JamesLHollyMD.com

	James L. Holly, M.D.

About SETMA Joint Commission Contact Information History Mission Statement Medical Home Scope of Services I-CARE Initiative Infusion Center The SETMA Way - What is it? SETMA's Model of Care Patient-Centered Medical Home The SETMA Approach to Patient Care	In The News Letters Vital Signs - Examiner Publication SETMA's Providers as of January, 2015 SETMA Knows - Abraham Lincoln and Healthcare Analytics SETMA – 1999 – Four Seminal Events PC-PCC Award January, 2015 Vital Signs Spring 2015 Vital Signs Q&A for PC-PCC Award Links to SETMA 2012 eHealth Innovator Award for LESS initiative Handout for Attendees eHealth Conference January 12, 2012 eHealth Initiative 2012 Award Program Application The eHealth Initiative's 2012 Award Letter 2012 National Quality Forum National Healthcare Improvement Award Effective prioritization of performance improvement goals Dashboard to Measure and Manage Whole System Performance Commitment to transparency Date-driven improvement of NQS priorities Demonstration of readiness to assume responsibilities of an ACO Demonstrated results on publicly reported performance measures Public Reporting Quality Metrics for 2009, 2010, 2011 Internally Tracked Reporting Quality Metrics for 2009, 2010, 2011 Complete Application in PDF Format SETMA's Medical Home Pilgrimage 2009 Medical Home Series I 2010 Medical Home Series II 2011 Medical Home Series Two 2009, 2010, 2011 Medical Home Miscellaneous Articles The Dr. and Mrs. James L. Holly Distinguished Professorship Universal American Letter of Transmittal for Support Dr. Holly's Acceptance Address for the 2012 Distinguished Alumnus Award CMS Medical Home Feedback Report Qualify & Cost SETMA questions Influenza Data SETMA I - October 2011 SETMA II - October 2011 Mark A. Wilson Clinic SETMA West - October 2011 SETMA and Fox 4 News - Healthy Living Videos SETMA Advertisements - Display and Video SETMA Announcements Featured Content Archive	Syllabus PC-MH Externship SETMA's MS4 Patient-Center Medical Home Selective Syllabus Introduction to SETMA's Senior Externship and Syllabus An Introduction to the Origins and Beginnings of Southeast Texas Medical Associates, LLP Patient-Centered Communication PC-MH Health Affairs August 15, 2013 Policy Brief -- Health Gap SETMA 8.20.13 Provider Training -- Health Affairs 2.14.13 -- Patient Engagement SETMA Provider Training 8.20.13 during First Senior Medical Student PC-MH Externship Medical Home Coordination Review Tutorial 2011 Medical Home Series Two Teaching Tool for PC-MH Course - Patient Care Activation, Engagement, Shared-Decision Making	Patient Information What Does Patient-Centered Medical Home Mean to You? What Does Patient-Centered Medical Home Mean to You? Health information exchange Patient Rights and Responsibilities Patient Directions Contact SETMA – Secure Texting What is HIPAA? Authorization To Release or Obtain Medical Records Complete Privacy Policy Website Privacy Policy	Presentations Invited Presentations SETMA Provider Training
Governance Board Governance Board Responsibilities Governance Board Leadership Training The SETMA Team and The SETMA Culture SETMA's Mission, Vision and Goals: Patient Safety and Quality Care Harassment, Neglect, Abuse, Exploitation - Role of HCAHPS & CAHPS Healthcare Provider Standards Providers Responsibility Medication Refills, Reconciliation and Maintenance Provider and Leadership Use of Data and Analytics Commitment To All Patients -- Ethnic Disparities Kaizen - Board Creates Culture of Safety and Quality SETMA's Policy and Practice for Advanced Directives SETMA's Policy on Completion of Medical Records Care Guidelines : Improve processes to evaluate and treat Integrated patient safety program (Sentinel Events) Effectively Manages all programs, services or sites Provides Patients with information about Primary-care Medical Home Organization-wide Planning