www.ohiokepro.com
Vol. 2 No. 3
Fall 2004
I
Preparing to Move
from SIP to SCIP
Page 5
I
Discharge Planning
for the Heart Failure
Patient
Page 7
I
Quality
Improvement
Plans Help Correct
Issues of Concern
Page 9
I
Electronic Medical
Records Improve
Quality of Care
Page 10
I
Flu and Pneumonia
Vaccination Rates
Still Lag in Ohio
Page 11
Rock Run Center, Suite 100
5700 Lombardo Center Drive
Seven Hills, Ohio 44131-2545
1.800.385.5080
IN THE NEWS
IN THE NEWS
Heart Disease: Not for Men Only
Guidelines published by the American Hear t Association in Februar y 2004 provide
updated recommendations for women at low, intermediate, and high risk for hear t
disease.
1
Smoking cessation and lifestyle changes remain the cornerstones for
cardiovascular disease prevention in women. However, aspirin, cholesterol-lowering
drugs, beta-blockers and ACE inhibitors are considered prudent treatment strategies
for women at high risk.
2
These inter ventions are consistent with the treatment
strategies in the Centers for Medicare & Medicaid Ser vices' (CMS) national Acute Myocardial Infarction and
Hear t Failure Projects, yet are less likely to be used in women and the elderly according to a 1996 study.
3
H
eart disease in women
has not been studied as
extensively as in men, but
this is changing. Studies are
being conducted to specifically
learn about how heart disease
develops and progresses in
women. While risk factors
for developing heart disease
are the same for men and
women (smoking, high
blood pressure, overweight,
sedentary lifestyle, diabetes,
high cholesterol, and family
history), women are more
likely to have atypical symp-
toms. These may include pain
or discomfort in the stomach,
nausea, fatigue, dizziness, pain
in the arms, neck or jaw, or
shortness of breath. Because
these symptoms are not
usually attributed to heart
disease, progression of the
disease can go undetected
in women until a coronary
event occurs.
Women tend to get heart
disease later in life than men,
so comorbidities often
contribute to the graveness
of their illness. In many
women, the first heart attack
is fatal. In addition, according
to 2001 statistics, 38 percent
of women die within one year
after a heart attack compared
to 25 percent of men.
4
Death rates in Ohio
According to a 1991-1995
Centers for Disease Control
and Prevention (CDC) study
of death rates in women by
state, women in Ohio died
at the rate of 437 per
100,000, ranking Ohio 40
out of 51 states (includes
the District of Columbia).
These were women aged 35
years and older, of all racial
and ethnic groups. Counties
in Ohio with the highest heart
disease death rates were found
around Toledo, the southern
part of the state, and the
eastern border near West
Virginia. The lowest rates
were found in the northwest
region to the central region
around Columbus.
Public campaigns such as Go
Red for Women (American
Heart Association), Women's
HeartAdvantage (The VHA
Foundation: a member-owned
and member-driven health-
care cooperative), and The
Heart Truth Campaign (The
Office on Women's Health
of the U.S. Department of
Health and Human Services
in conjunction with the
National Heart, Lung, and
Blood Institute of the
National Institutes of Health),
all focus on raising awareness
so women have accurate
information on heart disease
risks, prevention, and early
intervention.
Hospital Programs
in Ohio
Hospitals throughout Ohio
have embraced this effort
through community outreach
and employee programs. The
following hospitals have
agreed to share their programs
with Quality Matters' readers.
2
Lake Hospital System, Willoughby, Ohio
Lake Hospital System adopted the Women's HeartAdvantage
Program developed by the VHA. Its program, guided by a
steering committee, consists of activities directed to the
community as well as employees.
An initial telephone survey in Lake County revealed that of
500 random calls to women aged 40-70, 71 percent were at
risk for cardiovascular disease, yet only 27 percent were aware
of this risk. In terms of perception, almost one-half believed
their major health risk to be breast cancer. This survey formed
the basis for planning a comprehensive program.
Community activities have included the following:
·
A community kick off with heart-healthy food and
recipes offered by a local chef and education provided
by a dietitian.
·
"Get Healthy Lake County," a health promotion program
offered in partnerships with the Lake County YMCA,
Lake MetroParks, and Lake Hospital System. For a
$15.00 fee, members receive a pedometer and monthly
information on exercise activities.
·
Community walk cosponsored with the American Heart
Association, which raised $117,000 in 2004, its second year.
·
"Take Heart" program, which included a video lecture
by a VHA cardiologist, presentations on complementary
topics and heart screening assessments sponsored by a
grant from AstraZeneca. A similar program cosponsored
by Lakeland Community College will be held in
October 2004.
·
Free Smoking Cessation classes presented with funding
from the Tobacco Use Prevention and Control Foundation.
