SUNY Downstate Medical Center/University Hospital Oct - Dec 2013 (Q4)

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1 Value Based Purchasing-Clinical Process of Care Measures Denom Observed VBP VBP Benchmark Standard Denom Observed VBP VBP Benchmark Standard N Percent x/n N Percent x/n SCIP-Inf-9 Urinary catheter removed on postoperative day 1 or 2 AMI-7a Fibrinolytic therapy received within mins of arrival AMI-8a PCI received within 90 mins of arrival HF-1 Discharge instructions PN-3b Blood cultures in the ED prior to antibiotic PN-6 Antibiotic selection for CAP in immunocompetent patient SCIP-Inf-1a Antibiotic Received One Hour Prior to Surgical Incision SCIP-Inf-2a Antibiotic Selection for Surgical SCIP-Inf-3a Antibiotics Discontinued Within 24/ Hours After Surgery End SCIP-Inf-4 Cardiac surgery patients with controlled 6 AM postoperative serum glucose SCIP-Card-2 Surgery on Beta Blocker Therapy Prior to Admission Who Received a Beta Blocker During the Perioperative Period SCIP-VTE-2 Surgery Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery Composite Measures N Percent x/n N Percent x/n CMS Appropriate Care Measure /191 2, /188 Accountability Measure 1, /194 5, /191 AMI Composite / /171 HBIPS Composite / / 71 STK Composite / /132 VTE Composite / /176 CAC Composite HF Composite / /181 PN Composite / /178 SCIP Composite / /182 AMI Acute Myocardial Infarction AMI-1 Aspirin at arrival / /173 AMI-2 Aspirin prescribed at discharge / /170 AMI-3 ACEI or ARB for LVSD / /152 AMI-5 Beta blocker prescribed at discharge / / UHC. All rights reserved. 1

2 AMI Acute Myocardial Infarction AMI-7a Fibrinolytic therapy received within 30 mins of arrival AMI-8a PCI received within 90 mins of arrival / /133 AMI-10 Statin Prescribed at Discharge / /171 HF Heart Failure HF-1 Discharge instructions / /181 HF-2 Evaluation of LVS function / /181 HF-3 ACEI or ARB for LVSD / /180 PN Pneumonia PN-3a Blood culture within 24 hrs of arrival for / /171 patients transferred/admitted to ICU PN-3b Blood cultures in the ED prior to antibiotic / /178 PN-6 Antibiotic selection for CAP in / /177 immunocompetent patient PN-6a Antibiotic selection for CAP in / /143 immunocompetent ICU patient PN-6b Antibiotic selection for CAP in / /177 immunocompetent non-icu patient PC Perinatal Care Conditions PC-01 Elective Delivery / / 58 PC-02 Cesarean Section PC-05 Exclusive Breast Milk Feeding PC-05a Exclusive Breast Milk Feeding Considering Mothers Choice SCIP-Card-2 Surgery on Beta Blocker Therapy Prior to Admission Who Received a Beta Blocker During the Perioperative Period SCIP-Card-2 Surgery on Beta Blocker Therapy Prior to Admission Who Received a Beta Blocker During the Perioperative Period / /179 SCIP-Inf-1 Antibiotic Received One Hour Prior to Surgical Incision SCIP-Inf-1a Overall / /181 SCIP-Inf-1b CABG / /114 SCIP-Inf-1c Other cardiac surgery / /113 SCIP-Inf-1d Hip arthroplasty / /175 SCIP-Inf-1e Knee arthroplasty / /170 SCIP-Inf-1f Colon surgery / /176 SCIP-Inf-1g Hysterectomy / /165 SCIP-Inf-1h Vascular surgery /141 SCIP-Inf-2 Antibiotic Selection for Surgical SCIP-Inf-2a Overall / /181 SCIP-Inf-2b CABG / /114 SCIP-Inf-2c Other cardiac surgery / /112 SCIP-Inf-2d Hip arthroplasty / /175 SCIP-Inf-2e Knee arthroplasty / / UHC. All rights reserved. 2

