March 2010 - Trident Health System

From 2008 to 2009, these results are attributed to the numberof core measures missed was reduced by 50 percent. Thanks tophysician engagement, peer review, open dialog, concurrentmonitoring and reporting and physician-lead processimprovement teams.There are more than 30 million surgeries performed in theUnited States each year. Despite the evidence that VTE is oneof the most common postoperative complications and prophylaxisis the most effective strategy to reduce morbidity andmortality, it is often underused.Of the 75 Summerville and Trident Medical Center surgerypatients that fell into this measure for fourth quarter2009, 12 did not receive VTE prophylaxis. Either it was notordered or it was ordered and not timely. These 12 cases havebeen thoroughly reviewed with each surgeon.AMI HF PNAcute MyocardialInfarctionAMI1 Aspirin at ArrivalAMI3 ACEI/ARB for LVSDAMI4 Smoking CessationAMI5 BB at D/CAMI8a PCI w/in 90 minsHeart FailureHF1 DischargeInstructionsHF2 LVF assessmentHF3 ACEI/ARB atfor LVSDHF4 Smoking CessationPneumoniaPN2 PN vaxPN3b BCs prior to AbxPN4 Smoking CessationPN5c Abx w/in 6 hoursPN6 Appropriate AbxPN7 Flu vaxMeasure Q1 2008 Q2 2008 Q3 2008 Q4 2008AMI 98.48% 99.58% 99.62% 98.02%HF 89.95% 91.96% 94.05% 94.55%PN 96.08% 95.01% 98.41% 95.83%SCIP 94.30% 94.81% 95.21% 96.60%Measure Q1 2009 Q2 2009 Q3 2009 Q4 2009AMI 99.07% 99.58% 98.28% 100.00%HF 96.49% 98.88% 98.29% 97.83%PN 97.62% 98.00% 97.50% 98.28%SCIP 98.58% 97.89% 98.20% 97.77%Having made general, wide-sweeping process improvementsin 2009 as evidenced by the composite scores above, it isimperative that we now take a targeted approach with anindicator-specific focus.For example, the Q4 2009 composite SCIP score of 97.77 percent(below TJC/CMS 90th percentile) is much lower than theprevious three quarters of the year. Of the six indicators thatmake up the composite score for SCIP (see chart) the two thatmeasure Venous Thromboembolism (VTE) performance offerthe area for most improvement.SCIP VTE1 & 2 measures the number of surgery patients thathad the recommended Venous Thromboembolism Prophylaxisordered and administered in a timely manner.SCIPSurgical CareImprovement ProjectSCIP1 Abx 1hr priorto incisionSCIP2 Appropriate AbxSCIP3 Abx D/C w/in 24hrsSCIPVTE1 VTE OrderedSCIPVTE2 VTE ReceivedSTKStrokeSTK1 VTE OrderedSTK2 D/C w/AntithromboticTherapySTK3 Anticoag forAfid/FlutterSTK4 ThrombolyticTherapySTK5 AntithromboticTherapy by Day 2STK 6 D/C on StatinSTK8 Stroke EducationSTK10 Assessed forRehabIn 2010, Stroke core measures have been added as an additionalquality measure although Trident Health System doesnot currently publicly report this data via Hospital Compare.However our Stroke data is reported to TJC as part of ourStroke Accreditation Program. Our preliminary fourth quarterdata is trending in the 90th percentile for most of the 10measures, except for STK3 - Anticoag for Afib/Flutter, whichis currently at 80 percent. Final results were not available atthe time of publication.If you have any questions or concerns regarding core measures,please contact Alice Turner, AVP of quality in administration,at 843-847-4100.TridentHealthSystem.comMedstaff Communications MARCH 2010 9