2014 QUALITY INDICATOR METRICS
12/18/14
Allergy
1. Asthma Assessment / 85%2. Asthma - Pharmacologic Therapy / 80%
3. Asthma – Spirometry and/ or PFT Evaluation / 80%
4. Smoking Status Assessed / 89%
5. Smoking Cessation Advised / 70%
6. Flu Shot within 12 Months in Pt Age 65+ or Asthmatic / 50%
7. Pneumovax in Patients Age 65+ or Asthmatic / 50%
8. Rescue Inhaler Prescribed for Asthma / 75%
Anticoagulation
1. INR in A-Fib within 30 Days / 70%2. INR in A-Fib in Target Range within 30 Days / 65%
3. Patients with Hypertension - BP Measured within 12 Months / 90%
4. Smoking Status Assessed / 89%
5. Smoking Cessation Advised / 70%
Behavioral Health (prescribers: Mitchell, Ragan, Schack)
1. Pts on Lithium – Annual Creatinine, Thyroid, Lithium Levels (those who prescribe only) / 90%2. Smoking Status Assessed / 89%
3. Smoking Cessation Advised / 70%
4. Suicidality Assessment / 75%
5. Alcohol and Substance Use Assessment / 75%
6. Atypical Antipsychotic Use – BMI and /or Weight Measured Annually (prescribers only) / 75%
7. Atypical Antipsychotic Use–Glucose, Cholesterol, and A1c Measured Annually (prescribers only) / 75%
8. Primary Care Provider Notification of Behavioral Health Treatment / 75%
9. Prior Psychotropic Medication History in Children and Adolescents (those who prescribe only) / 75%
Dr. Laudenbach - Form to be put in place after update
Camelia had a note saying “Changes?”
Breast Health
1. No Open Breast Biopsy / 90%2. Markers Placed During Breast Biopsy / 80%
3. Image Confirmation of Non Palpable Lesions / 90%
4. SLN Biopsy in Breast Cancer / 70%
5. Smoking Status Assessed / 89%
6. Weight Mgmt Counseling for BMI Outside Parameters within 6 Months / 20%
Cardiology
2. HF Ejection Fraction Measured / 93%
3. HF with LVEF < 40 on ACEi or ARB or CI / 80%
4. Heart Failure Patient Instructions / 55%
5. HF with LVEF <40 on Beta Blocker / 80%
6. CAD Patients on a Statin / 80%
7. CAD BP <140/90 / 60%
8. Smoking Cessation Advised / 70%
Cardiology – EP (Kilaru)
1. EP – No Pericardiocentesis Following Supraventricular Tachycardia Catheter Ablation / 98%2. EP – No Pericardiocentesis Following VT or PVC Catheter Ablation / 98%
3. EP – No Pericardiocentesis Following Atrial Fibrillation/Flutter Catheter Ablation / 98%
4. EP – No Infection within 180 Days of Cardiac Implantable Electronic Device Implantation, Replacement, or Revision / 95%
5. EP – No Implantable Cardioverter-Defibrillator Complications / 95%
6. EP – Drug Safety – TSH, LFT, PFT – Amiodarone / 90%
7. EP – Drug Safety – Renal Function Test – Pradaxa/Xarelto/Eliquis / 90%
Dermatology
1. Melanoma Follow-up Aspects of Care / 75%2. Melanoma Skin Exam within 12 Months / 75%
3. Melanoma – Coordination of Care / 75%
4. Smoking Status Assessed / 89%
5. Smoking Cessation Advised / 70%
6. Drug Safety – LFT’s in Psoriasis Patients on DMARD Therapy (Henderson only) / 85%
7. Counseling on Sun Exposure within 12 Months / 80%
Digestive Health
1. IBD - No Corticosteroid Treatment / 75%2. DMARDS - Liver Function Testing Annually / 85%
3. IBD - Corticosteroid-Sparing Therapy / 95%
4. Smoking Status Assessed / 89%
5. HCV RNA Testing in Hepatitis C Patients on Antiviral Therapy / 95%
6. Genotype Testing in Hepatitis C Patients on Antiviral Therapy (NPP only) / 90%
7. Smoking Cessation Advised – Patients with GERD Seen within 365 Days / 70%
8. Scope Withdrawal Time (MD only) / > 6 min
Digestive Health – Hospitalists (Goff, Niemi, Stumm) – pay as a group
2. Cirrhosis Diagnostics – self report / 90%
3. ALD – Labs – self report / 90%
4. ALD Imaging – self report / 90%
5. ALD – Maddrey Score – self report / 90%
6. GI Bleed PPI – self report / 90%
Goff has no hospitalist numbers for himself, so he is to receive totals for Stumm and Niemi
Endocrinology
1. A1c < 9.0 / 89%2. Clinical Thyroid Examination within 365 Days / 90%
3. LDL Past 12 Months / 65%
4. Diabetic Patients on a Statin – Age 40 to 75 Years / 80%
5. Osteoporosis Screening/Therapy for Women 65-80 Years Old / 68%
6. Smoking Status Assessed / 89%
7. Weight Mgmt Counseling for BMI Outside Parameters within 6 Months / 75%
8. Smoking Cessation Advised / 70%
