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New Mexico Hospital Reinforces Efforts on Heart Failure Care

In partnership with HealthInsight New Mexico, a local hospital has successfully taken steps to ensure that patients admitted with congestive heart failure (CHF) receive the best possible care. This New Mexico hospital developed and implemented a comprehensive quality improvement program that included launching a number of interventions that have resulted in improved quality of care measures and decreased readmissions.

Quality department nursing staff initiated concurrent review of all charts for CHF patients. Any issues identified during this review are considered missed opportunities for optimal care and are forwarded to the chief nursing officer and chief of medical staff for appropriate action. The chief of medical staff reports on compliance with CHF core measures at all Quality Improvement Committee, Medical Executive Committee and board meetings until their goals are met and maintained for six consecutive months.

They formed a “Core Measures Action Team” that introduced daily interdisciplinary rounding to assure that all core care elements are addressed. This team is led by nursing and case management and may include professionals from operations, critical care, medical surgery, dietetics, respiratory therapy and medical imaging as needed. In addition, nursing leadership participates in daily rounding, which has proven especially successful.

Concurrent review and daily rounding worked together to promote accountability for each staff member and the criticality of their roles. Meetings took place with the Core Measures Action Team involving charge nurses, staff and the patient – at the patient’s bedside. Daily rounding meetings at the beginning lasted 20 to 30 minutes; now that staff is working more accountably, these meetings are under five minutes each.

The hospital’s electronic medical record system was altered to automatically prompt staff to focus on the core measure criteria systematically for every heart failure patient.

A nurse was hired to focus exclusively on core measurement surveillance. Each weekday, this individual conducts review, and the nurse supervisor fills this role on weekends. This focus keeps concurrent review on track each day, and has actually simplified their chart auditing process.

A number of educational activities have been conducted for physicians and clinical staff on best practices, including inpatient diagnosis, evaluation and management of CHF patients, the responsibilities of daily interdisciplinary rounding, and meeting the key care components of CHF care.

They learned how to provide more focused staff education. They went from covering all 10 core heart failure and quality improvement measures at the medical staff meeting, where they weren’t able to focus on them in much depth, to addressing selected topics at the appropriate specialty meetings and devoting deeper attention with the right people.

Hospital staff conducted an evaluation of the skill sets of their current clinical staff. If the skill set was found to be lacking and did not improve following education, difficult decisions were made to replace staff.

A number of measures to improve forms and printed materials were introduced. Pre-printed order forms for CHF patients were implemented. Medication reconciliation forms were revised. The intake, output and daily weight form was standardized.

Patient education materials with discharge instructions were updated, and now heart patient education information is provided to all CHF patients. Staff focuses on interacting with the patient, covering the information thoroughly and having a dialogue to ensure that the patient understands the education.

The process was standardized for post-discharge phone calls and appropriate home health care referrals for high-risk patients. Through these phone calls, staff learned that the most common factor placing patients at risk for readmission was neglecting to weigh themselves daily. The team evaluated how the primary care model, including home care, could support ongoing education and encouragement.

Based on their interventions, the hospital has seen significant improvements in rates for medication reconciliation, provision of discharge instructions, documentation of intake/output and daily weight and in discharge follow-up phone calls. As a result, this facility’s rate for CHF patient readmissions has seen a 42-percent relative decrease.

The performance improvement cycles they used to improve care for heart failure patients have also served to improve processes for all patient care. They report that after one year of focus, they are in full compliance for core measures for acute myocardial infarction, pneumonia, surgical care infection prevention and immunizations.