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

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:

We developed reliable processes/systems/interventions to assess LVF, screen and provide patients with smoking cessation counseling, screen for DVT risk and apply prophylaxis, review for ACEi/ARB and beta blocker use (or prompt documentation of omission rationale), and apply preventative strategies (immunization).  Providing discharge instructions continues to be a work in progress as we design and use PDSAs to determine what works best and mostly reliably in our model of care. Our process has had to be redesigned several times due to adoption of a new CPOE system. We are trying to maximize this system to drive the standardized delivery of several process measures.

LVEF assessment >(90% since 2002 ) 
ACEi/ARB use >90% since Feb 2004 
Smoking cessation/counseling >95% since Oct 2005
All patients screened for risk of VTE-appropriate prophylaxis applied >95% of HF patients 
All patients screened and immunized (influenza and pneumococcal) rate is currently 90%
Outpatient HF clinic launched after pilot demonstrated 1:1 work with clinicians helps patient self manage
Readmission rate was 25% in 2004 now between 4-10%
[3/13/07]

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Centra Health – Lynchburg, VA
Availability Status: Available to answer requests
Licensed Beds: 403
Teaching / Non-Teaching Status: Non-teaching
Setting: Urban
Start Date of Intervention Work: Sept 2005
Mentor Contact Name: Joan Deal, RN, Director of Nursing and Quality, Cardiovascular/Neurosciences
Mentor Contact Email: Joan.Deal@Centrahealth.com
Mentor Contact Phone: 434-528-2254

Additional Information:

In the fall of 2005, we reconvened a Congestive Heart Failure quality committee to meet monthly and focus on improving our compliance with achieving guideline therapy for our heart failure patients.  Primarily, through use of our outcomes reporting from our data registry, we implemented several successful process changes that helped to better identify the location of heart failure patients, and to improve our methods of achieving guideline therapy.

We have improved the documentation related to the provision of smoking cessation instructions by pre-printing on both our cardiac discharge contract and our nursing discharge instruction sheet all the pertinent information related to smoking cessation - website and appropriate contact numbers to call.  As a result smoking cessation core measure is now at 100%.

We have improved and continue to work on achieving improved scores with the documentation related to the ordering of an ACE / ARB at discharge.  We utilize a standard order set which prompts the physician to order these drugs or to provide documentation to the contrary.  In addition, we send quarterly letters to physician practices sharing with them their heart failure core measure performance compared to physicians nationwide. 

We also utilize inhouse patient educators and other members of the care team to provide reminders to physicians of the need to order these drugs or provide documentation to the contrary.  These reminders take the shape of pre-printed progress notes, sticky reminder notes, and / or telephone calls.   As a result, our compliance with ACE / ARB documentation has improved from 70% in October 2005 to 86% in October 2006.

Centra Health's 3rd qtr 06 readmission rate within 30 days was 20%
% receiving "perfect care" for April - June '06 was 80.93%.
[3/13/07]

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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. We have anecdotal evidence that we have been able to decrease hospitalizations and ED visits for some HF patients.

We have seen compliance with HF measures move from baseline to the following highs:
written discharge instructions - 23% to 77%
LVF assesment - 91% to 98%
ACEI/ARB for LVSD - 63% to 80%
Smoking cessation counseling - 44% to 94%

[8/13/07]

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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:  Liz Popwell, CHE
Mentor Contact Email: elizabeth.popwell@carolinashealthcare.org
Mentor Contact Phone: 704-487-3690

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: Jennifer Dunscomb
Mentor Contact Email: jdunscomb@crh.org
Mentor Contact Phone: 812-376-5575

Additional Information:

Developed a process for automated old echocardiogram retrieval
Performed Pugh concept selection with an interdisciplinary team consisting of nursing representatives from each nursing unit to standardize discharge instruction process including the development of a tool
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

2006 data:
CHF discharge instructions including signs/symptoms; daily weight; activity; medications; follow-up; and diet 91%
LVF assessment 97%
ACEI or ARB prescribed at discharge 97%
Smoking Cessation education 100%
Pneumococcal Vaccination:  CRH will start to collect rates starting in 2007
Influenza Vaccination: CRH will start to collect rates starting in 2007
Anticoagulant at Discharge for HF Patients with Atrial Fibrillation:  For 2005, CRH was at 97%.  Routinely, we did this as a large retrospective review per year.  For 2007, we will start to measure monthly with the other indicators
Percent of Congestive Heart Failure Patient Discharges with Readmission within 30 Days:  19%
Percent of Congestive Heart Failure Patients Receiving Perfect Care:  97%
[3/13/07]

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Fauquier Hospital – Warrenton, VA
Availability Status: Available to answer requests
Licensed Beds: 86
Teaching / Non-Teaching Status: Non-teaching
Setting: Rural
Start Date of Intervention Work: January 2005
Mentor Contact Name: Catherine Walsh
Mentor Contact Email: walshc@fauquierhospital.org
Mentor Contact Phone: 540 349 0584

