Core Measures
Evidence-Based Performance
Measurement
Lynne Hall, RN, BSN
Green 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
ACM is All
or nothing
Measures are specific to
that Measure
Measure
ASA on Arrival
ASA on D/C
BB on D/C
Met
ACM
Total
Patient A
Yes
Yes
Yes
Yes
Patient B
No
Yes
No
No
Patient C
Yes
Yes
No
No
2 of 3 or 67%
3 of 3 or
100%
1 of 3 or
33%
Total
1 of 3
or 33%
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?