Endocrinology (Pediatric)
1. Peds - A1c Past 6 Months / 83%2. Peds – Eye Exam Past 12 Months / 60%
3. Peds - Microalbumin Past 12 Months / 80%
4. Peds – LDL Past 12 Months / 80%
5. Weight Mgmt Age 2-17 Counseling for BMI Outside Parameters within 12 Months / 75%
6. Smoking Status Assessed / 89%
ENT
1. Treatment Options Offered for Sudden Hearing Loss / 50%2. Consent Documented for Nasal Endoscopy or Flexible Laryngoscopy / 80%
3. Auditory Status Assessment Prior to Tube Placement / 90%
4. Assessment of Bleeding History Prior to Surgery / 80%
5. Assessment of Anesthesia Risk Prior to Surgery / 80%
6. Smoking Status Assessed / 89%
7. Smoking Cessation Advised / 70%
Eye Center
2. No Infection Following Cataract Surgery within 12 Months (Ophthalmologists only) / 98%
3. Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy / 70%
4. AMD – Dilated Macular Exam / 65%
5. POAG - Optical Nerve Evaluation / 75%
6. 20/40 or Better VA Following Cataract Surgery DOS Before 10/1/xx or Before 4/1/xx (Ophthalmologists only) / 90%
Family Medicine
1. Mammogram Age 50-74 / 83%2. Patients with Hypertension – Microalb Measured Ever / 70%
3. Pneumococcal Vaccine / 75%
4. A1c Past 12 Months / 92%
5. A1c < 9.0 / 89%
6. CRCS – Patients 50 to 75 Years Old / 74%
7. LDL Past 12 Months in CAD or DM Patients / 75%
8. DM or CAD Patients on a Statin / 80%
9. Smoking Cessation Advised / 70%
GYN
1. Gyn Cervical Cancer Screening Age 24 – 64 / 90%2. Endometrial Sampling Prior to Endometrial Ablation / 50%
3. Osteoporosis Screening/Therapy for Women 65-80 Years Old / 68%
4. Smoking Status Assessed / 89%
Hematology / Oncology
1. Ferritin Test in MDS on ESAs Past 6 Months / 60%2. Vitamin D Supplementation for Patients on IV Bisphosphonate Therapy / 50%
3. DEXA Scan within 3 Years for Breast Cancer Patients on Aromatase Inhibitors / 75%
4. Multiple Myeloma (Dx Date > 90 Days) - Treatment with Bisphosphonate Therapy / 80%
5. Breast Cancer Hormonal Therapy / 60%
6. Cytogenetic Testing for MDS and Leukemia Patients / 80%
7. Smoking Status Assessed / 89%
8. Smoking Cessation Advised / 70%
Infectious Disease
2. On Truvada - Serum Creatinine Past 6 Months / 70%
3. CD4 Past 6 Months / 70%
4. PCP Prophylaxis in Patients with a Low CD4 within 365 Days / 80%
5. Glucose Testing Past 12 Months for HIV Patients on HAART / 80%
6. Hepatitis A & B Vaccines Given to HIV Patients with Hep C / 20%
Dr. B is sending note to Dr. Coulston about having his staff research - Hep vaccines are in paper historical records & they are working on getting data into EHR (if only find info on 2 pts, will then meet threshold)
Internal Medicine - Hospitalists (Core Measure metrics reported from hospital)
1. HF 2 – Evaluation of LVS Function / 99%2. PN 6b – Initial antibiotic selection for CAP in Immunocompetent – Non ICU patient / 95%
3. STK 6 – Discharged on a Statin Medication / 94%
4. STK 10 - Ischemic Or Hemorrhagic Stroke Patients Who were Assessed for Rehabilitation / 97%
5. VTE 1 – Venous Thromboembolism Prophylaxis / 83%
Internal Medicine
1. Mammogram Age 50-74 / 83%2. Patients with Hypertension – Microalb Measured Ever / 70%
3. Pneumococcal Vaccine / 75%
4. A1c Past 12 Months / 92%
5. A1c < 9.0 / 89%
6. CRCS - Patients 50-75 Years Old / 74%
7. LDL Past 12 Months in CAD or DM Patients / 75%
8. DM or CAD Patients on a Statin / 80%
9. Smoking Cessation Advised / 70%
Nephrology – Transplant (Carson)
1. Transplant patient survival at 1 year / 95%2. Transplant allograft survival at 1 year / 90%
3. Non-Rejection rate at 1 year post-transplant / 80%
4. Infection surveillance: BK virus PCR urine and plasma ≥ 4 times 1st year post-transplant / 95%
5. Allograft surveillance: Screen for proteinuria ≥ 2 times per year / 95%
6. Allograft surveillance: Screen for donor specific HLA antibodies yearly / 95%
7. Transplant aftercare (all measures must be done to meet metric):
a. BP check ≥ 90% of visits
b. Lipid profile once per year
c. FBS or HgbA1c annually
d. Referfor Dermatology skin exam or do comprehensive skin exam annually / 70%
Barb e-mailed Dr. Carson 10/29/14 about results for these measures – not yet heard back?
