Core Measures: The Imperative for Quality

Core Measures: Definition Core Measures are evidence-based best practices There are core measure sets for three (3) common medical diagnoses Pneumonia Acute Myocardial Infarction Congestive Heart Failure A fourth core measure set defines requirements for care of the surgical patient Surgical Care Improvement Project (SCIP)

Core Measures: Why do we care? Core Measures are the standard of care Core Measures are process indicators tied to clinical outcomes For example, giving aspirin early in an acute MI significantly reduces morbidity & mortality Core Measures are mandated by Federal, State and Regulatory Accreditation agencies and have been publicly reported since 2003 Compliance with Core Measures has enormous financial implications for the hospital with healthcare reform and value based purchasing, which link performance to reimbursement Core Measures are physician driven and reflect existing best practice literature As such you are responsible for compliance and documentation of compliance Core measures comprise the elements of “Perfect Care”

How are we measured? A composite of our individual Core Measure scores is called the Appropriateness of Care Measure (ACM) or “perfect care” The percent of times we get EVERYTHING right is equal to the percent of times we deliver “perfect care” For example, a patient who presents with an AMI who receives all six core measure interventions by this definition receives “perfect care”

When the patient receives all the treatments and interventions within the Core Measure set, we provided “perfect care” Heart Attack (AMI) CORE MEASURES Aspirin on arrival and prescribed at discharge Order LDL cholesterol level within 24 hours of arrival ACEI or ARB for LVSD Adult smoking cessation advice/counseling Beta blocker prescribed at discharge Complete “Door to Balloon” w/in 90 minutes Statin prescribed at discharge: (Low Density Lipoprotein cholesterol > 100) Elements of the Core Measures Heart Failure (CHF) CORE MEASURES Discharge Instructions Evaluation of LVS function ACEI or ARB for LVSD Adult smoking cessation advice/counseling

When the patient receives all the treatments/interventions within the Core Measure set, we provided “perfect care” Pneumonia CORE MEASURES Pneumococcal vaccine Blood cultures prior to antibiotics (ICU patients, suspected sepsis) Blood cultures for ICU admissions within 24 hrs. of arrival to ED Initial antibiotic within 6 hours Adult smoking cessation counseling/advice Appropriate antibiotic selection (ICU/Non-ICU) Influenza vaccine Elements of the Core Measures Surgical Care CORE MEASURES Peri-operative beta blocker Prophylactic antibiotic within 1 hour of incision Prophylactic antibiotic selection Prophylactic antibiotic discontinued within 24 hours Controlled 6am blood glucose for cardiac surgery patients post op Clippers used for appropriate hair removal Removal of urinary catheter within two days of surgery Peri-operative temperature management Appropriate VTE prophylaxis ordered VTE prophylaxis received within 24 hours of surgery

Are we measuring up? NOT YET!

Public Reporting of TUH Core Measures The Joint Commission (TJC) publically posts the Core Measures performance of all hospitals on its website www.jointcommission.org (Please see next slide)

The Joint Commission’s report on TUH Core Measures Performance: Statistically significant performance issues for Pneumonia and Surgery July 2009 Through June 2010 Desirable performance for AMI and CHF

Quality Insights Report The following slides are reported by Quality Insights, a non-profit company focused on assuring the right care for every patient every time. Quality Insights is the Pennsylvania Medicare Quality Improvement Organization (QIO) QIO’s are designed to protect the rights and improve the healthcare of Medicare consumers. As such they publish comparative hospital data on which patients can make decisions about where to receive healthcare

Quality Insights Reports Each bar represents a hospital in PA The black bar is TUH All the green bars represent hospitals exceeding our performance All the red bars represent hospitals performing at lower rates than TUH

Overall Appropriateness of Care Measure (ACM): The total percentage of heart attack, heart failure, pneumonia, and surgical care patients who received all recommended treatments based on their clinical condition July 2007 through March 2010 Good Bad October 2007 through June 2010

Pneumonia Bad Good 7/2007- 3/2010 10/2007-6/2010

AMI – Acute Myocardial Infarction Good Bad 7/2007- 3/2010 10/2007-6/2010

Heart Failure Bad Good 7/2007- 3/2010 10/2007-6/2010

SCIP – Surgical Care Improvement Program Good Bad 7/2007- 3/2010 10/2007-6/2010

PNEUMONIA: You are responsible for assuring the following elements are completed or an appropriate contraindication is documented: Pneumococcal vaccination Blood cultures drawn before antibiotics administered for ICU patients or suspected sepsis Blood cultures drawn within 24 hours after ED arrival for ICU admissions Adult smoking cessation counseling provided Antibiotic administration within 6 hours of admission Appropriate antibiotics selection Influenza vaccination Complete administration of antibiotics within 24 hours of arrival to hospital