to Maintain Focus on safety and quality Organization-wide Planning to Maintain Focus on safety and quality SETMA's Performance Quality & Safety Judged by CMS SETMA's Performance Quality & Safety Judged by CMS SETMA Awarded by HIMSS for Quality and Safety 2011 John M. Eisenberg Patient Safety and Quality Awards Application Healthcare Quality Award 2012 Principles of Quality and Metrics Principles Contacting SETMA & Secure Texting PC-MH Mission, Vision, Goal, Access, End-of-Life Communications and Public Reporting Change Existing Processes to Improve Performance Team Members Focused on Safety and Quality	Your Life Your Health View Articles by Subject Aging Well Behavioral Health Cardiovascular Disease Risk Care Coordination Care Transitions Children's Health COGNOS Project Diabetes Exercise Healthcare Reform:Public Policy HIPAA & Security Labor Day Less Initiative Medical Home Medical Records Men's Health Mental Health Nutraceuticals Nutrition Smoking Cessation Thanksgiving Weight Management Women's Health All Articles	Public Reporting Public Reports by Year (2009-2017) Public Reports by Type Fall Risk, Pain, Functional, Wellness, Stress Assessment Fall Risk, Pain, Functional, Wellness, Stress Assessment for 2011 AND 2012 Core Measures: SETMA & Baptist Hospital Core Measures for January to December 2011 PQRS Diabetes Measures - Blood Pressure Diabetes Measures - Glyco and LDL Diabetes Measures - Nephropathy Screening, Foot Exam, and Eye Exam Preventive Measures - Screening (BMI, Colorectal Cancer, Mammography, Osteoporosis) Preventive Measures - Influenza, Pneumococcal, Urinary Incontinence Preventive Measures - Tobacco Use NQF Care for Older Adults Comprehensive CHF Care Diabetes Measures Diabetes Measures - Blood Pressure Control Diabetes Measures - Glyco and LDL Diabetes Measures - Smoking Cessation Female Measures General Health Measures Medication Measures Persistent Medications Medication Measures Pediatric Measures HEDIS (NCQA) Effectiveness of Acute Care Effectiveness of Chronic Care - Clinic/Hospital Effectiveness of Chronic Care - Clinic Only Effectiveness of Chronic Care - Diabetes (Smoking Cessation) Effectiveness of Chronic Care - Diabetes (Glyco and LDL) Effectiveness of Chronic Care - Diabetes (Blood Pressure Control) Effectiveness of Preventive Care Effectiveness of Preventive Care - Older Adults Effectiveness of Chronic Care - Diabetes Measures Effectiveness of Chronic Care - Persistent Medications (MPM) NCQA Diabetes Recognition Program Audit LESS Initiative PCPI PCPI Hypertension PCPI Diabetes PCPI Chronic Stable Angina PCPI Care Transitions PCPI CHF PCPI Weight Management PCPI CKD Stages IV V SETMA Lipid Audit Lipids Treatment Audit Tutorial Lipids Tutorial AQA COGNOS Project SETMA Audit for CKD Stages I III Patient Satisfaction Survey	Accreditations/Awards Achievements which have Advanced SETMA: The Time-line, Philosophy and Principles which Underlie that Advancement Awards	Diabetes Center of Excellence Education Diabetes Order Referral Form Seven Stations 2011 Advances in Diabetes Diabetes Tutorial Diabetes Prevention
EPM Tools Association of Medication and Diagnosis Automated Team Function Behavioral Health Adult Weight Management Tutorial Annual Questionnaires: Fall, Functional, Pain, Stress, Wellness Behavioral Health in SETMA's Patient-Centered Medical Home Model of Care Depression Tutorial Fall Risk Tutorial Health Insurance Portability and Accountability Act (HIPAA) Privacy Tutorial Intensive Behavioral Therapy (IBT) Obesity and Cardiovascular Disease Medicare Preventive LESS Initiative Tutorial Medical Home Transtheoretical Model Assessment Stages of Change Tutorial Pain Management Tutorial Reduction of Antipsychotic Medications Toolkit Smoking Cessation Tutorial Stratifying End-of-Life Risk for Hospice Services Tutorial Chronic Conditions Tutorial Chronic Renal Disease Management Tool Tutorial Calculating