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Core Measures

Core Measures. Evidence-Based Performance Measurement. Lynne Hall, RN, BSN Green Belt Six Sigma. Updated: 06/16/2011. Objectives. Be able to describe evidence-based medicine Understand purpose of using Core Measures Describe each Core Measure Set. What is Evidence-Based Medicine?.

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Core Measures

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  1. Core Measures Evidence-Based Performance Measurement Lynne Hall, RN, BSN Green Belt Six Sigma Updated: 06/16/2011

  2. Objectives • Be able to describe evidence-based medicine • Understand purpose of using Core Measures • Describe each Core Measure Set

  3. What is Evidence-Based Medicine? Involves patient care that research has shown to result in better outcomes for patients such as lower: • Mortality and Morbidity • Disability • Length of stay • Readmissions These are also areas that CMS and Joint Commission focus on to make sure patients are receiving the right care at the right time!

  4. What is a Core Measure? The percentage of eligible patients that receive care represented by the measure set • Example: Percent of eligible patients that receive aspirin on arrival for AMI

  5. How do the two interact? • Evidence-based medicine was used in the development of core measures • Each question for each measure set was founded on evidence-based medicine principles by practicing physicians • Core measures are designed so that every patient is given the right care every time

  6. What are the benefits of Core Measures? • Provides a measure of quality for your hospital • Assures the community that your hospital is providing high quality of care • Assures your hospital gets reimbursement from Medicare

  7. What are the Core Measure Sets? Inpatient Clinical Areas of Focus are: • Heart Failure (HF) • Acute Myocardial Infarction (AMI) • Pneumonia (PN) • Surgical Care Infection Prevention (SCIP) • Venous Thromboembolism (VTE) • Stroke (STK) • Emergency Department (ED) • Prevention (Prev) • Children's Asthma Care (CAC)

  8. What are the Core Measure Sets? Outpatient Clinical Areas of Focus are: • Chest Pain • AMI (designed for those patients who are transferred from the ED for a different level of care) • Outpatient Surgery • Radiology Imaging • Structural Measures

  9. Heart Failure • HF-1: Discharge Instructions Given • HF-2: Evaluation of LVS Function • HF-3: ACEI / ARB Given for LVSD • HF-4: Adult smoking cessation advice/counseling given

  10. AMI • AMI-1: Aspirin given on Arrival • AMI-2: Aspirin prescribed at discharge • AMI-3: ACEI / ARB for LVSD • AMI-4: Adult smoking cessation advice / counseling • AMI-5: Beta Blocker prescribed at discharge

  11. AMI • AMI-7a: Fibrinolytic within 30 minutes of arrival • AMI-8a: Primary PCI received within 90 minutes of hospital arrival • AMI-9: Inpatient mortality • AMI-10: Statin Prescribed at Discharge

  12. Pneumonia • PN-2: Pneumococcal Vaccination • PN-3a: 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 • PN-3b: Blood cultures performed in the ED prior to initial antibiotic received in hospital • PN-4: Adult smoking cessation advice / counseling

  13. Pneumonia • PN-5c: Initial Antibiotic Received Within 6 Hours of Hospital Arrival • PN-6: Initial Antibiotic Selection for CAP in Immunocompetent Patient • PN-6a: Initial Antibiotic Selection for CAP in Immunocompetent – ICU Patient • PN-6b: Initial Antibiotic Selection for CAP Immunocompetent – Non ICU Patient • PN-7: Influenza Vaccination (October thru March)

  14. SCIP (Surgical Care Improvement Project) • *SCIP-Inf-1: Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision • *SCIP-Inf-2: Prophylactic Antibiotic Selection for Surgical Patients • *SCIP-Inf-3: Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time • SCIP-Inf-4: Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Blood Glucose *The first three SCIP-Inf measures drill down into individual surgeries such as hips, knees, cardiac, etc

  15. SCIP • SCIP-Inf-6: Surgery Patients with Appropriate Hair Removal. • SCIP-Inf-9: Urinary Catheter Removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) With Day of Surgery Being Day Zero. • SCIP-Inf-10: Surgery Patients with Perioperative Temperature Management.

  16. SCIP • SCIP-Card-2: Surgery Pts on Beta-Blocker Therapy Prior to Admission Who Received a Beta-Blocker During the Perioperative Period • SCIP-VTE-1: Surgery Pts with Recommended VTE Prophylaxis Ordered • SCIP-VTE-2: Surgery Patients Who Received Appropriate VTE Within 24 Hours Prior to Surgery to 24 Hours After Surgery

  17. Outpatient Measure Sets • OP-1: Median time to Fibrinolysis (AMI) • OP-2: Fibrinolytic therapy received within 30 min of hospital arrival (AMI) • OP-3: Median time to transfer to another facility for Acute Coronary Intervention (AMI) • OP-4: ASA on arrival (AMI / Chest Pain) • OP-5: Median Time to ECG (AMI / Chest Pain)

  18. Outpatient Measure Sets • OP-6: Timing of Antibiotic Prophalaxis (Outpatient Surgery) • OP-7: Prophylactic Antibiotics selection for surgical patients (Outpatient Surgery)

  19. Outpatient Measure Sets These measures are abstracted from Administrative Data Imagining Measures • OP-8: MRI Lumbar Spine for Low Back Pain • OP-9: Mammography Follow-up Rates • OP-10: Abdomen CT Use of Contrast Material • OP-11: Thorax CT Use of Contrast Material

  20. Outpatient Measure Sets These measures are abstracted from Administrative Data Imagining Measures • OP-13 Cardiac Imaging for Preoperative Risk Assessment for Non Cardiac Low Risk Surgery • OP-14 Simultaneous Use of Brain Computed Tomography (CT) and Sinus Computed Tomography (CT) • OP-15 Use of Brain Computed Tomography (CT) in the Emergency Department for Atraumatic Headache

  21. Outpatient Measure Sets These measures are abstracted from Administrative Data Structural Measures • OP-12 The Ability for Providers with HIT to Receive Laboratory Data Electronically Directly into their Electronic Health Record (EHR) System as Discrete Searchable Data • OP-17 Tracking Clinical Results Between Visits

  22. What is the difference between a measure score and an ACM?

  23. Met ACM Total Measure ASA on Arrival ASA on D/C BB on D/C Yes Yes Yes Patient A Yes No Patient B Yes No No Yes No Patient C Yes 1 of 3 or 33% 2 of 3 or 67% 3 of 3 or 100% Total Measure vs. ACM ACM is All or nothing Measures are specific to that Measure No 1 of 3 or 33%

  24. What can Physicians do to Help? • Communication with • Nurses • Family • Patient • Documentation, Documentation • This is not “cookbook” medicine but does involve documenting correctly on a Core Measure Patient • Give yourself credit for the work you do! • Look for “triggers” that are placed on charts by staff that act as reminders for documentation

  25. Examples • Example of unacceptable charting for “ASA at discharge” • “Hold ASA” • Example of ACCEPTABLE charting for “ASA at discharge” • “Hold EC ASA x 2 days” • “Hold aspirin until after endoscopy” Both of these imply the patient will start the ASA after a certain event or time frame

  26. Summary • Evidence-based medicine helps provide the right care for every patient every time! • Core Measures help focus that effort • Know who is a core measure patient • Become familiar with which core measures your facility is using and what you can do to help!

  27. Resources These resources give you the best insight into what evidence-based medicine is and how it effects your medical documentation and payment • www.qualitynet.org • www.hospitalcompare.hhs.gov • www.qualitycheck.org

  28. Questions?

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