What Are Core Measures?
Core Measures are a method of tracking and measuring a variety of evidence-based, scientifically researched standards of care in medicine which have been shown to result in improved clinical outcomes for patients. CMS (the Center for Medicare & Medicaid Services) established the Core Measures in 2000 and began publicly reporting hospital data relating to the Core Measures in 2003.
How Do Core Measures Help?
These measures are “evidence-based and scientifically researched” standards of care. What this means is that much time and effort has gone into researching and studying patient care to determine what produced the best outcomes for patients. These are not just random ideas presented by the government; these are based on science and research and have proven to improve the quality of care and outcomes or results of that care for patients. At Holy Cross Hospital we rely on these measures to help us improve the care we provide. We are able to determine where we are doing well and where we must focus our efforts in order to provide better outcomes. Physicians and hospital staff have collaborated in developing policies, guidelines and protocols that have resulted in optimal care for our patients.
What Do We Measure?
There are currently four main conditions that we are looking at, each of these conditions then have several specific procedures or required care measures that are monitored. We look at the care patients receive when they present with Acute Myocardial Infarction (AMI or Heart Attack), Congestive Heart Failure (CHF), Pneumonia (PN) and Surgical Care (SCIP or Surgical Care Improvement Project).
How Do We Measure?
Every month we review charts of patients who were admitted to the hospital for any of the conditions listed above. We review whether or not a patient who was admitted for AMI (heart attack) received the standard of care required for all patients presenting with that condition. Did he receive an aspirin within 30 minutes of arrival, was his oxygen saturation level monitored, did he receive other appropriate medications in a timely manner, all total there are 7 measures for AMI patients that we review.
This data is also collected by the New Mexico Medical Review Association (NMMRA). Data is collected by the individual hospitals but NMMRA also reviews these data on a quarterly basis and uses that data to assist hospitals in identifying areas for improvement.
About the Measures:
Below you will find charts showing the results of HCH performance on the Core Measures. Also included are descriptions or definitions of each of the measures and why they are important. You will note that some charts do not show any data for a particular month or quarter. This is because HCH often has such low volumes of patients in that particular measure during that time period and we did not have any data to report. These charts are shown in quarters and are reported through the end of March 2009.
This data is collected monthly and reported to the HCH Board of Directors and the Medical Staff. These data is also are reported to NMMRA (New Mexico Medical Review Association) and the CMS (Center for Medicare and Medicaid Services). Our goal is to be in the 98-100% range for all of the measures. There are multidisciplinary teams working together to bring our scores up and we have been very successful in most areas, in other areas we are starting to make great progress and hope to have our scores at 98-100% in a very short time.
Is This a Report Card on Quality?
Unfortunately, the scores on the Core Measures can create misleading impressions when used not as an improvement tool, but as a hospital rating tool, particularly for small hospitals such as Holy Cross Hospital. What we must remember when reviewing these data is that the core measures are a method for assessing areas where we can improve the care provided.
Small hospitals like Holy Cross Hospital often do not have the volume of patients presenting with the conditions that are being measured, therefore if a physician documents a care measure in an area of the patients chart other then the specified mandated area of the chart that is examined by the reviewer, we are given a miss or demerit because the documentation was not in the appropriate section. If we only have four patients in one quarter who presented with Pneumonia and for one of those four, the physician noted the discharge instructions in the “Doctors’ Order” section of the chart and not in the “Discharge Summary” section, because it is not in the mandated section, when the chart is abstracted and not found in the appropriate section it is counted as a miss or demerit . So because we got a miss in one of four charts we only receive a score of 75%. Does that mean 25% of patients received substandard care or that a hospital that scored 90% gave better care? Not necessarily. The other hospital might have 50 patients who qualify for the indicator and have provided nonstandard care (or not documented care correctly) on 5 of those. That earns a 90% rating. Which is better? You can’t tell without investigation; because the data is designed to assist improvement, not to appear as a grade on a report card regarding the performance of the hospital.
