescribed at discharge • • • ACE-I or ARB for LVSD Adult smoking cessation advise/counseling Beta blocker prescribed at discharge • • • Thrombolytic Agent within 30 minutes of hospital arrival PCI received within 90 minutes of hospital arrival Statin at discharge (beginning 1/1/2011) Heart Failure Patients • Discharge instructions • LV function assessment • • ACE-I or ARB for LVSD Adult smoking cessation advice/counseling Pneumonia Patients • Pneumococcal vaccination • Blood cultures performed in the Emergency Department prior to initial antibiotic received in hospital • • • • • Blood cultures within 24 hrs prior to or 24 hrs after arrival for patients transferred or admitted to ICU within 24 hrs of arrival Adult smoking cessation advice/counseling Initial antibiotic received within 6 hrs (360 min) of hospital arrival Initial antibiotic selection for Community-Acquired Pneumonia (CAP) in Immunocompetent patient Influenza vaccination Surgical Patients (SCIP) • Prophylactic antibiotic received within 1 hour prior to surgical incision • Prophylactic antibiotic selection for surgical patients • • • • Prophylactic antibiotic discontinued within 24 hrs after surgery end time Cardiac Surgery patients with controlled post-operative serum glucose (POD 1 & 2) Surgery patients with appropriate hair removal Surgery patients on a beta-blocker prior to arrival who received a beta-blocker during the perioperative period • • • • Surgery patients with recommended VTE prophylaxis ordered Surgery patients who received appropriate VTE prophylaxis within 24 hrs prior to surgery to 24 hrs after surgery Urinary catheter removed on post-op day 1 or 2 Surgery patients with perioperative temperature management Pediatric Asthma Patients • Relievers for inpatient asthma • Systemic Corticosteroids for inpatient asthma • Home Management Plan of Care HOSPITAL OUTPATIENT PROGRAM Acute Myocardial Infarction & Chest Pain (patients seen in the ED and discharged/transferred to a short term acute care hospital for inpatient care) • Median time to fibrinolysis • • Fibrinolytic therapy received within 30 minutes Median time to transfer to another facility for acute coronary intervention • • Aspirin at arrival Median time to ECG Outpatient Surgery • • Antibiotic timing Antibiotic selection Imaging Efficiency • • • • MRI Lumbar Spine for Low Back Pain Mammography Follow-up Rates Abdomen CT - Use of Contrast Material Thorax CT - Use of Contrast Material PRESENT ON ARRIVAL (POA) MEASURES • Object left in surgery • • • • Air embolism Blood incompatibility Catheter-Associated urinary tract infections Pressure ulcers (decubitis ulcers) stages III and IV • • • Vascular catheter-associated infection Surgical site infection – mediastinitis after CABG surgery Hospital acquired injuries – fractures, dislocations, intracranial injury, crushing injury, burn, etc. • Manifestations of poor glycemic control
CMS Tri-fold Pocket Guide
• • In keeping with our facility motto…
It takes a Team to go
GREEN
, a pocket sized education tool was developed.
These guides will be provided to our physicians and nursing staff – A small but great reminder of SAM’s commitment to the CMS quality measures
Educational Tools
Appropriate antibiotic selection tables posted in the physician dictation areas within Surgery, Outpatient Surgery, ICU and the medical/surgical inpatient units.
Request for Documentation
• Below is the documentation request that is left for the physicians when there is a potential measure non-compliance.
• Contact with the individual physician/surgeon occurs when note is not addressed.
Variances
• When a variance is identified, the Quality Rounders update a spreadsheet and issue a letter of non-compliance.
• Real-time information is available to department director and vice president.
Measure
Antibiotic Selection January February March April May June July August
PN Variances - 2010 Variances
100% compliant 100% compliant 100% compliant 100% compliant 100% compliant 100% compliant 100% compliant 1 = only one appropriate abx (Rocephin) ordered in the ED / EBOS not used, guideline recommends tw o (Rocephin & Zithromax)
Improvement in ACM Scores
Appropriate Care Measure (ACM) Set Total Year (before QR) (2008) Acute Myocardial Infarction (AMI) Heart Failure (HF) Pneumonia (PN) Surgical Care Improvement Program (SCIP)
86.6% 90.0% 68.2% 78.3%
Total Year (2009)
89.4% 95.7% 91.5% 85.5%
Year To Date (2010)
97.7% 98.8% 93% 94.1%
•
Source: SSFHS Quality Improvement CMS BIS Report-AMC Scores. Retrieved: 4/18/2011
CMS Quality Measures
It takes a Team to go
GREEN
!
