Quality Improvement for Institutions | Performance Improvement Through the ACTION Registry

Measuring performance through quality improvement initiatives has been embraced as a comprehensive and programmatic way to assess quality of care and outcomes in health care. Within the transition to value-based care and reimbursement, these initiatives have become increasingly salient. Importantly, such programs are instrumental in achieving the six principles for health care systems set by the Institute of Medicine in its 2001 report titled Crossing the Quality Chasm: A New Health System for the 21st Century: safety, effectiveness, patient-centeredness, timeliness, efficiency and equity.

The ACC began its journey in 1998 to more formally address the quality chasm by establishing the NCDR and its first program CathPCI. Now expanded to eight hospital-based and two outpatient registries, NCDR has had a measurable impact on cardiovascular care across the U.S. And countries around the world are now employing the NCDR registries as a recognized and proven quality improvement approach.

The NCDR registries afford a health care system a mechanism to identify their gaps in care and areas for improvement using the feedback on their attainment of evidence-based performance along with national benchmarks. The NCDR also reports on ACC appropriate use criteria, which provides feedback on the use of procedures in relation to evidence-based clinical parameters.

"The data team understands the value of data and definitions, which is vital to an efficient data abstraction process." Jan Willman, RN, BSN Aurora Health Care

A natural evolution of the NCDR programs is voluntary public reporting by hospitals of their performance, garnering endorsement by the National Quality Forum, which sets standards for public reporting performance measures. Participation in NCDR is among the parameters used by the U.S. News & World Report for its Best Hospital Rankings. So far, there is public reporting for the CathPCI and ICD Registries using CardioSmart’s Find Your Heart A Home tool and it is coming for the ACTION Registry.

Another evolution is the link between the NCDR registries and accreditation. Chest Pain Center Accreditation requirements can now be fulfilled through the ACTION Registry, for example.

The ACTION Registry

ACC has named over 300 recipients of the College’s annual ACTION Registry Performance Achievement Award program. The program, which will celebrate its 10th anniversary in 2018, recognizes hospitals that demonstrate sustained, top-level performance in quality of care and adherence to guideline recommendations by using the ACTION Registry to improve outcomes and impact the lives of patients experiencing acute myocardial infarction (AMI). The three award levels are silver, gold and platinum.

The award winners have been recognized with inclusion in the special “Best Hospitals” issue of U.S. News & World Report. Cardiology talked with four awardees to learn more about their processes, goals, accomplishments and lessons learned by participating in the ACTION Registry:

Candace Landis, RN, BSN, CathPCI and ACTION Registry site manager at Sentara Healthcare. Eight of its 12 hospitals in Virginia and northeastern North Carolina has been recognized with a Platinum award.

Kimberly Marshall, RN, BSN, CPHQ, AACC, Clinical Quality Specialist at the University of Colorado Hospital’s Cardiac and Vascular Center. The University of Colorado Hospital Authority has been recognized with a Silver award.

Andrea Price, MS, RCIS, CCA, director of Quality Databases at Indiana University Health, which has been recognized with a Platinum award.

Jan Willman, RN, BSN, a cardiovascular data analyst with Aurora Health Care. The 15-hospital system in eastern Wisconsin has been recognized with Platinum and Gold awards.

The ACTION Registry is a risk-adjusted, outcomes-based quality improvement program that focuses exclusively on high-risk patients with STEMI or NSTEMI. ACTION helps hospitals apply ACC clinical guideline recommendations in their facilities and provides invaluable tools to measure care and achieve quality improvement goals. When paired with the CathPCI Registry and ICD Registry, cardiovascular care teams get a closer, more in-depth look at the entire AMI patient population.

ACTION assesses the characteristics, treatments and outcomes of patients with acute myocardial infarction (AMI) who are older than 18 years and experience acute ischemic symptoms within 24 hours of being hospitalized with a diagnosis of an AMI.