·
Weight reduction programs offered.
The employee program was launched in 2003 and included
the following interventions:
·
Health fair screenings and risk assessments. About 25
percent of employees participated.
·
A Primary Care Symposium on Cardiology held in
July 2004.
·
Education by Emergency Room physicians to Emergency
Medical Service workers on initial signs and symptoms
of heart disease in women.
Lake Hospital System has mobilized the community in a very
successful effort to increase education and early treatment
of heart disease in women. Diana Doner, RN, the vice president
of women's and acute care services who co-chairs this project,
is very optimistic about the program and enjoys support from
senior administration, quality management, employees, and
the community.
Akron General Medical Center, Akron, Ohio
The Women's HeartAdvantage at Akron General Medical Center
was launched in February 2003. This program coordinated
by Suzanne Hughes, MSN, RN, and George Litman, MD,
Medical Director of the Heart & Vascular Center, and Deborah
Plate, DO, physician champion for Women's HeartAdvantage,
has enjoyed great success. A survey performed prior to and
after the awareness campaign revealed that women's
perceptions had changed as follows:
·
The percentage who answered that heart disease is
women's greatest health threat rose from 30 percent to
41 percent.
·
The percentage who perceived that breast cancer was
their greatest health threat decreased from 50 percent
to 33 percent.
In addition, the percentage of women arriving in the Emergency
Department within four hours of symptom onset rose from
50 percent to 75 percent by the end of the year.
A unique component of this program involved traveling to
reach women in the workplace. A grant (from AstraZeneca)
received through the VHA allowed Ms. Hughes, Dr. Plate, and
Alice Luse, area American Heart Association executive director,
all dressed in red, to visit six local businesses, houses of worship,
and schools to spread the message about women's heart health.
Six hundred women heard the message, received red dress pins
(symbol of women and heart disease), pedometers, and vouchers
for a complimentary cardiovascular risk assessment including
a lipid profile and blood pressure check.
Finally, Ms. Hughes developed an educational program on
women and heart disease that she has presented to multiple
professional groups at Akron General Medical Center and
other local healthcare facilities. The program offers continuing
education credits to both RNs and LPNs.
(Continued on page 4)
3
Hospital Programs in Ohio (Continued from page 3)
The Hear t Hospital at Forum Health,
Youngstown and Warren Ohio
According to Marla Sferra, Marketing and Public Relations
Specialist for Forum Health, the Heart Hospital launched its
support of Go Red for Women in 2004, an initiative of the
American Heart Association. The goal of this campaign is to
increase awareness and educate women about heart dis-
ease. This national initiative was supported by hospital
efforts such as distributing more than 2,500 red dress pins,
providing educational material, and participating in TV and
radio public service announcements.
Professional and community education programs were also
sponsored by the health system. Major components of the
message included:
·
Heart disease is the number one cause of death
among women.
·
Heart disease kills more women than all cancers
combined.
·
Gender differences exist in types of symptoms.
·
Menopausal symptoms confuse the diagnostic picture.
healthcare decisions for families, increasing awareness and
encouraging early intervention made sense as a focus of
ProMedica's efforts.
Interventions for employees led to some dramatic findings.
An employee with a blood sugar of 600 was identified, paged,
and gave permission to send her results to her primary care
physician. In another instance, an employee was sent for
a cardiac catheterization and had surgery one week after
screening.
These hospitals are but a few blending their responsibilities for
acute care with those for employee and community outreach.
Prevention is critical. If your hospital would like to share
its experience with community outreach and employee
programs related to heart disease and women in a future
issue of Quality Matters, please contact your Ohio KePRO
Quality Improvement Project Leader at 1-800-385-5080,
or via e-mail at hospital@ohqio.sdps.org.
New Medicare law
The new Medicare law provides Medicare coverage for an
initial preventive physical exam that includes cardiovascular
screening blood tests, such as total cholesterol, HDL, LDL, and
triglycerides. In order to be covered, the initial preventive
physical exam must be performed no later than 6 months
after the date a Medicare beneficiary's coverage first begins
under Part B. It only applies to those whose coverage for
Part B begins on or after January 1, 2005. Screenings are
paid for once every five years. There is no deductible or
co-pay for these tests.
5 Please help spread the word about
heart disease in women, as well as the new Medicare
coverage so that lives can be saved.
