Systems Approaches to Quality Care in Hospitals Kentuckys Get With the Guidelines Approach

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Systems Approaches to Quality Care in Hospitals
Kentuckys Get With the Guidelines Approach

• September 18, 2007
• Bonita A. Bobo, RN, IBCLC
• Program Manager
• Heart Disease and Stroke Prevention Program
• Kentucky Department for Public Health

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The Kentucky Derby The Race is On
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The Kentucky Problem-

• Kentucky has the highest smoking rate in the
  nation.
• Kentucky has higher than national averages in
  heart disease and stroke mortality.
• Hypertension in Kentucky whites and blacks is
  higher than the national average for all adults.
• Kentuckys average for high blood cholesterol is
  higher than the national average.
• Kentucky has no statewide network for system
  change.

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The Kentucky Problem-

• Health care costs increasing due to risk factors
  of heart disease and stroke
• Health care not always provided equally
• How do we reach the 2010 goals if we keep doing
  the same things the same way?

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The CDC Guidance-

• Promote policy and system change to assure
  quality care through adherence to primary and
  secondary prevention guidelines.

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Short Term Outcomes

• Increase the number of people who have high blood
  pressure under control
• Increase the number of people with total blood
  cholesterol less than 200 mg/dL
• Increase the number of people who know the signs
  and symptoms of heart attack and stroke, the risk
  factors for heart disease and stroke, and the
  importance of calling 9-1-1
• Improve Emergency Response

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Long Term Outcomes

• Improve quality of care
• Eliminate disparities in terms of race,
  ethnicity, gender, geography, or socioeconomic
  status
• Decrease mortality
• Decrease health care costs

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Partners

• American Heart Association/American Stroke
  Association
• Implement Get With the Guidelines for coronary
  artery disease, stroke and heart failure
• Health Care Excel (Kentucky Medicare QIO)
• Kentucky Hospital Association

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What Path Should We Take?

• Evidence based guidelines developed by AHA
• Implement Get With the Guidelines in Kentucky
  hospitals
• Provide guidelines-based care to all patients
  regardless of geography, race, socioeconomic
  status
• Eliminate disparities

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The Finish Line - Systems Change?
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Get With The Guidelines (GWTG)
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WHAT IS GWTG?
A prospective intervention process in the
hospital setting, for coronary artery disease,
heart failure, and stroke patients, designed to
significantly increase compliance with secondary
prevention treatment rates by the time of
discharge
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What is Get With The GuidelinesSM?
WHAT IS GWTG?

• The premier hospital-based quality improvement
  program for the American Heart Association
• Leverages the teachable moment immediately
  after a patient has had an acute event
• Tools that allow healthcare providers to
  concurrently assess treatment compliance

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WHAT IS GWTG?

• Provides a framework for Continuous Quality
  Improvement
• Winner of the 2004 Health and Human Services,
  Innovation in Prevention Award

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WHAT DOES GWTG DO?

• Supports system improvements for coronary artery
  disease, heart failure, and stroke patients
• Encourages links between cardiologists,
  neurologists, intensivists, primary care
  physicians, and ancillary healthcare providers
• Provides resources to build consensus and
  establish and execute protocols

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WHAT DOES GWTG DO?
Get With The Guidelines offers hospitals a
Recognition Program that encourages them to excel
by achieving 85 compliance in the indicators for
each module.
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WHAT DOES GWTG DO?
Get With The Guidelines offers hospitals three
(3) Performance Achievement Awards recognizing
hospitals that maintain a consistent, high level
of quality within the GWTG program.
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GWTG MODULES

• GWTG-Coronary Artery Disease (KY 2003)
• GWTG-Stroke (KY 2004)
• GWTG-Heart Failure (KY 2006)

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CAD Performance Measures

• Smoking cessation counseling for current smokers
  or persons who have smoked within the last twelve
  (12) months
• Aspirin on Discharge
• Beta-blocker on Discharge
• ACE-I on Discharge
• Lipid lowering therapy on Discharge
• In eligible patients without contraindications
  (designated by CMS as Ideal Patients)

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Stroke Performance Measures

• Percent of acute ischemic stroke patients who
  arrive at the ED at hospital within 120 mins of
  onset of stroke symptoms who receive IV t-PA
  within 180 mins of onset of stroke symptoms
• Percent of ischemic stroke or TIA patients who
  receive antithrombotic medication within 48 hours
  of hospitalization
• Percent of ischemic stroke or TIA patients
  discharged on antithrombotics
• Percent of ischemic stroke or TIA patients with
  atrial fibrillation who are discharged on
  anticoagulation therapy

