1. 06/11/13 1
Inpatient and Outpatient
Quality Measures
(Core Measures)
Education Program
Developed by The Stellaris Core Measure Workgroup

2. Goals
Provide Physician and Nursing staff with an overview
of the National Inpatient and Outpatient Quality
Measures (Core Measures)
Physician and Nursing staff will have an increased
awareness of the evidence based practice that
underlies the core measures
Physician and Nursing staff will have a better
understanding of the documentation requirements
related to Core Measures

3. 06/11/13 3
Core measures is a National Quality
Initiative
Mandated by the Center for Medicare & Medicaid Services
(CMS) and The Joint Commission (TJC) to monitor specific
hospital clinical processes and how well hospitals provide
recommended care
Evidence based best practice
All major payers moving toward using Core Measure
results to benchmark & for contract negotiations
Basis for Medicare Pay for Performance/Value Based
Purchasing
As of 2013, also the basis for Physician reimbursement

4. 06/11/13 4
Core measures is a National Quality
Initiative
Rigorous “inclusion” and “exclusion” criteria & guidelines
for “acceptable” documentation
Results undergo random validation studies
Penalties for failing validation
The Quality Management Department tracks and reports
data in order to achieve the goal of high quality care.
Data published on CMS public website:
http://www.hospitalcompare.hhs.gov

5. 06/11/13 5
Core Measures
Hospital Inpatient
Acute Myocardial Infarction (AMI)
Heart Failure (HF)
Pneumonia (PN)
Surgical Care Improvement Project (SCIP)
Emergency Department (ED) Throughput Measure-Admitted
Patients
Global Immunization
Hospital Out-patient (HOP)
Emergency Department (ED) Throughput Measures -Discharged
Patients
Surgery
AMI/Chest Pain

6. 06/11/13 6
Acute MI Indicators
Aspirin (ASA) within 24 hours before or after
arrival
ASA prescribed at discharge
Angiotensin Converting Enzyme Inhibitor
(ACEI)/Angiotensin II Receptor Blocker (ARB) at
discharge for LV systolic dysfunction (LVSD)
Fibrinolytic within 30 minutes of arrival
Percutaneous Coronary Intervention (PCI)
within 90 minutes of arrival
Beta Blocker prescribed at discharge
Statin prescribed at discharge

7. Acute MI
Indicator Documentation Requirements
ASA within 24 hrs before
or after arrival
ASA at discharge
•Must have documentation for WHY no ASA, unless there is
documentation of allergy, or patient currently on Coumadin
ACEI/ARB at discharge, if
LVSD
Reasons for not prescribing either an ACEI or ARB at discharge:
• ACEI allergy AND ARB allergy
• Moderate or severe aortic stenosis
• Other explicit reason must be documented for not
prescribing BOTH
(If there is documented hyperkalemia, angioedema, renal artery
stenosis, hypotension, or worsening renal disease, hold for one
sufficient to justify hold for the other)
Beta Blocker at discharge If not given, must document explicit reason
• Beta-blocker allergy (allergy to one specific medication NOT
explicit contraindication for the entire class)
• Second or third-degree heart block on ECG on arrival or
during hospital stay and does not have a pacemaker
• Explicit “hold parameters” met
• Other reasons explicitly documented

8. Acute MI
Indicator Documentation Requirements
Fibrinolytic within 30
minutes of arrival
•System reasons for delay are NOT acceptable.
•There must be MD/PA/NP documentation that there was
“hold”, “delay”, or “wait” in initiating Lytic/PCI AND this was
not system related.
If there’s a delay…. Acceptable documented reasons:
•“Hold lytics. Will do CAT scan to r/o bleed” or
•“Consent delay, patient deciding about treatment and
waiting to speak to husband before giving consent for
treatment.”
Not acceptable documentation:
•Equipment issue (IV pump malfunction)
•Staff related - “Not enough staff due to blizzard"
PCI within 90 minutes of
arrival
Statin prescribed at
discharge, if LDL > 100
•Documentation results of LDL assessment within 24 hrs of
arrival
•Allergy or specific other reason explicit for not prescribing must
be documented.

