Jean Roland, RN, BSN, CPHQ Quality Improvement Specialist. April 19, 2012
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1 Jean Roland, RN, BSN, CPHQ Quality Improvement Specialist April 19,
2 - Pneumococcal vaccination Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 PN-2 (current measure) Patients with pneumonia, age 65 and older, who were screened for pneumococcal vaccine status and were vaccinated prior to discharge, if indicated Moving forward IMMUNIZATION NATIONAL HOSPITAL INPATIENT QUALITY MEASURES (1Q12) 4 Set Measure ID# IMM-1a Measure Short Name Pneumococcal Immunization (PPV23) Overall Rate IMM-1b Pneumococcal Immunization (PPV23) Age 65 and Older IMM-1c Pneumococcal Immunization (Age 6 through 64 years) (PPV23) High Risk Populations IMM-2 Influenza Immunization
3 - Pneumococcal vaccination - Pneumococcal vaccination
4 - 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 - 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
5 - 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 - Blood cultures performed in the emergency department prior to initial antibiotic received in hospital
6 - Blood cultures performed in the emergency department prior to initial antibiotic received in hospital - Blood cultures performed in the emergency department prior to initial antibiotic received in hospital
7 - Adult smoking cessation advice/counseling Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 PN-4 (current) Description: Pneumonia patients with a history of smoking cigarettes who are given smoking cessation advice or counseling during hospital stay. For the purposes of this measure, a smoker is defined as someone who has smoked cigarettes anytime during the year prior to hospital arrival. *Recommended > 18 y/o TOBACCO TREATMENT NATIONAL HOSPITAL INPATIENT QUALITY MEASURES (1Q12) Collected for: The Joint Commission Only CMS Informational Only Measure ID # TOB-1 TOB-2 TOB-2a TOB-3 TOB-3a TOB-4 14 Measure Short Name Tobacco Use Screening Tobacco Use Treatment Provided or Offered Tobacco Use Treatment Tobacco Use Treatment Provided or Offered at Discharge Tobacco Use Treatment at Discharge Tobacco Use: Assessing Status After Discharge
8 - Adult smoking cessation advice/counseling - Adult smoking cessation advice/counseling
9 - Initial antibiotic received within 6 hours of hospital arrival - Initial antibiotic received within 6 hours of hospital arrival
10 - Initial antibiotic received within 6 hours of hospital arrival - Initial antibiotic selection for CAP in immunocompetent patient
11 - Initial antibiotic selection for CAP in immunocompetent patient - Initial antibiotic selection for CAP in immunocompetent patient
12 PN6 - Initial antibiotic selection for CAP in immunocompetent patient 23 - Influenza vaccination Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012
13 PN-7 (current) Description: Pneumonia patients age 50 years and older, hospitalized during October, November, December, January, February or March who were screened for influenza vaccine status and were vaccinated prior to discharge, if indicated. Moving forward IMM-2: Influenza Immunization Numerator: Inpatient discharges who were screened for Influenza vaccine status and were vaccinated prior to discharge if indicated. Denominator: Acute care hospitalized inpatients age 6 months and older discharged during October, November, December, January, February or March Influenza vaccination Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012
14 - Influenza vaccination Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota 28 April 2012
15 - Discharge instructions Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 HF-1 Numerator Statement: Heart failure patients with documentation that they or their caregivers were given written discharge instructions or other educational material addressing all of the following: 1. Activity level 2. Diet 3. Discharge medications 4. Follow-up appointment 5. Weight monitoring 6. What to do if symptoms worsen 30
16 - Discharge instructions - Discharge instructions
17 - Evaluation of LVS function Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 HF -2 Numerator Statement: Heart failure patients with documentation in the hospital record that LVS function was evaluated before arrival, during hospitalization, or is planned for after discharge. Suggested Data Sources: Consultation notes Discharge instruction sheet Discharge summary History and physical Procedure notes Progress notes Excluded Data Sources: Any documentation dated/timed after discharge, except discharge summary and operative/procedure/diagnostic test reports (from procedure done during hospital stay). 34
18 - Evaluation of LVS function - Evaluation of LVS function
19 - ACEI or ARB for LVSD - ACEI or ARB for LVSD
20 - ACEI or ARB for LVSD - Adult smoking cessation advice/counseling
21 - Adult smoking cessation advice/counseling - Adult smoking cessation advice/counseling
22 43 - Aspirin at arrival Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012
23 - Aspirin prescribed at discharge - ACEI or ARB for LVSD
24 - ACEI or ARB for LVSD - ACEI or ARB for LVSD
25 - Adult smoking cessation advice/counseling - Adult smoking cessation advice/counseling
26 - Beta blocker prescribed at discharge - Beta blocker prescribed at discharge
27 - Beta blocker prescribed at discharge - Fibrinolytic therapy received within 30 minutes of hospital arrival
28 - Fibrinolytic therapy received within 30 minutes of hospital arrival - Fibrinolytic therapy received within 30 minutes of hospital arrival
29 - Statin prescribed at discharge - Statin prescribed at discharge
30 - Statin prescribed at discharge Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota 60 April 2012
31 - Prophylactic antibiotic received within one hour prior to surgical incision - Prophylactic antibiotic selection for surgical patients
32 - Prophylactic antibiotics discontinued within 24 hours after surgery end time - Surgery patients with appropriate hair removal
33 - Urinary catheter removed on POD-1 or POD-2 with day of surgery being day 0 - Surgery patients with perioperative temperature management
34 - Surgery patients with recommended venous thromboembolism prophylaxis ordered - Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hrs prior to surgery to 24 hrs after surgery
35 - Surgery patients on beta blocker therapy prior to arrival who received a beta blocker during the perioperative period Analysis provided by North Dakota Health Care Review, Inc., Minot, North Dakota April 2012 North Dakota Health Care Review, Inc.... To improve health and healthcare for the people of North Dakota Jean Roland, RN, BSN, CPHQ jroland@ndqio.sdps.org 3520 North Broadway Minot, ND (Voice) (Fax) This material was prepared by North Dakota Health Care Review, Inc., Minot, ND, , the Medicare Quality Improvement Organization for North Dakota, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. ND-10SOW-12-PP-30 April
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