Quality Improvement
and Core Measures 101
Jill Daniels, BS
Quality Project Manager, Primaris
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Jill Daniels, BS
Quality Measure Project Manager, Primaris
Ms. Daniel has 10 years of experience in performance
improvement and clinical quality. She currently is a Project
Manager and the Educator for her department at Primaris. She
has used her training in lean six-sigma and root-cause analysis
to facilitate and improve processes to save healthcare organizations both time
and money. She has experience with all core measures, National Cardiovascular
Data Registry (NCDR) for CathPCI and ICD, the Society of Thoracic Surgery
(STS) Data Registry, and has served as a team lead for the GPRO abstraction
project.
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Greetings and
Introductions
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Core Measures History
1999
2002
• Institute of Medicine (IOM)
• 44 – 98,000 preventable
deaths
• Exceeds MVA’s, Breast
Cancer, and AIDS
• TJC solicits stakeholder input
2001
1998
• Healthcare safety
concerns
• Media attention
• Healthcare costs
• President Clinton
• TJC and CMS align measure
specifications
• July – Begin collecting data
• Launch Nursing Home Quality
Initiative (NH Compare)
Four Initial Core Measures Announced
• Acute Myocardial Infarction (AMI)
• Heart Failure (HF)
• Pneumonia (PN)
• Pregnancy Related conditions (PR) –
replaced with PC in 2010
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Today
 Hospital Based Inpatient
Psychiatric Services
(HBIPS)
 Surgical Care
Improvement (SCIP)
(voluntary for discharges
as of 1/1/15)
 Perinatal Care (PC –
Moms and Infants)
 Venous
Thromboembolism (VTE)
 Stroke (STK)
 Children’s Asthma Care
(CAC)
 Immunization (IMM)
 Emergency Dept (ED)
 Outpatient (OP)
Measures; ED, AMI,
Chest Pain, Surgery,
Pain Management,
Stroke
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October 2015 Adding Sepsis
On 04/01/15, CMS and TJC released the National
Hospital Quality Measures (NHQM) Specifications
Manual, v5.0 that is effective with October 1, 2015
discharges. Included in this manual were the new
specifications for the Sepsis Bundle which will be a
requirement for hospitals currently being reimbursed
by the Inpatient Prospective Payment System
(IPPS) beginning with October 1, 2015 discharges.
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Why are the New Sepsis Measures Important?
 CMS believes that this is an important area for
measurement because mortality rates range from 1649% for patients that are admitted with a sepsis
diagnosis.
 Early and effective treatment of severe sepsis will help
decrease mortality related to sepsis and also help
decrease the costs associated with inefficient care of
sepsis patients.
 CMS will be able to identify if care of severe sepsis and
septic shock patients is improving.
Material taken from email received from Quality Reporting Notification dated 3/26/2015.
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ANATOMY OF A CORE MEASURE
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Core Measures
 Core (Quality) Measures gauge how well an entity
provides care to its patients
 Measures are based on scientific
evidence (National Quality Forum –
NQF endorsed) and can reflect
guidelines, standards of care, or
practice parameters
 A Quality Measure converts medical
information from patient records into a
rate or percentage that assesses
performance
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CMS VS. TJC REQUIREMENTS
EFFECTIVE FOR DISCHARGES JANUARY
1, 2015 TO SEPTEMBER 30,2015
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LOCATING SPECIFICATIONS MANUALS
FOR CMS AND TJC
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CMS Specifications Manual
www.qualitynet.org
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CMS Specifications Manual
 Current CMS Specifications Manual v4.4a for
Discharges 01/01/2015-09/30/2015
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Specifications Manual for Joint Commission National
Quality Measures v2015A1
https://manual.jointcommission.org
Copy and paste above link
to your internet browser.
Once on webpage, click
current for the current
specifications manual
v2015A1.
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Pneumonia – That Was Then
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Pneumonia – This Is Now
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Anatomy of a Measure
 Measure Set: Pneumonia
 Measures: PN-6 Initial Antibiotic Selection
(6a ICU Patient, 6b Non ICU Patient)
 Data Elements:
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Who Are the patients?
Patients admitted to the hospital for inpatient acute care are included in the
PN Initial Patient Population and are eligible to be sampled if they have:
 An ICD-9-CM Principal Diagnosis Code for PN as define in Appendix A,
Table 3.1, NO ICD-9-CM Other diagnosis Code of Cystic Fibrosis as
defined in Appendix A, Table 3.4, a Patient Age (Admission Date minus
Birthdate) grater than or equal to 18 years, and a Length of Stay
(Discharge Date minus Admission Date) less than or equal to 120 days
OR
 An ICD-9-CM Principal Diagnosis Code of Septicemia or Respiratory