9. 06/11/13 9
Heart Failure Indicators
Discharge Instructions documented
o Diet, activity, weight management, what to do if
symptoms worsen, medications, physician
follow up appointment
Evaluation of Left Ventricular Systolic (LVS)
Function
ACEI or ARB for Left Ventricular Systolic
Dysfunction (LVSD)

10. 06/11/13 10
Heart Failure
Indicator Documentation Requirements
Discharge Instructions (diet,
activity, weight monitoring, what to
do if symptoms worsen,
medications, physician follow up)
•Provided by Nursing and on MD Discharge
instructions.
•National emphasis as part of readmission reduction
Evaluation of LVS Function •Even if an echo is not needed, some reference to past
echo or narrative description of LV function MUST be
documented in current record
ACEI or ARB for LVSD •If not prescribed, reason MUST be documented
appropriate data field
•Contraindication to one not necessarily
contraindication for the other; both need to be
referenced

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Pneumonia Indicators
Blood culture in ED prior to antibiotic
Blood cultures < 24 hours prior to or 24
hours after arrival for patients transferred
or admitted to ICU
Antibiotics selection ICU/non-ICU

12. 06/11/13 12
Pneumonia
Indicator Documentation Requirements
Blood cultures drawn prior
to antibiotic
•Use of pneumonia order sets by physicians
•Documentation of blood draw time on blood culture set
label
•Blood culture must be drawn prior to administration of
antibiotic
Blood cultures < 24 hours
prior to or 24 hours after
arrival for patients
transferred or admitted to
ICU
•Blood cultures must be ordered on patients transferred to
or admitted to ICU
Antibiotic selection
ICU/non-ICU
•See next slide “Guide for Antibiotic Selection for
Pneumonia” for physicians
•Use of pneumonia order sets by physicians

13. Pneumonia Antibiotic Consensus Recommendations
Non-ICU Patient
β-lactam (IV or IM) + Macrolide (IV or PO)
OR
Antipneumococcal Quinolone monotherapy (IV or PO)
OR
β -lactam (IV or IM) + Doxycycline (IV or PO)
OR
Tigecycline monotherapy (IV)
Antibiotic Selection List
β -lactam = Ceftriaxone, Cefotaxime, Ampicillin/Sulbactam, Ertapenem, Ceftaroline
Macrolide = Erythromycin, Clarithromycin, Azithromycin
Antipneumococcal Quinolones = Levofloxacin, Moxifloxacin, Gemifloxacin
Doxycycline
Tigecycline
Please note: the above requirements are incorporated into the Pneumonia Order Sets

14. Pneumonia Antibiotic Consensus
Recommendations
Non-ICU Patient with Pseudomonal Risk
These antibiotics are acceptable for Non-ICU patients with Pseudomonal Risk ONLY:
 Antipneumococcal/Antipseudomonal β -lactam (IV) + Antipseudomonal Quinolone (IV or
PO)
OR
 Antipneumococcal/Antipseudomonal β -lactam (IV) + Aminoglycoside (IV) + either
Antipneumococcal Quinolone (IV or PO) Or Macrolide (IV or PO)
These antibiotics are acceptable for Non-ICU patients with β -lactam allergy and Pseudomonal
Risk ONLY:
 Aztreonam (IV or IM) + Antipneumococcal Quinolone (IV or PO) + Aminoglycoside (IV)
OR
 Aztreonam (IV or IM) + Levofloxacin1 (IV or PO)
Antibiotic Selection List
 Antipseudomonal Quinolone = Ciprofloxacin, Levofloxacin
 Antipneumococcal/Antipseudomonal β -lactam = Cefepime, Imipenem, Meropenem,
Piperacillin/Tazobactam, Doripenem
 Aminoglycoside = Gentamicin, Tobramycin, Amikacin
 Antipneumococcal Quinolone = Levofloxacin, Moxifloxacin, Gemifloxacin
 Macrolide = Erythromycin, Clarithromycin, Azithromycin
Please note: the above requirements are incorporated into the Pneumonia Order Sets