As an improvement tool, this case allows us to do a few things: educate our physicians regarding documentation, standardize procedures, relocate our documentation, improve our discharge process, and create new guidelines and protocols for patient care. What this really means is that hospitals are forced to examine their processes to make adjustments to outdated practices, outdated methods of care and to use “evidence-based and scientifically researched” standards of care to improve patient outcomes.
Data Presented Can Be Misleading When:
▪ The number of cases is too small (less than 25) to reliably tell how well a hospital is performing.
▪ Data was collected during a shorter time period (fewer quarters) than the maximum possible time for this measure. (One quarter equals three months)
▪ “0 patients”—this hospital treats patients for this condition, but no patients met the criteria for inclusion in the measure calculation.
ACUTE MYOCARDIAL INFARCTION/AMI (Heart Attack)
Heart attack occurs when the blood vessels supplying the heart with oxygen, become clogged, either by blood clots or plaque. Once the blood flow has been interrupted, the heart muscle is damaged and begins to die. If blood flow is not restored quickly, irreversible damage to the heart muscle will begin to occur, which frequently leads to death. Every year, one million people will have Acute Myocardial Infarctions (AMI, or heart attacks) and of those people, 400,000 die. The goal is to immediately treat patients showing signs and symptoms of heart attack and once diagnosed, to restore blood flow within 30-60 minutes. Our goal at HCH is to provide immediate life saving treatment and then transfer the patient to a facility within NM with the ability to provide the higher level of care needed by that patient, such as a Cath Lab and/or cardiac surgery and a cardiac intensive care unit.
AMI-1 Aspirin at Arrival
What This Means:
Percent of Heart Attack Patients Given Aspirin at Arrival
Why This is Important:
The heart is a muscle that gets oxygen through blood vessels. Sometimes blood clots can block these blood vessels, and the heart can't get enough oxygen. This can cause a heart attack. Chewing an aspirin as soon as symptoms of a heart attack begin may help reduce the severity of the attack. This chart shows the percent of heart attack patients who were given (or took) aspirin within 24 hours of arrival at the hospital.
AMI-2 Aspirin Prescribed at Discharge
What This Means:
Percent of Heart Attack Patients Given Aspirin at Discharge
Why This is Important:
Blood clots can block blood vessels. Aspirin can help prevent blood clots from forming or help dissolve blood clots that have formed. Following a heart attack, continued use of aspirin may help reduce the risk of another heart attack. Aspirin can have side effects like stomach inflammation, bleeding, or allergic reactions. Talk to your health care provider before using aspirin on a regular basis to make sure it's safe for you.
AMI-3 ACEI Inhibitor or ARB Prescribed for LVSD (Left Ventricular Systolic Dysfunction)
What This Means:
Percent of Heart Attack Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)
Why This is Important:
ACEI (angiotensin converting enzyme inhibitors) and ARBs (angiotensin receptor blockers) are medicines used to treat patients with heart failure and are particularly beneficial in those patients with heart failure and decreased function of the left side of the heart. Early treatment with ACE inhibitors and ARBs in patients who have heart failure symptoms or decreased heart function after a heart attack can also reduce their risk of death from future heart attacks. ACE inhibitors and ARBs work by limiting the effects of
a hormone that narrows blood vessels, and may thus lower blood pressure and reduce the work the heart has to perform. Since the ways in which these two kinds of drugs work are different, your doctor will decide which drug is most appropriate for you. If you have a heart attack and/or heart failure, you should get a prescription for ACE inhibitors or ARBs if you have decreased heart function before you leave the hospital.
AMI-4 Adult Smoking Cessation Advice/Counseling Provided
What This Means:
Percent of Heart Attack Patients Given Smoking Cessation Advice/Counseling
Why This is Important:
Smoking increases your risk for developing blood clots and heart disease that can result in a heart attack, heart failure or stroke. Smoking causes your arteries to thicken and your blood vessels to narrow. Fat and plaque stick to the walls of your arteries, which makes it harder for blood to flow. Reduced blood flow to your heart may result in chest pain, high blood pressure, and an increased heart rate. Smoking is also linked to lung disease and cancer, and can cause premature death. It is important that you get information to help you quit smoking before you leave the hospital. Quitting may help prevent another heart attack.