Failure as defined in Appendix A, Table 3.2 and Table 3.3 accompanied
by an ICD-9-CM Other Diagnosis Code of PN as defined in Appendix A,
Table 3.1, NO ICD-9-CM Other Diagnosis Code of Cyctis Fibrosis as
defined in Appendix A, Table 3.4, a Patient Age (Admission Date minus
Birthdate) greater than or equal to 18 years, and a Length of Stay
(Discharge Date minus Admission Date) less than or equal to 120 days.
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What Do the Abstractors Do?
 Review hospital electronic medical records
 Understand and utilize Specifications
Manuals
 Answer Data Element questions according
to the CMS/TJC Specifications Manual
Instructions
 Enter answers/data into a hospital-selected
Vendor tool (electronic form)
 Perform Inter Rater Reliability within their team/peer groups for
assessment of accuracy
 Hospital then submits data to CMS/TJC for Reporting purposes
 Identify outliers (those that do not meet specification manual standards)
and communicates with Quality Improvement Staff to improve care.
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Measure Algorithm
PN-3b: Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in
Hospital
Numerator:
Denominator:
Number of pneumonia patients whose initial ED blood culture was performed prior to the administration
of the first hospital dose of antibiotics.
Pneumonia patients 18 years of age and older who have initial blood culture collected in the ED.
Start
Run cases that are included in the PN Initial Patient Population
and pass the edits defined in the Transmission Data
Processing Flow: Clinical through this measure.
PN-3b
X
Missing
Chest X-Ray
= 2, 3
PN-3b
B
=1
PN-3b
B
=1
PN-3b
X
Missing
Comfort
Measures Only
= 2, 3, 4
PN-3b
PN-3b
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Variable Key:
Antibiotic Timing
Blood Culture Timing
Blood Culture Collection Day
Duration of Stay
Initial Antibiotic Date
Initial Antibiotic Time
Measure Category Assignment/Outcomes
 B: Case is excluded from the denominator
 D: Case is in Measure population and the intent of
the measure was not met (failure)
 E: Case is in Numerator population and the intent
of the measure was met (pass)
 X: Data are missing that is required to calculate the
measure – record will be rejected
when transmitted
 Y: UTD Value does not allow
calculation of the measure
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Specific PN Case Outcomes
 PN3A – Blood Cultures 24 Hours Before/After Arrival – ICU Patients
Category assignment: “B” – Patient has been excluded from this measure.
Reason for exclusion: ICU Admission or Transfer was abstracted with the value
of “No”
 PN3B – Blood Culture Before First Antibiotic
Category assignment: “E” – Standard of care met.
 PN6A – Initial Antibiotic Selection for Immunocompetent Patient – ICU
Category assignment: “B” – Patient has been excluded from this measure.
Reason for exclusion: ICU admission or Transfer was abstracted with the value
of “No”
 PN6B – Initial Antibiotic Selection for Immunocompetent Patient – Non ICU
Category assignment: “B” – Patient has been excluded from this measure.
Reason for exclusion: Healthcare Associated PN was abstracted with the value
of “Yes”
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QUALITY
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Hospital Quality Initiative (HQI)
 Quality (Core) Measures
 Hospital Consumer Assessment
of Healthcare Providers and
Systems (HCAHPS) – patient satisfaction survey
 Medicare claims data: 30-day risk-standardized
mortality and readmission measures
 Infection control measures
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Consumer
 Public reporting = patients can
choose best facility
 2005 - Core Measure data
available on Hospital Compare
website for AMI, HF, PN, and
SCIP
 2008 - HCAHPS survey data
and mortality rates added
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Consumer
 2009 - Outpatient data added
 2012 - CMS readmission reduction program
 2013 – Hospital Value Based Purchasing (VBP)
program
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www.medicare.gov/hospitalcompare
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Hospital Compare
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Hospital Compare
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Hospital Compare
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Hospital Compare
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HOSPITAL VALUE BASED PURCHASING
(VBP)
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Value Based Purchasing
CMS is changing the way Medicare pays
for hospital care by rewarding hospitals
for delivering services of higher quality
and higher value
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Value Based Purchasing
VBP Program, established by the Affordable
Care Act, implements a pay-for- performance
approach that accounts for the largest share
of Medicare spending – affecting payment for
inpatient stays in approximately 3,000
hospitals across the country
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Value Based Purchasing
Purpose
 VBP seeks to encourage hospitals to improve the
quality and safety of care that all patients receive
during acute-care inpatient stays by:


