1. Core Measures: The Imperative for Quality

2. 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)

3. 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”

4. 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”

5. 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

6. 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

7. Are we measuring up?
NOT YET!

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

9. 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

10. 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

11. 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

12. 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

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

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

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

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

17. 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

18. 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

19. 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

20. 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

21. 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)

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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)

31. Are we meeting the core measure goals?
NOT YET!

32. 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

33. 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)

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