AMI (Acute MI)
Aspirin on arrival Aspirin prescribed at discharge ACEI or ARB for LVSD Beta blocker prescribed at discharge Fibrinolytic therapy received w ithin 30 minutes of hospital Primary PCI received w ithin 90 min. of hospital arrival Top 10% 100% 100% 100% 100% 100% 97% Betw een National Mean
94% 91% 89% 92% 82% 82%
1st Q 97% 100% 100% 2010 2nd Q 100% 100% 100% 3rd Q 100% 95% 100% 2011 4th Q Jan-11 Feb-11 Mar-11 100% 100% 100% 100% 100% N/A 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% N/A N/A N/A N/A N/A N/A N/A 100% 100% 100% 100% 100% 100% 100%
HF (Heart Failure)
Evaluation of LVS function ACEI or ARB LVSD Adult smoking cessation advise/counseling Discharge instructions
Celebrate the Green !!
Top 10% 100% 100% 100% 97% Betw een National Mean
87% 88% 90% 71%
1st Q 100% 100% 100% 2010 2nd Q 100% 100% 100% 3rd Q 100% 96% 100% 2011 4th Q Jan-11 Feb-11 Mar-11 100% 100% 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 98% 100% 98% 98% 100% 100% 100%
CMS Quality Measures
It takes a Team to go
GREEN
!
Betw een
PN (Pneum onia)
Pneumococcal vaccination Inf luenza vaccination Initial blood cultures collected in the ED prior to antibiotic Adult smoking cessation advise/counseling Initial antibiotic received w ithin 6 hours (360 min) of hospital arrival Initial antibiotic selection f or Community-Acquired Pneumonia (CAP) in Immunocompetent patient Top 10% 97% 97% 99% 100% 100% 97% National Mean
82% 82% 90% 87% 93% 87%
1st Q 92% 94% 96% 2nd Q 100% 100% 3rd Q 96% 97% 4th Q 100% 98% Jan-11 Feb-11 Mar-11 100% 100% 100% 100% 100% 100% 100% 90% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 96% 100% 97% 100% 100% 100% 100% 100% 95% 96% 100% 100% 100%
Continually work on opportunities
SCIP (Sur gical Car e Im pr ove m e nt Pr oje ct)
Prophylatic antibiotic received w ithin 1 hour prior to surgical incision Prophylatic antibiotic selection f or surgical patients Prophylatic antibiotic discontinued w ithin 24 hours af ter surgery end time Cardiac surgery patients w ith controlled blood Glucose in days right af ter surgery A ppropriate hair removal A ppropriate V TE prophylaxis ordered Receive appropriate V TE prophylaxis w ithin 24 hours prior to surgery to 24 hours af ter surgery Urinary catheter removed w itin tw o days of surgery Surgery pateints w ith perioperative temperature management Top 10% 98% 99% 98% 100% 100% 97% 96% 97% Betw een National Mean
Data Not Pub lished
85% 92% 83% 86% 95% 82% 82% 82%
1st Q 2010 2nd Q 3rd Q 4th Q 2011 Jan-11 Feb-11 Mar-11 96% 97% 97% 99% 100% 97% 97% 99% 100% 100% 94% 100% 100% 100% 100% 96% 98% 97% 96% 100% 94% 100% 100% 100% 100% 100% 100% 98% 100% 100%
83%
100% 98% 100% 100% 100% N/A 100% 92% 100% 100% 92% 100% 98% 100% 98% 100% 92% 92% 98% 95% 100% 99% 100% 100% 100% 100% 99% 100% 100% 100% 100% 100%
Continuous Improvement
Prophylactic antibiotic received within 1 hour prior to surgical incision
SAM Monthly Data Top 10% Scoring Hospitals National Average State Average 100% 95% 90% 30/32 19/20 24/25 30/31 16/17 17/18 85% 80% 75% 70% 65% 60%
March 2010
Emergent ruptured AAAs - Quality educated physicians on requirement for 1hr abx to include even emergent cases
April & May 2010
New CRNAs began
October 2011
OR at 1044 and abx given at 0910
December 2011
OPS RN gave abx at 0820 but OR did start until 1257 - CRNA didn't redose abx.