AMI-5 Beta Blocker Prescribed at Discharge
What This Means:
Percent of Patients Given Beta Blockers at the Time of Discharge From the Hospital
Why This is Important:
This medicine can help reduce the amount of damage to the heart muscle in heart attack patients.
AMI-6 Beta Blocker at Arrival
What This Means:
Percent of Patients Given Beta Blockers on Admission to the Hospital
Why This is Important:
This medication can help reduce the damage to heart muscle in heart attack patients.
Data shown is through June 2009
HEART FAILURE
Congestive Heart Failure is a chronic condition in which the heart’s function as a pump is inadequate to meet the body’s requirements. Because the ‘pump’ is failing, it can cause blood to “back up” which results in congestion. Congestion leads to fluid build up in the lungs and other body tissues.
The goal in treating heart failure is to understand the level of ‘pump failure’ through certain tests, and then to treat the condition using drugs that are very effective in assisting the heart to pump better. Another treatment goal is make sure patients eat a healthy diet which will reduce fluid build up in the body’s tissues, and to be well educated around the signs and symptoms of congestion.
HF-1 Discharge Instructions
What Does This Mean:
Percent of patients that receive the patient education booklet and instructions about heart failure management at the time of discharge from the hospital.
Why This is Important:
Heart failure is a chronic condition. It results in symptoms such as shortness of breath, dizziness, and fatigue. Before you leave the hospital, the staff at the hospital should provide you with information to help you manage the symptoms after you get home. The information should include your: activity level (what you can and can't do); diet (what you should, and shouldn't eat or drink); medications; follow-up appointment; watching your daily weight; and what to do if your symptoms get worse.
HF-2 Left Ventricular Function (LVF) Assessment
What Does This Mean:
Percent of Patients given an LVF Assessment
Why This is Important:
The proper treatment for heart failure depends on what area of your heart is affected. An important test is to check how your heart is pumping, called an "evaluation of the left ventricular systolic function." It can tell your health care provider whether the left side of your heart is pumping properly. Other ways to check on how your heart is pumping include: your medical history; a physical examination; listening to your heart sounds; and other tests as ordered by a physician (like an ECG (electrocardiogram), chest x-ray, blood work, and an echocardiogram).
HF-3 ACEI, or ARB Prescribed for LVSD (Left Ventricular Systolic Dysfunction)
What This Means:
Percent of Heart Failure Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)
Why This is Important:
ACE (angiotensin converting enzyme) inhibitors and ARBs (angiotensin receptor blockers) are medicines used to treat patients with heart failure and are particularly beneficial in those patients with heart failure and decreased function of the left side of the heart. Early treatment with ACE inhibitors and ARBs in patients who have heart failure symptoms or decreased heart function after a heart attack can also reduce their risk of death from future heart attacks. ACE inhibitors and ARBs work by limiting the effects of a hormone that narrows blood vessels, and may thus lower blood pressure and reduce the work the heart has to perform. Since the ways in which these two kinds of drugs work are different, your doctor will decide which drug is most appropriate for you. If you have a heart attack and/or heart failure, you should get a prescription for ACE inhibitors or ARBs if you have decreased heart function before you leave the hospital.
HF-4 Smoking Cessation Advice/Counseling
What This Means:
Percent of Heart Failure Patients Given Smoking Cessation Advice/Counseling
Why This is Important:
Smoking increases your risk for developing blood clots and heart disease, which can result in a heart attack, heart failure or stroke. Smoking causes your blood vessels to thicken. Fat and plaque then stick to the wall of your blood vessels, which makes it harder for blood to flow. Reduced blood flow to your heart may result in chest pain, high blood pressure, and an increased heart rate. Smoking is linked to lung disease and cancer, and can cause premature death. It is important for your health that you get information to help you quit smoking before you leave the hospital.