Additional Information:

• Developed a "click six" slogan to ensure that EMR documentation reflects that all components are included in discharge instructions
• Discharge standing orders developed
• Extending initiative across continuum by collecting data through Home Health Program on re-admissions for CHF exacerbation and with follow up telephone calls 2-3 days post discharge from hospital to ascertain if patient received discharge packet and follow-up appointment; additional phone call made at 21-27 days
• Standing orders for ACEI/ARB developed
• Mailbox in-services and articles in physician newsletter for all components
• Orders available and visible in carousel racks on each inpatient unit and ED
• Standardized language on discharge instructions related to Fauquier Hospital's commitment to all patients being smoke-free and giving pulmonary rehab contact info for more information
• Concurrent chart audits completed to capture incidents of non-compliance with recommendations

2006:

LVF Assessment – Maintained 100% compliance for 7 months and never fell below 85%
ACE/ARB – Maintained 100% compliance for 5 months and never fell below 60%
Smoking Cessation – Developed and implemented a smoking cessation packet that has led to our 100% compliance throughout 06 and into 07 for this indicator
Discharge Instructions – Maintained compliance at or above 70%
10.38% CHF readmission rate for FY 06
[4/7/07]

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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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Lake Pointe Medical Center – Rowlett, TX
Availability Status: Available to answer requests
Licensed Beds: 99
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: January 2005
Mentor Contact Name:  Patty Sewalt
Mentor Contact Email: patricia.sewalt@tenethealth.com
Mentor Contact Phone: 972-412-2273 x 1618

Additional Information:

Lake Pointe Medical Center standardized instructions for all discharged patients to include: medications (home and new prescriptions), smoking cessation information, physician follow up appointment, weight monitoring, and signs and symptoms to report.
Identify smoking status on all admissions.  Developed smoking cessation program for all smoking patients
Developed Home Medication Form that is completed on admission and at discharge
Hired a clinical case manager August 2006 to concurrently audit CHF records and work with the physician within 48 hours of admission.
Implemented a policy mandating that all patients who did not have a record of LVEF previously have an echo performed.
Clinical case manager works with the physician to make sure CHF patients are discharged on ACE Inhibitors/ARB if indicated prior to discharge or contraindications documented

Discharge instructions:  Went from 22% the first quarter of 2005 to 92 % in the fourth quarter of 2006.

Smoking cessation:  Went from 90% the first quarter of 2005 to 100 % in the fourth quarter of 2006.

LVEF assessment and ACE:  Went from 71% the first quarter of 2005 to success of 100 % in the fourth quarter of 2006 for LVEF assessment and from 25% to 100% for ACEI/ARB at discharge if indicated.
[3/13/07]

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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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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:

Implemented use of patient education discharge material, incorporating concepts of health literacy, teachback, and involvement of significant others in care.
Information includes:
• Emergency Plan Magnet to place near scale in home
• Red Yellow Green Zone reference for warning signs
• Weight log
• General information on heart failure and diet

Tested information with focus group of heart failure patients and family members prior to implementation.

Conduct a full day outpatient HF class 5-6 times per year.
Perform follow-up phone calls within 48 hours of discharge to assess the patient on home arrival.
Implemented understanding using teachback techniques.
Complimentary home visits 48 hours after discharge beginning January 2007.

Evaluation of LVS Function: Q1 2006 = 93%; Q2 2006 = 95%; Q3 2006 = 93%

ACEI or ARB: Q1 2006 = 83%; Q2 2006 = 84%; Q3 2006 = 77%

Smoking Cessation Counseling: Q1 2006 = 67%; Q2 2006 = 100% ; Q3 2006 = 100%

Answers to the teachback questions in follow up calls are showing that patients are able to give the correct answer 80% of the time.

Our current 30-day readmission rate is 11.2%.  Reported Medicare 30-day Readmission Rate for 616,000 Medicare discharges in 2005 was 27%. 

Patient satisfaction with education material is at 90% or better.

Discharge Instructions: Q1 2006 = 94%; Q2 2006 = 89%; Q3 2006 = 75%*

*In 2004, we began utilizing a daily BNP report (an automatic report generated by the lab and sent to the nursing unit Care Coordinator) to help identify all CHF patients and begin proper education and intervention.  If the BNP was elevated and physician documentation stated a CHF diagnosis, preprinted d/c instructions were initiated.  After this implementation, we ran 90-100% compliance for discharge instructions.

However, in July 2006, Medicare changed the definition of this indicator.  The new indicator stated medications needed to be reconciled with the physicians’ discharge summary and this new definition made a significant impact on our compliance.  Since this report can be done several days after discharge, there were times when medications stated in the summary did not match the discharge orders.  We continue to work with physicians on this on a daily basis.  We have reviewed the process with the physicians and identified some champions to assist us with the whole medication reconciliation process.  We are seeing improvements particularly in the last three months.
[4/19/07]

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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:

We have worked as a System of 6 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.

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

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

[3/13/07]

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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]