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Heart Failure, AMI and Stroke: Composite, Defect-Free Care, how GWTG Helps. Robert M. Stein, MD, FACC Co-chair of California’s Medicare QIO effort for ACM Program Immediate past President, Greater San Diego AHA Board Barbara Ann Buesch RN, BSN Quality Management Department

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heart failure ami and stroke composite defect free care how gwtg helps

Heart Failure, AMI and Stroke:Composite, Defect-Free Care, how GWTG Helps

Robert M. Stein, MD, FACC

Co-chair of California’s Medicare QIO effort for ACM Program

Immediate past President, Greater San Diego AHA Board

Barbara Ann Buesch RN, BSN

Quality Management Department

Palomar Medical Center,

Escondido, CA

Unfortunately, No Disclosures. Not one


August 29, 2007

10:00 AM DST


  • Review measures.
  • Definitions.
  • Tips to achieve success.
  • Maintaining gains.
  • Impediments to maintaining gains.
  • Hardwiring?
  • Future directions.
    • 30-day mortality measures.
    • PQRI. Get With The Guidelines is ahead of the curve.
    • New DRG regulations, rules.
ami performance indicators
AMI Performance Indicators
  • ASA at arrival
  • Time to thrombolytics*
  • Time to PCI*
  • ASA ,BB,ACE/ARB, Statin for LDL<100 at discharge
  • Smoking counseling
  • 30-Day post discharge mortality*

(* CMS Measures)

hf performance indicators
HF Performance Indicators
  • ACE/ARB if LVEF <40 %
  • Beta blocker if LVEF <40%**
  • Smoking counseling
  • LV assessment documented
  • All discharge instructions documented
    • Daily weights
    • 2 gm sodium diet
    • Follow up care
    • Activity prescription
    • What to do if the symptoms worsen
    • Medication education
  • 30-Day post discharge Mortality*

(** Physician CMS PQRI Measure)

(*CMS Measure)

stroke indicators
Stroke Indicators
  • Lytic considered for those eligible within 3 hrs of onset.
  • Antithrombotics within 48 hrs
  • DVT prophylaxis
  • Discharge on lipid lowering
  • Discharge on antithrombotics
  • Anticoagulation for atrial fibrillation
  • Smoking cessation
composite measure definition
Composite Measure Definition
  • The composite performance is the mean % of eligible measures received by each patient.
  • Calculated by summing the number of times patients received selected interventions and dividing that by the total number of interventions for which they were eligible.
composite measure example
Composite Measure Example
  • If 5 patients were eligible for 20 measures and received 18, then the Composite Measure Performance is 18/20, or 90%.
  • Any measure for which a patient isn’t eligible, e.g. beta blocker use precluded by active airways disease, does not appear in the numerator or denominator for that patient.
defect free measure definition
Defect Free Measure Definition
  • The number of patients who received all eligible interventions.
  • If a patient were eligible for 5 measures and only received 4, the Defect Free score is 0 %. If one patient received 5/5 measures, and a second received 4/5, the overall defect free percent would be ½ or 50% for those two patients. If each of 5 patients received 4/5 eligible measures, the defect free score for that group of 5 would be 0/5 or 0%.
  • Defect Free equals 100% compliance with eligible measures.
example of the value of defect free care calculation
Example of the Value of Defect-Free Care Calculation
  • 7 patients had STEMI’s in a reporting period.
  • Defect free care is defined as 90 minutes or less for door to wire.
  • Times were 100, 95, 35, 98, 23, 105, 104 minutes.
  • The mean door to wire time was 80 minutes. Not bad!
  • But defect free care was only 2/7 or 28%! This is a more thoughtful way to look at the data.
reduction in failure rate rfr definition
Reduction in Failure Rate (RFR) Definition
  • This is the difference between a hospital’s baseline score (calculated from the 2004 qtr 4 data for example)and its current score (2006 qtr 2 for example).
  • If there has been an increase from baseline to current, there has been a reduction in the failure rate.
rfr example
RFR Example
  • If a hospital has a 75% compliance rate with measures, then 25% is the failure rate. If the hospital wished to halve its failure rate, it would need to increase compliance to 75%+ 1/2(25%), or to 87.5%. Now the new failure rate would be 12.5%, or ½ of the old rate.
new ami hf pneumonia measures
New AMI/HF/Pneumonia Measures
  • Value Based Purchasing (CMS) (Hospital Measurement)
    • 30-day AMI mortality.
    • 30-day HF mortality.
    • 30-day Pneumonia mortality
value based purchasing
Value Based Purchasing

