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Core Measures

Core Measures. What are Core Measures?. Indicators that are evidence based best practice for specified diagnoses. Why do I want to know about Core Measures?. Evidence based best practice! Public Reporting (www.hospitalcompare.hhs.gov)

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Core Measures

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  1. Core Measures

  2. What are Core Measures? • Indicators that are evidence based best practice for specified diagnoses.

  3. 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

  4. Core Measure Diagnoses • Acute Myocardial Infarction (AMI) • Heart Failure (HF) • Pneumonia (PN) • Surgical Care Improvement Project (SCIP) • Pregnancy Related Conditions

  5. 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.

  6. 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.

  7. 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.

  8. 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.

  9. Pregnancy Related Conditions • VBAC Rate • Inpatient Neonatal Mortality • Third or Fourth Degree Laceration

  10. How have we done? AMI

  11. How have we done? Heart Failure

  12. How have we done? Pneumonia

  13. How have we done? SCIP

  14. How have we done? Pregnancy Related Conditions

  15. 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.

  16. 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.

  17. 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.

  18. 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.

  19. Every Patient, Every Time!!

  20. Questions? Contact the Quality Department @ 394-3685

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