Performance is measured at the institution level, along with composite metrics that provide a more comprehensive assessment of care of AMI patients, quality metrics of in-hospital performance and safety metrics, such as proper dosing of anticoagulant and antiplatelet agents, especially unfractionated heparin. Data is collected on in-hospital outcomes, including death, reinfarction, heart failure, shock, stroke and bleeding events.

Understanding Performance Through Data

The recent “Trends in U.S. Cardiovascular Care” report illustrates the power of registry data to understand performance within a hospital as well as clinical characteristics, care and outcomes of patients with cardiovascular disease. The report, published in the Journal of the American College of Cardiology, provides insights based on 2014 data in four NCDR registries.

Key findings from the ACTION Registry include:

  • Of the 182,903 patients with AMI in 2014, 71,368 had STEMI, while 111,535 had NSTEMI.
  • There is room for improvement in the areas of overall defect-free care (78.4 percent); P2Y12 inhibitor use in eligible patients (56.7 percent); and use of aldosterone antagonists in patients with left ventricular systolic dysfunction and either diabetes or heart failure (12.8 percent).
  • Compared with NSTEMI patients, STEMI patients were more likely to experience certain adverse events during hospitalization, including death (6.4 percent vs. 3.4 percent); cardiogenic shock (4.4 percent vs. 1.6 percent) or bleeding (8.5 percent vs. 5.5 percent).
  • Of the STEMI patients, 95.8 percent underwent coronary angiography and 90.7 percent underwent PCI, compared with NSTEMI patients of whom 81.9 percent underwent coronary angiography and 52.4 percent underwent PCI.

Critical to the success of a quality improvement program in a health care system (and the NCDR overall) is the data team that is dedicated to abstracting and analyzing the data. “The data team understands the value of data and definitions, which is vital to an efficient data abstraction process,” says Jan Willman, RN, BSN, a cardiovascular data analyst with Aurora Health Care, a 15-hospital system in eastern Wisconsin.

“Data are used for a variety of audiences and purposes, so the data team members should know how to utilize data accordingly,” notes Willman. In addition to its use within the ACTION Registry, for example, Aurora’s Cardiology Fellowship Program allows collected data to be used for research and publication.

"We hope our teams will impact care provided to patients at other organizations because of NCDR’s forum for shared learning." Andrea Price, MS, RCIS, CCA Indiana University Health

One premier location for sharing such research with the registry community is the NCDR Annual Conference. “From networking during the poster session, we gained ideas for improvement that we took back to our organization,” says Andrea Price, MS, RCIS, CCA, director of Quality Databases at Indiana University Health (IUH). This year, three IUH sites - IUH Methodist, Saxony and Ball Memorial - received a Platinum award, the highest of the three ACTION Registry Performance award designations.

“We hope our teams will impact care provided to patients at other organizations because of NCDR’s forum for shared learning,” Price adds. Fully unlocking the data and understanding its messages also requires including the data team in regular meetings. “Tap into their registry expertise to understand the metrics and what are your opportunities,” advises Candace Landis, RN, BSN, CathPCI and ACTION Registry site manager at Sentara Healthcare, which serves patients in Virginia and northeastern North Carolina. She adds, “Use the data to promote change within your organization and plan future goals.”

Frequent data entry and report generation allows a hospital to monitor its performance on a timely basis and identify trends that should be addressed. “At UCHealth, we enter and submit our patients on a weekly basis so we can run our performance metrics whenever asked,” notes Kimberly Marshall, RN, BSN, CPHQ, AACC, Clinical Quality Specialist at the University of Colorado Hospital’s Cardiac and Vascular Center. The University of Colorado Hospital Authority (UCHealth) is a 2017 Silver award recipient. “We can monitor whether any changes are occurring to share with the team to address or provide positive feedback.”

Over the years, IUH discovered that an interprofessional triad approach resulted in timely and meaningful quality improvement dialogue for its sites. “Our ACC Registry data team partners with the cardiovascular operations team and physicians and routinely meets to share performance and discuss how to process impactful organizational performance,” says Price. This shared learning extends to IUH sites that are new to participating in the ACTION Registry. Price notes that when two more IUH sites joined the ACTION Registry, they used lessons learned at the sites already participating in ACTION to improve performance at the newest sites.