Value based purchasing is an attempt by CMS to actively affect quality of care delivered to Medicare recipients. Payments will vary depending on degree of adherence to quality measures. Some of these measures will require new relationships with doctors such as 30-day HF and AMI mortality. Other hospital outpatient measures are being developed. So far, they include AMI, HF, CAP, SCIP, and HCAHPS.

the quality goal
The Quality Goal
  • Every patient…
  • Every time…
  • Every admission…
  • Every discharge…
  • 100% compliance
  • It’s the right thing to do!!
  • Can the gains be sustained year after year?
  • Is there a process for maintaining gains?
  • What are the impediments to sustained performance?
  • What is the “Hardwiring” issue?
ami composite measure
AMI Composite Measure

2006-07 reflects Oct 06 – March 07

  • Can the gains be sustained year after year?
  • Is there a process for maintaining gains?
  • What are the impediments to sustained performance?
  • What is the “Hardwiring” myth?
who is responsible for quality
Who is responsible for Quality?

I’m sure glad the

hole isn’t in our end...

components of a quality program
Components of A Quality Program
  • Champions
  • Board, senior leadership support.
  • Committees
  • Forms
  • Education
  • Nursing support
  • Physician support.
  • Concurrent data entry
  • Data review
  • Accountability
  • Champions are found everywhere:
    • Nursing,
    • Medical staff,
    • Case management
    • Administration
board senior leadership support
Board, Senior Leadership Support
  • CEO and Board support mandatory.
  • Most boards are not willing to compromise on quality.
  • Senior leaders have the personnel you will need to accomplish your goals
  • They have the resources!!
  • Silos are for farms, not hospitals!!
  • Interdepartmental committees need to be created (ER- Cardiology)
  • Be sure you have the correct players at the table.
  • If they don’t come to the meetings, they don’t get to vote!
  • Enforce the rules of engagement!
  • Necessary to the quality effort.
  • Make what you want the norm.
  • Enable forced functions
  • Disable escape keys
  • Not cookbook medicine
  • Rapid and frequent change.
  • Must be user friendly.
  • Handoff checklist. Very important!! Checklist on admission and beginning and end of each shift!
what works for compliance strategies for improving vaccination rates inpatient
What Works For ComplianceStrategies for Improving Vaccination Rates (inpatient)

Crouse BJ, et al. J Fam Pract 1994; 38: 258-61.

computer based reminders not effective either
Computer-Based Reminders (Not Effective Either)
  • Physician order entry with decision support
  • Care-rules based on national guidelines
  • Escape-key was disabled!

Dexter PR, et al. N Engl J Med. 2001;345:965-970.

cautionary tale physician reminders alone are not effective either
Cautionary Tale:Physician Reminders AloneAre Not Effective Either
  • Setting
    • Primary MDs in 10 high-volume hospitals, 1996
  • Intervention
    • Explanatory fax sent to Primary MD requesting vaccination before hospital discharge
  • Result
    • 1.96% for influenza vaccine (n = 3)
    • 0.65% for pneumococcal vaccine (n = 1)
  • Survey – why not successful?
    • not stable for vaccination before discharge
    • patients were already vaccinated per MD (not always true!)