I
References
1. Circulation. 2004; 109: 558-560, 672-692
2. Circulation. 2004;109: 558-560, 672-692
3. McLaughlin, TJ, Soumerai SB, Willison DJ et al. Arch Intern Med.
1996:156:799-805 AHRQ Grant HS07357)
4. (AHA: Women and Coronary Heart Disease http://www.americanheart.org)
5. Medicare Modernization Act of 2003 or http://www.cms.hhs.gov/media/press
ProMedica Hospitals, Greater Toledo
ProMedica Hospitals (The Toledo Hospital, Toledo Children's
Hospital, Flower Hospital and Bay Park Community Hospital)
have all embraced the Women's Heart Advantage program of
the VHA. Paula Grieb, RN, Community Health Manager for
ProMedica Hospitals, reveals the scope of the program includes
employee and community activities. Beginning in late 2003,
this program encompasses system-wide goals of cardiovascular
disease prevention.
An educational program was provided to the community
in conjunction with Owens Community College, Pfizer, the
American Heart Association, Kohl's, and SOTO, a salon and
day spa. Four hundred women attended to hear lectures and
a panel of experts and to witness a survivors' fashion show.
Health screenings took place with referrals to primary care
physicians if the women were found to be at risk. Follow-up
phone calls were made to ensure that these women had visited
their physicians. Based on the fact that women typically drive
Useful Web Sites
--Barbara G. Stiebeling, RN, MSN, QI Project Leader
4
PREPARING TO MOVE
FROM SIP TO SCIP
The Surgical Care Improvement Project (SCIP) is a joint endeavor of the Centers
for Medicare & Medicaid Ser vices (CMS) and the Centers for Disease Control and
Prevention (CDC), with the ultimate goal of significantly improving surgical care in
the United States through the prevention of complications associated with surger y.
SCIP is a multifaceted project encompassing three separate but interrelated
components. The following describes these three impor tant components.
W
hat is the SCIP Pilot?
Led by a Steering Committee
comprised of CMS, CDC, the Department
of Veterans Affairs (VA) and numerous
national professional organizations, a
pilot project was initiated to determine
the most effective ways to reach the
CMS and CDC goal.
In September 2003, CMS awarded
contracts to two state Medicare Quality
Improvement Organizations (QIOs).
Ohio KePRO, the Ohio QIO, and Health
Care Excel, the Kentucky QIO, are the
Medicare contractors for the two-state
pilot. The Oklahoma Foundation for
Medical Quality, the Oklahoma QIO,
is also contributing to the Ohio pilot.
The SCIP Pilot is a Medicare demon-
stration project designed to assess the
feasibility of engaging private sector
hospitals to reduce the incidence of
postoperative morbidity and mortality.
What is the SCIP Program?
The SCIP Program refers to the pro-
grammatic and technical elements of
SCIP. In the future, the program is likely
to encompass materials and activities
such as educational aids for clinicians
use, an information exchange network
for organizations implementing SCIP,
a communication toolkit to reach
decision makers, clinical guidelines to
address SCIP measures, and other
implementation tools that capture
best practices to assist practitioners
with achieving successful improvements
at their hospital.
The technical elements consist of process
measures (including specifications),
outcome measures (including appro-
priate risk adjustment methods), and
the Surgical Processes and Outcomes
Tool (SPOT) database and electronic
data collection tool.
infarction (AMI), cardiac arrest, pul-
monary embolism, deep vein thrombosis,
and ventilator-associated pneumonia
seen during index hospitalization.
Finally, to simplify and standardize the
data collection, analysis and reporting
process for the measures, CMS has
developed SPOT for use at participating
hospitals. SPOT is a database that
incorporates both the National Surgical
Quality Improvement Program (NSQIP)
tool developed by the Veterans Health
Affairs and the National Healthcare
Safety Network system developed by
CDC. SPOT also offers a user-friendly
interface for data gathering in the clinic.
The tool includes a number of unique
features that allow ease of use and
flexibility while still requiring strict
consistency of field definitions.
The pilots are testing the feasibility of
collecting, reporting, and analyzing
surgical processes and outcome
measures in a community setting, and
enhancing quality improvement through
appropriate interventions. Lessons
learned in the two-state pilot will guide
a national approach to surgical care
improvement as the SCIP goals are
incorporated into the larger QIO
program during the 8th Scope of Work,
which begins on August 1, 2005.
The measures were identified and
selected by the SCIP technical expert
panel and approved by the SCIP steering
committee. Together the process and
risk-adjusted outcome measures describe
a robust performance measurement
program for surgical care improvement.
The process measures currently focus on
reducing or preventing complications in
four broad areas: infection, respiratory,
thromboembolic, and cardiovascular.
The outcome measures include 30-day
mortality and hospital readmission.
Also included are the proportion of
wound infections, acute myocardial
(Continued on page 6)
5
SIP to SCIP (Cont. from page 5)
What is the SCIP Par tnership?
The SCIP Partnership is a coalition of
organizations interested in improving
surgical care through the reduction of
postoperative complications. The
Partnership was initiated by CMS in
recognition of the significant efforts
required to make surgical care
improvements.
