Core Measures
October 2013
Division of Quality and Patient Safety
NewYork-Presbyterian Hospital
What are Core Measures?
• Core Measures are widely agreed upon quality metrics
the federal government use to assess how well hospitals
care for patients
• Core Measures initiative by the CMS help promote
higher quality and more efficient care for Medicare
beneficiaries
• Impact of Core Measures
– Quality of Patient Care
– Reputation
– Reimbursement
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Process of Care Measures
• Measures are based on both expert opinion and
evidenced based practice
• Measures evaluate timeliness and effectiveness of care
• Measures are endorsed by National Quality Forum
• The program requires hospitals to submit data for
specific measures for health conditions common among
people with Medicare
• Hospitals that do not participate will receive a reduction
of 2.0 percent in their Medicare Annual Payment Update
for fiscal year 2013
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What is Value Based Purchasing?
• Value Based Purchasing is a program implemented by
CMS in 2011 to promote better clinical outcome and
patient experience of care with Pay-For-Performance
– CMS will pay for care that rewards better value and
patient outcomes, instead of just volume of services
– Financial penalties are effective 2012 for our Core
Measure performance
– Current performance is compared to baseline from
prior year. We are rewarded for performance based
on achievement and improvement score
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Venous Thromboembolism
New
Core Measure
started in
Q1 2013
Q1 2013
Q2 2013*
Q3 2013*
N = 583
N = 626
N = 168
Hospital Compare
National Average
(Q2 2012 – Q1
2013)
97%
97%
90%
82%
100%
100%
100%
90%
VTE Patients with Anticoagulation
Overlap Therapy
88%
93%
100%
91%
VTE Patients Receiving
Unfractionated Heparin with
Dosages/Platelet Count Monitoring
by Protocol or Nomogram
100%
100%
100%
96%
VTE Discharge Instructions
53%
77%
94%
70%
Incidence of PotentiallyPreventable VTE
(Goal for Rate Low)
0%
0%
7.7%
11%
Sample
VTE Prophylaxis
ICU VTE Prophylaxis
*Q2 and Q3 2013 data preliminary; Q2finalized after 10/25/13; Q3 finalized after 1/25/2013
Green = 90% or greater and equal to or above national average
Yellow = Equal to or above national average, but below 90% OR
Above 90% , but below national average
Red = Below 90% and below national average
Data Source: CMS
Privileged and Confidential Information for Quality Assurance and Performance Improvement Purposes and
Protected under New York Education Law Section 6527 and Public Health Law Section 2805 J, K, L, and M
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VTE-1: Prophylaxis
• Admitted patients who:
– Received VTE prophylaxis, or
– Have documentation why no VTE prophylaxis was
given
• Timeframe:
– The day of/after hospital admission, or surgery end
date, for surgeries that start the day of/after admission
VTE-3: Overlap Therapy
• Patients diagnosed with confirmed VTE who received an
overlap of parenteral (IV or SubQ) anticoagulation and
warfarin therapy
• Overlap should be administered for at least 5 days with
an INR greater than or equal to 2 prior to
discontinuation of the parenteral anticoagulant, or else:
– Discharged on both medications, OR
– Have a documented reason for discontinuation of
parenteral anticoagulation
VTE-3: Overlap Therapy
• Included VTE types:
– Any pulmonary embolus
– Proximal lower extremity veins: Inferior vena cava; Iliac, femoral, or popliteal veins
VTE-5: Discharge Instructions
• Patients diagnosed with confirmed VTE that are
discharged to home, home care, court/law enforcement,
or home on hospice care on warfarin
• Written discharge instructions must address all four
criteria:
– Compliance issues,
– Dietary advice,
– Information about the potential for adverse drug
reactions/interactions
– Follow-up monitoring
Value Based Purchasing Core Measures
New Performance Period: FY2015 (Q1 2013 – Q4 2013)
FY14
FY15
Q4
2012
Q1
2013
Q2
2013*
Q3
2013*
Hospital Compare
National Average
(Q2 2012 – Q1 2013)
VBP Range
FY15
HF - Discharge
instructions
100%
100%
100%
99%
94%
92.66% 100.00%
PN - Blood cultures in
ED prior to ABX
96%
99%
98%
98%
98%
94.12% 100%.00
PN - Initial ABX selection
for CAP
97%
95%
98%
96%
95%
97.78% 100.00%
AMI - PCI within 90 min.
