HQSI and New Jersey hospitals are working to improve healthcare quality within the four clinical topics: Acute Myocardial Infarction, Heart Failure, Pneumonia and Surgical Care Improvement Project. Each topic has a number of quality of care measures that hospitals will be addressing.
8SOW CMS Inpatient Quality of Care Measures
|
Quality of Care Measure |
CMS Description |
Acute Myocardial Infarction |
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AMI-1 Aspirin at Arrival |
Acute myocardial infarction (AMI) patients without aspirin contraindications who received aspirin within 24 hours before or after hospital arrival. |
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AMI-2 Aspirin Prescribed at Discharge |
Acute myocardial infarction (AMI) patients without aspirin contraindications who are prescribed aspirin at hospital discharge |
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AMI-3
ACEI or ARB for LVSD |
Acute myocardial infarction (AMI) patients with left ventricular systolic dysfunction (LVSD) and without angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor block (ARB) contraindications who are prescribed an ACEI at hospital discharge. For purposes of this measure, LVSD is defined as chart documentation of a left ventricular ejection fraction (LVEF) less than 40% or a narrative description of left ventricular function (LVF) consistent with moderate or severe systolic dysfunction. |
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AMI- 4
Adult Smoking Cessation Advice/Counseling |
Acute myocardial infarction (AMI) patients with a history of smoking cigarettes who are given smoking cessation advice or counseling during hospital stay. |
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AMI-5
Beta Blocker Prescribed at Discharge |
Acute myocardial infarction (AMI) patients without beta blocker contraindications who are prescribed a beta blocker at hospital discharge |
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AMI-6
Beta Blocker at Arrival |
Acute myocardial infarction (AMI) patients without beta blocker contraindications who received a beta blocker within 24 hours after hospital arrival. |
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AMI-7A
Fibrolytic Agent Received Within 30 Minutes of Hospital Arrival |
Acute myocardial infarction (AMI) patients receiving primary fibrolytic therapy during the hospital stay with a time from hospital arrival to fibrolytic of 30 minutes or less. |
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AMI-8A
PCI Received within 90 Minutes of Hospital Arrival
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Acute myocardial infraction (AMI) patients receiving primary Percutaneous Coronary Intervention (PCI) during the hospital stay with a time from hospital arrival to PCI of 90 minutes or less. |
Heart Failure |
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HF-1
Discharge Instructions |
Heart Failure patients discharged home with written instructions or educational material given to patient or caregiver at discharge or during the hospital stay addressing all of the following:
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HF-2
LVF Assessment |
Heart Failure patients with documentation in the hospital record that left ventricular function (LVF) was assessed before arrival, during hospitalization, or is planned for after discharge. |
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HF-3
ACEI or ARB for LVSD |
Heart Failure patients with left ventricular systolic dysfunction (LVSD) and without angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) contraindications who are prescribed an ACEI or ARB at hospital discharge. For purposes of this measure, LVSD is defined as chart documentation of a left ventricular ejection fraction (LVEF) less than 40% or a narrative description of left ventricular function (LVF) consistent with moderate or severe systolic dysfunction |
|
HF-4
Adult Smoking Cessation
Advice/Counseling |
Heart Failure patients with a history of smoking cigarettes who are given smoking cessation advice or counseling during hospital stay |
Pneumonia |
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PN-1
Oxygenation Assessment |
Pneumonia patients who had an assessment of arterial oxygenation by arterial blood gas measurement or pulse oximetry within 24 hours prior to or after arrival at the hospital
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PN-2
Pnuemococcal Immunization
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Pneumonia patients age 65 and older who were screened for penumococcal vaccine status and were administered the vaccine prior to discharge, if indicated
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PN-3A
Blood Cultures Performed within 24 hours prior to or after hospital arrival for Patients who were transferred or admitted to the ICU within 24 hours of Hospital Arrival |
Pneumonia patients admitted or transferred to the ICU who had blood cultures performed within 24 hours prior to or after arrival |
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PN-3B
Blood Culture Performed before first antibiotic received in hospital |
Pneumonia patients in the emergency room whose initial hospital blood culture specimen was collected prior to the first hospital dose of antibiotics
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PN-4
Adult Smoking Cessation Advice/Counseling
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Pneumonia patients with a history of smoking cigarettes who are given smoking cessation advice or counseling during hospital stay
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PN-5B
Initial Antibiotic received within 4 hours of hospital arrival |
Pneumonia patients who receive their first antibiotic dose within 4 hours after arrival at the hospital
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PN-6
Initial Antibiotic Selection for CAP in Immunocompetent |
Immunocompetent patients with Community Acquired Pneumonia (CAP) who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines |
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PN-7
Influenza Vaccination |
Pneumonia patients age, 50 years or older, hospitalized during October, November, December, January, or February who were screened for influenza vaccine status and were vaccinated prior to discharge, if indicated |
Surgical Care Improvement Project |
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Infection
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SCIP-Inf 1 |
Prophylactic antibiotic received within 1 hour prior to surgical incision (2 hours if vancomycin or a fluoroquinolone) |
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SCIP-Inf 2 |
Prophylactic antibiotic selection consistent with current recommendations |
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SCIP-Inf 3 |
Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours if cardiac surgery) |
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SCIP-Inf 4 |
Controlled perioperative serum glucose (<200 mg/dl) in major cardiac surgery patient |
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SCIP-Inf 6 |
Appropriate hair removal |
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SCIP-Inf 7 |
Perioperative normothermia in colorectal surgical patient (³ to 96.8º F) |
Venous Thromboembolis(VTE) |
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VTE-1 |
Appropriate thromboembolism prophylaxis ordered |
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VTE-2 |
Appropriate thromboembolism prophylaxis administered perioperatively |
Cardiovascular |
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CARD-2 |
Major surgery patient receives beta blocker perioperatively if maintained on a beta-blocker prior to admission |
*NEW*
Appropriate Care Measure (ACM)
The Appropriate Care Measure (ACM) is a composite patient level score of the ten-measure starter set in Section 501(b) of the Medicare Modernization Act (MMA) (5 AMI measures, 2 heart failure measures, and 3 pneumonia measures).
All patients eligible for care in at least 1 of the 10 measures are counted in the denominator. However, only the patients receiving all the care they are eligible for are counted in the numerator.
Acute Myocardial Infarction
AMI-1 Aspirin on arrival
AMI-2 Aspirin at discharge
AMI-3 ACEI for LVSD
AMI-5 Beta blocker at discharge
AMI-6 Beta blocker at arrival
Heart Failure
HF-2 LVF assessment
HF-3 ACEI for LVSD
Pneumonia
PN-1 Oxygenation assessment
PN-2 Pneumococcal Vaccination
PN-5b Antibiotic within 4 hours
AMI Example:
Patient only eligible for aspirin and beta blocker at arrival (excluded from aspirin & beta blocker at discharge and ACEI for LVSD)
· receives aspirin at arrival only-fails ACM
· receives beta blocker at arrival only-fails ACM
· receives both aspirin and beta blocker at arrival-passes ACM
Why use the ACM?
It reinforces CMS’s commitment to the right care for every patient every time and encourages organizational-wide improvement at each hospital by demonstrating a commitment to quality improvement through administrative support/communication.