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