JOINT CONFERENCE COMMITTEE CORE MEASURE UPDATE APRIL 13, 2010 See attached Core Measure Performance Graphs Data through Quarter 4 2009. Core Measure Performance is reported publicly at: WWW.HOSPITALCOMPARE.HHS.GOV CURRENT CORE MEASURE IMPROVEMENT FOCUS: PUBLIC HOSPITAL IMPROVEMENT COLLABORATIVE (2009/2010 Grant from California Health Care Foundation to assist public hospitals improve core measure performance). SFGH AIM: Improve performance on all Pneumonia (PN) measures to 95% by July 30, 2010 FOCUS: Improvement of measures related to care provided in the Emergency Department MEASURE AIM ACTION Blood Cultures in ED prior to Initial Antibiotic Initial Antibiotic Selection for CAP ICU and Non ICU Initial Antibiotic Received within 6 Hours of Arrival 95% of PN patients who have blood cultures drawn in ED have documented date and time of specimen collection prior to first antibiotic dose. Data: Q3 2009 77% Q4 2009 75% 95% of eligible patients with community acquired pneumonia receive recommended antibiotic regimen. Data: Q3 2009 67% Q4 2009 95% of PN patients receive 1 st dose of antibiotics within 6 hours of hospital arrival. Data: Q3 2009 74% Q4 2009 89% Actions: ED Faculty will consider adopting standard PN order set requiring collection of Blood Cultures on all PN patients Future Process: ED Information System will store collection time (~1 year away) Actions: Involvement of Infectious Disease Physician and Antibiotic Pharmacist, providing physician education re: Antibiotic Regimens. Test use of sample PN order set to guide antibiotic ordering Instituted re-review of selected cases by Antibiotic Pharmacist to validate data collection Actions: Test strategies to find pneumonia patients quicker : o Assess Triage accuracy o Re-assess all patients in waiting room at established intervals. ED Flow Committee established to assess and improve patient through-put.
Pneumonia Performance Measures Pneumonia: 2 - Pneumococcal Vaccination (>age 65) Pneumonia: 3b - Blood Cultures - ED Pneumonia: Pneumococcal screen (>age 65) 2 - Pneumococcal screen (>age 65): Targets Pneumonia: Blood Cultures (before Abx) 3b - Blood Cultures - ED: Targets Pneumonia: 4 - Smoking Cessation Pneumonia: 5b - Antibiotics within 6 Hours 7/08 10/08 Pneumonia: 4 - Smoking Cessation 4 - Smoking Cessation: Targets Pneumonia: Antibiotics within 8 Hours 5b - Antibiotics within 6 Hours: Targets San Francisco General Hospital Page 1 04/0
Pneumonia Pneumonia: 6b - Antibiotic Selection - Non ICU Pneumonia: 7 - Influenza Vaccination Physician/Pharm D Involvement/Education ED Focus on PN Improvement Vaccine policy implemented 7/08 10/08 Pneumonia: 6 - Antibiotic Selection Targets Pneumonia: Influenza Vaccination 7 - Influenza Vaccination: Targets San Francisco General Hospital Page 2 04/0
AMI Performance Measures AMI: 1 - Aspirin at Arrival AMI: 2 - Aspirin at Discharge AMI: Aspirin at Arrival Targets AMI: Aspirin at D/C 2 - Aspirin at Discharge: Targets AMI: 3 - ACEI or ARB for LVSD AMI: 4 - Adult Smoking Cessation 3 cases 5 cases 6 cases 7 cases AMI: ACEI for LVSD 3 - ACEI or ARB for LVSD: Targets AMI: Adult Smoking Cessation 4 - Adult Smoking Cessation: Targets San Francisco General Hospital Page 1 04/0
AMI AMI: 5 - Beta Blocker at D/C AMI: 8 - PCI Within 90 Minutes of Arrival 4 cases 3 cases 3 cases with D2B over 90 min 2 cases i case AMI: Beta Blocker at D/C 5 - Beta Blocker at D/C: Targets AMI: PCI Within 90 Minutes of Arrival 8 - PCI Within 90 Minutes of Arrival: Targets AMI: 9 - Inpatient Mortality AMI: Inpatient Mortality 9 - Inpatient Mortality: Targets San Francisco General Hospital Page 2 04/0
Heart Failure Performance Measures Heart Failure: 1 - Discharge Instructions include all required elements Heart Failure: 2 - Evaluation of LVS Function Clinical Lead assigned New Hospital D/C Instructions New Cardiac D/C Instructions Heart Failure: Discharge Instructions 1 - Target: National Average Heart Failure: Evaluation of LVS Function National Average Heart Failure: 3 - ACEI for LVSD Heart Failure: 4 - Adult Smoking Cessation Advice/Counceling Heart Failure: ACEI for LVSD National Average Heart Failure: 4 - Adult Smoking Cessation 4 - Adult Smoking Cessation: Targets San Francisco General Hospital Page 1 04/0
Surgical Care Improvement Project Performance Measures Surgical Care Improvement Project: 1 Antibiotic within 1 hour of incision Surgical Care Improvement Project: 2 Appropriate antibiotic selection Surgical Care Improvement Project: 2 - Antibiotic within 1 hour of incision 2 - Surgical Care Improvement Project: Appropriate antibiotic selection Surgical Care Improvement Project: Antibiotic discontinued within 24 hours Surgical Care Improvement Project: CARD 2 Beta Blocker therapy for patients on BB Clinical Lead Assigned Pre-printed order form Documentation improvement in process Surgical Care Improvement Project: 1 - Antibiotic discontinued within 24 hours National Rate Surgical Care Improvement Project: 3 - Beta Blocker therapy San Francisco General Hospital Page 1 04/0
Surgical Care Improvement Project Surgical Care Improvement Project: 6 Appropriate Hair removal Surgical Care Improvement Project: VTE 1 VTE Prophylaxis ordered Partial Data Surgical Care Improvement Project: 4 - Hair removal Surgical Care Improvement Project: VTE 2 VTE given Surgical Care Improvement Project: 7 - VTE Prophylaxis ordered Partial Data Surgical Care Improvement Project: 6 - VTE given San Francisco General Hospital Page 2 04/0