3 SCIP-Inf-2 Antibiotic Selection for Surgical SCIP-Inf-2f Colon surgery / /175 SCIP-Inf-2g Hysterectomy / /165 SCIP-Inf-2h Vascular surgery /140 SCIP-Inf-3 Antibiotics Discontinued Within 24/48 Hours After Surgery End SCIP-Inf-3a Overall / /181 SCIP-Inf-3b CABG / /114 SCIP-Inf-3c Other cardiac surgery / /111 SCIP-Inf-3d Hip arthroplasty / /175 SCIP-Inf-3e Knee arthroplasty / /169 SCIP-Inf-3f Colon surgery / /175 SCIP-Inf-3g Hysterectomy / /165 SCIP-Inf-3h Vascular surgery /140 SCIP-Inf-4 Cardiac Surgery with Controlled 6 AM Postoperative Serum Glucose SCIP-Inf-4 Cardiac surgery patients with controlled 6 AM postoperative serum glucose SCIP-Inf-6 Surgery with Appropriate Hair Removal / /115 SCIP-Inf-6 Surgery patients with appropriate hair removal / /183 SCIP-Inf-9 Urinary catheter removed on postoperative day 1 or 2 SCIP-Inf-9 Urinary catheter removed on postoperative day 1 or / /181 SCIP-Inf-10 Surgery patients with perioperative temperature management SCIP-Inf-10 Surgery patients with perioperative temperature management / /182 SCIP-VTE-2 Surgery Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery SCIP-VTE-2 Surgery Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery CAC-1 Relievers for Inpatient Asthma CAC-1a Relievers for Inpatient Asthma (age 2 years through 17 years) - Overall Rate CAC-1b Relievers for Inpatient Asthma (age 2 years through 4 years) CAC-1c Relievers for Inpatient Asthma (age 5 years through 12 years) CAC-1d Relievers for Inpatient Asthma (age 13 years through 17 years) / / UHC. All rights reserved. 3

4 CAC-2 Systemic Corticosteroids for Inpatient Asthma CAC-2a Systemic Corticosteroids for Inpatient Asthma (age 2 years through 17 years) - Overall Rate CAC-2b Systemic Corticosteroids for Inpatient Asthma (age 2 years through 4 years) CAC-2c Systemic Corticosteroids for Inpatient Asthma (age 5 years through 12 years) CAC-2d Systemic Corticosteroids for Inpatient Asthma (age 13 years through 17 years) CAC-3 Home Management Plan of Care (HMPC) Document Given topatient/caregiver CAC-3 Home Management Plan of Care (HMPC) Document Given topatient/caregiver IMM Immunization IMM-1a Pneumococcal Immunization - Overall Rate / /180 IMM-1b Pneumococcal Immunization - Age 65 and / /180 Older IMM-1c Pneumococcal Immunization - High Risk / /180 Populations (Age 6 through 64 years) IMM-2 Influenza Immunization / /195 STK Stroke STK-1 Venous Thromboembolism (VTE) Prophylaxis / /131 STK-2 Discharged on Antithrombotic Therapy / /131 STK-3 Anticoagulation Therapy for Atrial / /121 Fibrillation/Flutter STK-4 Thrombolytic Therapy / / 90 STK-5 Antithrombotic Therapy By End of Hospital / /131 Day 2 STK-6 Discharged on Statin Medication / /130 STK-8 Stroke Education / /130 STK-10 Assessed for Rehabilitation / /131 VTE Venous Thromboembolism Prophylaxis VTE-1 Venous Thromboembolism Prophylaxis / /175 VTE-2 Intensive Care Unit Venous Thromboembolism / /170 Prophylaxis VTE-3 Venous Thromboembolism with / /172 Anticoagulation Overlap Therapy VTE-4 Venous Thromboembolism Receiving / /165 Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol VTE-5 Venous Thromboembolism Discharge / /172 Instructions VTE-6 Incidence of Potentially-Preventable Venous Thromboembolism / / UHC. All rights reserved. 4

5 HBIPS-1 Assessment of violence risk, substance use disorder, trauma and patient strengths completed HBIPS-1a Admission Screening- Overall Rate / / 46 HBIPS-1d Admission Screening- Adult (18 through / / years) HBIPS-1e Admission Screening- Older Adult (>65 years) / / 39 HBIPS-4 discharged on multiple antipsychotic medications HBIPS-4a Multiple Antipsychotic Medications at / / 67 Discharge- Overall Rate HBIPS-4d Multiple Antipsychotic Medications at / / 65 Discharge- Adult (18 through 64 years) HBIPS-4e Multiple Antipsychotic Medications at Discharge- Older Adult (>65 years) / / 54 HBIPS-5 Multiple antipsychotic medications at discharge with appropriate justification HBIPS-5a Multiple Antipsychotic Medications at Discharge with Appropriate Justification- Overall Rate HBIPS-5d Multiple Antipsychotic Medications at Discharge with Appropriate Justification- Adult (18 through 64 years) HBIPS-6 Post Discharge Continuing Care Plan HBIPS-6a Post Discharge Continuing Care Plan- Overall Rate HBIPS-6d Post Discharge Continuing Care Plan- Adult (18 through 64 years) HBIPS-6e Post Discharge Continuing Care Plan- Older Adult (>65 years) HBIPS-7 Post Discharge Continuing Care Plan Transmitted HBIPS-7a Post Discharge Continuing Care Plan Transmitted- Overall Rate HBIPS-7d Post Discharge Continuing Care Plan Transmitted - Adult (18 through 64 years) HBIPS-7e Post Discharge Continuing Care Plan Transmitted - Older Adult (>65 years) AMI - Hospital Outpatient Department Quality Measures / / / / / / / / / / / / / / 59 AMI-OP-2 Fibrinolytic Therapy Received Within Minutes AMI-OP-4 Aspirin at Arrival CP - Hospital Outpatient Department Quality Measures CP-OP-4 Aspirin at Arrival CP-OP-16 Troponin Results Received Within 60 Minutes SCIP - Hospital Outpatient Department Quality Measures SCIP-OP-6 Antibiotic Timing / /156 SCIP-OP-7 Antibiotic Selection / / UHC. All rights reserved. 5