Nephrology (Benedetti & Desmond)
1. CKD Lab - Calcium, Phosphorus, iPTH Past 12 Months / 80%2. CKD III-V – BP Management / 60%
3. CKD – Hgb between 9.5 and 12 on ESA's / 60%
4. CKD Patients with DM or CAD on a Statin / 60%
5. Ferritin Test in Anemia on ESAs Past 130 days / 60%
6. Smoking Status Assessed / 89%
7. Smoking Cessation Advised / 70%
Nephrology – Dialysis Doctors (Christ, Jones, Mielke, Musa, Petersen, Sanchez, Singh, Wickre)
1. CKD Lab - Calcium, Phosphorus, iPTH Past 12 Months / 80%2. CKD III-V – BP Management / 60%
3. CKD – Hgb between 9.5 and 12 on ESA's / 60%
4. CKD Patients with DM or CAD on a Statin / 60%
5. Osteoporosis Screening within 3 years or on Osteoporosis Medication – Transplant Patients on Chronic Steroids / 60%
6. Ferritin Test in Anemia on ESAs Past 120 days / 60%
7. eKdrt/V 1.2 Fresenius / 90% of pts
8. Hemoglobin 10-11 g/dL Fresenius / 50%tile
9. No Catheter rate Fresenius / 50%tile
Nephrology – Dialysis NPPs get #s from provider they help the most (Comstock, Fiola, Hanson, Hedden, Koncz K, Stout)
1. eKdrt/V 1.2 / 90% of pts2. Hemoglobin 10-11 g/dL / Fresenius 50%tile
3. Albumin 4.0 g/dL / Fresenius 50%tile
4. Phosphorus 3.0 – 5.5 mg/dL / Fresenius 50%tile
5. No Catheter Rate / Fresenius 50%tile
Neurology
1. Osteoporosis Screening within 3 Years or on Osteoporosis Medication - Pts on Chronic Steroids / 50%2. Fall Risk Assessed / 50%
3. Plan of Care – Falls / 95%
4. Dysphagia Assessed / 50%
5. Plan of Care for High Risk Dysphagia / 95%
6. Smoking Status Assessed / 89%
7. Smoking Cessation Advised / 70%
Neurology – MS (Yashma Patel)
2. MS Patients - Yearly LFT & CBC for Patients on Beta Interferon / 89%
3. MS Patients - Depression Questionnaire / 80%
4. MS Patients – Fatigue Questionnaire / 80%
5. MS Patients - Vision Check / 80%
6. MS Patients – Ambulation Assessment / 80%
7. MS Patients – Fall Risk Assessed / 80%
8. MS Patients – Dysphagia Assessed / 80%
Neurology – Epilepsy (Nievera & Cassels)
1. Folic Acid Education for Women on Anticonvulsants / 66%2. Discussion of WA State Driving Laws with Pt with Epilepsy / 66%
3. Osteoporosis Screening within 3 Years or on Osteoporosis Medication - Patients with Epilepsy / 50%
4. Smoking Status Assessed / 89%
5. Smoking Cessation Advised / 70%
Neuropsychology testing - Baldwin
1. Neuropsychology Pt – Vitamin D / B12 Assessed / 79%2. Neuropsychology Pt – Substance Abuse Assessed / 79%
3. Neuropsychology Pt – Suicidality Addressed / 79%
4. Neuropsychology Pt – ADLs Assessed / 79%
5. Neuropsychology Pt – Balance / Falls Assessed / 79%
Neurology – Stroke (Core Measures from Hospital) (Geraghty, Ween, Worley)
1. Stk 1 – VTE Prophylaxis / 92%2. Stk 2 – Discharge on Antithrombotic Therapy / 99%
3. Stk 5 - Thrombolytic Therapy by End of Hospital day 2 / 93%
4. Stk 6 – Discharged on Statin Medication / 94%
5. Stk 8 – Stroke education / 87%
6. Stk 10 – Ischemic or Hemorrhagic Stroke Patients who were Assessed for Rehabilitation / 97%
Neurosurgery (SCIP Metrics from Hospital) (Demakas, Heller, McClatchy, White)
1. SCIP Card 2 – Surgery Patients on Beta Blocker Therapy Prior to Admission Who Received a Beta Blocker During the Perioperative Period / 98%2. SCIP Inf 1 (OP 6) - Prophylactic Antibiotic Within 1 Hour Prior to Surgical Incision / 98%
3. SCIP Inf 2 (OP 7) – Prophylactic Antibiotic Selection for Surgical Patients – Overall Rate / 98%
4. SCIP Inf 9 – Urinary Catheter Removed on Postop Day 1 or Postop Day 2 with Day of Surgery Being Day Zero / 97%
5. SCIP VTE 2 – Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery. / 98%
OB/Gyn