Spreadsheet: 16daf1ba-eb03-4599-a3b9-4f9d68f902c8
Sheet: Sheet1

Measure | Measure Indicator | Tips | Attributing Provider
ACUTE MYOCARDIAL INFARCTION | Aspirin Received Within 24 Hours Before or After Hospital Arrival. Documented time and date | Or provider documented contraindication i.e. GI bleeding OR allergy, on pre-arrival [NAME] | Emergency
 | Aspirin Prescribed at Discharge | Or provider documented contraindication i.e. retroperitoneal bleeding OR allergy, on warfarin | Discharging
 | ACEI or ARB (or RAS or RAAS-blockers) for LVSD (Ejection Fraction <40% or moderate-severe LVSD) prescribed at discharge | Or provider documented contraindication to both ACEI and ARB i.e. cough OR allergy OR moderate-severe aortic stenosis | Discharging
 | Smoking Cessation Advice/Counseling. If the pt has smoked cigarettes anytime during the previous year | Documentation by any care provider to stop smoking | Discharging
 | Beta-Blocker prescribed at discharge | Or provider documented contraindication i.e. significant hypotension OR allergy OR second or  third-degree heart block on ECG on arrival or during hospital stay and does not have a pacemaker | Discharging
 | Primary PCI Received within 90 minutes of [NAME] or Fibrinolytic Received within 30 minutes of [NAME] if ST-elevation. or new [NAME] on Initial 12-lead ECG (Initial ECG=ECG performed closest to hosp arrival) | *EMS ECGs up to 1 hr prior to hosp arrival are considered for Initial ECG & must be timed and filed in chart. | Emergency
 |  | *Document any NON-system reasons for delay such as “Hold on PCI; Will do TEE to rule out aortic dissection,” “PCI delayed due to intermittent hypotensive episodes when crossing lesion” or other patient-related reasons that caused a delay, hold or wait in transfer to cath lab, PCI or fibrinolytic tx | Procedure Provider
 |  | *Or document patient’s initial concern or refusal, cardiopulmonary arrest, balloon pump insertion, respiratory failure requiring intubation within 30 minutes (for fibrinolytics) or within 90 minutes (for PCI) of arrival. Document if PCI is not primary i.e. Not emergent / immediate/ urgent, Secondary, or  Elective
CONGESTIVE HEART FAILURE | Written) Instructions Address Discharge Medications | Generally, the Discharge Medication List in the Provider’s Discharge Summary or [NAME] must match the Discharge Medication List given to the patient (Epic After Visit Summary- AVS or Epic Interfacility Transfer Report.) | Discharging
 |  | Accuracy between the provider and patient’s Discharge Medication Lists can be improved by:
 |  | • Reconciling discharge medications in Epic before the Discharge Summary is completed AND
 |  | •Utilizing up-to-date Epic “smart links” in your Epic Discharge Summaries and Notes
 |  | (Written) Discharge Instructions also Address Activity, Diet, Follow-up with physician/APN/PA, [NAME], and What to do if HF symptoms worsen (description of specific HF symptoms). Instructions may be provided any time during the hospitalization.
 | Evaluation of LVS Function | Documented results from before arrival, during hospitalization, or is planned for after discharge | Discharging
 | ACEI or ARB (or RAS or RAAS-blockers) for LVSD (EF<40% or moderate-severe LVSD). Prescribed at discharge | Or provider documented contraindication to both ACEI and ARB i.e. cough OR allergy OR moderate-severe aortic stenosis | Discharging
 | Smoking Cessation Advice/Counseling. If the pt has smoked cigarettes anytime during the previous year | Documentation by any care provider to stop smoking | Discharging
PNEUMONIA | Pneumococcal Vaccination Pneumonia patients, age 65 and older given prior to hospital discharge | Patients can be excluded by Cystic Fibrosis, allergy, or bone marrow transplant within the past 12 months, or if currently receiving a scheduled course of chemotherapy or radiation therapy or rec’d chemotherapy or radiation therapy during this hospitalization. | Discharging
 | Blood Cultures Performed Within 24 Hrs Prior to or After [NAME] for Pts Who Were Transferred or Admitted to the ICU Within 24 Hrs of Hosp Arrival |  | Emergency  Admitting
 | [NAME] in the ED Prior to Initial Antibiotic Received in Hosp ED |  | Emergency
 | Smoking Cessation Advice/Counseling. If the pt has smoked cigarettes anytime during the previous year | Documentation by any care provider to stop smoking | Discharging
 | Initial Antibiotic Received Within 6 Hours of Hospital Arrival-dated and timed | If the patient’s initial clinical picture was questionable, unclear or not suggestive of pneumonia and this created a delay in the diagnosis of PN at the time of admission, this must be clearly documented | Emergency  Admitting
 | Initial Antibiotic Selection for CAP in Immunocompetent ICU & Non–ICU Patients consistent with current guidelines- See MHS Pharmacy Antibiotic Recommendations | Patients can be excluded by Cystic Fibrosis, healthcare associated PN, documented compromising condition including chronic systemic steroid use such as prednisone, an identified pathogen documented within 24 hrs, another suspected (non-pulmonary) source of infection; sepsis must be specified as not due to PN or pt has a central line at time of arrival | Emergency  Admitting
