The Department of Quality and Risk Management

Institution-Wide Quality Activities Core Measures Focused Quality Projects Review of Adverse Events

What Are Core Measures? National measures that use evidence-based medicine to establish standards of care for given diagnoses High volume, high cost diagnoses associated with increased rate of morbidity or mortality Federal goal  Greatest good for the most people Results reported as % of patients admitted with a specific diagnosis who received the recommended care measure Now being used by Medicare for Value-Based Purchasing

Core Measures Acute Myocardial Infarction (AMI) Heart Failure (HF) Early administration of aspirin* Aspirin at discharge Beta-blocker at discharge ACE-inhibitor or ARB at discharge for patients with systolic dysfunction Timely initiation of reperfusion * Statin prescribed at discharge Heart Failure (HF) Left ventricular function assessment ED Measure *

Core Measures (cont.) Pneumonia (PN) ED Measure * Blood culture prior to initial antibiotic for ICU patients * Appropriate antibiotic selection * ED Measure *

Core Measures (cont.) Surgical Care Improvement Project (SCIP) Prophylactic antibiotic received within one hour prior to surgical incision Appropriate prophylactic antibiotic selection Prophylactic antibiotics discontinued within 24 hours after surgery end time Appropriate hair removal Urinary catheter removal on POD1 or POD2 Perioperative temperature management Patients on beta-blocker prior to arrival receive a beta-blocker during the perioperative period Surgery patients with recommended VTE prophylaxis ordered Surgery patients who receive appropriate VTE prophylaxis within 24 hours before and after surgery

Core Measures (cont.) Immunizations Tobacco Use Screening Pneumococcal vaccination, if applicable Influenza vaccination, if applicable Tobacco Use Screening Include type, volume and timeframe of use Treatment: Cessation counseling; medication

Focused Quality Projects Sepsis: Early Recognition & Treatment Glucose Management Reducing Hospital-Acquired Infections -CLABS -CAUTI -Surgical Site Infections Reducing Medication Errors Reducing Falls and Injuries from Falls

Adverse Events Investigation – “Fact-Finding” Root Cause Analysis Morbidity and Mortality Conference Corrective Actions Monitoring for Improvement

Events reported for investigation Falls resulting in fracture or cerebral bleed Pneumothorax secondary to central line insertion DVT/PE not present on admission Unplanned conversion from laparoscopic to open procedure CVA within 48 hours of surgery Cardiac arrest within 48 hours of surgery MI within 48 hours of surgery Intraoperative injury requiring surgical repair Unplanned reoperation Postoperative wound infection following clean case requiring treatment, reoperation or readmission within 30 days

Events reported for investigation (cont.) Retained foreign body Cardiorespiratory arrest as a result of an unexpected adverse occurrence Impairment or loss of limb, organ, or bodily function Second and third degree burns Equipment malfunctions during treatment or diagnosis of a patient Death within 24 hours of restraints or seclusion use

What Are Residents Expected to Do? Communicate! Escalate! Document! Participate!

Hospital Consumer Assessment of Healthcare Provider and Systems (HCAHPS)