March 2011
Abx given at 0920 and incision occurred at 1038, 18 mintues too late 55% 50% Ja n 09 Fe b 09 M ar -0 9 Ap r 09 M ay -0 9 Ju n 09 Ju l-0 9 Au g 09 Se p 09 O ct -0 9 N ov -0 9 D ec -0 9 Ja n 10 Fe b 10 M ar -1 0 Ap r 10 M ay -1 0 Ju n 10 Ju l-1 0 Au g 10 Se p 10 O ct -1 0 N ov -1 0 D ec -1 0 Ja n 11 Fe b 11 M ar -1 1
Continuous Improvement
Primary PCI received within 90 minutes of arrival - AMI patients (breaks in data = no population)
SAM Monthly Data Top 10% Scoring Hospitals National Average State Average 100% 95% 90% 85% 80% 75% 70% 65% 60% 2/3 Quality Rounders work with physicians to educate regarding thorough documentation for compliance 55% 50% 1/2 45% 40% Ja n 09 Fe b 09 M ar -0 9 Ap r 09 M ay -0 9 Ju n 09 Ju l-0 9 Au g 09 Se p 09 O ct -0 9 N ov -0 9 D ec -0 9 Ja n 10 Fe b 10 M ar -1 0 Ap r 10 M ay -1 0 Ju n 10 Ju l-1 0 Au g 10 Se p 10 O ct -1 0 N ov -1 0 D ec -1 0 Ja n 11 Fe b 11 M ar -1 1
Continuous Improvement
Surgery patients on a beta-blocker prior to arrival who received a beta-blocker during the perioperative period
SAM Monthly Data Top 10% Scoring Hospitals National Average State Average 100% 95% 90% 85% 80% 75% 70% 65% 60% 55%
Action:
Quality Rounding continually educated Nursing staff on documenting date & time of patient’s last home dose.
Attended Nursing and Physician Department meetings to review measure and results.
Anesthesia pre-op assessment form revised to ensure compliance.
50% Ja n 09 Fe b 09 M ar -0 9 Ap r 09 M ay -0 9 Ju n 09 Ju l-0 9 Au g 09 Se p 09 O ct -0 9 N ov -0 9 D ec -0 9 Ja n 10 Fe b 10 M ar -1 0 Ap r 10 M ay -1 0 Ju n 10 Ju l-1 0 Au g 10 Se p 10 O ct -1 0 N ov -1 0 D ec -1 0 Ja n 11 Fe b 11 M ar -1 1
Continuous Improvement
CHF Discharge Instructions - HF Patients
SAM Monthly Data Top 10% Scoring Hospitals National Average State Average 100% 95% 90% 13/14 19/20 19/20 85% 80% 75% 70% 65% 60% 55%
July 2010
MD ordered med on d/c but it was not put on pts med list for home
October 2010
Discharge medications did not match. Discharge summary did not list all medications patient went home on. MD dictated addendum but was over 30 from discharge.
January 2011
Discharge medication did not match. Discharge summary did not list all medications patient went home on.
50% Ja n 09 Fe b 09 M ar -0 9 A pr -0 9 M ay -0 9 Ju n 09 Ju l-0 9 A ug -0 9 S ep -0 9 O ct -0 9 N ov -0 9 D ec -0 9 Ja n 10 Fe b 10 M ar -1 0 A pr -1 0 M ay -1 0 Ju n 10 Ju l-1 0 A ug -1 0 S ep -1 0 O ct -1 0 N ov -1 0 D ec -1 0 Ja n 11 Fe b 11 M ar -1 1
Continuous Improvement
Pneumococcal Vaccination Administered prior to Discharge - PN Patients
SAM Monthly Data Top 10% Scoring Hospitals National Average State Average 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% Ja n-0 9 Fe b-0 9 Ma r-0 9 Ap r-0 9 Ma y-0 9 Ju n-0 9 Ju l-0 9 Au g-0 9 Se p-0 9 O ct -0 9 N ov-0 9 D ec-0 9 Ja n-1 0 Fe b-1 0 Ma r-1 0 Ap r-1 0 Ma y-1 0 Ju n-1 0 Ju l-1 0 Au g-1 0 Se p-1 0 O ct -1 0 N ov-1 0 D ec-1 0 Ja n-1 1 Fe b-1 1 Ma r-1 1
Continuous Improvement
Ultrasound Guided Biopsies Pre-operative Antibiotic Documented
(breaks in data = no patients) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% S ep -0 9 Action: July 2009 - changed vendors for CMS data submission.
October 2009 - Began abstraction of 3Q2009 data. Previous vendor did not capture ultrasound guided biopsies in patient population. Abstracted missing population and resubmitted cases. During abstraction of these cases identified issue with no documentation of pre operative antibiotic.
O ct -0 9 N ov 09 D ec 09 Ja n 10 Fe b 10 M ar -1 0 A pr -1 0 M 11% ay 10 60% Ju n 10 Ju l-1 0 A ug -1 0 S ep -1 0 O ct -1 0 N ov 10 D ec 10 Ja n 11
Continuous Improvement
Pacemaker Procedures Appropriate Antibiotic Selection (breaks in data = no patients)
100% 90% 80% 70% 60% 50% 80% 80% 75% 40% 30% 20%
Action: Change in practice identified w ith particular practitioner. Quality Services, along w ith Infection Control, m et w ith practitioner to explain m easure guidelines.
10%
Pre-printed pre and post operative order set changed to include guidelines, w hich w ill ensure com pliance.
