Lean Six Sigma CHF Core Measure

Monday, June 29, 2009 at 12:04:24 PM

The Lean Six Sigma Congestive Heart Failure Team has been working hard though the month of June to improve the process to help meet our CHF Core Measure requirements and provide ever-better patient care. We would like to thank everyone who provided input into the new process, which is summarized below. This process was designed to have all the CHF Core Measure requirements in one place. This will decrease the amount of times you will need to be questioned by the coder and abstractor.

In talking with nurses and providers over the last few weeks, we identified that some do not realize that any patient with newly diagnosed CHF or a history of CHF will fall into the CHF Core Measure, even if the patient is not having an exacerbation of CHF during their stay. As an organization, we do well with a primary diagnosis of CHF. It seems to be the cases where CHF is not the primary diagnosis that we fall out.

In the new process, when the CHF diagnosis is made or when a history of CHF is identified by the provider or nurse, then the nurse will print a CHF Core Measure Packet. In the packet will be pre-printed orders for CHF, a CHF Core Measure worksheet and the needed teaching material for the nurse. This worksheet will become part of the permanent record. It is a place where all the required documentation can be found by anyone who picks up the patientís chart. The worksheet was developed to decrease the defects in the current process.

Once a diagnosis of CHF is made, a CHF sticker will be placed on the bottom spine of the patientís chart to prompt to look for the worksheet. The worksheet will be found in the patientís chart under a new tab labeled ďCore Measure.Ē As a provider, you can write an order or ask for the packet to be printed. If the patient discloses a history of CHF during the nursing history, then the nurse will automatically put the CHF Core Measure material in the patientís chart.

Currently we are at the 70th percentile for the CHF Core Measure. We feel the implementation will help us reach our goal of 90th.

If there are CHF Core Measure failures: During the chart review, the worksheet will be reviewed if it was not utilized by nursing or the provider and inquiry will be made as to why. If there are blanks in the providerís section of the worksheet on discharge: The nurse will be calling the provider and documenting in the record that the provider was notified.

Roll-out: The new process will be rolled out on three units at Wilson Medical Center - South Tower 3, North Tower 3 and North Tower 4 - and on one unit at Binghamton General Hospital - Memorial 3 - over the next 30 days. This will be done to assess the improvements in the documenting process. On Aug. 1, we will have the roll-out United Health Services Hospitals-wide, with any improvements that were identified during the 30-day period.

If you have any feedback, suggestions or comments on this new Congestive Heart Failure process, it would be greatly appreciated if you could contact Emily Dorval at 763-6062 or Kim Brady 762-2859.


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