CAH Quality Data - Center for Rural Health
Transcription
CAH Quality Data - Center for Rural Health
Jean Roland, RN, BSN, CPHQ Quality Improvement Specialist April 19, 2012 2 - 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) 4 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 14 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 23 - 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. 25 - 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 30 - 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). 34 - 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 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 70