"…we enter and submit our patients on a weekly basis so we can run our performance metrics whenever asked. We can monitor whether any changes are occurring to share with the team to address or provide positive feedback." Kimberly Marshall, RN, BSN, CPHQ, AACC University of Colorado Hospital Authority

Across large hospital systems, this tactic of shared learnings is particularly important. In part, this is due to differences in data definitions. At Sentara, for example, the data abstraction team works closely with both leadership and clinical teams to understand which metrics are being evaluated, ultimately decreasing variation across its facilities. “As other hospitals join our organization, they are able to adopt the processes we have in place, which has helped them improve their performance – translating to care delivered on a consistent basis,” says Landis.

“Many of our facilities have undergone NCDR audits and performed at registry standards,” adds Landis. “We internally audit ourselves as well and hold high standards to those abstraction inter-rater audit match rates. Any missed opportunity is a chance to improve care and is a lesson learned across our system.”

“Participating in the NCDR registries provides us with robust and consistent data to be used in process improvement, providing feedback to providers who may be missing the mark at times,” says Willman at Aurora Health Care. “We can also compare ourselves by utilizing the national benchmarks to assure we are providing top quartile care.” Aurora has been participating since the start of the ACTION Registry, receiving Gold award designation annually since 2008.

Profiles of ACTION Registry Performance Awardees

Consistent, high-quality data collection for at least a year along with individual performance measures are among the eligibility requirements for becoming an ACTION Registry Performance Awardee. Three composite measures are also evaluated to determine a hospital’s compliance score.

One of the composite measures is overall defect free care, an “all or nothing” measure, requiring hospitals to provide each patient with each of the individual care measures for which they are eligible. For some awardees, overall defect free care was the most challenging but fulfilling measure to achieve this year. It requires a clear focus on increasing the proportion of patients receiving all performance measure opportunities for which they are eligible. “Providing ‘perfect care’ for the entire STEMI and NSTEMI population is a success that we are proud to have accomplished,” says Price at IUH.

Overall defect free care was a focus for UCHealth too. Prior to 2017, its biggest hurdle was the cardiac rehabilitation measure. “It took us quite a few stages to get to where we are now,” says Marshall. “We used to wait for an order to come across the printer. Now, we proactively request referrals from physicians.”

"Tap into their registry expertise to understand the metrics and what are your opportunities. Use the data to promote change within your organization and plan future goals." Candace Landis, RN, BSN, Sentara Healthcare

Since 2015, when UCHealth last received a Silver Award, the team has focused on two measures: percentage of door to ECG within 10 minutes and percentage of door to balloon (D2B) within 90 minutes. “We gave monthly updates to our emergency department and cardiac catheterization lab as to how many days went by without a D2B time being greater than 90 minutes,” says Marshall. These updates continue to be consistently shared with the team so that UCHealth can provide optimal care for its MI patients.

At Sentara Healthcare, eight of its 12 hospitals are Platinum awardees, demonstrating how larger organizations can use the ACTION Registry data to successfully make quality improvements within an individual hospital and across a large system. “We worked to improve and standardize our approach to care for these patients to ensure they received the same level of care regardless of the location,” says Landis. “Some of the processes included ensuring early cardiac rehab referral, working more efficiently with transferring hospitals and emergency medical services (EMS) agencies and improving processes in the emergency departments (EDs).”

Aurora Health Care is a Platinum award recipient for the first time this year, after maintaining improvements in the measure of appropriately discharging patients with a prescription for an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB). Improvements in the evaluation of left ventricular ejection fraction and systolic function and pre-hospital electrocardiograms were also achieved. What spurred this improvement? Benchmarking. Willman says that when they saw they were not in the top percentile, they created their own “Best Practice Box” to ensure that ACTION Registry measures were addressed and reviewed before discharging each patient.