The Partnership is intended to help
bring about national change in surgical
care. The effort will eventually reach a
wide variety of clinical providers,
healthcare leaders, and health policy
decision makers. Only when providers
such as surgeons, anesthesiologists,
perioperative nurses, pharmacists, and
infection control professionals work
together with hospital executives to
elevate surgical care improvement as
a priority within their organization
will real progress be made. The partners
work both together and independently
to raise the profile of SCIP and make
the case for the importance of surgical
care improvement. In joining SCIP,
partner organizations signal to both
their own members and to external
audiences that they support the goal
of improving surgical care through the
prevention of complications. They
also support and endorse the SCIP
measures as national standards of quality
in perioperative surgical care and
commit to working together to establish
and maintain consistency and alignment
in a core set of measures. Moreover,
SCIP partners agree to help advance the
goal of SCIP through the contribution
or deployment of organizational
resources. At a minimum, such a
contribution may simply mean providing
expert talent to SCIP workgroups.
However, a number of partners have
expressed interest in making a greater
contribution through activities such as:
·
Educating clinical providers and
healthcare leaders on the objectives
of SCIP and the need to prevent
complications associated with
surgery;
·
Conducting member outreach to
inform and educate members about
SCIP and its goals and methods;
·
Working with other SCIP partners
to develop and disseminate tools and
information on how to reduce
complications;
·
Helping to create incentives to
reward improvements in peri-
operative surgical care.
The Partnership is coordinated through
a steering committee that includes
representatives of both public agencies
and private organizations. A technical
expert panel supplements the expertise
of this broad coalition with representatives
from an additional 15 organizations.
SCIP Steering Committee Members
American Hospital Association (AHA)
Agency for Healthcare Research
and Quality (AHRQ)
Depar tment of Veterans Affairs (VA)
Association of periOperative
Registered Nurses (AORN)
Centers for Disease Control and
Prevention (CDC)
American College of Surgeons (ACS)
American Society of
Anesthesiologists (ASA)
Centers for Medicare & Medicaid
Services (CMS)
Joint Commission on Accreditation of
Healthcare Organizations (JCAHO)
How can we prepare?
Hospitals that wish to be prepared for
the transition of the Surgical Infection
Prevention Project (SIP) into SCIP in the
8th SOW can take specific steps now.
Ohio KePRO has developed a "Phase
Two Level of SCIP Involvement" for
hospitals that are not in the group
currently collecting data for the pilot.
If you are currently collecting data for
SIP, or considering adding SIP measures
to your quality improvement program,
Ohio KePRO is interested in working
with you on a one-to-one basis to plan
for positioning your facility for SCIP.
I
For Fur ther Information
For further information, please call or e-mail: Lynn Mistovich, RN, Project Leader, 1-800-385-5080, ext. 2138,
lmistovich@ohqio.sdps.org.
--Lynn Mistovich, RN, QI Project Leader
6
Ohio Hospitals Need to Improve
Discharge Instructions Given to
Heart Failure Patients
Providing appropriate discharge instructions to the hear t failure patient is an integral piece of the patient's
treatment plan. The Centers for Medicare & Medicaid Ser vices (CMS) monitors a number of best practice/
evidence-based criteria for Hear t Failure. HF-1 is the measure that captures documentation of the care and
education provided to the patient at discharge. This is a CMS and Joint Commission on the Accreditation
of Healthcare Organizations (JCAHO) core measure.
recent article in the
Journal of the American
Medical Association (JAMA)
underscores CMS's and
JCAHO's emphasis on
appropriate discharge
documentation and education
of heart failure patients at
discharge.
1 Phillips, Wright,
Kern et al. state "Readmissions
have increased since the
introduction of the Medicare
Prospective Payment System
and may reflect suboptimal
assessment of readiness for
discharge, fragmented dis-
charge planning, a breakdown
in communication and
information transfer between
hospital-based physicians
and community physicians,
inadequate postdischarge
care and follow-up, or some
combination of these
processes whose resolution
may require better coordina-
tion of care or comprehensive
discharge planning."
A
The authors further state
that in the "United States
approximately 700,000
Medicare beneficiaries with
CHF are discharged annually
from nonfederal short stay
hospitals, and 50 percent will
be readmitted within 6 months
at an average cost of $7000
per readmission. Based on
the results of this meta-
analysis and assuming a
25 percent reduction in
readmissions, the authors
conclude that postdischarge
support with a home visit
could prevent 84,000 read-
missions, with an estimated
reduction in Medicare
payments of $424 million
per year, after adjusting for
the cost of the discharge
planning with a home visit."
