Core Measures

October 2013

Division of Quality and Patient SafetyNewYork-Presbyterian Hospital

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What are Core Measures?• Core Measures are widely agreed upon quality metrics

the federal government use to assess how well hospitals care for patients

• Core Measures initiative by the CMS help promote higher quality and more efficient care for Medicare beneficiaries

• Impact of Core Measures

– Quality of Patient Care– Reputation– Reimbursement

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Process of Care Measures• Measures are based on both expert opinion and

evidenced based practice• Measures evaluate timeliness and effectiveness of care• Measures are endorsed by National Quality Forum• The program requires hospitals to submit data for

specific measures for health conditions common among people with Medicare

• Hospitals that do not participate will receive a reduction of 2.0 percent in their Medicare Annual Payment Update for fiscal year 2013

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What is Value Based Purchasing?

• Value Based Purchasing is a program implemented by CMS in 2011 to promote better clinical outcome and patient experience of care with Pay-For-Performance

– CMS will pay for care that rewards better value and patient outcomes, instead of just volume of services

– Financial penalties are effective 2012 for our Core Measure performance

– Current performance is compared to baseline from prior year. We are rewarded for performance based on achievement and improvement score

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Venous Thromboembolism

Q1 2013 Q2 2013* Q3 2013*Hospital Compare National Average

(Q2 2012 – Q1 2013)Sample  N = 583 N = 626 N = 168

VTE Prophylaxis 97% 97% 90% 82%

ICU VTE Prophylaxis 100% 100% 100% 90%

VTE Patients with Anticoagulation Overlap Therapy 88% 93% 100% 91%

VTE Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol or Nomogram

100% 100% 100% 96%

VTE Discharge Instructions 53% 77% 94% 70%

Incidence of Potentially-Preventable VTE (Goal for Rate Low)

0% 0% 7.7% 11%

New Core Measure

started in Q1 2013

Privileged and Confidential Information for Quality Assurance and Performance Improvement Purposes and Protected under New York Education Law Section 6527 and Public Health Law Section 2805 J, K, L, and M

*Q2 and Q3 2013 data preliminary; Q2finalized after 10/25/13; Q3 finalized after 1/25/2013Green = 90% or greater and equal to or above national averageYellow = Equal to or above national average, but below 90% OR Above 90% , but below national averageRed = Below 90% and below national averageData Source: CMS

VTE-1: Prophylaxis• Admitted patients who:

– Received VTE prophylaxis, or – Have documentation why no VTE prophylaxis was

given• Timeframe:

– The day of/after hospital admission, or surgery end date, for surgeries that start the day of/after admission

VTE-3: Overlap Therapy• Patients diagnosed with confirmed VTE who received an

overlap of parenteral (IV or SubQ) anticoagulation and warfarin therapy

• Overlap should be administered for at least 5 days with an INR greater than or equal to 2 prior to discontinuation of the parenteral anticoagulant, or else:– Discharged on both medications, OR– Have a documented reason for discontinuation of

parenteral anticoagulation

• Included VTE types:– Any pulmonary embolus– Proximal lower extremity veins: Inferior vena cava; Iliac, femoral, or popliteal veins

VTE-3: Overlap Therapy

VTE-5: Discharge Instructions• Patients diagnosed with confirmed VTE that are

discharged to home, home care, court/law enforcement, or home on hospice care on warfarin

• Written discharge instructions must address all four criteria:– Compliance issues,– Dietary advice,– Information about the potential for adverse drug

reactions/interactions– Follow-up monitoring

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Value Based Purchasing Core MeasuresNew Performance Period: FY2015 (Q1 2013 – Q4 2013)

FY14 FY15

Q4 2012

Q1 2013

Q2 2013*

Q3 2013*

Hospital Compare National Average

(Q2 2012 – Q1 2013)VBP Range

FY15

HF - Discharge instructions 100% 100% 100% 99% 94% 92.66% -

100.00%

PN - Blood cultures in ED prior to ABX 96% 99% 98% 98% 98% 94.12% -

100%.00

PN - Initial ABX selection for CAP 97% 95% 98% 96% 95% 97.78% -

100.00%

AMI - PCI within 90 min. of hospital arrival 100% 100% 100% 100% 95% 95.35% -

100.00%

*Q2 and Q3 2013 data preliminary; Q2finalized after 10/25/13; Q3 finalized after 1/25/2013Green = 90% or greater and equal to or above national averageYellow = Equal to or above national average, but below 90% OR Above 90% , but below national averageRed = Below 90% and below national averageData Source: CMS

Privileged and Confidential Information for Quality Assurance and Performance Improvement Purposes and Protected under New York Education Law Section 6527 and Public Health Law Section 2805 J, K, L, and M

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Acute Myocardial InfarctionQ4 2012 Q1 2013 Q2 2013* Q3 2013*

Hospital Compare National Average

(Q2 2012 – Q1 2013)Sample  N = 208 N = 211 N = 206 N = 97

Aspirin at arrival 100% 100% 100% 100% 99%

Aspirin prescribed at discharge 100% 100% 100% 100% 99%

ACEI/ARB for LVSD 100% 100% 100% 100% 97%

Beta Blocker Prescribed at discharge 100% 100% 99% 100% 99%

Statin Prescribed at Discharge 100% 100% 100% 99% 98%

*Q2 and Q3 2013 data preliminary; Q2finalized after 10/25/13; Q3 finalized after 1/25/2013Green = 90% or greater and equal to or above national averageYellow = Equal to or above national average, but below 90% OR Above 90% , but below national averageRed = Below 90% and below national averageData Source: CMS