Data shown is through June 2009
PNEUMONIA
Pneumonia is an inflammatory disease of the lungs. It is caused mainly by viruses, bacteria or a combination of both, but can also be caused by inhaling food, liquid, gases or dust and by fungi. Certain diseases, such as tuberculosis, can also cause pneumonia.
Pneumonia is a common illness which occurs in all age groups, and is a leading cause of death among the elderly and people who are chronically and terminally ill. There are vaccines available to prevent certain types of pneumonia. Typical symptoms associated with pneumonia include cough, chest pain, fever, and difficulty breathing.
PN-2 Pneumonia Vaccination Given
What This Means:
Percent of Pneumonia Patients Assessed and Given Pneumococcal Vaccination
Why This is Important:
The pneumococcal vaccine may help you prevent, or lower the risk of complications of pneumonia caused by bacteria. It may also help you prevent future infections. Patients with pneumonia should be asked if they have been vaccinated recently for pneumonia and, if not, should be given the vaccine. Higher percentages are better. Scientific literature has shown that people over the age of 65 years of age are more at risk for pneumonia.
PN-3b Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital
What This Means:
Percent of Pneumonia Patients Whose Initial Emergency Room Blood Culture Was Performed Prior To The Administration Of The First Hospital Dose Of Antibiotics
Why This is Important:
Different types of bacteria can cause pneumonia. A blood culture is a test that can help identify which bacteria may have caused the pneumonia and which antibiotic should be prescribed. A blood culture is not always needed, but for patients who are first seen in the emergency department, it is important for the accuracy of the test that blood culture be completed before any antibiotic is started. It is also important to start the antibiotic as soon as possible.
PN-4 Adult Smoking Cessation Advice/Counseling
What This Means:
Percent of Pneumonia Patients Given Smoking Cessation Advice/Counseling
Why This is Important:
Smoking damages your lungs and can make it hard to breath. Smoking increases your chances of getting pneumonia or other chronic lung diseases like emphysema and bronchitis. Smoking is also linked to lung cancer, heart disease, and stroke, and can cause premature death. It is important for you to get information to help you quit smoking before you leave the hospital. Quitting may reduce your chance of getting pneumonia again.
PN-5c Initial Antibiotic Within 6 Hours
What This Means:
Percent of patients who were given their first dose of antibiotics within 6 hours of arrival at the hospital. Patients who get pneumonia during their stay at the hospital are not counted in this measure.
Why This is Important:
Antibiotics are used to treat adults with pneumonia caused by bacteria. Early treatment with antibiotics can cure bacterial pneumonia and reduce the possibility of complications.
PN-7 Influenza Vaccination
What This Means:
Percent of Patients Assessed and Given Influenza Vaccination
Why This is Important:
Flu shots reduce the risk of influenza, a serious and sometimes deadly lung infection that can spread quickly in a community or facility. Hospitals should check to make sure that pneumonia patients, particularly those who are age 50 or older, get a flu shot during flu season to protect them from another lung infection and to help prevent the spread of influenza. Since a flu shot is effective for just one flu season, the period of time used to calculate this rate is the flu season (from approximately November through March), in contrast to other measures on Hospital Compare, which are generally collected throughout the year.
Data shown is through June 2009
SURGICAL CARE IMPROVEMENT PROJECT
The Surgical Care Improvement Project (SCIP) is a national quality partnership of organizations interested in improving surgical care by significantly reducing surgical complications. SCIP Partners include the Steering Committee of 10 national organizations who have pledged their commitment and full support for SCIP:
We Care About Your Safety
- Agency for Health care Research and Quality
- American College of Surgeons
- American Hospital Association
- American Society of Anesthesiologists
- Association of Perioperative Registered Nurses
- Centers for Disease Control and Prevention
- Centers for Medicare & Medicaid Services
- Institute for Health care Improvement
- The Joint Commission
- Veterans Health Administration
In addition, each of the SCIP target areas is advised by a technical expert panel (TEP). These groups have provided hours of technical expertise and resources to ensure the SCIP measures are fully supported by evidence-based research.