15. Pneumonia Antibiotic Consensus Recommendations
ICU Patient
 Macrolide (IV) + either β -lactam (IV) Or Antipneumococcal/Antipseudomonal β -lactam (IV)
OR
 Antipseudomonal Quinolone (IV) + either β -lactam (IV) OR Antipneumococcal/
Antipseudomonal β -lactam (IV)
OR
 Antipneumococcal Quinolone (IV) + either β -lactam (IV) OR Antipneumococcal/
Antipseudomonal β -lactam (IV)
OR
 Antipneumococcal/Antipseudomonal β -lactam (IV) + Aminoglycoside (IV) + either
Antipneumococcal Quinolone (IV) OR Macrolide (IV)
If the patient has Francisella tularensis or Yersinia pestis risk as determined by Another Source of
Infection the following is another acceptable regimen:
 Doxycycline (IV) + either β -lactam (IV) OR Antipneumococcal/Antipseudomonal β
-lactam (IV)
Antibiotic Selection List
β -lactam = Ceftriaxone, Cefotaxime, Ampicillin/Sulbactam
Antipneumococcal/Antipseudomonal β -lactam = Cefepime, Imipenem, Meropenem, Piperacillin/Tazobactam,
Doripenem
Macrolide = Erythromycin, Azithromycin
Antipneumococcal Quinolones = Levofloxacin, Moxifloxacin
Antipseudomonal Quinolone = Ciprofloxacin, Levofloxacin
Aminoglycoside = Gentamicin, Tobramycin, Amikacin
Please Note; The above requirements have been incorporated into the Pneumonia Order Sets

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SCIP Indicators
Antibiotic within 1 hour of surgical incision
Prophylactic antibiotic selection
Antibiotic discontinued within 24 hours of anesthesia end
time
Appropriate hair removal
Urinary catheter removed by Postoperative Day #1 or #2
Perioperative temperature management
Venous thrombo-embolism (VTE) prophylaxis ordered &
administered within 24 hours of anesthesia end time
Beta Blocker given in the perioperative period if on Beta
blocker prior to arrival

17. 06/11/13 17
SCIP
Indicator Documentation Requirements
Pre-op antibiotic
administration within 1 hour
of incision (2 hr window
allowed for Vancomycin &
Levaquin)
•Date/time/route of antibiotic administration MUST be
clearly documented in the appropriate data field
•Be mindful of delays in surgery
Antibiotic selection •MDs must use prophylactic antibiotic order sets
•Document clarification of appropriate antibiotic selection
for patients with beta- lactam allergy using prophylaxis
order set
Antibiotic discontinued w/in
24 hours of anesthesia end
time
•MDs must use prophylactic antibiotic order sets
•MD order reflecting continuation of antibiotics must have
documentation of current or suspected infection.
•The date/time/route of antibiotic administration MUST
clearly documented in the appropriate data field
Appropriate hair removal •No hair removal, hair removal with clippers or depilatory
is considered appropriate. Shaving is considered
inappropriate

18. SCIP
Indicator Documentation Requirements
Urinary Catheter removed by
Postoperative Day (POD) #1 or
#2
•Placement and discontinuance of catheter MUST be clearly
documented in the appropriate data field
•MD order required to maintain catheter beyond POD#2, if
clinically indicated
•Reason for continuance of catheter must be documented by MD
Peri -op temperature
management
•Use of Bair hugger MUST be clearly documented in the
appropriate data field
•First temperature documented in PACU must be <15 minutes
VTE ordered & given w/in 24
hours anesthesia end time
•MDs must use order sets
•Date/time/route of VTE administration MUST be clearly
documented by Nursing in the appropriate data field
Beta Blocker given
perioperatively, if on Beta
Blocker prior to arrival
•Last dose, date and time of Beta Blocker must be
communicated to medical team and documented in the
appropriate data field
•Perioperative period defined as the day prior to surgery through
postoperative Day#2 with day of surgery being Day Zero
•If postoperative length of stay is ≥ 2 days, Beta Blocker should be
administered the day prior to or day of surgery AND on
postoperative Day#1 or Day#2 unless reason for not administering
is documented in the appropriate data field

19. Recommended Prophylactic Antibiotic Regimen Selection for Surgery
Surgical Procedure Approved Antibiotics
CABG, Other
Cardiac or
Vascular
Cefazolin, Cefuroxime or Vancomycin 1
If β-lactam allergy: Vancomycin2
or Clindamycin
Hip/Knee
Arthroplasty
Cefazolin, Cefuroxime or Vancomycin 1
If β-lactam allergy: Vancomycin2
or Clindamycin
Colon Cefotetan, Cefoxitin, Ampicillin/Sulbactam or Ertapenem 3
OR Cefazolin or Cefuroxime + Metronidazole
If β-lactam allergy:
Clindamycin + Aminoglycoside OR Clindamycin + Quinolone OR Clindamycin +
Aztreonam
OR Metronidazole + Aminoglycoside OR Metronidazole + Quinolone
Hysterectomy Cefotetan, Cefazolin, Cefoxitin, Cefuroxime, OR Ampicillin/Sulbactam
If β-lactam allergy:
Clindamycin + Aminoglycoside OR Clindamycin + Quinolone OR Clindamycin +
Aztreonam OR Metronidazole + Aminoglycoside OR Metronidazole + Quinolone
Hysterectomy
with an Other
Procedure Code
of Colon Surgery
Cefotetan, Cefazolin, Cefoxitin, Cefuroxime, OR Ampicillin/Sulbactam OR Ertapenem 3
If β-lactam allergy:
Clindamycin + Aminoglycoside OR Clindamycin + Quinolone OR Clindamycin +
Aztreonam OR Metronidazole + Aminoglycoside OR Metronidazole + Quinolone
Please Note: The above requirements have been incorporated into the Surgical Order Sets
Special Considerations:
1
Vancomycin is acceptable with a physician/APN/PA/pharmacist documented justification for its use.
2
For cardiac, orthopedic, and vascular surgery, if the patient is allergic to beta-lactam antibiotics, Vancomycin or Clindamycin are acceptable substitutes.
3
A single dose of Ertapenem is recommended for colon procedures.