Discharge measure
HF-1 is stated as follows:
Heart failure patients dis-
charged home with written
discharge instructions or
educational material given
to patient or caregiver at
discharge or during the
hospital stay addressing
ALL of the following:
·
Activity level
·
Diet
·
Discharge medications
·
Follow-up appointment
·
Weight monitoring
·
What to do if
symptoms worsen
Ohio hospitals have reported
on this measure for some
time. Performance varies
widely in the state, ranging
from 0 to 100 percent. Many
hospitals fall between 50
to 60 percent. Obviously,
there is a lot of room for
improvement.
This article will focus on
ways that hospitals in Ohio
can improve the quality and
quantity of their discharge
documentation and educa-
tion for heart failure patients,
thereby enabling them to
improve care and meet the
CMS and JCAHO measures.
Documentation
Many hospitals use a booklet
or brochure for the patient
and family to take home that
includes detailed discharge
instructions. Although this
may provide all the infor-
mation that a patient and
(Continued on page 8)
7
Discharge Instruction and Planning
(Continued from page 7)
family needs, it still leaves gaps in the intent of the discharge
instruction measure. The Illinois Foundation for Quality Health
Care (IFQHC) suggests in its January 2004 position statement
on Heart Failure Discharge Instructions that "hospitals not
use solely `documentation that a booklet was given' as acceptable
for hospital-generated data but reinforce documentation of
all discharge teaching elements in the record as the best means
of ensuring continuity of care. This also avoids handing out
a booklet with no further explanation or education provided."
The IFQHC recommends "the location of this documentation
in the patient chart is important. Recommended locations to
record written discharge instructions or education material
provided to the patient or caregiver include: care plans/
clinical pathways, discharge instruction sheet, discharge
progress notes, discharge summary, home health referral
form, nursing discharge notes, physical therapy notes, dietary
notes, and teaching sheets."
Ohio KePRO emphasizes that to be fully compliant with the
discharge measure, patients or their families must go home
with written heart failure discharge instructions.
Overcoming discharge planning barriers
The authors of the JAMA article cited above note there are
many opportunities for "disconnects" for discharged Heart
Failure patients. These include the following:
·
Fragmented discharge planning.
·
A breakdown in communication and information
transfer between hospital-based physicians and
community physicians.
·
Inadequate postdischarge care and follow-up or
some combination of these processes whose resolution
may require better coordination of care or comprehensive
discharge planning.
Cheryl Gies, RN, Inpatient Cardiac Rehabilitation Cardiovascular
Case Manager, Blanchard Valley Regional Health Center, has
significant experience with these problems and offers many
solutions. "It is important to involve the right people when
doing discharge planning for CHF patients: follow the patient,
follow the family and/or caregivers, understand the
communication pathways in the hospital, and then go
about connecting the staff in the acute and post acute
care departments," said Gies.
At Blanchard Valley Regional Health Center, Gies has worked
hard to connect the staff. When a patient is admitted, the
nurse begins the discharge planning process using the Meditech
system to produce an interdisciplinary discharge assessment.
Before discharge, explains Gies, nursing will sometimes call
the physician's office to schedule follow-up appointments and
reviews the written discharge instructions with the patient
and/or family before discharge. The Social Work Department
coordinates the discharge arrangements with the family and,
if necessary, a home health agency or a nursing home.
However, there are still significant disconnects for Gies and
her patients. One of the most significant problems is with
medications schedules for home administration. Gies uses the
Identi-Drug System with the Medi-chest pill organizer to help
her patients coordinate their medications. But many other
factors come into play: Is the patient being sent home too
soon? Are the discharge instructions adequate? Is the staff
doing an adequate job communicating the discharge
instructions? Does the patient understand the instructions?
Other factors
Did you know that any patient education material should be
designed and written at a 6th grade level to ensure that all
patients have a chance at comprehension? How widespread
is the problem of illiteracy in Ohio? Almost 50 percent of
Ohioans read at or below the 8th grade level. In a 1992 study,
which reports the latest data on literacy in Ohio, 16 to 18
percent of Ohioans read at Level 1--about 5th grade. Twenty-
seven to 31 percent read at about an 8th grade level. Most
printed and Web-based health information is at a 10th grade
reading level or above and does not follow research-based
Plain Language guidelines. This gap between reading
comprehension level and the actual reading level of printed
and Web-based materials can adversely affect patient care.
The 1992 study found that in the following groups about
three-quarters read at an 8th grade level or below, and
about one-half read at a 5th grade level or below:
·
Those 65 years of age or older
·
Minority populations
·
Immigrant populations
·
Those who receive welfare
·
People with chronic mental and physical health conditions
Health literacy
Reading level can be an indicator
of how a patient will compre-
hend materials given to him or
her by a healthcare provider.