Surgical infections remain a common complication of surgery. Surgical site infections account for approximately 40% of all hospital associated infections among surgical patients in the USA and 3% of all post operative patients will develop infections. Using preventative measures, such as appropriate antibiotics before, during and up to 24 hours after surgery, clipping the operative site versus shaving, and keeping the patient warm during the perioperative period have all been shown to reduce the likelihood of infection as a complication.
SCIP-Inf-1 Prophylactic Antibiotic Received Within 1 Hour Prior to Surgery
What This Means:
Percent of surgery patients who were given an antibiotic at the right time (within one hour before surgery) to help prevent infection
Why This is Important:
Surgical wound infections can be prevented. Medical research shows that surgery patients who get antibiotics within the hour before their surgery are less likely to get wound infections. Getting an antibiotic earlier, or after surgery begins, is not as effective. Hospital staff should make sure surgery patients get antibiotics at the right time.
SCIP-Inf-2 Prophylactic Antibiotic Selection for Surgical Patients
What This Means:
Percent of Surgery Patients Who Were Given the Right Kind of Antibiotic to Help Prevent Infection
Why This is Important:
Surgical wound infections can be prevented. Medical research has shown that certain antibiotics work better to prevent wound infections for certain types of surgery. Hospital staff should make sure patients get the antibiotic that works best for their type of surgery.
SCIP-Inf-3 Prophylactic Antibiotics Discontinued Within 24 Hours of Surgery End Time
What This Means:
Percent of surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery)
Why This is Important:
Antibiotics are often given to patients before surgery to prevent infection. Taking these antibiotics for more than 24 hours after routine surgery is usually not necessary. Continuing the medication longer than necessary can increase the risk of side effects such as stomach aches and serious types of diarrhea. Also, when antibiotics are used for too long, patients can develop resistance to them and the antibiotics won't work as well.
SCIP-VTE-1 Venous Thromboembolism (Blood Clot) Prophylaxis Ordered for Surgical Patients
What This Means:
Percent of surgery patients whose doctors ordered treatments to prevent blood clots after certain types of surgeries
Why This is Important:
Certain surgeries increase the risk that the patient will develop a blood clot (venous thromboembolism). When patients stay still for a long time after some types of surgery, they are more likely to develop a blood clot in the veins of the legs, thighs, or pelvis. A blood clot slows down the flow of blood, causing swelling, redness, and pain. A blood clot can also break off and travel to other parts of the body. If the blood clot gets into the lung, it is a serious problem that can cause death. To help prevent blood clots from forming after surgery, doctors can order treatments to be used just before or after the surgery. These include blood-thinning medications, elastic support stockings, or mechanical air stockings that help with blood flow in the legs.
SCIP-VTE-2 Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery
What This Means:
Percent of patients who got treatment at the right time (within 24 hours before or after their surgery) to help prevent blood clots after certain types of surgery
Why This is Important:
Many factors influence a surgery patient's risk of developing a blood clot, including the type of surgery. When patients stay still for a long time after some types of surgery, they are more likely to develop a blood clot in the veins of the legs, thighs, or pelvis. A blood clot slows down the flow of blood, causing swelling, redness, and pain. A blood clot can also break off and travel to other parts of the body. If the blood clot gets into the lung, it is a serious problem that can sometimes cause death. Treatments to help prevent blood clots from forming after surgery include blood-thinning medications, elastic support stockings, or mechanical air stockings that help with blood flow in the legs. These treatments need to be started at the right time, which is typically during the period that begins 24 hours before surgery and ends 24 hours after surgery.
Data shown is through June 2009
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