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Core Measures What you need to know
Quality, Accreditation, & Patient Safety Department
What is a core measure?
An evidenced based indicator that is used to measure the quality of patient care.
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Why do Hospitals Perform Core Measures?
• To provide the best care to our patients according to evidence based research.
• The hospital’s results are reported to the Joint Commission and CMS where they are compared to other hospitals.
• Receive higher reimbursement from Medicare and other payers.
• Hospitals that do not participate in the initiative will receive a reduction of 2 percent in their Medicare Annual Payment
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Clinical Focus Areas
• Heart Failure (HF)
• Acute Myocardial Infarction (AMI)
• Pneumonia (PN)
• Surgical Care Improvement Project (SCIP)
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Heart Failure Measures • Discharge Instructions (6 key components):
– Diet – Activity level – Follow-up appt. – What to do if symptoms worsen – Weight monitoring – Discharge Medications
• Evaluation of Left Ventricular Systolic Function • Angiotensin Converting Enzyme Inhibitor (ACEI) or
Angiotensin Receptor Blocker ( ARB) for Left Ventricular Systolic Dysfunction (LVSD)
• Beta-blocker prescribed at discharge for LVSD
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Why are we here today? #1 Reason: The PATIENT
It isn’t just about the numbers….
it is about the right care every time.
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Proper care must be reflected in the Medical Record with the appropriate
and specific information
What can physicians do to help?
• Improve documentation:
– Use pre-printed orders
– Document contraindication such as ACEI / ARB, Beta-blockers, foleys, antibiotics, etc.
• Understand the discharge process and what documentation is needed from you
– ex. Medications per Medication Reconciliation
What can physicians do to help?
• Realize you can impact patient outcomes.
• Be a part of the process…work with the hospital team on implementations.
• Be aware of the specific metrics for AMI, HF, PNE, and SCIP.
• Communicate frequently with hospital team (Nursing, Quality, Case Management, etc.)
Examples of No and Yes of proper documentation
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Each Yes = $ 56, 000/Patient Each No = $ 0/Patient
Reimbursement per Value Based Purchasing program (VBP)
Use the right
Forms
Yes
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Form C290jr
Enter all required
information Not appropriate
State the indication
NO
YES
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Form C568
NO Missing
information
Complete forms
correctly D/C Order
Yes
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Dictation Summary
When dictating please state: “Discharge Medications per
D/C written order”
No
Yes
Acute MI Measures • Aspirin at Arrival • Aspirin Prescribed at Discharge • ACEI or ARB for LVSD • Beta-Blocker Prescribed at Discharge • Fibrinolytic Therapy Received within 30 Minutes of
Hospital Arrival • Primary Percutaneous Coronary Intervention (PCI)
Received within 90 Minutes of Hospital Arrival • Statin Prescribed at Discharge
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Use the right
Forms
Yes
Pneumonia Measures • Blood Cultures before first Antibiotic
• Blood Cultures on arrival for ICU patients
• Appropriate initial antibiotic selection
• Influenza Vaccination
• Pneumococcal Vaccination
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Arrival time: 16:20 Blood culture done: 01:01
Levofloxacin given at 23:06
No Antibiotic given first prior to BC
Recommended Antibiotics for PN Yes
Use recommended
lists
SCIP
• Prophylactic antibiotic within 1 hour prior to incision
• Prophylactic antibiotic selection
• Antibiotic discontinued within 24 hours
after Anesthesia end time
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Complete entire
section
Yes
Example: Colon Surgery Surgeon ordered correct ABX.
Yes
Anesthesiologist administered Cefazolin (incorrect)
No Wrong
Antibiotic given
Example of incorrect use of form- Part 1
No Circling the
selection
Example of incorrect use of form- Part 2 Should use same form for preop and postop order
No
Surgeon started Empiric ABX post op NOT a reason for continuing ABX
documented
No Incorrect
prophylaxis form used.
YES Example of good documentation of
reason to continue ABX
SCIP • Cardiac Surgery Patients with Controlled 6 A.M.
Postoperative Blood Glucose (< or = to 200mg/dl)
• Perioperative Temperature Management (equal to or greater than 96.8 Fahrenheit/36 Celsius recorded within the 30 minutes immediately prior to or the 15 minutes immediately after Anesthesia End Time)
• Urinary catheter removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2)
SCIP • Surgery patients on Beta-Blocker therapy prior to arrival,
who have received a Beta-Blocker during the perioperative period ( the day prior to surgery through POD 2 )
• Venous Thromboembolism (VTE) Prophylaxis Order and administered within 24 hrs prior to or 24 hrs after surgery
Elective Total Hip Replacement with a reason for not administering
pharmacological prophylaxis Any of the following: •Intermittent pneumatic compression devices (IPC) •Venous foot pump (VFP)
Hip Fracture Surgery with a reason for not administering pharmacological
prophylaxis Any of the following: •Graduated Compression Stockings (GCS) •Intermittent pneumatic compression devices (IPC) •Venous foot pump (VFP)
*Patients who receive neuraxial (spinal/epidural) anesthesia or have a documented reason for not administering pharmacological prophylaxis may pass the performance measure if either appropriate pharmacological or mechanical prophylaxis is ordered.
VTE prophylaxis
Must have order for mechanical and pharmaceutical or rationale for not to have it
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Stamp used to show reason for maintaining foley. Only physician documentation is accepted.
• Foley must be removed by post-op day 2.
• If there is a need for the foley to remain,
document the reason for maintaining the foley catheter.
CMS Core Performance Measures
www.hospitalcompare.hhs.gov
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