20. Please Note; The above requirements have been incorporated into the Surgical Order Sets

21. Global Immunization
Pneumococcal Immunization
Patients age 65 and older
Patients age 6-64 years with high risk
conditions
Influenza Immunization
Patients 6 months and older

22. Global Immunization
Indicator Documentation Requirements
Pneumococcal
Vaccination
•Includes:
Inpatients age 65 & older;
Inpatients age 6 to 64 with a High Risk Diagnosis
(High Risk Diagnosis - Diabetes, Nephrotic syndrome,
ESRD, CHF, COPD, HIV or Asplenia)
Inpatients age 19-64 years with Asthma
•Contraindications:
Hypersensitivity to components of the vaccine
Bone marrow transplant within the past 12 months
Received chemo or radio therapy during this hospitalization or
within 2 weeks prior
Received Shingles vaccine within 4 weeks prior to arrival
Pt 6 yrs of age who received a conjugate vaccine within the
previous 8 weeks
•Screening questions in the RN admission and discharge
assessments must be completed
•Patients have the option of declining the vaccine

23. Global Immunization
Indicator Documentation Requirements
Influenza Vaccination •Includes inpatients age 6 months and older
•Contraindications:
-Hypersensitivity to eggs or other components of the
vaccine
-Bone marrow transplant within the past 6 months
-History of Guillain-Barre’ Syndrome within 6 weeks
after a previous influenza vaccination
-Anaphylactic latex allergy
•Screening questions in the RN admission and discharge
assessments must be completed
•Patients have the option of declining the vaccine

24. 06/11/13 24
Emergency Department Throughput for
Admitted Patients
• Median Time from ED Arrival to ED
Departure for Admitted ED Patients
• Admit Decision Time to ED Departure for
Admitted Patients

25. ED Throughput – Admitted Patients
Indicator Documentation Requirements
Median Time from ED
Arrival to ED
Departure for
Admitted ED Patients
•Arrival time MUST be clearly documented in the
appropriate data field
•Departure time from ED MUST be clearly documented
in the appropriate data field
Admit Decision Time
to ED Departure for
Admitted Patients
•Decision to admit can be the bed request time or
admission order

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Emergency Department Throughput for
Discharged Patients
Median Time from ED Arrival to ED Departure
Door to Diagnostic Evaluation by MD/NP/PA
Left Without Being Seen
Median Time to Pain Management for Long Bone
Fracture (patients >= 2 years of age)
Head CT scan results for Stroke (acute ischemic or
hemorrhagic) interpreted within 45 minutes of
Arrival

27. ED Throughput – Discharged Patients
Indicator Documentation Requirements
Median time arrival to ED
departure
•Arrival time and time left ED MUST be clearly documented in the
appropriate data field
Median time door to
diagnostic evaluation by
MD/APN/PA
•Arrival time and time seen by physician, advanced practice nurse or
physicians assistant (MD/APN/PA) MUST be clearly documented in
the appropriate data field
Left Without Being Seen Includes patients who leave the ED without being evaluated by a
physician/advance practice nurse/physician’s assistant
Median time to pain mgt for
long bone fracture
Includes patients >= 2 years of age
Head CT scan results for
Stroke interpreted within 45
minutes of arrival
Includes pts > 18 years of age with acute ischemic or hemorrhagic
stroke

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Hospital Outpatient Surgery (HOP
Surgery) Indicators
Timing of Antibiotic Prophylaxis
Antibiotic Selection