of hospital arrival
100%
100%
100%
100%
95%
95.35% 100.00%
*Q2 and Q3 2013 data preliminary; Q2finalized after 10/25/13; Q3 finalized after 1/25/2013
Green = 90% or greater and equal to or above national average
Yellow = Equal to or above national average, but below 90% OR
Above 90% , but below national average
Red = Below 90% and below national average
Data Source: CMS
Privileged and Confidential Information for Quality Assurance and Performance Improvement Purposes and
Protected under New York Education Law Section 6527 and Public Health Law Section 2805 J, K, L, and M
10
Acute Myocardial Infarction
Q4 2012
Q1 2013
Q2 2013*
Q3 2013*
N = 208
N = 211
N = 206
N = 97
Hospital Compare
National Average
(Q2 2012 – Q1 2013)
Aspirin at arrival
100%
100%
100%
100%
99%
Aspirin prescribed at
discharge
100%
100%
100%
100%
99%
ACEI/ARB for LVSD
100%
100%
100%
100%
97%
Beta Blocker Prescribed at
discharge
100%
100%
99%
100%
99%
Statin Prescribed at
Discharge
100%
100%
100%
99%
98%
Sample
*Q2 and Q3 2013 data preliminary; Q2finalized after 10/25/13; Q3 finalized after 1/25/2013
Green = 90% or greater and equal to or above national average
Yellow = Equal to or above national average, but below 90% OR
Above 90% , but below national average
Red = Below 90% and below national average
Data Source: CMS
Privileged and Confidential Information for Quality Assurance and Performance Improvement Purposes and
Protected under New York Education Law Section 6527 and Public Health Law Section 2805 J, K, L, and M
11
Heart Failure
Q4 2012
Q1 2013
Q2 2013*
Q3 2013*
N = 292
N = 296
N = 289
N = 133
Hospital Compare
National Average
(Q2 2012 – Q1 2013)
Evaluation for LVS
function
100%
100%
99%
100%
99%
ACEI/ARB for LVSD
98%
100%
100%
100%
97%
Sample
*Q2 and Q3 2013 data preliminary; Q2finalized after 10/25/13; Q3 finalized after 1/25/2013
Green = 90% or greater and equal to or above national average
Yellow = Equal to or above national average, but below 90% OR
Above 90% , but below national average
Red = Below 90% and below national average
Data Source: CMS
Privileged and Confidential Information for Quality Assurance and Performance Improvement Purposes and
Protected under New York Education Law Section 6527 and Public Health Law Section 2805 J, K, L, and M
12
Global Immunization
Q4 2012
Q1 2013
Q2 2013*
Q3 2013*
N = 337
N = 337
N = 336
N = 237
Pneumococcal
Immunization
93%
97%
95%
90%
90%
Influenza Immunization
98%
100%
N/A
N/A
90%
Sample
Hospital Compare
National Average
(Q2 2012 – Q1 2013)
*Q2 and Q3 2013 data preliminary; Q2finalized after 10/25/13; Q3 finalized after 1/25/2013
Green = 90% or greater and equal to or above national average
Yellow = Equal to or above national average, but below 90% OR
Above 90% , but below national average
Red = Below 90% and below national average
Data Source: CMS
Privileged and Confidential Information for Quality Assurance and Performance Improvement Purposes and
Protected under New York Education Law Section 6527 and Public Health Law Section 2805 J, K, L, and M
13
Perinatal Care Elective Delivery
Q4 2012
Sample
Perinatal Care Elective
Delivery
(Goal for Rate Low)
Q1 2013
Q2 2013*
Q3 2013*
N = 345
N = 346
N = 313
0%
0%
0%
New
Core Measure
started in
Q1 2013
Hospital Compare
National Average
(Not Available)
*Q2 2013 data preliminary and finalized after 10/25/13.
Data source: CMS
Privileged and Confidential Information for Quality Assurance and Performance Improvement Purposes and
Protected under New York Education Law Section 6527 and Public Health Law Section 2805 J, K, L, and M
14
New
Core Measure
started in
Q1 2013
Stroke
Q4 2012
Hospital Compare
National Average
(Q2 2012 – Q1 2013)
Q1 2013
Q2 2013*
Q3 2013*
N = 423
N = 372
N = 245
VTE Prophylaxis
98%
98%
97%
92%
Discharged on Antithrombotic
Therapy
100%
100%
100%
99%
Anticoagulation Therapy for
AFib/AFlutter
100%
100%
100%
95%
Thrombolytic Therapy
96%
100%
84%
60%
Antithrombotic Therapy By
End of Hospital Day 2
98%
98%
93%
97%
Discharged on Statin
Medication
98%
98%
98%
93%
Stroke Education
95%
93%
96%
85%
Assessed for Rehabilitation
98%
97%
99%
97%
Sample
*Q2 2013 data preliminary.
Data source: CMS
Privileged and Confidential Information for Quality Assurance and Performance Improvement Purposes and
Protected under New York Education Law Section 6527 and Public Health Law Section 2805 J, K, L, and M
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Areas for Improvement
• VTE-3 (Overlap Therapy)
– Ensure that pts with confirmed VTE who are treated with
warfarin receive at least 5 days of overlap AND have
INR ≥ 2 prior to stopping overlap
– OR document a reason for discontinuing overlap in the
“VTE Core Measures” section of the DC Summary
• VTE-5 (Warfarin Discharge Instructions)
– Explicitly document how to monitor warfarin post-discharge
in the “Follow-Up Appointments” or “Additional
Instructions” section of the DC Summary
Areas for Improvement
• HF-1 (Discharge Instructions)
– Explicitly document follow-up appointments with MD/PA/NP
name and date (specific provider name is required)
– Use of "PMD” or “Primary MD” is NOT acceptable by CMS
Areas for Improvement
• IMM-1 (Pneumococcal Immunization) Screening Year Round
– Eligible patients:
• All patients 65 or older
• Patients age 5-64 with a high risk condition:
• DM, ESRD, COPD, Nephrotic Syndrome, CHF, HIV,
Asplenia
• Asthma (for pts age 19-64)
– Ensure that vaccine orders are not discontinued during
transfer to another level of care
• IMM-2 (Influenza Immunization) Screening Sept 1-March 31
– Eligible patients: All patients age 6 months or older
– Ensure that vaccine orders are not discontinued during
transfer to another level of care
Core Measure Education Guide
• Versions for measures relevant to your area
• Infonet > Quality & Pt Safety > Core Measures
• infonet.nyp.org/QA/Pages/coremeasures.aspx
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