 | [NAME] patients age 50 years and older, hospitalized during October thru March given prior to hospital discharge | Patients can be excluded by Cystic Fibrosis, Patients with a secondary diagnosis of 487.0 (influenza with pneumonia), allergy OR is medically contraindicated because of bone marrow transplant within the past 12 months OR prior history of [NAME] syndrome. | Discharging
SURGICAL CARE IMPROVEMENT PROJECT | Prophylactic ABX Rec'd Within One Hour Prior to Surgical Incision. Received Within Two Hours for (No Suggestions) or a fluoroquinolone | Documentation must include drug name, time, and route unless there is a current, suspected or actual infection documented preoperatively. | Anesthesiologist
 | Prophylactic Antibiotic Selection for Surgical Patients | Antibiotics consistent with recommended guidelines (justification for use of (No Suggestions) must be documented in the medical record) | Surgeon
 | Prophylactic Antibiotic Discontinued Within 24 Hrs After Anesthesia) End Time Or within 48 hrs after anesthesia end time for CABG or other cardiac surgery | Document reasons to Extend Antibiotics i.e. suspected or actual infection, treatment of hepatic encephalopathy or erythromycin administered postop for the purpose of increasing gastric motility | Surgeon
 | Cardiac Surgery Patients with Controlled 6 A.M. Postop Blood Glucose Day 1 & 2 |  | Surgeon
 | Surgery Patients with Appropriate Hair Removal | Clippers only in OR | Surgeon
 | Urinary Catheter Removed on Postop Day 1 or 2 with Day of Surgery being Day Zero | Patients are excluded if there is documentation that the patient had an indwelling catheter prior to admission or prior to surgery or a urological, GYN or perineal procedure is performed or the principal diagnosis is suggestive of preop infection, or if they were in the ICU and receiving diuretics [NAME] any other reason for not removing the urinary catheter postoperatively | Surgeon
 | Surgery Patients with Perioperative Temperature Management | Active warming was used intraoperatively to maintain normothermia OR At least one body temperature [NAME] 96.8° documented within 30 minutes before or 15 minutes after anesthesia end time. Patients are excluded if there is documentation of intentional hypothermia, cardiopulmonary bypass. | Anesthesiologist
 | Surgery Patients with Recommended VTE Prophylaxis Ordered |  | Surgeon
 | Recommended VTE prophylaxis implemented within 24 hours before or after surgery |  | Surgeon
 | Perioperative beta-blocker in patients on beta-blockers as a home or prior-to-arrival medication | Document date and time of last beta-blocker dose taken by patient | Anesthesiologist  Surgeon
HOSPITAL OUTPATIENT CHEST PAIN/AMI | Median Time to Fibrinolysis |  | Emergency
 | Fibrinolytic Therapy Received Within 30 Minutes of ED Arrival | Documented date and time of administration | Emergency
 | Median Time to Transfer to Another Facility for Acute Coronary Intervention |  | Emergency
 | Aspirin at Arrival | Documented date and time of administration | Emergency
 | Median Time to ECG | ECG must be dated and timed | Emergency
HOSPITAL OUTPATIENT SURGERY | Prophylactic ABX Rec'd Within One Hour Prior to Surgical Incision. Received Within Two Hours for (No Suggestions) or a fluoroquinolone | Documentation must include drug name, time, and route unless there is a current, suspected or actual infection documented preoperatively. | Anesthesiologist
 | Prophylactic Antibiotic Selection for Surgical Patients | Antibiotics consistent with recommended guidelines (justification for use of (No Suggestions) must be documented in the medical record) | Surgeon
HOSPITAL PATIENT SATISFACTION RATES | Hospital Consumer Assessment of Healthcare Providers and System Survey-Publically reported patient satisfaction taken from our Press-Ganey scores to the Center for Medicare. | Overall rating of hospital  Willingness to recommend this hospital  Communication with nurses  Communication with doctors  Responsiveness of hospital staff  Pain management  Communication about medicines  Discharge information  Cleanliness of hospital environment  Quietness of hospital environment | All Providers
OUTPATIENT IMAGING ORDERS | MRI [NAME] for Low Back Pain | Clearly document reasoning for test | Ordering Provider
 | Mammography Follow-up Rates | Clearly document reasoning for test | Ordering Provider
 | Abdomen CT - Use of Contrast Material | Clearly document reasoning for test | Ordering Provider
 | [NAME] Contrast Material | Clearly document reasoning for test | Ordering Provider
MORTALITY RATES | Acute Myocardial Infarction 30 day Mortality Rate
 | Heart Failure 30 day Mortality Rate
 | Pneumonia 30 day Mortality Rate
READMISSION RATES | Acute Myocardial Infarction 30 day Readmission Rate
 | Heart Failure 30 day Readmission Rate
 | Pneumonia 30 day Readmission Rate