Site Spotlight - Trinity Health Ann Arbor

The Structural Heart Team at Trinity Health Ann Arbor realized that their pre-procedural baseline and 30-day KCCQ questionnaire documentation compliance was below the consortium’s average. Kim Simons, RN, BSN, led the team to scrutinize their process, reach out to other MISHC-participating sites for ideas about how they might improve, and set their goal to 90% compliance for documentation of baseline and 30-day KCCQ. 

“Based on our clinical flow, we determined that the best way to document KCCQ was to have our medical assistants administer the questionnaire and do the 5-meter walk at the patient’s TAVR evaluation visit at Michigan Heart,” said Kim.

She and her colleague, Amy Ogar, RN, held in services for Trinity Health Ann Arbor medical assistant staff and discussed the “why” behind the 5-meter walk and collection of the KCCQ. It is a CMS requirement and would help the site achieve its VBR goal but, most importantly, it would help determine if patients are benefitting from their TAVR procedures.

Lead Medical Assistant, Cheryle Caldwell, was instrumental in scheduling the in services and ensuring attendance while Structural Heart Team Assistant, Michelle Calhoun, added notes to appointments that indicated the patient would need KCCQ, 5-meter walk, and to see one of the Structural Heart nurses during their visit.

At each visit, the Structural Heart nurses double-checked that the KCCQ and 5-meter walk were documented.  “By setting up checks, we were able to make sure no one fell through the cracks,” explained Kim.  To keep the documentation goal in the forefront of the Structural Heart physicians’ minds as they saw patients in the clinic, she began quarterly progress reports. “This would also help them remind the medical assistant staff.”

In the beginning, medical assistants were documenting KCCQ and the 5-meter walk on a printed form which they would place in a mailbox outside the Structural Heart office for Kim and Amy to review.  The duo would then send the form to Medical Records to be scanned into the patient’s chart. While this worked well for the most part, forms would sometimes get misplaced. The second plan was for the medical assistants to send the forms directly to Medical Records but that made it difficult for Kim and Amy to track whether the documentation had indeed been completed.

During this time, Trinity Health switched over to Epic. This allowed the team to create a smart phrase for KCCQ and 5-meter walk documentation that the medical assistants could access, making it immediately available in the chart. Data Abstractor, Emily Naquin, RN, promptly informs Kim if there are missing KCCQs, or other metrics, so they can be completed before deadlines. If the KCCQ was not completed during a visit, Kim or Amy could phone the patient for documentation before the TAVR procedure.  

Trinity Health Ann Arbor’s current compliance of KCCQ and 5-meter walk documentation is at 91% and the team continues to strive for improvement. They check in with the medical assistants intermittently and have found that this, and keeping the physicians informed via updates, helpful. Their next step is to improve their 1-year KCCQ compliance and Emily is at the forefront of the effort as she mails the questionnaires to patients and collects the information they provide.

The team’s dedication benefits current patients in their ability to see how undergoing TAVR has improved their quality of life and providers can use what they learn to improve the care and selection of future patients.