JPMC Core Measures Quality Report Comparison

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AMI Measures	1Q11	4Q10	3Q10	2Q10	1Q10	Total Avg.	10/09 - 09/10 Nat'l Top 10	Nat'l Avg	State Avg
1. Aspirin at arrival Acute myocardial infarction (AMI) patients without aspirin contraindications who received aspirin within 24 hours before or after hospital arrival.	100	100	100	100	100	100	100	99	98
2. Aspirin at d/c Acute myocardial infarction (AMI) patients without aspirin contraindications who are prescribed aspirin at hospital discharge.	100	100	100	100	100	100	100	99	98
3. Beta blocker at d/c Acute myocardial infarction (AMI) patients without beta-blocker contraindications who are prescribed a beta-blocker at hospital discharge.	100	97	100	100	100	99	100	96	98
4. ACEI/ARB at D/C for LVSD Acute myocardial infarction (AMI) patients with left ventricular systolic dysfunction (LVSD) and without both angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) contraindications who are prescribed an ACEI or ARB at hospital discharge.	100	100	100	100	100	100	100	96	95
5. Smoking cessation counseling Acute myocardial infarction (AMI) 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.	100	100	100	100	100	100	100	100	100
6. Time to PTCA ⟨= 90 min Acute myocardial infarction (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.	100	100	100	100	100	100	100	90	89


CAP Measures	1Q11	4Q10	3Q10	2Q10	1Q10	Total Avg.	10/09 - 9/10 Nat'l Top 10	Nat'l Avg	State Avg
1. Pneumococcal Screening/Vaccinated Pneumonia patients, age 65 and older, who were screened for pneumococcal vaccine status and were administered the vaccine prior to discharge, if indicated.	96	100	88	87	95	93	100	93	91
2. Blood cultures pts admitted through ER Blood cultures performed in the Emergency Department prior to initial antibiotic received in hospital.	94	86	100	78	86	90	100	96	97
3. Blood cultures for patients in ICU 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.	100	97	88	98	98	97	100	96	96
4. Smoking cessation counseling Pneumonia patients with a history of smoking cigarettes who are given smoking cessation advice or counseling during hospital stay.	100	100	100	100	100	100	100	97	95
6. Antibiotic administered =⟨ 6hr of arrival Pneumonia patients who receive their first dose of antibiotics within 6 hours after arrival at the hospital.	96	97	97	92	100	97	100	95	95
7. Initial antibiotic selection-ICU initial antibiotic selection for Community-Acquired Pneumonia (CAP) in immunocompetent patients – Intensive Care Unit (ICU) patients.	40	100	83	100	100	77	100	71	70
8. Initial antibiotic selection-non-ICU Initial antibiotic selection for Community-Acquired Pneumonia (CAP) in immunocompetent patients – non ICU patients.	100	96	87	87	97	94	99	91	91
9. Influenza vaccination 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.	89	93	N/A	N/A	94	94	100	91	89


CHF Measures	1Q11	4Q10	3Q10	2Q10	1Q10	Total Avg.	10/09 - 9/10 Nat'l Top 10	Nat'l Avg	State Avg
1. D/C 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: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen.	100	90	96	92	89	93	100	89	84
2. LVF Assessment Heart failure patients with documentation in the hospital record that left ventricular systolic (LVS) function was evaluated before arrival, during hospitalization, or is planned for after discharge	97	100	100	100	98	99	100	98	94
3. ACEI/ARB for LVSD Heart failure patients with left ventricular systolic dysfunction (LVSD) and without contraindications who are prescribed an ACEI or ARB at hospital discharge.	100	100	100	100	100	100	100	95	94
4. Smoking Counseling Heart failure patients with a history of smoking cigarettes, who are given smoking cessation advice or counseling during hospital stay. For purposes of this measure, a smoker is defined as someone who has smoked cigarettes anytime during the year prior to hospital arrival.	100	100	100	100	100	100	100	99	97


Surgical Care Improvement Project	1Q11	4Q10	3Q10	2Q10	1Q10	Total Avg.	10/09 - 9/10 Nat'l Top 10	Nat'l Avg	State Avg
1. Beta Blocker Surgery patients on beta blockers who received a BB peri-operatively.	100	96	100	95	94	97	100	92	91
2. Prophylactic antibiotic start within 1 hour Surgical patients with prophylactic antibiotics initiated within one hour prior to surgical incision.	97	99	94	94	96	96	100	97	97
3. Prophylactic antibiotic dc'd within 24 hrs Surgical patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time	97	100	97	98	93	97	100	95	95
4. Appropriate ATB Selection Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure).	98	100	93	99	99	98	100	97	98
5. Appropriate Hair Removal Surgery patients with appropriate surgical site hair removal. No hair removal, or hair removal with clippers or depilatory is considered appropriate. Shaving is considered inappropriate.	100	100	100	100	100	100	100	100	100
6. Urinary cath removal Urinary cath removed postoperative day 1 or 2.	98	100	96	93	74	93	100	91	88
6. Temperature Management Surgery patients with perioperative temperature management.	100	100	100	100	100	100	100	New Measure	New
6. VTE Prophy Ordered Surgery patients with recommended venous thromboembolism (VTE) prophylaxis ordered anytime from hospital arrival to 48 hours after surgery end time.	91	90	89	98	94	93	100	94	94
7. VTE Propy w/I 24 hr prior/after Surgery Surgery patients who received appropriate venous thromboembolism (VTE) prophylaxis within 24 hours prior to surgical incision time to 24 hours after surgery end time.	90	87	90	95	91	91	100	93	92