Michelle Kelly

National Organization:
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
Evaluation Strategy: Core Measure Standard (CMS) on heart failure
A comprehensive description of all measures can be found on:
http://www.jcaho.org/pms/core+measures/core+measures.htm.

While there are four CMS performance measures that comprise the Heart Failure
measure set, I selected one (Discharge Instructions) of the four for the purpose of
this assignment.
Four CMS for HF
1. Left ventricular systolic (LVS) function in records
2. Heart failure patients with LVS dysfunction and
w/o both angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker
(ARB) contraindications who are prescribed an ACEI or ARB at dc.
3. Adult Smoking Cessation Advice/Counseling
4. Discharge Instructions

CMS – Heart Failure

Measure Set: Heart Failure (HF)
Set Measure ID#: HF-1
Performance Measure Name: Discharge Instructions
Description: Heart failure patients discharged home with written 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, and what to do if symptoms worsen

Rationale: Patient non-compliance with diet and medications is an important reason for
changes in clinical status. Health care professionals should ensure that patients and their
families understand their dietary restrictions, activity recommendations, prescribed medication
regimen, and the signs and symptoms of worsening heart failure. National guidelines strongly
support the role of patient education (Hunt, 2005). Despite this recommendation,
comprehensive discharge instructions are rarely provided to eligible older patients hospitalized
with heart failure (CMS National Heart Failure Project baseline data).

Type of Measure: Process

Improvement Noted As: An increase in the rate
Numerator Statement: Heart failure patients with documentation that they or their caregivers
were given written discharge instructions or other educational material addressing all of the
following:
1. activity level
2. diet
3. discharge medications
4. follow-up appointment
5. weight monitoring
6. what to do if symptoms worsen

Does this strategy work?

A RN once said in a class, why is JACHO holding RN’s accountable for standards
they should already be performing to maximize client health outcomes? First of all
JACHO CMS are process measures and that is one methodology to evaluate a
hospital as a system. Overall the CMS tool works “because when you shine a bright
light on an area, you will see improvement” (T. Starr, personal communication).
Public Report Cards of hospital system performance were synoconus with the
implementation of CMS five years ago. The CMS are process indicators and should
lead to improved client outcomes, which are lower rates of mortality and
readmission as well as shorter length of stay. In October 2009 another evaluation
policy came into play. In addition to public reporting, the current policy is that
funding must be returned if a hospital system falls below CMS indicators. Serious
stuff.

So let take someone who is discharged from the hospital – is the moment the client
is told they are to be discharged the RN attempts to instruct on points #1-6 above.
Bad idea, the client is ready to leave and timing couldn’t be worse for a major
teaching moment. The discharge RN is tasked with making sure the client is
provided information – information and self-management should be initiated much
earlier in the levels of health care. Why are we just measuring health teaching for a
chronic disease in acute care? So the client says yes, yes to everything the RN asks
and scoots out the door happy to be on their way home. Once at home the client
doesn’t fully understand what medication they are supposed to take, their follow up
appointment with their primary is in 3 weeks, and they don’t have a scale. This
client has an increased risk of a medication error leading to readmission and early
mortality. My critique not of the JACHO CMS method but of the narrow scope and
failing to bridge evaluation across care settings

Implications for ANP/DNP direct and indirect practice roles.

Measuring process indicators on hospitalized HF clients is put solely on the
shoulders of hospital systems and currently primary health care (PHC) are spared in
the public evaluation reporting process. But that is soon to change; evaluating the
quality of primary care is about to start with PHC physicians. What are the
implications for APNP in PHC? Historically, studies indicate self-care management
indicators are stronger in nurse practitioner caseloads and in nurse managed
centers. Will advanced practitioners be recognized as top performers in
prevention? The DNP role has an emphasis on evidenced based practice so my
thought is hopefully yes.

The implementation of public reports on PHC practitioners provides an opportunity

for direct and indirect advanced practice roles to work together from the acute care
and primary care. President Obama recently said in was in the transition of an
individual’s health care from one setting to another that led poor outcomes. Will
new DNP’s use this evidence of quality of care as a means to building – or
rebuilding a higher level of accountability across care settings?