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 (September 14 –> March 31, annually)
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
Good
Bad
7/2007-
3/2010
10/2007-6/2010
1/2008-9/2010

13. Pneumonia
Good
Bad
7/2007-
3/2010
10/2007-6/2010
1/2008-9/2010

14. AMI – Acute Myocardial Infarction
Bad
Good
7/2007-
3/2010
10/2007-6/2010
1/2008-9/2010

15. Heart Failure
Good
Bad
7/2007-
3/2010
10/2007-6/2010
1/2008-9/2010

16. SCIP – Surgical Care Improvement Program
Good
Bad
7/2007-
3/2010
10/2007-6/2010
1/2008-9/2010

17. PNEUMONIA: You are responsible for assuring the following elements are completed or an appropriate contraindication is documented:
Pneumococcal vaccination assessment
Antibiotic administration within 6 hours of arrival
Blood cultures drawn before antibiotics administered
For ICU admissions & suspected sepsis patients, blood cultures are drawn within 24 hours after ED arrival
Adult smoking cessation counseling is provided and documented
Appropriate antibiotics are selected
Influenza vaccination assessment (September 14 – March 31)
Complete administration of antibiotics within 24 hours of arrival to hospital

18. Pneumonia Core Measures Case Study:
Mr. Jones presents to your floor with fever, cough and shortness of breath and a diagnosis of pneumonia. In order to comply with the Pneumonia Core Measures, you must:
Review “Pneumonia Orders” Set in MIS or Med Host as placed by physician
When indicated (ICU admission or suspected sepsis), draw ordered blood cultures before administering any antibiotic
Ensure blood cultures are ordered within 24 hours of arrival to ED for ICU admissions
Antibiotics must be started within 6 hours of patient’s arrival to hospital
Antibiotic administration must be completed within 24 hours of arrival to hospital
Be sure a vaccination assessment is completed and activates appropriate protocol orders are activated *(Influenza vaccine: Sept. 14th through March 31st)

19. Acute Myocardial Infarction (AMI) As a patient advocate you must assure the following:
Aspirin is administered on arrival (ED)
It is the responsibility of the physician to:
prescribe Aspirin at discharge
order low density lipoprotein cholesterol (LDLc) level within 24 hours of arrival
prescribe ACEI/ARB for left ventricular systolic dysfunction (LVSD)
provide Adult smoking cessation counseling
prescribe Beta blocker at discharge
prescribe “statin” at discharge for LDL cholesterol > 100
Door to Balloon (PCI) within 90 minutes of arrival

20. AMI Core Measures Case Study:
Mrs. Brown presents to ED with chest discomfort, pain in the upper body, shortness
of breath, diaphoresis, and a positive EKG. Physician makes a diagnosis of AMI.
In order to comply with the AMI Core Measures, the following is to be assured:
Administer Aspirin on arrival using the standard AMI order set or physician documents the appropriate contraindications
It is the responsibility of the physician to ensure the following:
A low density lipoprotein cholesterol (LDLc) level is ordered within 24 hours of patient arrival to hospital
Left ventricular systolic function (LVSF) is evaluated
Aspirin is included on the Discharge Medications list
An ACEI/ARB is ordered for left ventricular systolic dysfunction (LVSD) as indicated and included in the discharge medication list or the appropriate contraindication is documented
Beta blocker is ordered and included in Discharge Instructions or the appropriate contraindication is documented
A statin is ordered at discharge for LDLc > 100

21. Heart Failure (CHF): The physician is 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 and documented

22. Surgical Care Improvement Project (SCIP): The physicians are responsible for assuring the following elements are completed:
Antibiotic within 60 minutes of “incision”
Appropriate Antibiotic used
Antibiotic is 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 per protocol by nurse with completion of MIS order. Documents in Intensive Care Flow-sheet, MIS order or progress note
Peri-operative temperature management
Beta blocker received perioperatively (within 24 hours of surgery or within PACU period)
Venous thromboembolism (VTE) prophylaxis applied within 24 hours (before or after) certain surgeries (i.e., general, urologic, gynecologic, orthopedic & intracranial neurosurgery)

23. SCIP Core Measures Case Study: Nurses are responsible for assuring the following elements are completed: :
CT Surgery (CABG & valves): patient glucose control at 6AM post-operative days (POD) #1 and #2 must be < 200mg/dL
Nursing plans for Q2hr POCT POD #1 through POD #2
Urinary catheter removed POD #1 or #2 per protocol by nurse with completion of MIS order.
Documents removal of catheter in Intensive Care Flow-sheet, MIS order or progress note
Antibiotic is discontinued within 24 hrs of surgical “end time”
Follow standing post-op MIS order set – “Now and Q 8 hrs X 2” to ensure antibiotics are discontinued within 24 hours of surgery

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

25. URGENT: Improvement Required!
We must reach 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

26. 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)

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

28. Action Plan: Nursing Core Measure Compliance
Nursing Operations members will complete CM Post-Test (3/28/11)
Nurse Managers will print, post Core Measures presentation and Post-tests on units (3/30/11)
Nursing IT to produce list of all TUH nurses by unit for Manager tracking and trending
Clinical Education Specialists will provide staff education & support to Managers
ALL nursing staff will complete and submit completed Post-tests to Nurse Managers by April 22nd
Managers will submit their Staff lists of post-test “completion” weekly to DON’s for compliance review