Hospital revamps CHF documentation process

Core measure compliance improves dramatically

At Maimonides Medical Center in Brooklyn, NY, congestive heart failure (CHF) has been among the top discharge diagnoses for many years.

"Long before Joint Commission and CMS [the Centers for Medicare & Medicaid Services] said that CHF was high on their list for patient care improvement, we were taking this population very seriously," says Sheila J. Namm, JD, RN, MA, vice president of professional affairs. "We are working to prevent a revolving door readmission process for these patients."

Here are key changes that were made to improve compliance with core measure requirements for CHF documentation:

• The discharge instruction sheet was revised to make documentation easier for clinical staff.

Before the format was changed, Namm held meetings with staff who used the discharge instructions and reviewed monthly compliance data. "We got a lot of feedback to make sure the documentation is not onerous," she says. "Initially, the sheet had a statement about specific criteria that had to be documented, but it turned out that wasn't sufficient."

Checkboxes were added and highlighted stating "for CHF patients, please address the following." This prompts the clinician to cover all the required criteria with the patient, gives the patient a document to take home and read, and allows this to be documented quickly and easily.

As a result of this change, there was some improvement in compliance noted, but not sufficient to meet the desired goal, so the CHF core measure team is working on additional improvements, says Namm. Compliance rates for discharge instructions went from 30% in 2005 to 84% in 2007, she reports.

• A monthly core measure team meeting is held with the clinical staff leadership that provides care to CHF patients.

Representatives from cardiology, nursing, and pharmacy meet each month to review cases identified by performance improvement, to see which aspects of the care didn't meet criteria. "We are now down to individual cases, which have failed to meet the criteria set by CMS," says Namm. "We have initiated several improvement projects around that. Most often, we find that the problem is documentation issues, and we then educate specific physicians."

For example, documentation may be required in several places in the patient's chart, such as the progress notes and discharge summary, but is found only in one place. "You can see the care was given, but the documentation was not as specific as CMS would like," says Namm.

• Physician-specific data are provided to the chairman of the department on a quarterly basis.

"We can see if certain individuals come up frequently as not providing the care or not documenting the care. But what we have found so far is that no specific physician or group of physicians stands out," says Namm.

• The CHF team is now capturing patients managed by a clinical department other than medicine, and are diagnosed with CHF while in the hospital for another diagnosis or procedure.

This group of patients doesn't necessarily have CHF as its primary diagnosis, if, for example, they come in for a surgical procedure and develop CHF as a new condition. "The CHF nurse practitioners are identifying these patients prior to discharge, consulting and recommending the plan of care," says Namm.

• The discharge prescription process for patients was automated, so the clinician only has to write prescriptions once.

At the same time the prescriptions are printed and electronically documented in the patient's record, an information sheet is printed for the patient about their medications. "That medication sheet can also be provided to their next treating practitioner," says Namm. "This was a major initiative."

Even though the organization has computerized order entry, physicians, residents, and physicians' assistants still had to hand write prescriptions at discharge, and then document these medications in the medical record.

"There were multiple places they had to write the information," says Namm. "Now, they just have to do it in the computer system, which prints the actual prescription and provides instructions for patients. Since physicians don't have to do it two or three times, our rates continue to go up in compliance."

• Monthly chart reviews are done.

"We review several hundred medical records per quarter, so we are doing a very adequate sampling. We get a very good picture about whether the changes we made in processes are working," says Namm. "And if they are not working, we bring it back to the core measure committee."

For example, the process for documenting that adult smoking cessation advice was given was changed to flow better. Although a smoking history is documented on the initial history and physical, there was not a consistent place designated in the medical record to document that smoking cessation counseling was given that would satisfy CMS requirements. This information is now included on the discharge summary.

The hospital's compliance rate for smoking cessation counseling increased from 89% in 2005 to 100% in 2007. "We also decided that all patients should be given smoking cessation advice and resources available for support, although CMS only requires that this information be given to patients with a history of smoking within one year prior to admission," says Namm. "We are not singling out one patient population. It has become routine for all patients upon admission."

[For more information, contact:

Sheila J. Namm, JD, RN, MA, Vice President of Professional Affairs, Maimonides Medical Center, 4802 Tenth Ave., Brooklyn, NY 11219. Phone: (718) 283-6839. E-mail: snamm@maimonidesmed.org.]