Privileged and Confidential Information for Quality Assurance and Performance Improvement Purposes and Protected under New York Education Law Section 6527 and Public Health Law Section 2805 J, K, L, and M

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Heart FailureQ4 2012 Q1 2013 Q2 2013* Q3 2013*

Hospital Compare National Average

(Q2 2012 – Q1 2013)Sample  N = 292 N = 296 N = 289 N = 133

Evaluation for LVS function 100% 100% 99% 100% 99%

ACEI/ARB for LVSD 98% 100% 100% 100% 97%

*Q2 and Q3 2013 data preliminary; Q2finalized after 10/25/13; Q3 finalized after 1/25/2013Green = 90% or greater and equal to or above national averageYellow = Equal to or above national average, but below 90% OR Above 90% , but below national averageRed = Below 90% and below national averageData Source: CMS

Privileged and Confidential Information for Quality Assurance and Performance Improvement Purposes and Protected under New York Education Law Section 6527 and Public Health Law Section 2805 J, K, L, and M

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Global ImmunizationQ4 2012 Q1 2013 Q2 2013* Q3 2013*

Hospital Compare National Average

(Q2 2012 – Q1 2013)Sample  N = 337 N = 337 N = 336 N = 237

Pneumococcal Immunization 93% 97% 95% 90% 90%

Influenza Immunization 98% 100% N/A N/A 90%*Q2 and Q3 2013 data preliminary; Q2finalized after 10/25/13; Q3 finalized after 1/25/2013Green = 90% or greater and equal to or above national averageYellow = Equal to or above national average, but below 90% OR Above 90% , but below national averageRed = Below 90% and below national averageData Source: CMS

Privileged and Confidential Information for Quality Assurance and Performance Improvement Purposes and Protected under New York Education Law Section 6527 and Public Health Law Section 2805 J, K, L, and M

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Perinatal Care Elective Delivery

Q4 2012 Q1 2013 Q2 2013* Q3 2013*Hospital Compare National Average

(Not Available)Sample  N = 345 N = 346 N = 313

Perinatal Care Elective Delivery(Goal for Rate Low) 0% 0% 0%

Privileged and Confidential Information for Quality Assurance and Performance Improvement Purposes and Protected under New York Education Law Section 6527 and Public Health Law Section 2805 J, K, L, and M

New Core Measure

started in Q1 2013

*Q2 2013 data preliminary and finalized after 10/25/13.Data source: CMS

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Stroke

Q4 2012 Q1 2013 Q2 2013* Q3 2013*Hospital Compare National Average

(Q2 2012 – Q1 2013)

Sample  N = 423 N = 372 N = 245

VTE Prophylaxis 98% 98% 97% 92%

Discharged on Antithrombotic Therapy 100% 100% 100% 99%

Anticoagulation Therapy for AFib/AFlutter 100% 100% 100% 95%

Thrombolytic Therapy 96% 100% 84% 60%

Antithrombotic Therapy By End of Hospital Day 2 98% 98% 93% 97%

Discharged on Statin Medication 98% 98% 98% 93%

Stroke Education 95% 93% 96% 85%

Assessed for Rehabilitation 98% 97% 99% 97%

New Core Measure

started in Q1 2013

Privileged and Confidential Information for Quality Assurance and Performance Improvement Purposes and Protected under New York Education Law Section 6527 and Public Health Law Section 2805 J, K, L, and M

*Q2 2013 data preliminary.Data source: CMS

Areas for Improvement• VTE-3 (Overlap Therapy)

– Ensure that pts with confirmed VTE who are treated with warfarin receive at least 5 days of overlap AND have INR ≥ 2 prior to stopping overlap

– OR document a reason for discontinuing overlap in the “VTE Core Measures” section of the DC Summary

• VTE-5 (Warfarin Discharge Instructions)– Explicitly document how to monitor warfarin post-discharge

in the “Follow-Up Appointments” or “Additional Instructions” section of the DC Summary

Areas for Improvement• HF-1 (Discharge Instructions)

– Explicitly document follow-up appointments with MD/PA/NP name and date (specific provider name is required)

– Use of "PMD” or “Primary MD” is NOT acceptable by CMS

Areas for Improvement• IMM-1 (Pneumococcal Immunization) Screening Year Round

– Eligible patients:• All patients 65 or older• Patients age 5-64 with a high risk condition:

• DM, ESRD, COPD, Nephrotic Syndrome, CHF, HIV, Asplenia

• Asthma (for pts age 19-64)– Ensure that vaccine orders are not discontinued during

transfer to another level of care• IMM-2 (Influenza Immunization) Screening Sept 1-March 31

– Eligible patients: All patients age 6 months or older– Ensure that vaccine orders are not discontinued during

transfer to another level of care

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Core Measure Education Guide• Versions for measures relevant to your area• Infonet > Quality & Pt Safety > Core Measures• infonet.nyp.org/QA/Pages/coremeasures.aspx