Core Measures What you need to know Quality, Accreditation, & Patient Safety Department

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.
Proper care must be reflected in the
Medical Record with the appropriate
and specific information
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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
Reimbursement per Value Based
Purchasing program (VBP)
Each Yes = $ 56, 000/Patient
Each No = $ 0/Patient
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Yes
Use the
right
Forms
YES
Form
C290jr
Enter all
required
information
NO
Not
appropriate
State the
indication
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NO
Missing
information
Form
C568
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Yes
Complete
forms
correctly
D/C Order
Dictation Summary
No
When dictating please state:
“Discharge Medications per
D/C
written
order”
Yes
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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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Yes
Use the
right
Forms
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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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No
Antibiotic
given first
prior to BC
Arrival time: 16:20
Blood culture done: 01:01
Levofloxacin given at 23:06
Yes
Recommended Antibiotics for PN
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
Yes
Example: Colon Surgery
Surgeon ordered correct ABX.
Anesthesiologist administered Cefazolin (incorrect)
No
Wrong
Antibiotic
given
Example of incorrect use of formPart 1
No
Circling the
selection
No
Example of incorrect use of form- Part 2
Should use same form for preop and postop order
No
Incorrect
prophylaxis
form used.
Surgeon started Empiric ABX post op
NOT a reason for continuing ABX
documented
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
VTE prophylaxis
Must have order for mechanical and pharmaceutical or
rationale for not to have it
Elective Total Hip Replacement with a
reason for not administering
pharmacological prophylaxis
Hip Fracture Surgery with a reason for
not administering pharmacological
prophylaxis
Any of the following:
•Intermittent pneumatic compression devices (IPC)
•Venous foot pump (VFP)
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.
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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