Southeast Texas Medical Associates, LLP James L. Holly, M.D. Southeast Texas Medical Associates, LLP

Public Reporting - Core Measures
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Core Measures -Baptist Hospital of Southeast Texas
Results for Southeast Texas Medical Associates, LLP (SETMA)

What are Core Measures?

Hospitals across the country adhere to a set of care processes called Core Measures, which were developed by The Joint Commission, the nation's predominant standards-setting and accrediting body in health care, to improve the quality of health care by implementing a national, standardized performance measurement system. The Core Measures were derived largely from a set of quality indicators defined by the Centers for Medicare and Medicaid Services (CMS). They have been shown to reduce the risk of complications, prevent recurrences and otherwise treat the majority of patients who come to a hospital for treatment of a condition or illness. Core Measures help hospitals improve the quality of patient care by focusing on the actual results of care.

Comparing Performance

Hospitals across the country are measured and compared by The Joint Commission against all other accredited institutions on their performance in these Core Measures. You will note there is a time lag of several months between when data is reported from hospitals and when it is posted for the public to review. Hospitals have to wait for state and national statistics to be compiled before it can post its quality data for a given period. Hospitals report their results internally and more and more hospitals are beginning to share this data with the public.

What does each of the Core Measures stand for?

There are 33 Core Measures altogether, in 4 categories (acute myocardial infarction, community-acquired pneumonia, congestive heart failure, and surgical care improvement project). Under each category, key actions are listed that represent the most widely accepted, research-based care process for appropriate care in that category.

It is important to note that these care recommendations are subject to the professional medical advice of each patient's physician and the particular health conditions of each patient. If a physician determines that a patient is not an appropriate candidate for a particular care process, the patient will not be included in the data. A good example is aspirin. Some patients are allergic to aspirin; for others, taking aspirin will make another medical problem worse. In these cases, the patient's physician may determine that aspirin should not be administered or prescribed for the patient. Therefore, the patients will not be included in the data.

The following are technical descriptions of all of the core measures.

Core Measures (Process of Care Measures) Accurate as of March 1, 2012

Measure Designation

Measure Abbreviation



AMI measures speak to actions taken in the care of patients presenting with Acute Myocardial Infarction (AMI - commonly called “heart attack”)


ASA on Arrival

ASA = Aspirin.


ASA on Discharge

ASA = Aspirin. Patient is instructed to take aspirin daily at home following discharge.



Patients who are diagnosed with left ventricular systolic dysfunction (LVSD - the heart, a pump, is not effectively pumping blood) are provided medications that improve the pump effectiveness. (These drugs are either classified as ACE inhibitors or an ARB).


BB at discharge

A beta-blocker (BB) is prescribed for the patient to take following discharge. Beta-blockers provide protection to the heart following an AMI.

AMI 8a

PCI w/in 90 minutes.

Percutaneous Coronary Intervention (PCI) should be implemented (if the patient is a candidate) in less than 90 minutes. This involves the patient being taken to the cath lab for procedure. The PCI time is calculated from the time the patient enters the facility until the time when “the lesion is crossed” and blood flow is restored.

AMI 10

Statin prescribed at discharge

If the patient is on a Statin at home, the Statin must be prescribed at discharge unless there is a medical reason for the patient to not continue on the medication.


Perfect Care AMI

AMI Patients received all applicable process measures.


HF=Heart Failure Sometimes referred to as “CHF” or Chronic Heart Failure

HF 1

Discharge Instructions

The patient receives specific instruction regarding five important elements of care that must be addressed following discharge.

HF 2

LVF Assessment

LVF = Left Ventricular Failure. There are a variety of ways for a physician to measure the function of the left ventricle. Assessment must be performed during the hospitalization, or test results performed prior to admission may be used as part of the evaluation. (Results must be present in the patient record during the patient stay.)

HF 3


See AMI 3 above.


Perfect Care for Patients with Heart Failure

HF Patients received all applicable process measures.



IMM 1a

Pneumococcal Immunization (overall)

All patients who meet criteria are provided an opportunity to receive a Pneumococcal Vaccine prior to discharge.

IMM 1b


Pneumococcal Immunization
(Age 65 and older)

All patients who meet criteria (Age 65 or older) are provided an opportunity to receive a Pneumococcal Vaccine prior to discharge.

IMM 1c

Pneumococcal Immunization, High Risk Population
(Age 6-64)

All patients who meet criteria (Age 6-64 and determined to be high risk) are provided an opportunity to receive a Pneumococcal Vaccine prior to discharge.


Influenza Immunization

All patients who meet criteria are provided an opportunity to receive an Influenza Vaccine prior to discharge.


Perfect Care r/t Immunization Recommendations

All Patients who required immunizations received all applicable immunizations.


Outpatient Treatment

OP 4

Aspirin at Arrival - OP AMI

All patients who meet the diagnosis of AMI receive Aspirin prior to transfer to a higher level of care.