0% Ju l-0 9 Au g 09 Se p 09 O ct -0 9 N ov -0 9 D ec -0 9 Ja n 10 Fe b 10 M ar -1 0 Ap r 10 M ay -1 0 Ju n 10 Ju l-1 0 Au g 10 Se p 10 O ct -1 0 N ov -1 0 D ec -1 0 Ja n 11 Fe b 11 M ar -1 1
Quality Rounding (QR)
• Highlights of our teamwork… 2E ACEI/ARB for LVSD Per cardiology consult pt had moderate decrease in LV function. However, no ACEI was prescribed during stay or on discharge. Situation identified during QR, and QR spoke with MD who then dictated the reason for not prescribing in the discharge summary. Contraindication dictated in discharge summary – record excluded.
ICU ICU 3S 2S Beta-Blocker ACEI/ARB for LVSD HF Education Continued post op abx Beta-Blocker ordered on admission MAR but was not on medication list. QR re-faxed paperwork to Pharmacy during rounding. Medication now on current MAR – measure passed.
No documented reason why patient was not prescribed an ACE/ARB for LVSD. Quality Services spoke with Cardiologist. Cardiologist stated patient is allergic to ACE and ARB. Allergy order documented within chart – measure passed.
QR left per protocol order in chart for HUC to order. Called Cardiac Services 5/11/2010 because referral not completed and patient getting ready for discharge. QR spoke with Cardiac Services RN. Education completed – measure passed.
MD ordered one dose of Ancef past 24 hr timeframe which would result in noncompliance. During rounding, QR paged MD and explained criteria for ordering post op ABX. MD then cancelled the order for Ancef as criteria not met – measure passed.
Rounding Successes
Variances Corrected Prior to Discharge
Measure 1Q2009 2Q2009 3Q2009 4Q2009 1Q2010 2Q2010
Pneumococcal Vaccines 0 issues 2 issues corrected w/o corrections =
91%
Actual =
96%
3 issues corrected w/o corrections =
86%
Actual =
96%
Pre-operative Antibiotics LV Assessments VTE Documented Timely 2 issues corrected w/o corrections = 78
%
Actual =
82%
1 issue corrected w/o corrections =
97%
Actual =
99%
0 issues 5 issues corrected w/o corrections =
91%
Actual =
99%
3 issues corrected w/o corrections =
96%
Actual =
100%
4 issues corrected w/o corrections =
85%
Actual =
100%
5 issues corrected w/o corrections =
88%
Actual =
95%
2 issues corrected w/o corrections =
97%
Actual =
100%
0 issues 0 issues 0 issues 3 issues corrected w/o corrections =
88%
Actual =
100%
2 issues corrected w/o corrections =
94%
Actual =
98%
3 issues corrected w/o corrections =
94%
Actual =
100%
0 issues 5 issues corrected w/o corrections =
86%
Actual =
96%
3 issues corrected w/o corrections =
95%
Actual =
100%
2 issues corrected w/o corrections =
95%
Actual =
100%
7 issues corrected w/o corrections =
88%
Actual =
97%
3 issues corrected w/o corrections =
94%
Actual =
100%
2 issues corrected w/o corrections =
94%
Actual =
98%
Objectives Met:
• Performing concurrent review and abstraction
– QR uses the daily census report and surgery schedule – Specific admission reports – Daily discussions w/ charge nurse, and the clinical documentation specialist for identification for chart review.
Objectives Met:
• Capturing CMS documentation compliance prior to discharge
– QR identifies standard compliance opportunities and discusses individual cases w/ nurses and MD’s – Calls MD’s directly, or leaves rounding notes – Emails clinical mgrs and supervisors w/ open cases – The QR team also works with the EBOS Facilitator to ensure CMS compliance
Objectives Met:
• Providing “just-in-time” education and support for staff and physicians
– The success of this program is relationship driven – QR has developed a good report with physicians and staff through continual communication offering daily support while rounding on the units – The QR team has developed a one page Core Measure Fact Sheet and CMS Pocket Guide – Quality Services page on the Intranet which includes CMS data definitions.
Objectives Met:
• Ensuring timely feedback of results for accountability – Provides daily feedback via:
• rounding • staff meetings • email alerts • variance reporting through letters to physicians and clinical managers • reporting variances at medical staff meetings
Objectives Met:
• Identifying and improve processes to eliminate barriers to compliance
– When trends are identified while rounding, the QR team brings stakeholders together more timely to work on processes.
Overall Impact:
Improved teamwork, awareness, and accountability through relationship building and ongoing and timely communication among Quality Services, Medical Staff, Nursing and Ancillary Staff resulting in increased quality of care delivery, consistency in practice and compliance to standards as evidenced by our results!
Amy Baker, AD CMS Data Analyst [email protected]
Deborah Kelley, LPN Clinical Data Coordinator [email protected]
Genevieve Koehler, RN, CPHQ Director of Quality [email protected]