29. 06/11/13 29
Hospital Outpatient Surgery
Indicator Documentation Requirements
Timing of Antibiotic Prophylaxis
(2 hour window allowed for Vancomycin &
Levaquin)
•Requirement of one hour timing applies to
ALL procedural areas
•MDs must use prophylactic antibiotic order
sets
•Date/time/route of antibiotic administration
MUST be clearly documented in the appropriate
data field
Antibiotic Selection •MDs must use prophylactic antibiotic order sets
•Document clarification of appropriate antibiotic
selection for patients with beta- lactam allergy
•Date/time/route of antibiotic administration
MUST be clearly documented in the appropriate
data field

30. 06/11/13 30
Hospital Outpatient AMI/Chest Pain
(HOP AMI/Chest Pain)
Median Time to Fibrinolysis-patients with ST
elevation MI (STEMI) or left bundle branch block
(LBBB)
Fibrinolytic Therapy Received Within 30 Minutes
Median Time to Transfer to Another Facility for
Acute Coronary Intervention
Aspirin at Arrival
Median Time to ECG

31. 06/11/13 31
Hospital Outpatient AMI/Chest Pain
Indicator Documentation Requirements
Median Time to Fibrinolysis (STEMI or
LBBB)
•Time of arrival MUST be clearly documented in the
appropriate data field
•Medication administration time MUST be clearly
documented in the appropriate data field
Fibrinolytic Therapy Received Within 30
Minutes
•System reasons for delay are NOT acceptable
•There must be MD/PA/NP documentation that there
was “hold”, “delay”, or “wait” in initiating Lytic/PCI AND
this was not system related
Median Time to Transfer to Another
Facility for Acute Coronary Intervention
•Time of arrival and transfer MUST be clearly
documented in the appropriate data field
•Patient disposition MUST be clearly documented in the
appropriate data field
Aspirin at Arrival •Should be considered even if clinical
presentation is atypical
•If Aspirin not given, the reason must be documented
Median Time to ECG •ECG to be completed within 10 minutes of arrival
•Must document accurate arrival time
•Date/time of ECG MUST be clearly documented in the
appropriate data field

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Core Measure
Overview
Indicators
Acute MI ASA w/in 24 hrs of
arrival
ASA at discharge ACE/ARB at
discharge, if
LVSD
Fibrinolytic within
30 min of arrival
PCI within 90
minutes of arrival
Beta Blocker at
discharge
Statin prescribed at discharge, if
LDL>100
Heart Failure
D/C Instructions Evaluation of LV
systolic function
ACEI/ARB for LV
systolic
dysfunction
Pneumonia
Blood Culture
prior to Antibiotic
Administration
Blood Culture <24 hrs prior to or 24
hrs after arrival for pts transferred or
admitted to ICU
Antibiotic
Selection ICU/non-
ICU
Surgical Care
Improvement
Program (SCIP)
Antibiotic given
within one hour of
incision time
Prophylactic
Antibiotic
selection
Antibiotic d/c
w/in 24 hrs of
anesthesia end
time
Appropriate Hair
Removal
Removal of Foley
Catheter Post-op
Day #1 or #2
Peri-op Temp
Management
VTE ordered &
given w/in 24 hrs
of anesthesia end
time
Beta Blocker in
Peri-op period
Pneumococcal
Vaccine
Pts age 65 & older are screened for
vaccine and receive, if indicated
Pts age 6-64 years with high risk
condition-screened for vaccine and
receive, if indicated

33. 06/11/13 33
Core Measure
Overview
Influenza
Vaccine
Patients 6 months & older-screened for & receive vaccine in season if indicated
ED Throughput-
Admitted
Patients
ED Arrival Time to ED Departure for
Admitted Patients
Admit Decision Time to ED Departure
for admitted pts
ED Throughput –
Discharged
Patients
ED Arrival time to ED Departure Time Door to
Diagnostic
Evaluation by
MD/NP/PA
Left Without Being
Seen
Time to Pain Medication
Administration for Long Bone Fracture
Head CT scan results for Stroke (acute
ischemic or hemorrhagic) interpreted
within 45 minutes of arrival
Hospital
Outpatient
Surgery
Antibiotic
Selection
Timing of Antibiotic Prophylaxis
Hospital
Outpatient
AMI/CP
Median Time to
Fibrinolysis
Fibrinolytic
therapy within 30
minutes
Mean time to
EKG
ASA at arrival
Median time to transfer for Acute Coronary Intervention