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eliminating or reducing the occurrence of adverse
events (healthcare errors resulting in patient harm)
adopting evidence-based care standards and
protocols that result in the best outcomes for the
most patients
re-engineering hospital processes that improve
patients’ outcomes
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Hospital Value Based Purchasing
 Uses 12 quality measures that hospitals already
report to Medicare
 Measures fall under four clinical areas focused on
improving care and paying for good quality care
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Value Based Purchasing
 Medicare is adjusting a portion of payments to
hospitals beginning in FY 2013 based on either:
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How well they perform on each measure compared
to all hospitals, or
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How much they improve their own performance on
each measure compared to their performance during
a prior baseline period
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Value Based Purchasing
A hospital’s performance in HVBP will be
based on its performance according to the
following:
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Value Based Purchasing
 Fiscal Year (FY) 2015
 12 Clinical Process of Care measures
 Eight Patient Experience of Care dimensions of the Hospital Consumer
Assessment of Healthcare Providers and Systems (HCAHPS) survey
 Three 30-Day Outcome Mortality measures:
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Acute Myocardial Infarction (AMI)
Heart Failure (HF)
Pneumonia (PN)
 One Agency for Healthcare Research and Quality (AHRQ) Composite
Measure:
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Patient Safety Indicator (PSI-90)
 One Healthcare Associated Infection:
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Central Line-Associated Blood Stream Infection (CLABSI)
 One Efficiency measure:

