CICU Quality Improvement Orientation

1. CICU Quality Improvement Orientation Chief Residents 2013

2. Objectives • Improve quality of patient care in the CICU by providing “just in time” teaching on the following key aspects of discharge planning: • Clinical Documentation • Core Measures • Discharge Planning

3. Clinical Documentation • Leslie Schultz, RN, BSN • Clinical Documentation Improvement Specialist in CICU

4. Understanding MS-DRGs • Medical Severity-Diagnostic Related Groups (MS-DRG) • The system used for hospital inpatient admission reimbursement • Physician documentation is the basis for coding • Lab/Imaging can only be coded for when the physician indicates their clinical significance in the A&P • Documentation needed for proper coding has specific requirements that are different than those needed for clinical care

5. Documentation of all pertinent diagnoses has a significant impact on Severity of Illness and Risk of Mortality scores. In turn, accurate reporting of Severity of Illness and Risk of Mortality has a significant impact on quality of care reports as well as reimbursement

6. CDI Specialists Query in order to… Clarify Present on Admission (POA) status of diagnosis Clarify Principal Diagnosis (primary reason for admission) Ensure physician documentation includes all co-morbidities Include Manifestations of chronic conditions Diabetic nephropathy, stage of CKD, hypertensive cardiomyopathy Clarify diagnosis when unapproved abbreviations are used Example: “CRS” could have multiple meanings. Write out meaning for accuracy http://www.medabbrev.com/index.cfm for UH approved abbreviations

7. Clarify whether a diagnosis &/or event is a complication of a procedure - Provider must make the link between condition & procedure Clarify source of infection can be “possible”, “probable” or “suspected” Clarify possible etiology of symptoms Hematuria, abdominal pain, chest pain, syncope Capture appropriate mortality scores Example: must specify “Multi System Organ Failure” CDI Specialists Query in order to…

8. Documentation Tips

9. Documentation Tips

10. Opportunities to improve documentation… Patient admitted with AMI. H&P notes PMH of CHF Home meds include Lisinopril and Lasix daily Recent echo with EF 10-15% BNP noted to be elevated on admission Documentation indicates pt with “volume overload” and diuresis initiated

11. Impact of improved documentation…

12. Clinical Documentation Improvement Program Goal • Complete and accurate documentation in the EHR to reflect the patient’s true severity of illness and risk of mortality

13. Core Measures

14. National standardized evidence-based performance measures defined by the Joint Commission Derived from quality indicators defined by the Centers for Medicare and Medicaid Services (CMS) Hospitals improve quality of patient care by focusing on results of care What are Core Measures? Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252

15. Inpatient Core Measure Sets 2013 2011 University Hospitals Case Medical Center 15 15 15

16. Inpatient Core Measure Sets 2013 2011 University Hospitals Case Medical Center 16 16 16

17. Inpatient Core Measure Sets 2013 Required in 2014 by TJC for hospitals with > 1, 100 births 2011 University Hospitals Case Medical Center 17 17 17

18. Hospital Compare www.hospitalcompare.hhs.gov Improving care through information 4500 hospital across the country report More than 50 quality measures The Joint Commission www.qualitycheck.org Ohio Department of Health www.odh.ohio.gov Ohio Hospital Compare Leapfrog www.leapfroggroup.org Self Reported Survey Encourage health providers to publicly report Consumers make informed health choices Health Grades www.healthgrades.com/ Independent rating company Use Medicare Claims Data 721,356 patients in Cleveland used information between January and June 2011 Where is data reported to the public?