However, health literacy goes
beyond the simple ability to read.
Rather, it is the ability to read,
understand, and use health informa-
tion. It requires a complex group of
reading, listening, analytical, and
decision-making skills that can be
applied to health situations.
The following are some tips
healthcare providers can use
when preparing
written
discharge
materials to
improve the
health literacy
of their patients:
(Continued on page 9)
8
·
Clearly define the audience and message.
·
Write information at a 6th grade reading level or lower.
·
Make informational reading quick and easy.
·
Limit text to minimize required reading.
·
Focus on behavior.
·
Limit concepts.
·
Emphasize positive behavior, not incorrect action.
·
Use common words and concrete examples.
Avoid "medicalese" and jargon.
·
Define new words and medical terms, and then
identify them.
·
Health Literacy: It's Time to Take it Seriously.
(A list of articles.)
·
Examples of Rewritten Consumer Health Information.
·
Physician Office Quality Improvement Teleconference
Health Literacy CD. This teleconference features the
health literacy presentation, "Health Literacy: It's Time
to Take it Seriously" by Sandra Cornett, PhD, RN,
OSU/AHEC. The CD may be ordered by clicking on
"Shopping Bag."
Other excellent sources of health literacy information are
the following:
·
"Providers Guide to Quality and Culture" at
http://erc.msh.org.
·
Information on Health Literacy from the Partnership for
Clear Health Communication at www.askme3.org.
·
"NMA Cultural Competency Primer" at www.askme3.org.
This primer can also be found in Ohio KePRO's
Physician Office Toolkit at www.ohiokepro.com.
The following items are available free of charge to healthcare
providers from Ohio KePRO's Web site at
http://www.ohiokepro.com/providers/physician/index.asp#pokotpm
Coordination crucial
There are many barriers to success with high-quality care for
the heart failure patient. It is clearly a patient population
that requires coordination of acute and nonacute caregivers
working together to decrease the risk of readmission and
to improve survival rates. Research shows that providing a
well-coordinated, high quality, "best practice" approach
decreases the cost of care and produces cost savings.
Comprehensive discharge planning plus postdischarge
support for older patients with heart disease optimizes the
transition from acute hospital care to home.
I
·
Tips from Literacy Experts: How to Get Your Message Across.
·
OSU/AHEC (Ohio State University/Area Health
Education Center) Health Literacy Program--Assessing
Reading Ability and Literacy Levels.
·
How to Use the SMOG Formula. (A method to determine
the reading level of materials.)
·
OSU/AHEC Health Literacy Program--Complex Versus
Simple Words and Phrases.
References
1. Phillips, C.O., Wright, S.M., Kern, D.E., et al. Comprehensive Discharge
Planning With Postdischarge Support for Older Patients With Congestive
Heart Failure: A Meta-analysis. JAMA. 2004; 291 (11), 1358-1367.
--Diane Oye, RN, BA, QI Project Leader
Quality Improvement
Plans Help Correct
Issues of Concern
Ohio KePRO's Review Department is
working with providers throughout the
state to improve quality of care delivered
to Medicare beneficiaries. The quality
improvement plan is a valuable tool used
by the Review Department to help correct
issues of concern related to quality,
utilization, and coding.
Typically, a physician-reviewer or
review coordinator determines from
beneficiary complaints or chart reviews
that there might be an instance or pat-
tern of care that merits intervention.
Ohio KePRO's Medical Director then
sends a letter to the provider outlining
the concern(s) and requests a Quality
Improvement Plan be implemented to
address the area of concern and improve
the process. If necessary, Ohio KePRO
helps the provider develop the quality
improvement plan. Ohio KePRO is
required to notify the Centers for Medicare
& Medicaid Services (CMS) if a provider
refuses to participate in the development
of a quality improvement plan.
Quality Improvement Plans must
contain the following elements:
·
A description of expected outcomes
and goals. These must be measurable.
·
A description of actions to be taken
to correct the quality concern.
·
A timeframe for initiating and
completing the plan.
·
A description of the process for
ensuring the actions resolve the
pattern of concern.
At predetermined intervals, Ohio KePRO
monitors the progress of the quality
improvement plan. After successful
completion of the quality improvement
plan, Ohio KePRO sends a letter to the
provider indicating the case has been
closed.
I
--Carole Tarbuck, RHIT,
Review Specialist
9
Electronic Medical Records
Improve Quality of Care
Electronic medical records (EMR) are
revolutionizing the practice of outpatient
medicine, according to Gerald Ehrsam, MD,
a board-cer tified internist with the Licking
Memorial Internal Medicine group in Newark,
Ohio. Dr. Ehrsam's group of about 70
providers "took the plunge" with electronic
medical records four years ago and have
seen substantial dividends in terms of quality
of care improvements and office efficiency.