Pneumonia Core Measures Case Study: Mr. Jones presents to you with fever, cough and shortness of breath. You make a diagnosis of pneumonia. In order to comply with the Pneumonia Core Measures, you must: Utilize the standing “Pneumonia Order Set” in MIS or Med Host When indicated (ICU admission or suspected sepsis), order blood cultures before administering any antibiotic Ensure blood cultures are ordered within 24 hours of arrival to ED for ICU admissions Document in the chart if an “atypical” presentation resulted in a “delay” in the diagnosis of pneumonia Ensure that antibiotic selection is based on presentation, suspected pathogen and possible allergy If blood cultures are obtained for a non-ICU patient, ensure they are obtained before antibiotic administration Start antibiotics within 6 hours of patient’s arrival to hospital Ensure antibiotic administration is complete within 24 hours of arrival to hospital Ensure the nurse performs a vaccination assessment and activates appropriate protocol orders

PN Antibiotic Recommendations: Non-ICU Patients Beta-lactam (IV or IM) + Macrolide (IV or PO) OR Anti-pneumococcal Quinolone monotherapy (IV or PO) Beta-lactam (IV or IM) + Doxycycline (IV or PO) If less than 65 with no Risk Factors for Drug-Resistant Pneumococcus Macrolide monotherapy (IV or PO) Beta-lactam = Ceftriaxone, Ampicillin/Sulbactam Macrolide = Erythromycin, Clarithromycin, Azithromycin Anti-pneumococcal Quinolones = Moxifloxacin

PN Antibiotic Recommendations: ICU Patients Macrolide (IV) + either Beta-lactam (IV) OR Anti-pneumococcal/Anti-pseudomonal Beta-lactam (IV) OR Anti-pneumococcal Quinolone (IV) OR Anti-pseudomonal Quinolone (IV) + either Beta-lactam (IV) OR Anti-pneumococcal/ Anti-pseudomonal Beta-lactam (IV) Anti-pneumococcal/ Anti-pseudomonal Beta-lactam (IV) + Aminoglycoside (IV) + either Anti-pneumococcal Quinolone (IV) OR Macrolide (IV) Beta-lactam = Ceftriaxone, Ampicillin/Sulbactam, Anti-pneumococcal/ Anti-pseudomonal Beta-lactam = Imipenem (preferred), Cefepime, Meropenem (restricted to patients who meet defined criteria), Piperacillin/Tazobactam Macrolide = Erythromycin, Azithromycin Anti-pneumococcal Quinolones = Moxifloxacin Anti-pseudomonal Quinolone = Ciprofloxacin Aminoglycoside = Gentamicin, Tobramycin, Amikacin

PN Antibiotic Recommendations: Non-ICU Patients w/ Pseudomonal Risk ONLY Anti-pneumococcal/Anti-pseudomonal Beta-lactam (IV) + Anti-pseudomonal Quinolone (IV or PO) OR Anti-pseudomonal Beta-lactam (IV) + Aminoglycoside (IV) + either Anti-pneumococcal Quinolone (IV or PO) OR Macrolide (IV or PO)

PN Antibiotic Recommendations: ONLY Non-ICU Patients w/ Beta-lactam Allergy & Pseudomonal Risk Aztreonam (IV or IM) + Anti-pneumococcal Quinolone (IV or PO) + Aminoglycoside (IV) Aminoglycoside = Gentamicin, Tobramycin, Amikacin Anti-pneumococcal Quinolone = Moxifloxacin

Acute Myocardial Infarction (AMI): You are responsible for assuring the following elements are completed or an appropriate contraindication is documented: Aspirin administered on arrival Aspirin prescribed at discharge Order low density lipoprotein cholesterol (LDLc) level within 24 hours of arrival to hospital ACEI/ARB prescribed for left ventricular systolic dysfunction (LVSD) Adult smoking cessation counseling provided Beta blocker prescribed at discharge Door to Balloon within 90 minutes of arrival Statin prescribed at discharge for LDL cholesterol > 100

