Checklists Transform Performance Measures for Heart Failure Care

Cleveland Clinic’s Sydell and Arnold Miller Family Heart & Vascular Institute is focusing efforts on providing high-level treatment to heart failure patients – and doing it right the first time – to reduce morbidity, mortality and readmission rates.

Umesh Khot, MD, Vice Chairman of the Robert and Suzanne Tomsich Department of Cardiovascular Medicine in the Miller Family Heart & Vascular Institute (HVI), and his team are shifting the focus from care following a hospitalization to standardizing treatment in the hospital to ensure that all patients receive high-level care from the outset.

A heart failure checklist

Using a multidisciplinary checklist, all team members – including nursing, nutrition, pharmacy, care management and physician providers – are on board with a specific care path. Each group has a specific responsibility – including education, medication review, discharge planning and follow-up appointments – that must be completed before a heart failure patient can be discharged.

“Early results have shown that this does seem to have an impact on readmission rates,” Dr. Khot says. “Through the process, if you do it right the first time while they are in the hospital, they do better in the long term versus trying to catch them once they’ve left to prevent a readmission.”

The heart failure checklist began as a 12-week paper-based pilot project in the HVI in April 2013. Kathleen Kravitz, MBA, BSN, RN, HVI Quality Director, says the pilot was limited to one nursing unit and two physician service groups.

“By implementing this multidisciplinary checklist, we were able to reduce 30-day readmission rates pretty significantly compared to other efforts, which didn’t move the needle as much,” Kravitz says, adding that the pilot groups exceeded their internal target of 20 percent readmission – which dropped to 14.6 percent compared to a rate of 26.5 percent the previous year.

Systemic change

Based on that success, the entire institute implemented an electronic checklist in October 2014. Kravitz says while there are still some issues to work out in the conversion to an electronic checklist, a great deal of education was done to bring everyone on board and that HVI remains under target for readmission rates for heart failure patients.

“If you came into the hospital with heart failure, these are things we expect to complete on every patient – and now we have a way of making sure it gets done,” Kravitz says. “It’s not duplication in documentation. Regular workflows continue, but the checklist pulls in information automatically so you have real-time information on what needs to be done and where we stand on each patient.”

National quality improvement efforts

Heart failure is the leading cause of hospitalization for Americans over age 65, and cases are increasing due to the aging population and a rise in the number of people with conditions that contribute to its development, including ischemic heart disease, hypertension and diabetes.

According to the American Heart Association, heart failure costs are projected to more than double in the next 20 years as the U.S. population ages and the incidence of the condition climbs. Direct and indirect costs to treat heart failure could more than double from $31 billion in 2012 to $70 billion by 2030.

Based on these numbers, the U.S. Centers for Medicare & Medicaid Services placed a focus on national quality improvement efforts to reduce readmissions. While other reasonable solutions to prevent readmissions failed – including patient monitoring by nurse practitioners or telemedicine and outpatient care following hospitalizations – Cleveland Clinic’s efforts to standardize treatment in the hospital are proving successful.

Umesh N. Khot, MD, is a Vice Chairman of the Robert and Suzanne Tomsich Department of Cardiovascular Medicine and a staff cardiologist in the Section of Clinical Cardiology in the Sydell and Arnold Miller Family Heart & Vascular Institute.

Kathleen Kravitz, MBA, BSN, RN, is Quality Director in the Miller Family Heart & Vascular Institute.