Core Measures

Evidence-Based Performance Measurement

Lynne Hall, RN, BSNGreen 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?

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!

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

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

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

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)

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

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

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

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

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

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)

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

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.

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

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)

Outpatient Measure Sets

OP-6: Timing of Antibiotic Prophalaxis (Outpatient Surgery)

OP-7: Prophylactic Antibiotics selection for surgical patients (Outpatient Surgery)

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

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

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

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

Measure vs. ACM

Patient A

Patient B

Patient C

Measure

Total

ASA on Arrival

Yes

Yes

No

2 of 3 or 67%

ASA on D/C

Yes

Yes

Yes

3 of 3 or 100%

BB on D/C

No

No

1 of 3 or 33%

Yes

Met ACM Total

Yes

No

No

1 of 3 or 33%

ACM is All or nothingMeasures are specific to

that Measure

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

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

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!

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

Questions?