6 STK - Hospital Outpatient Department Quality Measures STK-OP-23 Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke who Received Head CT or MRI Scan Interpretation Within 45 minutes of ED Arrival ED - Emergency Department (Inpatient) ED-1a Median Time from ED Arrival to ED Departure for Admitted ED Overall Rate ED-1b Median Time from ED Arrival to ED Departure for Admitted ED Reporting Measure ED-1c Median Time from ED Arrival to ED Departure for Admitted ED Observation ED-1d Median Time from ED Arrival to ED Departure for Admitted ED Psychiatric/Mental Health ED-2a Admit Decision Time to ED Departure Time for Admitted Overall Rate ED-2b Admit Decision Time to ED Departure Time for Admitted Reporting Measure ED-2c Admit Decision Time to ED Departure Time for Admitted Psychiatric/Mental Health AMI - Hospital Outpatient Department Quality Measures / N Minutes x/n N Minutes x/n / / / / / / / / / / AMI-OP-1 Median Time to Fibrinolysis AMI-OP-3 Median Time to Transfer to Another Facility for Acute Coronary Intervention AMI-OP-5 Median Time to ECG CP - Hospital Outpatient Department Quality Measures CP-OP-5 Median Time to ECG ED - Hospital Outpatient Quality Measures ED-OP-18a Median Time from ED Arrival to ED Departure for Discharged ED Overall Rate ED-OP-18b Median Time from ED Arrival to ED Departure for Discharged ED Reporting Measure ED-OP-18c Median Time from ED Arrival to ED Departure for Discharged ED Observation ED-OP-18d Median Time from ED Arrival to ED Departure for Discharged ED Psychiatric/Mental Health ED-OP-18e Median Time from ED Arrival to ED Departure for Discharged ED Transfer ED-OP-20 Door to Diagnostic Evaluation by a Qualified Medical Personnel / / / / / / / / / / UHC. All rights reserved. 6

7 PM - Hospital Outpatient Department Quality Measures PM-OP-21 Median Time to Pain Management for Long Bone Fracture HBIPS-2 Hours of Restraint Use / /158 Hours Event rate/1000 patient hrs x/n Hours Event rate/1000 patient hrs HBIPS-2a Physical Restraint- Overall Rate 45, / , / 44 HBIPS-2d Physical Restraint- Adult (18 through 64 40, / 44 94, / 42 years) HBIPS-2e Physical Restraint- Older Adult (>65 4, / 45 8, / 42 years) HBIPS-3 Hours of Seclusion Use HBIPS-3a Seclusion- Overall Rate 45, / , / 44 HBIPS-3d Seclusion- Adult (18 through 64 years) 40, / 44 94, / 42 HBIPS-3e Seclusion- Older Adult (>65 years) 4, / 45 8, / 42 x/n 2014 UHC. All rights reserved. 7

8 Symbol Legend HQA Hospital Quality Composite Measures HQA Non-Risk-Adjusted Hospital Quality Measures (higher is better) Substantially Worse than Target Range < 75% < lower target limit > upper target limit Worse than Target Range >= 75% and < 90% N/A N/A HQA Non-Risk-Adjusted Hospital Quality Measures (lower is better) Within Target Range >= 90% and < 97% >= lower limit and <= upper limit >= lower limit and <= upper limit Substantially Better than Target Range >= 97% > upper target limit < lower target limit Interpret with Caution Denominator < 30 cases Denominator < 30 cases Denominator < 30 cases

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