AMI Core Measures Case Study: Mrs. Brown presents to you with chest discomfort, pain in the upper body, shortness of breath, diaphoresis, and a positive EKG. You make a diagnosis of AMI. In order to comply with the AMI Core Measures, you must: Order aspirin on arrival using the standard AMI order set or document any contraindications Ensure aspirin is included on the Discharge Medications list Evaluate left ventricular systolic function (LVSF) Order an ACEI/ARB for left ventricular systolic dysfunction (LVSD) as indicated and include in the discharge medication list or document the appropriate contraindication Order a beta blocker and include in Discharge Instructions or document the appropriate contraindication Order a low density lipoprotein cholesterol (LDLc) level within 24 hours of patient arrival to hospital Prescribe a statin at discharge for LDLc > 100

Heart Failure (CHF): You are responsible for assuring the following elements are completed or that an appropriate contraindication is documented: All medications are documented in Discharge Instructions ONLY Left ventricular systolic function (LVSF) assessment is completed ACEI/ARB for left ventricular systolic dysfunction (LVSD) is prescribed Adult smoking cessation advice/counseling provided

CHF Core Measures Case Study: Mr. Smith presents to you with dyspnea, fatigue, lower extremity edema and shortness of breath. You make a diagnosis of Congestive Heart Failure. In order to comply with the CHF Core Measures, you must: Use the CHF Discharge pathway for listing discharge medications in the Discharge Instructions ONLY. (Do not mention specific meds is discharge summary or discharge note) Use the CHF Discharge pathway to specify patient education for diet, activity, weight gain, medications & symptoms of worsening condition Evaluate left ventricular systolic function (LVSF); which must be documented in progress notes or MIS “outpatient” LVSF referral note Prescribe an ACEI/ARB for LVSD as indicated during inpatient stay and at discharge. Include in Discharge Instructions medication list or document the appropriate contraindication

Surgical Care Improvement Project (SCIP): You are responsible for assuring the following elements are completed: Antibiotic within 60 minutes of “incision” Appropriate Antibiotic used Antibiotic discontinued within 24 hrs of surgical “end time” CT Surgery (CABG & valves): patient glucose control at 6AM post-operative days (POD) #1 and #2 must be < 200mg/dL Appropriate hair removal Urinary catheter removed POD #1 or #2 (or document why continuation is justified) Peri-operative temperature management Beta blocker received perioperatively (within 24 hours of surgery or within PACU period) Appropriate venous thromboembolism (VTE) prophylaxis ordered Venous thromboembolism (VTE) prophylaxis ordered within 24 hours of surgery

SCIP Core Measures Case Study: Mrs SCIP Core Measures Case Study: Mrs. Jones is scheduled for a routine surgical procedure. In order to comply with the SCIP core measures, you must: Ensure antibiotics appropriate to the procedure are ordered pre-operatively Order antibiotics using recommended guidelines (Form Checker) Verify during time out when antibiotic has been started (time included) – must be within 1 hour of “incision” Utilize standing MIS order set – “Now and Q 8 hrs X 2” to ensure antibiotics are discontinued within 24 hours of surgery Document clearly when “new” or prolonged antibiotic therapy exceeds 24 hours – “treatment” is not the same as prophylaxis

Continued: SCIP Core Measures Case Study: Mrs Continued: SCIP Core Measures Case Study: Mrs. Jones is scheduled for a routine surgical procedure. In order to comply with the SCIP core measures, you must: Utilize appropriate insulin orders via pump X 72 hours For CT surgery patients: ensure monitoring of hourly blood glucose (must be <200mg/Dl) at 6AM Post-Operative Day (POD) #1 and POD #2 Utilize standing orders in operating room Document reason for prolonged urinary catheter usage if it cannot be removed during Post-Operative Day (POD) #1 or POD #2 For patients on beta blocker prior to or during admission, ensure beta blocker administration within 24 hours before surgery OR by the end of the recovery period in PACU Ensure completion of all appropriate VTE orders (pharmacological & mechanical)

Are we meeting the core measure goals? NOT YET!

URGENT: Improvement Required! We must hit 100% on all measures No excuses 90-95% is not good enough In the absence of compliance, we will not be able to compete for patients on the basis of quality and we will lose business

What’s going to happen…if we don’t get to 100%? We will be delivering substandard care We will not be able to compete in the marketplace We will not be “reimbursed” at the highest level for all discharges after July 1, 2011 In the future, we will not be accredited by The Joint Commission (TJC)

Every patient, every time – without fail! Core Measures “Perfect Care” Every patient, every time – without fail!