T
he system used by the
Licking Memorial Health
Professionals enables patients
and physicians to view the
patient's medical record on a
flat screen monitor located
in each exam room. "We use
the computer as an educa-
tional tool," said Dr. Ehrsam.
The physician and patient can
simultaneously review the
patient's medical history,
including test results and
medications. Numerous
personalized handouts as
well as prescriptions can be
printed directly to a printer
located in each exam room.
Information can be added to
the EMR in the exam room
during the patient's visit,
thereby saving the physician
time. In addition, the elec-
tronic medical records of all
patients are accessible to the
group's physicians in any
location where needed (home,
hospital, etc.). Dr. Ehrsam
notes that his group's system
has strong security features
and is HIPAA compliant.
"Being successful with pre-
ventive measures is all about
improving one's processes,"
said Dr. Ehrsam. The EMR
helps by generating prompts
that display directly on the
patient's chart to remind
providers of needed tests or
preventive services. It is also
linked electronically with
the laboratory and radiology
department at Licking
Memorial Hospital. Test
results are added directly
to a patient's EMR.
A key aspect of the Health
System's quality program
is its Intranet portal. This
monitors all quality measures
and provides physicians 24/7
availability from any com-
puter. Physicians in the group
can track how well the
practice is performing in
specific areas such as
disease management (i.e.,
diabetes, heart disease),
immunizations, or patient
safety issues.
"The system informs physi-
cians in our group how they
are doing with respect to
particular quality measures,
said Dr. Ehrsam. He adds that
this process allows physicians
to answer questions such as
"Are particular tests being
done?" "What are the out-
comes?" "How are we as
providers performing?"
Patient safety
Dr. Ehrsam emphasizes
EMR systems have the
potential to dramatically
enhance patients' safety
and reduce medical errors.
For example, the system
used by Licking Memorial
Health Professionals gener-
ates warnings about drug
interactions and even alerts
the provider as to which
drugs are on the patient's
insurance formulary. In
addition, notes Dr. Ehrsam,
"within 24 hours we can
notify our patients if a drug
they are taking has been
recalled."
A new way to look at quality
Dr. Ehrsam emphasizes that
his group's EMR improves
the accuracy of quality
reporting. "This has resulted
in a tremendous improve-
ment in our quality measures
numbers," he said. "We're
now able to look at whole
populations of patients and
get exact numbers with
respect to how our group is
performing on specific
quality measures rather
than relying on random
chart audits."
Dr. Ehrsam acknowledges that
there is a learning curve
when a practice switches from
a paper medical records
system to an electronic one.
But he's quick to point out
that once the system is up
and running, practices will
never look back.
I
--Linda Wozniak, LPN, QI
Project Leader
10
Flu and Pneumonia Vaccination
Rates Still Lag in Ohio
The Centers for Medicare & Medicaid Ser vices (CMS)
Sur veillance Data for 2003 paint a dismal picture
regarding pneumococcal and influenza vaccination
rates in Ohio. As the accompanying char t shows, for
Medicare patients admitted for pneumonia in 2003,
nurse, and Abdul Halawa, MD, IC physician, designed a form
that assesses patients' immunization status on admission and
prompts the physician to order the administration of the
vaccine if the patient is not immunized or if his or her status
is unknown. In addition, the patient's immunization status
is part of the discharge instruction sheet. This "final look"
helps ensure that the patient receives appropriate immu-
nizations. If a patient is transferred to a nursing home, that
facility is given on transfer the patient's immunization status.
The non-nursing home patient is given the immunization
status form to take to his or her primary care physician.
only 32 percent and 28 percent received the pneu-
mococcal and influenza vaccines, respectively, prior
If your hospital has an immunization "best practice" it would
like to share in future issues of Quality Matters, please contact
your Ohio KePRO Quality Improvement Project Leader.
I
to discharge. These low rates exist despite a 2002
federal regulation regarding standing orders that
Gaps in Appropriate Care
promote greater access to influenza and pneumonia
Medicare Patients Admitted for Pneumonia in 2003 Who Received the
Influenza and Pneumoccal Vaccines
vaccinations for hospitalized patients. Under this
regulation, if a patient chooses to be immunized,
appropriate healthcare professionals may administer
a shot on the spot without the need for a physician
to write a new order each year.
For the exact text on the use of standing orders in Ohio, please
refer to the joint regulatory statement of the State Medical
Board of Ohio, the Ohio Board of Pharmacy, and the Ohio
Board of Nursing on the following Web sites:
http://med.ohio.gov/positionpapers/Protocols.htm, and
http://pharmacy.ohio.gov/rphAdminImmun-030919.htm.