Bloom HG, Wheeler DA, Linn J. J Am

Geriatr Soc. 1999 Jan;47(1):106-10

  • PowerPoint presentations developed for each group specific to education/responsibility levels.
  • (Carry a flash drive with you)
  • Teach everyone anywhere they are:
    • Secretaries
    • Hospitalists
    • CEO’s
    • EMS personnel
    • Students (both nursing and MD)
physician s accountability
Physician’s Accountability
  • Do what is yours to do
    • MD specific (timely diagnosis, antibiotic selection, PCI response time, follow up)
    • Document accurately and thoroughly
  • Stay out of the way
    • Support standing orders / protocols based on evidence
    • Make use of and support system changes
  • Stay receptive
    • Openly receive concurrent support
    • Utilize summative feedback
    • Expect failure – make it obvious – engage in redesign
physician accountability
Physician Accountability
  • By law changes to reflect compliance with quality measures
  • Education to all new physicians on quality efforts
  • Progress reports
  • Calls and letters to non compliant physicians
  • Celebrate physicians’ contributions at annual meetings!
  • New CMS physician measures should help a lot.
concurrent data entry
Concurrent Data Entry
  • The most essential piece
  • Always has immediate impact in scores upon implementation.
  • Makes “100%” an attainable goal
  • Allows immediate correction of missing intervention before discharge
  • PDCA cycle will show that concurrent review is well worth the time and effort!!
  • GWTG helps with immediate data feedback prior to discharge when the data is entered concurrently and makes reporting even weekly possible
data and accountability
Data and Accountability
  • Timeliness is always an issue
    • Public reporting sites
    • CMS measures
  • Whose data is it anyway?
    • Admitting MD’s?
    • Attending MD’s?
    • Discharging MD’s?
    • Primary Care MD’s?
  • Can the gains be sustained year after year?
  • Is there a process for maintaining gains?
  • What are the impediments to sustained performance?
  • What is the “Hardwiring” myth?
  • People: As they lose interest, they need to be replaced
  • Time: No one has enough
  • Resources: No one has enough
  • Competing priorities among staff, senior leaders, and physicians
  • Schedule conflicts
  • Turnover of key players
  • Lack of strong role models
  • Perceived lack of support from management and senior leaders
  • Physicians are not taught organizational mentality
  • Nurses are not always willing to interact with a physician on quality issues
  • Availability or lack of qualified champions for all disciplines
  • A handful of people always tend to carry quite a bit of the program.
  • Can the gains be sustained year after year?
  • Is there a process for maintaining gains?
  • What are the impediments to sustained performance?
  • What is the “Hardwiring” myth?
hardwiring and backsliding
Hardwiring and Backsliding
  • The quality process requires constant maintenance or else it crumbles.
  • As errors inevitably arise they need to be investigated and the deficient area (e.g., a missing form, lack of new MD education, etc.) corrected.
  • Individual oversight type committees must meet regularly to find and correct problems in an ongoing fashion.
hardwiring and backsliding1
Hardwiring and Backsliding
  • Steering committee to oversee all quality initiatives needs to be set up with all key players represented.
  • Each core measure has its’ own team representation on the main steering committee
  • This steering committee reports directly to the Board of Directors
getting to the right care every time system change
Getting to the Right Care,Every Time System Change
  • Prevent unreliability
    • Build decision aids and reminders into the system
    • Standardize
    • Make the desired action the default
    • Use redundancy: built-in checking
  • Recognize failure
    • Make failure obvious – use metrics to measure the most common failure
  • Redesign the process constantly and quickly to reflect the changes to the measures.
future directions
Future Directions
  • Physician Quality Reporting Initiative (74+ measures).
  • New MS-DRG codes start October 2007
  • 30-day mortality issues.
  • Seamless continuum between office and hospital.
  • Present on admission (POA) requirements start January 2008.
lumetra collaborative results
Lumetra Collaborative Results
  • Mission: To reduce defect rate in HF, AMI and CAP
  • Results
    • State improved 40%
    • Collaborative improved 53%
  • Success!!

Qtr 4 2004 through qtr 4 2006

qualities of successful hospital in a collaborative
Qualities of Successful Hospital in a Collaborative
  • Ability to change immediately vs. months of committee discussion
  • Individuals are empowered to make these changes
  • Senior management believes in the power of the collaborative
  • As MD’s are being measured plus P4P, they will (and should)take a vigorous role in hospital QI programs, heretofore the purview of nursing.
  • Since the above is inevitable, this collaboration should begin now!
  • Programs like Metastar ACM and GWTG offer hospitals/MD’s a template for success not only in CV but other areas.
  • Sustaining any successful program over time is very difficult (just ask the Packers!! ) and requires much individual and group effort and creative, nimble systems.
  • Nevertheless, our patients deserve no less than our best efforts.
  • Medicare’s new programs should only add further incentive to hospitals and physicians in our efforts in quality care.
contact information
Contact Information

Robert M. Stein MD

1-760-781-8972 (pager)

1-760-212-1512 (cell)


Barbara A Buesch RN, BSN




albert einstein

“One should not pursue goals that are easily achieved. One must develop an instinct for what one can just barely achieve through one’s greatest efforts.”

-Albert Einstein