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Core Measures. What are Core Measures?. Indicators that are evidence based best practice for specified diagnoses. Why do I want to know about Core Measures?. Evidence based best practice! Public Reporting (www.hospitalcompare.hhs.gov)

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What are core measures
What are Core Measures?

  • Indicators that are evidence based best practice for specified diagnoses.


Why do i want to know about core measures
Why do I want to know about Core Measures?

  • Evidence based best practice!

  • Public Reporting (www.hospitalcompare.hhs.gov)

  • Reported to: CMS (Center for Medicare and Medicaid Services) and JCAHO


Core measure diagnoses
Core Measure Diagnoses

  • Acute Myocardial Infarction (AMI)

  • Heart Failure (HF)

  • Pneumonia (PN)

  • Surgical Care Improvement Project (SCIP)

  • Pregnancy Related Conditions


Acute myocardial infarction ami
Acute Myocardial Infarction (AMI)

  • Aspirin & Beta Blocker given in first 24 hours or contraindications charted.

  • LVF evaluated or planned to be done.

  • Aspirin & Beta Blocker prescribed at discharge or contraindications charted.

  • ACEI/ARB prescribed at discharge if LVF <40% or contraindications charted.

  • Smoking counseling, if smoker.


Heart failure hf
Heart Failure (HF)

  • LVF evaluated or planned to be done.

  • ACEI/ARB prescribed at discharge if LVF <40% or contraindications charted.

  • Smoking counseling, if smoker.

  • Discharge instructions given.


Pneumonia pn
Pneumonia (PN)

  • Blood culture prior to antibiotic.

  • Antibiotic in first 4 hours of arrival.

  • Appropriate antibiotic based on allergy and if healthcare acquired.

  • Smoking counseling, if smoker.

  • Influenza & pneumococcal vaccination status.


Surgical care improvement project scip
Surgical Care Improvement Project (SCIP)

  • Antibiotic within 1 hour of surgery.

  • Appropriate antibiotic according to guidelines.

  • Discontinue antibiotics within 24 hours of surgery end time.

  • Patients who are on beta blockers at home, have taken prior to surgery.

  • Venous thromboembolism prophylaxis.

  • Appropriate hair removal.

  • Colorectal temp.


Pregnancy related conditions
Pregnancy Related Conditions

  • VBAC Rate

  • Inpatient Neonatal Mortality

  • Third or Fourth Degree Laceration



How have we done1
How have we done?

Heart Failure




How have we done?

Pregnancy Related Conditions


How can i help ami
How can I help? AMI

  • Aspirin and Beta Blockers in first 24 hours, or contraindications documented.

  • LVF documented in record (past, current or future planned).

  • Aspirin and Beta Blockers prescribed at discharge, or contraindications documented.

  • ACEI/ARB prescribed at discharge for LVF <40%, or contraindications documented for both the ACEI and the ARB.


How can i help hf
How can I help? HF

  • LVF documented in record (past, current or future planned).

  • ACEI/ARB prescribed at discharge for LVF <40%, or contraindications documented for both the ACEI and the ARB.


How can i help pneumonia
How can I help?Pneumonia

  • Antibiotics within 4 hours of arrival.

  • Appropriate antibiotics based on the patient’s allergy and community verses healthcare acquired. Following the pathway is the best way comply.


How can i help scip
How can I help? SCIP

  • Antibiotics based on the patient’s allergy and surgery. Following the pathway is the best way to comply.

  • Only continue antibiotics longer than 24 hours post surgery if there are signs of an infection; document those signs of infection in the record.



Questions

Questions?

Contact the Quality Department @ 394-3685


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