Core Measures – Focused Feedback Report
for
Facility Name & Location
4TH Quarter 2012
Discharges between 10/1/2012 – 12/31/2012
Core Measures – Focused Feedback Report
Facility Name & Location
4th Quarter 2012
(Discharges between 10/1/2012-12/31/2012)
This focused feedback report summarizes Amphion’s observations and recommendations to core measure abstraction for Facility
Name & Location for 4th Quarter 2012, discharges from October 1, 2012 through Dec. 31, 2012.
Amphion Abstraction Activity
For 4th Quarter 2012, Amphion abstracted a total of 794 cases. The following table summarizes the number of cases for each core
measure topic.
INP ED/
IMMUN
AMI
HF
PN
IP
301
20
47
62
cases
OP
cases
TOTAL # of cases abstracted for 4Q2012
SCIP
CAC
HBIPS
85
1
72
HOPSurgery
HOPAMI/CP/
PM/STK
HOP-ED
TOTAL
588
36
72
98
206
794
Performance Measure Data
This report does not provide data regarding performance for each specific core measure. Therefore, we recommend monitoring
reports provided through QualityNet and your vendor, Thomson Reuters CareDiscovery™ Quality Measures .
All references to Guidelines were directly quoted from the SPECIFICATIONS MANUAL for NATIONAL HOSPITAL QUALITY
MEASURES for Discharges 07/01/2012-12/31/2012).
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Core Measures – Focused Feedback Report
Facility Name
4 Quarter 2012
(Discharges between 10/01/2012-12/31/2012)
th
Abstractor Observations and Recommendations
Measure
Set(s)
Observations
Recommendations/Comments
MEASURE PERFORMANCE
AMI
AMI-1: ASA on Arrival
16/17 cases met criteria=94% (↓from last quarter)
MRN 3497047
AMI-2: ASA Presribed at Discharge
13/14 cases met criteria= 93 (↓ from last quarter)
MRN 3497047
This AMI patient was not on aspirin or statin prior to
arrival, found to have an MI and was not prescribed
either during the admission or at discharge, with no
allergy or contraindication noted.
This AMI patient was not on aspirin or statin prior to
arrival, found to have an MI and was not prescribed
either during the admission or at discharge, with no
allergy or contraindication noted.
AMI-3: ACEI or ARB for LVSD
4/4 cases met criteria=100% (same as last quarter)
n/a
AMI-5: Beta Blocker prescribed at Discharge
16/16 =100% (↑ from last quarter)
n/a
AMI -10: Statin Prescribed at Discharge
15/16 cases met criteria= 94% (↓ from last quarter)
MRN 3497047
This AMI patient was not on aspirin or statin prior to
arrival, found to have an MI and was not prescribed
either during the admission or at discharge, with no
allergy or contraindication noted. ]
HF
3
Measure
Set(s)
Observations
Recommendations/Comments
HF1: Discharge Instructions
33/39 cases met all criteria (diet, activity, symptoms
worsening, and medications, wt. monitoring and follow-up)
=85% (↓ from last quarter)
MRN 3229306, 3491478, 3496538, 3604411, 3458950,
3629057
Since HF1 Discharge Instructions address all 6 Elements
is one of the Clinical Process Measures included in the
Value Based Purchasing program to start FY 2013/2014,
a success rate of 100% (0 failed cases) can be a goal
soon.
Hospitals can incur a 1% withholding in Medicare
Reimbursement in FY 2013 (increasing to 2% by 2017).
Where deficiencies are found, hospitals would do well
to take a proactive approach and focus their efforts
there at this time.
HF2: LVF Assessment
46/46 cases met criteria=100% (same as last quarter)
HF3: ACEI/ARB for LVSD
16/18 cases met criteria=89% (↓ from last quarter)
MRN 3229306, 3491478
n/a
Implementing computerized physician discharge order
sets that address ACE/ARB or contraindications could be
a goal.
There can be contraindications for not prescribing an
ACEI or ARB at discharge, and can be documented
anytime during the stay; but this must occur in writing
and cannot be inferred unless the patient has moderate
or severe aortic stenosis.
PN
PN 3a: Blood Cultures w/in 24 hrs of Hospital Arrival – ICU
patients 7/7 cases met criteria=100% (same as last quarter)
PN3b: Blood Cultures Prior to Giving Antibiotics in the ED
32/32 cases met criteria = 100% (↑ from last quarter)
n/a
n/a
4
Measure
Set(s)
Observations
Recommendations/Comments
PN6a, PN6b: ABX Selection for CAP in Immunocompetent Patients
PN6a : 3/3 cases met criteria = 100%
PN6b : 20/21 cases met criteria = 95% (↑ from last quarter)
n/a
MRN 4466316
Only one antibiotic was given within the first 24 hours for this
December patient.
SCIP
SCIP1a: Prophylactic ABX Started w/in 1 hr of Incision Time –
Overall Rate
54/55 cases met criteria = 98% (↑ from last quarter)
MRN 3655351 Oct.
n/a
SCIP2a: Prophylactic ABX Selection – Overall Rate
53/54 cases met criteria = 98% (↑ from last quarter)
MRN 3621383 Oct.
n/a
SCIP3a: Prophylactic ABX End w/in 24 hrs- Overall Rate
53/54 cases met criteria = 98% (↑ from last quarter)
n/a
MRN 3650341 Dec.
SCIP6: Appropriate Hair Removal
85/85 cases met criteria. 100% (same as last quarter)
n/a
5
Measure
Set(s)
Observations
Recommendations/Comments
SCIP9: Patients with Urinary Catheter Removed on POD 1
(PostOperative Day One) or POD 2 (PostOperative Day Two)
23/26 cases met criteria = 89% (↓ from last quarter)
If catheters are left in >2 days Post Op, a reason
must be documented.