19. How are Core Measure Patients Identified? Core Measure diagnosis is not always clear on admission Identified by Coding after discharge based on documentation by Physician or Licensed Independent Practitioner (LIP) Goal is to identify patients early in admission and achieve all components of care by discharge Patients with symptoms of Core Measure diagnosis should have core measure parameters followed Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252

20. Value Based PurchasingBasics Began in 2011 Non-compliance results in- 2013 - 1% reduction total Medicare payment 2017 - 2% reduction total Medicare payment Potential impact at UH 2013 – $ 5.9 million 2017 - $18.8 million Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252

21. UHCare Order Set Utilization and Core Measures UHCare order sets have been created to help practitioners satisfy the Core Measure indicators that are monitored in the UH System Each disease specific Core Measure order set contains options for all needed components UHCare order sets are care paths that communicate treatment and interventions to the interdisciplinary team members (ie. Nursing, Respiratory, Pharmacy, Laboratory, and Ancillary Departments). Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252

22. UHCare Order Set Utilization and Core Measures Compliance depends on: Licensed independent practitioners selection of each order as appropriate Licensed independent practitioners selection of omission order when a medication is not indicated Non-use of order sets requires documentation in the medical record of omission reason Orders being followed as written for the patient Disease specific order sets include everything needed to meet core measure requirements Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252

23. Disease Specific Core Measure:Acute Myocardial Infarction Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252

24. Acute Myocardial Infarction Admission Indicators: Aspirin prescribed at Arrival – within 24 hours Angioplasty within 90 minutes of arrival Discharge Indicators: Aspirin prescribed at discharge Beta Blocker prescribed at discharge Medication (Ace at discharge for left ventricular dysfunction (Ejection Fraction <40%*) Statin Prescribed at Discharge Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252

25. Acute Myocardial Infarction Order Set Physicians and other LIP’s can access the Acute Myocardial Infarction order set by typing “AMI, Acute Myocardial Infarction, or STEMI” in the UHCare order browse

26. Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252

27. Disease Specific Core Measure:Heart Failure Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252

28. Heart Failure Indicators Left ventricular function assessment ACE1 or ARB ordered at discharge for left ventricular dysfunction (Ejection Fraction <40%*) Patient education Activity Diet Weight monitoring Symptoms worsening Follow up appointments Accurate medication reconciliation Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252

29. Heart Failure Order Set Physicians and other LIP’s can access the Heart Failure Order by typing “Heart Failure or CHF” into the order browse in UHCare Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252

30. Please use omission orders when indicated Or you will get this error message  Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252

31. Guidelines For a Healthy Lifestyle

32. Conclusion - Key Points Use of prepared order sets makes compliance with core measures and “best practice” easier for end user Core measures contribute to better patient outcomes Affect our payment for services rendered Publicly available for evaluation EVERYONE plays a role in meeting core measure compliance Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252

33. Discharge Planning

34. The Bottom Line: Discharge Begins on Admission The CICU discharges many patients to home, long term care facilities, and short term rehab. The impact of improper discharge planning can extend the stay of CICU patients for days or hours which has a direct impact on: Patient Satisfaction Scores Increased Length of Stay (LOS) Non-Compliance of Core Measures such as HF and AMI Patient Readmission

35. Team Collaboration and Communication Provides the Best Care Touch base rounds occur daily for each patient to determine patient needs and update developments in care Interdisciplinary Rounds occur every Tuesday and Thursday 10:00 @ the CICU center table.

36. Your Role in Discharge Planning Participate in Interdisciplinary Rounds (One intern to attend and report out to group) Anticipate and communicate the expected date of discharge Anticipating discharge can alleviate common needs that delay discharge Common barriers: inability to afford medications, PT/OT consults, home care arrangements, SNF and long term placement approvals, home IV therapy approvals, and transportation issues When discharge is anticipated, the recommendation is to have the discharge profile completed the night before discharge This includes medication reconciliation, discharge instructions, home care orders, cardiac rehabilitation orders, and a gold form

37. The Day of Discharge Medication Reconciliation can be a time consuming process. Proper admission medication reconciliation will alleviate many discharge errors and decrease the time it takes for you to discharge a patient. The CICU RN will perform a discharge timeout with you to ensure that your instructions and medications meet the needs for our patients and hospital standards of care.