CAH Quality Data - Center for Rural Health

CAH Quality Data - Center for Rural Health

Jean Roland, RN, BSN, CPHQ
Quality Improvement Specialist
April 19, 2012
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- Pneumococcal vaccination
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 PN-2 (current measure)
Patients with pneumonia, age 65 and older, who were screened for
pneumococcal vaccine status and were vaccinated prior to discharge, if
indicated
Moving forward…
IMMUNIZATION NATIONAL HOSPITAL INPATIENT
QUALITY MEASURES (1Q12)
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Set Measure ID#
IMM-1a
Measure Short Name
Pneumococcal Immunization (PPV23) –
Overall Rate
IMM-1b
Pneumococcal Immunization (PPV23) –
Age 65 and Older
IMM-1c
Pneumococcal Immunization (Age 6 through 64
years) (PPV23) – High Risk Populations
IMM-2
Influenza Immunization
- Pneumococcal vaccination
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 April 2012 - Pneumococcal vaccination
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota - Blood cultures performed within 24 hours prior to or 24 hours after hospital arrival for patients who were
transferred or admitted to the ICU within 24 hours of hospital arrival
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 - Blood cultures performed within 24 hours prior to or 24 hours after hospital arrival for patients who were
transferred or admitted to the ICU within 24 hours of hospital arrival
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 - Blood cultures performed within 24 hours prior to or 24 hours after hospital arrival for patients who were
transferred or admitted to the ICU within 24 hours of hospital arrival
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 - Blood cultures performed in the emergency department prior to initial antibiotic received in hospital
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 - Blood cultures performed in the emergency department prior to initial antibiotic received in hospital
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 - Blood cultures performed in the emergency department prior to initial antibiotic received in hospital
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 - Adult smoking cessation advice/counseling
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 PN-4 (current)
Description: Pneumonia patients with a history of smoking cigarettes who are
given smoking cessation advice or counseling during hospital stay. For the
purposes of this measure, a smoker is defined as someone who has smoked
cigarettes anytime during the year prior to hospital arrival.
*Recommended > 18 y/o
TOBACCO TREATMENT NATIONAL HOSPITAL
INPATIENT QUALITY MEASURES (1Q12)
Collected for: The Joint Commission Only
CMS Informational Only
Measure
ID #
TOB-1
TOB-2
TOB-2a
TOB-3
TOB-3a
TOB-4
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Measure Short Name
Tobacco Use Screening
Tobacco Use Treatment Provided or Offered
Tobacco Use Treatment
Tobacco Use Treatment Provided or Offered at Discharge
Tobacco Use Treatment at Discharge
Tobacco Use: Assessing Status After Discharge
- Adult smoking cessation advice/counseling
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 April 2012 - Adult smoking cessation advice/counseling
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota - Initial antibiotic received within 6 hours of hospital arrival
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 April 2012 - Initial antibiotic received within 6 hours of hospital arrival
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota - Initial antibiotic received within 6 hours of hospital arrival
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 April 2012 - Initial antibiotic selection for CAP in immunocompetent patient
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota - Initial antibiotic selection for CAP in immunocompetent patient
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 April 2012 - Initial antibiotic selection for CAP in immunocompetent patient
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota PN6 - Initial antibiotic selection for CAP in immunocompetent patient
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- Influenza vaccination
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 PN-7 (current)
Description: Pneumonia patients age 50 years and older, hospitalized
during October, November, December, January, February or March who were
screened for influenza vaccine status and were vaccinated prior to discharge,
if indicated.
Moving forward…
IMM-2: Influenza Immunization
Numerator: Inpatient discharges who were screened for Influenza vaccine
status and were vaccinated prior to discharge if indicated.
Denominator: Acute care hospitalized inpatients age 6 months and older
discharged during October, November, December, January, February or
March.
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- Influenza vaccination
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 - Influenza vaccination
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota 28
April 2012 - Discharge instructions
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 HF-1
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
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- Discharge instructions
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 April 2012 - Discharge instructions
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota - Evaluation of LVS function
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 HF -2
Numerator Statement: Heart failure patients with documentation in the
hospital record that LVS function was evaluated before arrival, during
hospitalization, or is planned for after discharge.
Suggested Data Sources:
• Consultation notes
• Discharge instruction sheet
• Discharge summary
• History and physical
• Procedure notes
• Progress notes
Excluded Data Sources:
Any documentation dated/timed after discharge, except discharge
summary and operative/procedure/diagnostic test reports (from procedure
done during hospital
stay).
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- Evaluation of LVS function
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 April 2012 - Evaluation of LVS function
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota - ACEI or ARB for LVSD
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 April 2012 - ACEI or ARB for LVSD
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota - ACEI or ARB for LVSD
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 April 2012 - Adult smoking cessation advice/counseling
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota - Adult smoking cessation advice/counseling
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 April 2012 - Adult smoking cessation advice/counseling
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota 43
- Aspirin at arrival
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 - Aspirin prescribed at discharge
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 April 2012 - ACEI or ARB for LVSD
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota - ACEI or ARB for LVSD
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 April 2012 - ACEI or ARB for LVSD
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota - Adult smoking cessation advice/counseling
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 April 2012 - Adult smoking cessation advice/counseling
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota - Beta blocker prescribed at discharge
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 April 2012 - Beta blocker prescribed at discharge
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota - Beta blocker prescribed at discharge
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 April 2012 - Fibrinolytic therapy received within 30 minutes of hospital arrival
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota - Fibrinolytic therapy received within 30 minutes of hospital arrival
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 April 2012 - Fibrinolytic therapy received within 30 minutes of hospital arrival
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota - Statin prescribed at discharge
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 April 2012 - Statin prescribed at discharge
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota - Statin prescribed at discharge
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota 60
April 2012 - Prophylactic antibiotic received within one hour prior to surgical incision
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 April 2012 - Prophylactic antibiotic selection for surgical patients
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota - Prophylactic antibiotics discontinued within 24 hours after surgery end time
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 April 2012 - Surgery patients with appropriate hair removal
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota - Urinary catheter removed on POD-1 or POD-2 with day of surgery being day 0
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 April 2012 - Surgery patients with perioperative temperature management
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota - Surgery patients with recommended venous thromboembolism prophylaxis ordered
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 - Surgery patients who received appropriate venous thromboembolism prophylaxis within
24 hrs prior to surgery to 24 hrs after surgery
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 - Surgery patients on beta blocker therapy prior to arrival who received a beta blocker
during the perioperative period
Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 North Dakota Health Care Review, Inc. . . .
To improve health and healthcare for the people of North Dakota
Jean Roland, RN, BSN, CPHQ
[email protected]
3520 North Broadway Ÿ Minot, ND 58703
701-852-4231 (Voice)
701-857-9755 (Fax)
www.ndhcri.org
This material was prepared by North Dakota Health Care Review, Inc., Minot, ND, 701-852-4231, the Medicare Quality Improvement Organization for North Dakota, under contract with the Centers for Medicare
& Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. ND-10SOW-12-PP-30 April 2012
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