Transcript Core Measures e

e-Module
CMS
Core Measures
CORE MEASURES
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e-Module
CMS
Core Measures
Purpose
To provide education for health care
providers on Core Measures
Objectives
• Define Core Measures
•
List the Quality Measures for NSLIJHS top
three Core Measure diagnoses
•
Identify health team members roles in
carrying out core measure quality measures
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e-Module
CMS
Core Measures
Please review this module in its entirety.
When you have finished, take the post –test.
Passing score is 100%.
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e-Module
CMS
Core Measures
CORE
MEASURES
A
standardized
set of
performance
measures
that are
illness or
condition
specific
WHY
Core Measures allow
the institution to:
Measure quality
patient care
Identify treatment
standards for specific
illness or conditions
Provide
documentation
required for
reimbursement
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e-Module
CMS
Core Measures
Core Measures
ensure a minimum
standard of care for
TOP THREE
NSLIJHS
Acute MI
Core
Measure
Heart
Failure
Diagnoses
Community
Acquired
Pneumonia
Acute MI
all patients who
come in with core
measure diagnosis
Heart Failure
Community Acquired
Pneumonia 5
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Core Measures
What are Quality Measures?
Interventions & Outcomes that we
want the patient to experience
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Core Measures
Quality Measures for Acute Myocardial Infarction
On Arrival/Admission:
Aspirin
Beta Blockers
Fibrinolytics within 30 minutes
PTCA within 90 minutes of arrival
ACE or ARB for LVSD
Click the link below for additional information
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http://www.jointcommission.org/acute_myocardial_infarction/
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Core Measures
Upon Discharge:
Smoking cessation counseling
Prescriptions for:
Aspirin
ACE OR ARB
BETA BLOCKER
Click the link below for additional information
http://www.jointcommission.org/assets/1/6/Acute%20Myocardial%20Infarction.pdf
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Core Measures
Quality Measures for Heart Failure
Echocardiogram
Documentation of Ejection Fraction %
Daily weights
Clearly defined:
Activity level
Diet
Follow-up appointment
What to do if symptoms worsen
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Click here to view the NSLIJHS Heart Failure Admission Order Set
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Core Measures
Quality Measures for
Community Acquired Pneumonia
Within 24 hours of admission:
• Oxygen assessment
• Blood cultures before 1st dose of antibiotic
• Appropriate antibiotic within 6 hours
• Assess pneumococcal status
• Smoking cessation counseling
Click below to view the pneumonia order set
https://nslijhp.northshorelij.com/physician/SOS%20North%20Shore%20Univ
ersity%20Hospital/Adult%20Pneumonia%20Admission%20Orders.pdf
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Core Measures
Primary and Secondary Core Measure Diagnoses
• Primary diagnosis is a core measure i.e. Heart
Failure follow all core measure criteria for a
patient with heart failure
• Primary diagnosis is not a core measure, i.e.
GI Bleed, and patient has a secondary
diagnosis or history a core measure – i.e.
history of heart failure
Ensure that the criteria for caring
for a patient with heart failure are
included in the current plan of
care
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Core Measures
Responsibilities: On Admission for
Physicians, Physician Assistants, Nurse
Practitioners, Nurse Midwives
• Collaborate
• Complete order set
• Document a contraindicated intervention
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Core Measures
Responsibilities: Upon Discharge for
Physicians, Physician Assistants, Nurse
Practitioners, Nurse Midwives
• Reconcile all medications
• Educate patient re: medications, regime
• Reinforce follow-up
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Core Measures
Responsibilities of Admission & Discharge:
The Professional Nurse should
• Execute appropriate interventions
• Notify provider/practitioner if listed
intervention has not been ordered
• Perform medication reconciliation
• Review admission/ discharge plan with
patient
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Core Measures
Core Measures…It’s All or Nothing !
Compliance influences:
• reimbursement
• Consumers choices in selecting where they
seek care
Quality measure compliance is:
• Publicly reported
• Impacts hospital rankings
There is no partial compliance with core measure
criteria
If we miss one quality measure = failure for the
entire patient care compliance standard
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Core Measures
CMS Core Measures
You may visit
http://www.northshorelij.com/NSLIJ/Public+Reporting
to view your hospital’s quality
reports on CMS Core Measures
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Core Measures
You have completed this module
• It is required that you complete a post test
on this module.
Click here to take the Core Measures Post Test
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Core Measures
References
• NSLIJHS Standards, Policy, Procedure
guidelines
• NSLIJHS CareMaps®
• NSLIJHS website:
http://www.northshorelij.com/NSLIJ/Public+Reporting
• CMS website: http://www.cms.gov/
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