1. Core Measures
Core measures are evidence based practice standards that
have been researched and shown to improve patient
outcomes
Center for Medicare and Medicaid Services (CMS)
established the core measures in 2000
Reporting core measures is a CMS requirement for
reimbursement
The scores obtained on the quality measures are reported
quarterly to CMS
 The data is then reported publicly on Hospital Compare
This can be considered a public report card on how all
hospitals perform in regard to quality

2. Core Measures
At WCMC we currently report on and/or monitor:
• Acute Myocardial Infarction (AMI)
• Heart Failure (HF)
• Pneumonia (PN)
• Surgical Care Improvement Project (SCIP)
• VTE protocols
• Stroke
Each clinical focus has a team composed of a physician, managers,
administrative staff, staff nurses, and case managers that collect
data and review processes to improve WCMC’s performance
Patients admitted with one of the clinical focuses will have an
identifiable red chart

3. Core Measures (continued)
The red chart will have the
publicly reported measures that
MUST be addressed listed on a
laminated sheet located on the
inside front cover
It is EVERYONE’S responsibility
to make sure these measures
are met according to the
patient’s diagnosis

4. Core Measures - AMI
AMI patients will have:
• ACE/ARB on discharge for LVSD (EF < 40%)
• PCI within 90 minutes of arrival (STEMI or LBBB, or MI with any
mention of location if described as acute or evolving)
• Smoking Cessation
• Beta-Blocker AND Statin at discharge
• ASA on arrival AND at discharge
Any medication contraindication must be documented in the
medical record and it must also be documented that it is the
reason for not prescribing the drug

5. Core Measures - HF
HF or CHF patients will have:
• LV function assessment or Discharge on these
documentation of EF in chart patients is a three part
• ACE/ARB for LVSD (EF < 40%) at process:
discharge (1) Nursing Discharge
• Smoking Cessation Summary must match
• Written discharge instructions to the (2)MD’s medication
address ALL of the following; reconciliation and that
• Medications must match (3)the MD’s
• Diet Discharge summary
• Activity
• F/U with MD
• Weight monitoring
• Worsening symptoms

6. Core Measures - Pneumonia
Pneumonia patients will have:
• First antibiotic RECEIVED within 6 hours of arrival (time is from first
time of any documentation on chart)
• Smoking cessation advice/counseling
• Ordered blood cultures must be collected in the ED prior to initial
antibiotic – no exceptions
• Blood cultures within 24 hours (prior to or after) arrival on patients
transferred or admitted to the ICU
• Appropriate antibiotic selection

7. Core Measures - SCIP
SCIP or Surgical Care Improvement Project patients will have:
• Appropriate antibiotic selection
• Antibiotics within 1 hour of incision time
• Antibiotics discontinued within 24 hours after anesthesia end time
• Patients on beta-blockers prior to arrival will have beta blocker
given within 24 hours of incision (must have documentation of last
dose given to comply with measure)
• Appropriate hair removal – surgical clippers

8. Core Measures – SCIP (cont)
 Temperature management documentation (> 96.8 F 30 minutes
prior through 15 minutes after anesthesia end time)
 Urinary catheters MUST be removed by post-op day 2 or
documented reason why not
 VTE Prophylaxis (pharmacological and/or mechanical) ordered
anytime from hospital arrival to 24 hours after anesthesia end
time
 VTE prophylaxis received within 24 hours after anesthesia end
time

9. Core Measures - VTE
VTE or Venous Thromboembolism measures the number of
patients who receive VTE prophylaxis or have documentation of
why no prophylaxis was given
VTE patients with anticoagulation overlap – This measure
assesses the number of patients diagnosed with confirmed VTE
that receive both Lovenox and warfarin for 5 days and until the
INR > 2.o before the Lovenox is discontinued. Both criteria have
to be met. The overlap for 5 days and INR > 2.0.
For example, if the INR is less than 2.0 then the Lovenox is
continued longer than the 5 days until the INR of 2.0 is met. If the
INR is 2.0 and the overlap has only occurred for 3 days, the
Lovenox is continued for the full 5 days.

10. Core Measures – VTE (cont)
 VTE Discharge instructions – This measure assesses the number
of patients diagnosed with confirmed VTE that are discharged
to home, home health, court/law enforcement or home on
hospice care on warfarin with written discharge instructions
that address all four criteria: Compliance issues, dietary advice,
follow-up monitoring, and information about the potential for
adverse drug reactions
 Incidence of potentially preventable VTE – This measure
assesses the number of patients diagnosed with confirmed VTE
prophylaxis during hospitalization (not present on admission)
who did not receive VTE prophylaxis between hospital
admission and the day before the VTE diagnostic testing order
date

11. Core Measures – VTE (cont)
Discharge instructions on Coumadin is imperative whether a home
med or a new med
• Click the box under educational needs for patients discharged on
Coumadin, review Coumadin education packet with patient.
• Address F/U monitoring including name and number of MD/office
• Date for next PT/INR blood draw
Patients must be discharged on BOTH Lovenox and Warfarin unless
BOTH criteria are met;
• Has had 5 days of Lovenox
• INR greater than 2

12. Core Measures - Stroke
Stroke patients will have;
• Received VTE prophylaxis or have documentation why none was
given the day of or the day after hospital admission
• Stroke patients will have SCD’s instead of the anti-embolic
stockings
• Antithrombic therapy and Statin at discharge
• Anticoagulation therapy for A-Fib/Flutter at discharge
• Assessed for Rehab during stay

13. Core Measures – Stroke (cont)
The following will be addressed
• Follow up appointment (not as needed - document specifics Dr.
Spock in 1 week, or date and time)
• Discharge Medications (be sure they are clearly identified)
• Discharge instructions; check the stroke box under educational
needs and provide the required education elements reviewing with
patient
• Activation of the emergency medical system (EMS)
• Risk factors for stroke
• Warning signs and symptoms of a stroke