Pneumoccal Vaccine
Influenza Vaccine
68%
32%
Goal = 100%
I
Received Appropriate Vaccination I Did Not Receive Appropriate Vaccination
28%
72%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% of Patients
Graph prepared by Meghan Harris, MS, Biostatistician
Best practices
The flu and pneumonia vaccination situation is not entirely
bleak, however. A number of hospitals in Ohio have instituted
best practices that are yielding results. The following are
two examples:
Union Hospital, Dover
At Union Hospital, a physician who spearheaded its
Immunization Project was able to gain physician support
for immunization standing orders. Tom Kelly, DO, Vice
President of Medical Affairs, was able to communicate and
champion the need for the use of standing orders that do
not require a physician signature to assess and administer
immunizations. The final protocol, which was developed by
the hospital's interdisciplinary project team (pharmacy,
nursing, and quality improvement staff), contains standing
orders for the flu and pneumonia vaccine. In practice, hos-
pital staff uses an order sheet for both flu and pneumonia
vaccine to increase vaccination rates, according to Kathy
Cummings, RN, Manager, Care Management.
--Patricia Nelson, RN, QI Project Leader
TV Segment to Promote Pneumococcal
and Influenza Vaccination
Joseph Sopko, MD, the Director of the Department of
Medicine at St. Vincent Charity Hospital in Cleveland, will
represent Ohio KePRO as its pulmonary consultant in an
upcoming television segment to promote pneumococcal
and influenza vaccination. Dr. Sopko will be a guest on
"Golden Opportunities" on WKYC-TV 3 in Cleveland on
Sunday, October 17, 2004 at 12:30 p.m. Viewers will be
invited to receive free of charge the Ohio KePRO pneumonia
brochure for beneficiaries, and will be encouraged to
update their vaccination status with their physician.
Free Patient Education Materials
Geauga Regional Hospital, Chardon
UHHS Geauga Regional Hospital is having success with a
system where assessment for immunization status occurs
from a patient's admission to discharge. Rita Johnson, IC
To order, go to www.ohiokepro.com and click on
"Shopping Bag," or call 1.800.385.5080.
11
Are You Connected?
QUALITY IMPROVEMENT CALENDAR
2004 Fall Regional Seminars
With a weekly healthcare update, you can be.
Human Factors
Patient Safety Quality Improvement
Sign up to receive a weekly e-mail that highlights
FREE healthcare events presented by Ohio KePRO
and other healthcare-related events around Ohio.
Ohio KePRO supports training sessions for topics
relevant to hospitals, physician offices, nursing
homes, and home health agencies. Continuing
education is available for most sessions.
To subscribe, call 1.800.385.5080 or go to
www.ohiokepro.com and click on Publications >
Newsletters > Subscribe.
October 7, 2004
Roberts Convention Center
Ramada Plaza
123 Geno Road
Wilmington, Ohio
937-283-3200
October 8, 2004
Quest Business Center
8405 Pulsar Place
Columbus, Ohio
614-540-5540
For more information on the above seminars, please contact Ohio
KePRO's Acute Care Services Team at 1-800-385-5080;
hospital@ohqio.sdps.org.
Publication No. 4020-OH-004-9/2004. This material was prepared by Ohio
KePRO, the Medicare Quality Improvement Organization for Ohio, under contract
with the Centers for Medicare & Medicaid Services (CMS), an agency of the
U.S. Department of Health and Human Services. The contents presented do
not necessarily reflect CMS policy.
www.ohiokepro.com
Acute Care Ser vices Team
David A. Bitonte, DO, MBA, FAOCA
Rita Bowling, RN, MSN, MBA, CPHQ
Jennifer Bitterman, RHIA, MBA
Meghan Harris, MS
Lynn Mistovich RN
Donna Moore, RN, MBA, CPHQ
Patricia Nelson, RN
Diane Oye RN, BA
Karl E. Peters
Rosann Pasko, MS
Liz Simpson
Barbara G. Stiebeling, RN, MSN
Amanda Stroupe, MPH
Mona D. Wendell, RN, BA, MBA
Alina S. Wilkinson, MA
Medical Editor:
David A. Bitonte, DO, MBA, FAOCA
Executive Editor:
Suzana C. Iveljic, MBA
Editor:
Rober t A. Feigenbaum, MS
Associate Editor:
Barbara G. Stiebeling, RN, MSN
T H E FA L L 2 0 0 4 I S S U E O F Q U A L I T Y M AT T E R S H A S A R R I V E D !
A Newsletter for Acute Care Ser vices
Ohio KePRO Provider QIC Line--Your Quality Improvement Connection: 1-800-385-5080 · www.ohiokepro.com · hospital@ohqio.sdps.org