Medicare Spending Per Beneficiary (MSPB)
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Value Based Purchasing

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Fiscal Year (FY) 2016
Eight Clinical Process of Care measures
Eight Patient Experience of Care dimensions (HCAHPS)
Three 30-Day Outcome Mortality measures:
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Acute Myocardial Infarction (AMI)
Heart Failure (HF)
Pneumonia (PN)
 One Agency for Healthcare Research and Quality (AHRQ) Composite measure:
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Patient Safety Indicator (PSI-90)
 Four Healthcare Associated Infection:
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Central Line-Associated Blood Stream Infection (CLABSI)
Catheter-Associated Urinary Tract Infection (CAUTI)
Surgical Site Infection
o Abdominal Hysterectomy
o Colon Surgery
 One Efficiency measure:
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Medicare Spending Per Beneficiary (MSPB)
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VBP Clinical Process of Care Domain for FY 2015
 AMI-7a fibrinolytic therapy received within 30 minutes of hospital
arrival
 AMI-8a primary PCI received within 90 minutes of hospital arrival
 HF-1 discharge instructions
 PN-3b blood cultures performed in the ED prior to initial antibiotic
received in hospital
 PN-6 initial antibiotic selection for CAP in immunocompetent
patient
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AMI= Acute Myocardial Infarction
HF= Heart Failure
PN=Pneumonia
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VBP Clinical Process of Care Domain for FY 2015
(Continued)
 SCIP-Card-2: Surgery patients on a beta blocker prior
to arrival that received a beta blocker during the
perioperative period
 SCIP Inf-1: Proyphylactic 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= Surgical Care Improvement Project
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VBP Clinical Process of Care Domain for FY 2015
(Continued)
 SCIP-Inf-4: Cardiac surgery patients with
controlled 6am postoperative serum glucose
 SCIP -Inf-9: Postoperative urinary catheter
removal on post operative day one or two
 SCIP-VTE-2: Surgery patients who received
appropriate venous thromboembolism prophylaxis
within 24 hours prior to surgery to 24 hours after
surgery
 SCIP=Surgical Care Improvement Project
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Value Based Purchasing
Scoring - A hospital’s performance in HVBP is based
on measures/dimensions for the domains per FY. The
Total Performance Score (TPS) is composed of:
FY 2015 Scoring
Domain
Weight
Clinical Process of Care
20%
Patient Experience of Care
30%
Outcome
30%
Efficiency
20%
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Value Based Purchasing
FY 2016 Scoring
Domain
Weight
Clinical Process of Care
10%
Patient Experience of Care
25%
Outcome
40%
Efficiency
25%
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NEXT STEPS
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Using Data to Improve Quality
 Working smarter instead of
harder
 Electronic Medical Record
(EMR)
 Hardwiring success
 Concurrent review – “real
time”
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How Can Data Help to Improve Quality?
Problem:
 Facility is performing poorly on the
immunization measure influenza
vaccination status. Patients who
have not received a flu vaccination during the
current flu season are slipping through the cracks,
and are not getting the vaccination while in the
hospital. Pneumonia and influenza are the fifth
leading cause of death in older adults in the U.S.
according to the Centers for Disease Control and
Prevention (CDC)
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Why Is the Flu Vaccine Important?
 Pneumonia and influenza are the fifth leading
cause of death in older adults in the U.S. according
to the Centers for Disease Control and Prevention
(CDC). According to CMS, there are over 200,000
hospitalizations from influenza on the average
every year, and an average of 36,000 Americans
die annually due to influenza and its complications
(most are 65 years and older). The best way to
prevent the flu is to get vaccinated each year during
the fall season
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How Can We Keep Patients from Slipping
Through the Cracks?
 Ensure that flu vaccine questions are a part of the
initial Nursing Assessment
 If the patient has not received a flu vaccine during
the season, and would like one, have it set up
where the EMR automatically generates an order
from the Nursing Assessment that orders the
vaccine from the pharmacy
 This will not only improve Quality scores, it will also
help improve quality of care and patient satisfaction
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About Primaris
 Trusted healthcare advisors
 Work with providers to drive better health
outcomes, improved patient experience, and a
better bottom line
 Translate healthcare data into actionable quality
improvement processes
 Create highly reliable healthcare organizations
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Upcoming Programs
Quality Update Webinar Series

May Quality Update – Peer Review
May 29, 2015 11:00 – 12:00 p.m. CT
Quality Classroom Programs:

New Quality Director Boot Camp (May 6-8, 2015)

Advanced Quality Director Forum (October 20-21, 2015)
Register at www.qhrlearninginstitute.com
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QHR Learning Institute Recordings and Videos:
Come Visit Our Library
http://videos.qhr.com/
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 Thank you for joining us today. We value your feedback and hope that you
will take a few minutes to evaluate this program so that we may continue to
improve and bring you the quality educational programming you expect.
 As a reminder, you will have two opportunities to complete an evaluation
and receive a completion certificate:
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At immediate conclusion of webinar

Post event: within two business days of the webinar, you will receive an
email containing links to the online evaluation and a recording of this
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 Upon completing the online evaluation, you will receive an email with a link
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 If you have questions or need assistance, please contact
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For More Information
Contact:
[email protected]
(800) 233-1470, ext. 4513
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Thanks for Attending!
Intended for internal guidance only, and not as
recommendations for specific situations. Readers should
consult a qualified attorney for specific legal guidance.
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