In the 2009 HICPAC guideline on prevention of CAUTI, they
listed generally accepted indications for a urinary catheter:
· Patient has acute urinary retention or bladder outlet
obstruction
· Need for accurate measurements of urinary output in
critically ill patients
· Perioperative use for selected surgical procedures:
o Patients undergoing urologic surgery or other surgery
on contiguous structures of the genitourinary tract
o Anticipated prolonged duration of surgery (catheters
inserted for this reason should be removed in PACU)
o Patients anticipated to receive large-volume infusions
or diuretics during surgery
o Need for intraoperative monitoring of urinary
output
· To assist in healing of open sacral or perineal wounds in
incontinent patients
· Patient requires prolonged immobilization (e.g., potentially
unstable thoracic or lumbar spine, multiple traumatic injuries such
as pelvic fractures)
· To improve comfort for end of life care if needed
SCIP10: Perioperative Temperature Management
86/86 cases met criteria = 100% (same as last quarter)
n/a
____________________________________________________________
SCIP-Card-2: Pts. on B-blockers who Recvd. B-blockers
Perioperatively
20/21 cases met criteria = 95% (↓ from last quarter)
________________________________________________
n/a
SCIP-VTE-1: Pts. w/recommended VTE Prophylaxis Ordered
SCIP-VTE-2: Pts. receiving VTE Prophylaxis w/in 24 hrs of Surgery
n/a
VTE 1 : 73/73 = 100% cases met criteria (same as last quarter)
VTE 2 73/73 = 100% cases met criteria (same as last quarter)
6
Measure
Set(s)
Observations
Recommendations/Comments
HBIPS1a: Admission Screening – Overall Rate
38/38 cases passed criteria = 100% (same as last quarter)
n/a
HBIPS
(HBIPS 1a is all inclusive of indicators 1b, 1c, 1d, & 1e)
HBIPS4a: Multiple Antipsychotic Meds at D/C-Overall Rate
32/35 met the criteria =91% (↓ from last quarter) of prescribing
ONE Antipsychotic medication (recommended).
1 case was prescribed 2 Antipsychotic medications:
MRN 928507, 3522592, 4677593
HBIPS4a – Stress the importance of providing
documentation of the only acceptable reasons for
prescribing >1 antipsychotic medication at discharge:
(HBIPS4a is all inclusive of indicators 4b, 4c, 4d, & 4e)
*plan to taper to monotherapy due to previous use of multiple
antipsychotic medications OR documentation of a cross-taper in
progress at the time of discharge.
*history of a minimum of three failed multiple trials of monotherapy.
*augmentation of Clozapine
HBIPS5a: Multiple Antipsychotic Meds at D/C with Appropriate
Justification- Overall Rate
explanation above
This quarter had 0 out of 3 cases that qualified for Appropriate
Justification of Multiple Antipsychotic Medications at Discharge.
HBIPS6a: Post Discharge Continuing Care Plan – Overall Rate
66/69 cases passed this difficult measure 96% (↓ from last quarter)
3 cases did not:
MRN 346.341, 4675247 November; 882391 December
The indication for use was missing on all 3 cases.
HBIPS6a:
The medical record must contain a continuing care plan
which includes the discharge medications, dosage and
indication for use or that no medications were ordered
at discharge.
All medications must have the names, dosage and
indication for use listed in the continuing care plan. The
indication for use can be as short as one to two words,
but must be present for all medications, not just
psychotropic medications.
7
Measure
Set(s)
Observations
Recommendations/Comments
HBIPS7a: Post Discharge Continuing Care Plan Transmitted – Overall
Rate
63/69 cases passed this measure (92%, same as last quarter)
participating in the Continuing Care Plan Indicator
6 failed due to CCP not Transmitted to Next LOC provider within 5
days.
MRN 4670086 Oct.; 3463641, 4675247 Nov.; 3564980, 882391,
4679378 Dec.
HBIPS7a:
Continued Care Plans not only need to contain the 4
data elements, but they also each or all need to be
transmitted (via fax, US Mail, email, or EMR access) to
the next LOC provider/clinician with 5 days post
discharge. Utilizing Inter-agency form, ROI form, and
Routing history on DCS.
2 of 3 Dec. cases did not show documentation that the Continuing
Care Plan was sent/faxed to the next level of care provider. The Oct.
& 3rd Dec. case had situation where patient was moving after
discharge, so no aftercare was set up or offered and then refused by
patient. The Nov. cases failed because the CCP was considered
Incomplete, and therefore transmittal did not count.
OUT
PATIENT
8
Measure
Set(s)
OP
 AMI
 CP
 Surg
Observations
Recommendations/Comments
OP1-4, 4b, 4c, : Aspirin on Arrival for AMI and Chest Pain Measures
n/a
All 16 cases of both measures met all criteria = 100% (same as last
quarter)
------------------------------------------------------------------------------------------------OP 6 : Antibiotic Timing
21/22 cases met criteria = 95% (↑ from last quarter); 1 case did not.
MRN 3621954 Dec.
------------------------------------------------------------------------------n/a
------------------------------------------------------------------------------------------------OP 7: Antibiotic Selection
33/34 cases met criteria = 97% (↑ from last quarter)
MRN 4655970 Oct.
------------------------------------------------------------------------------n/a
IMMUN 1 : Pneumococcal Immunization
164/165 cases met criteria = 99%
n/a
IMMUN 2 : Influenza Immunization
268/273 cases met criteria = 98%
n/a
IMMUN
GREAT JOB!
Congratulations on the completion of your 4th Quarter 2012!
Any questions or comments, please let me know via email: brenda.bartkowski@amphionmedical.com
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