Core Measures

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What are Core Measures?

Indicators that are evidence based best practice for specified diagnoses.

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Why do I want to know about Core Measures?

Evidence based best practice! Public Reporting

(www.hospitalcompare.hhs.gov) Reported to: CMS (Center for Medicare

and Medicaid Services) and JCAHO

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Core Measure Diagnoses

Acute Myocardial Infarction (AMI) Heart Failure (HF) Pneumonia (PN) Surgical Care Improvement Project (SCIP) Pregnancy Related Conditions

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Acute Myocardial Infarction (AMI)

Aspirin & Beta Blocker given in first 24 hours or contraindications charted.

LVF evaluated or planned to be done. Aspirin & Beta Blocker prescribed at

discharge or contraindications charted. ACEI/ARB prescribed at discharge if LVF

<40% or contraindications charted. Smoking counseling, if smoker.

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Heart Failure (HF)

LVF evaluated or planned to be done. ACEI/ARB prescribed at discharge if

LVF <40% or contraindications charted. Smoking counseling, if smoker. Discharge instructions given.

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Pneumonia (PN)

Blood culture prior to antibiotic. Antibiotic in first 4 hours of arrival. Appropriate antibiotic based on allergy and if

healthcare acquired. Smoking counseling, if smoker. Influenza & pneumococcal vaccination status.

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Surgical Care Improvement Project (SCIP)

Antibiotic within 1 hour of surgery. Appropriate antibiotic according to guidelines. Discontinue antibiotics within 24 hours of surgery

end time. Patients who are on beta blockers at home, have

taken prior to surgery. Venous thromboembolism prophylaxis. Appropriate hair removal. Colorectal temp.

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Pregnancy Related Conditions

VBAC Rate Inpatient Neonatal

Mortality Third or Fourth Degree

Laceration

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How have we done?

AMI

IndicatorJan 2006

Feb 2006

Mar 2006

Apr 2006

May 2006

Jun 2006

Aspirin at arrival 100% 88% 100% 100% 100% 100%

Aspirin prescribed at discharge 100% 100% 100% 100% 100% 100%

ACEI or ARB for LVSD 75% 100% 67% 100% 50% 100%

Adult smoking cessation advice/counseling 100% 0% 100% 100% 100% 100%

Beta blocker prescribed at discharge 100% 100% 100% 100% 100% 100%

Beta blocker at arrival 100% 100% 100% 91% 100% 75%

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How have we done?

Heart Failure

IndicatorJan 2006

Feb 2006

Mar 2006

Apr 2006

May 2006

Jun 2006

All Discharge Instructions 90% 100% 93% 100% 100% 100%

Evaluation of LVS Function 100% 92% 100% 100% 100% 100%

ACEI or ARB for LVSD 67% 100% 100% 89% 100% 78%

Adult smoking cessation advice/counseling 100% 100% 100% 100% 100% 100%

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Pneumonia

IndicatorJan 2006

Feb 2006

Mar 2006

Apr 2006

May 2006

Jun 2006

Oxygenation assessment 100% 100% 100% 100% 100% 100%

Blood culture in ED prior to initial antibiotic 85% 100% 88% 81% 100% 95%

Antibiotic within 4 hours of arrival 64% 81% 83% 83% 86% 92%

Antibiotic selection for ICU/non-ICU patients 75% 82% 75% 82% 79% 100%

Adult smoking cessation advice/counseling 100% 100% 100% 83% 67% 100%

Pneumococcal Vaccination 95% 93% 85% 80% 93% 100%

Influenza vaccination 100% 96% NA NA NA NA

How have we done?

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SCIP

IndicatorJan 2006

Feb 2006

Mar 2006

Apr 2006

May 2006

Jun 2006

Antibiotic within 1 hr of incision-Overall 91% 95% 89% 95% 100% 89%

Antibiotic selection-Overall 95% 92% 95% 97% 97% 88%

Antibiotic disc. within 24 hrs-Overall 95% 87% 93% 97% 80% 91%

How have we done?

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Pregnancy Related Conditions

IndicatorJan 2006

Feb 2006

Mar 2006

Apr 2006

May 2006

Jun 2006

Third or fourth degree laceration 7% 9% 12% 7% 8% 6%

How have we done?

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How can I help? AMI

Aspirin and Beta Blockers in first 24 hours, or contraindications documented.

LVF documented in record (past, current or future planned).

Aspirin and Beta Blockers prescribed at discharge, or contraindications documented.

ACEI/ARB prescribed at discharge for LVF <40%, or contraindications documented for both the ACEI and the ARB.

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How can I help? HF

LVF documented in record (past, current or future planned).

ACEI/ARB prescribed at discharge for LVF <40%, or contraindications documented for both the ACEI and the ARB.

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How can I help? Pneumonia

Antibiotics within 4 hours of arrival. Appropriate antibiotics based on the

patient’s allergy and community verses healthcare acquired. Following the pathway is the best way comply.

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How can I help? SCIP

Antibiotics based on the patient’s allergy and surgery. Following the pathway is the best way to comply.

Only continue antibiotics longer than 24 hours post surgery if there are signs of an infection; document those signs of infection in the record.

Every Patient, Every Time!!

Questions?

Contact the Quality Department @ 394-3685