For organizations like Sentara, this year’s award adds another page to their ACTION Registry story. “Nine of our facilities joined the ACTION Registry in 2012. Many qualified for their first performance awards after the first year of data was submitted to the NCDR,” says Landis. “Seven of the nine facilities have qualified for the Platinum Award four years in a row.”

Communication has been a key factor in Sentara’s success in improving the timeliness of identifying and treating AMI patients. To ensure a transfer patient receives reperfusion as quickly as possible after presenting to a location that does not have a cardiac catheterization laboratory or 24/7 coverage, Sentara reached out to “transferring facilities and streamlined the process to transfer a patient,” says Landis.

In past years, Sentara also focused on improving outpatient cardiac rehabilitation referrals, developing smoking cessation education and providing patients with medication orders prior to discharge. “We ensured not only aspirin, beta-blockers and ACE inhibitors or ARBS were ordered, if appropriate, but also statins,” Landis continues.

“The ACTION Registry acts as a safety net for our medical staff in ensuring patients have everything they need when it is time for discharge,” says Landis. “It also helps ensure patients are progressing appropriately, and, in turn, strengthens overall facility performance, signaling to our communities that we are invested in improving the lives and outcomes of patients.”

IUH is also no stranger to the award process. “IU Health Methodist in Indianapolis has been an ACTION Registry Performance Award recipient since the College established the criteria,” notes Price. “IU Health Ball Memorial and IU Health Saxony have been recipients since 2015.”

But in 2017, the IUH team took a different approach. “Historically, most health care professionals visualize a STEMI with primary PCI when hearing AMI. Consequently, well-established processes were designed for AMI patients receiving PCI,” says Price. “In recent years, our teams have had success isolating eligible STEMI and NSTEMI patients who did not receive a PCI during the AMI episode of care. Through the ACTION Registry dashboards and reports, we have expanded our focus to include NSTEMI and those patients who are medically managed.”

Updates for the ACTION Registry

The updated version of the ACTION Registry provides participating hospitals and health care systems even more data to help develop additional quality improvement programs. Additions will include 90-day readmission rates for Medicare’s Advancing Care Coordination through Episode Payment Models (EPMs) and the Cardiac Rehabilitation Incentive Payment Model. Users also will be able to participate in two new national quality campaigns for reducing 30-day and 90-day readmissions and 30-day mortality, as well as decreasing bleeding in PCI. Public reporting through “Find Your Heart a Home” will be available in the coming months. Current CathPCI Registry and ICD Registry participants can get a 90-day glimpse at all the ACTION Registry offers. For more information, visit ACC.org/ACTIONRegistry.

Looking ahead, each awardee is re-doubling their efforts to provide even better and more consistent care to their patients.

IUH is simultaneously pursuing three accreditations – ACC Chest Pain Center, Cath Lab and Atrial Fibrillation – along with making data available to the public. “The use of the ACTION Registry to fulfill some of the accreditation data requirements only further strengthen our internal processes,” says Price. “We take great pride in the level of cardiovascular care that we provide and participate in public reporting for all of our registries.”

The team at Aurora Health Care will also use their data to support Chest Pain Center Accreditation and make improvements to its 24/7 STEMI Program. “By reviewing the executive summary at our cardiac core meeting and emergency department and emergency medicine services meeting, we’ll continue to provide as close to real-time feedback as possible,” Willman says.

UCHealth is seeking new areas of focus in its quest for quality improvement – and achieving the Platinum award next year. “To be transparent with the care we provide our MI population, we will continue to share our outcomes in monthly meetings and review all STEMI cases within 48 hours of arrival to ensure our focus metrics stay within the foreground of all involved,” says Marshall.

“To plan for the future, Sentara makes sure to look at least annually at where we have been in years past in our performance of quality metrics, where we are currently and where the registry stands,” says Landis. “Our facilities benefit from that check and balance, validating that the processes put in place become part of the culture of the organization.”

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Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Dyslipidemia, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Nonstatins, Novel Agents, Statins, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Interventions and Imaging, Angiography, Nuclear Imaging

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