1. The Department of Quality and Risk Management

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

3. 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

4. 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 *

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

6. 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

7. 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

8. 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

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

10. 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

11. 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

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

13. Hospital Consumer Assessment of Healthcare Provider and Systems (HCAHPS)