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Continued

• 5. Percent of patients at risk for DVT who
  received DVT prophylaxis by the 2nd hospital day
• 6. Percent of ischemic stroke or TIA patients
  with LDLgt100 mg/dL OR on cholesterol reducer
  prior to admission who are discharged on
  cholesterol reducing drugs
• 7. Percent of smokers who receive smoking
  cessation advice or medication

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Heart Failure Performance Measures

• HF discharge instructions provided to all
  eligible patients
• Measurement of LV function in all eligible
  patients
• ACE inhibitor and/or ARB at discharge provided to
  eligible patients with LVEF lt or 0.40
• Beta blocker at discharge provided to eligible
  patients
• Smoking cessation counseling provided to all
  eligible patients (current or recent smokers)

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What Path Did We Take? (The Process)

• AHA provided training/education
• HDSP program provided facilitation, education
  materials, facilities for training and initial
  funding source
• Open invitation to all hospitals
• Trained hospitals at statewide workshops with
  partners
• QIO (Health Care Excel) spoke at workshops on
  quality improvement processes within the hospital
• 26 hospitals contracted to do GWTG
• Received funds to implement module(s)
• Follow-up GWTG Quality Improvement Workshop in
  January 2004

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Land Between the Lakes
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Results

• Partnership developed into contract with the
  University of Louisville Stroke Team for stroke
  systems of care
• U of L provided
• Provider education
• Nursing symposium
• EMS education, and
• Community education

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Results

• Presentation to Get Healthy Kentucky Board on
  burden of stroke in Kentucky
• Kentucky Heart Disease and Stroke Prevention
  Program Manager
• University of Louisville Stroke Team Medical
  Director
• American Heart Association

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Results

• University of Louisville Stroke Team Medical
  Director presented to Kentucky Legislature
• Stroke Resolution adopted by senate to urge the
  development of a statewide system of stroke
  care. (2006)

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GWTG Module Data - Hospitals
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Kentucky GWTG Progress (Hospital Results)
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Kentucky GWTG Progress (Hospital Results)
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Kentucky GWTG Progress (Hospital Results)
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Kentucky GWTG Progress (Hospital Results)
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Kentucky GWTG Progress (Hospital Results)
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Kentucky GWTG Progress (Hospital Results)
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Kentucky GWTG Progress (Hospital Results)
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Data Utilization

• Outcome Sciences, Inc. houses data need 100
  data abstraction
• quality improvement program helps hospitals
  collect and analyze information about their
  stroke care, and enables physicians and hospital
  staff to monitor their performance in real time
  with guidelines and national benchmarking
• AHA is giving recognition to hospitals that excel
  by achieving 85 compliance in the indicators for
  each module
• Hospital demographic data helps to identify where
  to expand GWTG in other hospitals to cover all of
  Kentucky

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Performance Achievement Award Winners

• Follow treatment guidelines in certain key
  measures at least 85 percent of the time and
  maintained for a period of time 90 Days, 12
  Months or gt24 Months

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Award Winning Hospitals

• The Medical Center Bowling Green Initial
  Performance Achievement Award for Coronary Artery
  Disease
• Kings Daughters Medical Center-Ashland Initial
  Performance Achievement Award for Heart Failure
• St Elizabeth Medical Center Edgewood - Initial
  Performance Achievement Award for Stroke
• St Elizabeth Medical Center Edgewood - Initial
  Performance Achievement Award for Heart Failure

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Award Winning Hospitals (cont)

• University of Louisville Hospital Sustained
  Performance Achievement Award for Stroke
• 1 of only 6 in the nation recognized for this
  exceptional award

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Spotlighted in Recognition Ads

• US News and World Report
• Americas Top Hospital issue
• (July 2007)
• Circulation Journal (November 2007)
• Stroke Journal (February 2008)

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Lessons Learned

• Hospitals willing to participate when given
  funding
• Need to continue GWTG and expand into rural
  hospitals
• Partnerships with UL, AHA, and KHA led to
  increase in number of JCAHO certified primary
  stroke centers (PSC)
• Working to add three more PSC to cover all
  regions of state

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One Hospitals Progress
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Kentuckys Promise for a Brighter Tomorrow
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CONTACT INFORMATION

• Contact Info
• Bonita A. Bobo, RN, IBCLC
• Program Manager
• 502-564-7996 ext. 3625
• bonitaa.bobo_at_ky.gov
• Tricia McLendon, MPH
• Epidemiologist
• 502-564-7996 ext. 3819
• patricia.mclendon_at_ky.gov