OP 4c

Aspirin at Arrival - Chest Pain

Outpatients with Chest Pain receive Aspirin on arrival to the ED prior to transfer to a higher level of care.


Perfect Care for Outpatients with Chest Pain

All patients with a diagnosis of CP received all applicable process measures.

OP 6

Timing of Antibiotic Prophylaxis

Outpatient surgical patients who require prophylactic antibiotics, were provided an antibiotic within one hour of the surgical incision.

OP 7

Prophylactic Antibiotic Selection for Surgical Patients

Outpatient surgical patients received the appropriate antibiotic to prevent infection.

PC OP Surgical

Perfect Care for Surgical Outpatients

All surgical outpatients received all applicable process measures.

OP 16

Troponin Results for ED AMI or ED CP

Troponin results were available for patients presenting with AMI or CP in time to insure appropriate treatment.

OP 19

Transition Record with Specified Elements Received by Discharged Patients

Specific outpatients seen in the Ed received appropriate discharge instructions.


Perfect Care for the ED Outpatient

Patient in the emergency department received all applicable process measures.


PN measures are provided to patients with a diagnosis of pneumonia.

PN 3a

Blood Culture within 24 hours of arrival for patients admitted to ICU

If a patient is admitted to ICU with a diagnosis of Pneumonia, blood cultures are performed within 24 hours of admission to the ICU.

PN 3b

Blood Culture in ER before first antibiotic

A blood culture (BC) should be drawn while the patient is in the emergency room (ER) before any antibiotics (Abx) are provided to the patient

PN 6

Appropriate ABX

Antibiotic (Abx) selection should follow evidence based guidelines.

PN 6a

Appropriate ABX ICU Pneumonia patient

Antibiotic (Abx) selection should follow evidence based guidelines.

PN 6b

Appropriate ABX Non-ICU Pneumonia patient

Antibiotic (Abx) selection should follow evidence based guidelines.


Perfect Care of the Pneumonia Patient

Pneumonia patients received all applicable process measures.


SCIP = Surgical Care Improvement Project. The National Surgical Care Improvement committee has developed, in conjunction with the surgical and cardiac professional societies, best practice recommendations for the prevention of infection following a surgical procedure.

SCIP Inf 1

Abx w/in 1 hour of surgery

Prophylactic antibiotic (Abx) should be administered no more than one hour prior to the start of the surgery (defined as the ‘cut time’).

SCIP Inf 2

Abx Selection

An appropriate antibiotic to prevent infection was administered.

SCIP Inf 3

Abx d/c’d w/in 24 hours of surgery

Antibiotic was stopped within 24 hours of the surgical procedure. Continuing antibiotics has not been proven to be effective in preventing infection; however, overuse of antibiotics can lead to antibiotic resistance. Antibiotics may be continued up to 48 hours following certain cardiac procedures.

SCIP Inf 4

BS control am day 1 & 2 cardiac

Blood Sugar (BS) should be controlled following surgery as an elevated blood sugar may increase the risk for infection. Blood sugar is measured in the early morning the first and second day following cardiac surgeries to insure that it is in the appropriate range.

SCIP Inf 6

Appropriate hair removal

Surgical site should not be shaved as shaving can leave microscopic cuts that increase the risk for infection. If hair needs to be removed, it should be clipped, not shaved.

SCIP Inf 9

Removal of Urinary Catheter before 2nd Post-op Day

Urinary Catheter is removed by the end of the second day following surgery.

SCIP Inf 10

Perioperative Temperature Management

Patients maintain the proper temperature in the operating room as recommended to prevent infection.


BB periop when on BB at home

If the patient is taking a beta-blocker medication at home, it is important that it not be stopped prior to surgery. The medication can be given with a ‘sip of water’ prior to the scheduled procedure.


Appropriate VTE ordered

VTE = Venous Thrombo Embolism (commonly called ‘blood clot.’) Chemical and mechanical measures have been defined that can prevent the formation of blood clots following surgery. This measure reflects that the physician has ordered treatment.


VTE 24 hours before/24 hours after

To be effective, activities to prevent clots should be started within 24 hours of the surgical procedure. Most often, the measures are put into place prior to the operation, but some medications are not started until after surgery. If prophylaxis is not ordered (SCIP VTE 1) then the measures can not be implemented.


Perfect Care for the Surgical Patient

Surgical patients received all applicable process measures.




VTE Prophylaxis

Patient receives appropriate chemical or mechanical measures to prevent clots or patient is up and walking without assistance by the second day.


Discharged on Antithrombotic Therapy

Discharged on recommended Antithrombotic medications.


Antithrombotic Therapy by end of Hospital Day 2

Antithrombotic medications are started in the hospital as recommended.


Discharged on Statin

Stroke patients are discharged on Statin medication as recommended.


Stroke Education

Education is provided to the Stroke patient that is appropriate to the diagnosis

STK 10

Assessed for Rehab

Stroke patients receive all necessary assessments to determine appropriate rehab treatment.


Stroke Perfect Care

Stroke patients received all applicable process measures.

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