the Stages of Renal Disease Proteinuria Disease Management Tools Acute Coronary Syndrome Tutorial Adult Weight Management Tutorial Angina Tutorial Cardiometabolic Risk Syndrome Tutorial Chronic Renal Disease Tutorial Congestive Heart Failure Tutorial Diabetes Tutorial Hypertension Tutorial Lipids Tutorial Lipid Quality Audit Tutorial Primary Pulmonary Hypertension Tutorial Framingham Cardiovascular Risk Cardiometabolic Risk Assessment Framingham Heart Study Risk Calculators Tutorial Frederickson Classification of Dyslipidemia LDL Level Lipid Disease Management Risk Assessment General principles about ICD-9 Codes and HCC/RxHCC Codes Charge Posting Tutorial Coding to Ensure Accurate Health Risk Scoring E & M Codes Tutorial HCC & RxHCC Risk HCC/RxHCC Risk Tutorial ICD-9 Code Training Manual Hepatitis Screening Hospital Based Tools Hospital Care Summary and Post Hospital Plan of Care and Treatment Plan Tutorial Admission Orders Tutorial Daily Progress Notes Tutorial Care Transition Data Set from PCPI Tutorial Using The Clinic and Hospital Follow-up Call Templates Respiratory Failure Tutorial Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS): Tutorial for SETMA's Internal HCAHPS Survey Master GP Suite of Templates Master GP Suite of Templates Tutorial Medical Home Support Materials Department of Care Coordination, Director of Care Coordination and Care Coordination Referral Template Electronic Tickler File Electronic Tickler File Tutorial Follow-up Calls Intensive Behavioral Therapy (IBT) Obesity and Cardiovascular Disease Medicare Preventive Services Medical Home Coordination Review Tutorial Medical Home Plan of Care and Treatment Plan Medical Home Transtheoretical Model Assessment Stages of Change Tutorial Patient-Centered Medical Home Annual Questionnaires Patient-Centered Medical Home: SETMA's Medical Home Coordination Review (MHCR) Tutorial Patient Document for Coordination of Care Transitions of Care Management Coding (TCM Code) Tutorial Merit-Based Incentive Payment System (MIPS) Quality Metric Tool Tutorial Nursing Home Depression Tutorial Fall Risk Tutorial Hydration Assessment Tutorial Nursing Home Guidelines for Care Tutorial Nursing Home Principal Suite of Templates Nutrition Assessment Tutorial Reduction of Antipsychotic Medications Toolkit Skin Care Tutorial Outpatient Infusion Center for Intravenous Antibiotic Therapy and Other Meds Preventive Health Tools Adult Weight Management Tutorial CHF Exercise Tutorial Diabetic Exercise Tutorial Diabetes Prevention Tutorial Exercise Prescription Tutorial Hypertension Prevention Tutorial Intensive Behavioral Therapy (IBT) Obesity and Cardiovascular Disease Medicare Preventive Initial Preventive Physical Exam & Annual Wellness Visit Tutorial LESS Initiative Tutorial Progression to Type 2 Diabetes Smoking Cessation Tutorial Progression to Type 2 Diabetes Quality Metrics ACO and Medicare Advantage Stars HEDIS: NCQA, History, Quality, Safety, STARS, ACO ACO Quality Measures Performance Tool ACO Quality Measures Performance Tool Tutorial STARs - A Tutorial for Utilizing SETMA's Deployment of the STARS MA Program Specialized Tools Annual Questionnaires: Fall, Functional, Pain, Stress, Wellness Association of Medication & Diagnosis Chronic Conditions Tutorial Chronic Care Management Code (CCM) Tutorial Depression Tutorial Drug Interactions Tutorial Electronic Tickler File Tutorial Evaluation Lower Urinary Tract Symptoms in the Male Fall Risk Tutorial Future Labs Tutorial Hydration Assessment Tutorial HCC Risk Training Tool Hypertension: Fulfilling Quality Metrics for the PCPI Program Laboratory Results - Signing Off: Why and How Medication Module Tutorial Medication Reconciliation Tutorial Nutrition Tutorial Pain Management Tutorial Problem List Reconciliation Tutorial Progression to Type 2 Diabetes Referral Skin Care Tutorial SOAAP Opioid Risk Assessment Stratifying End-of-Life Risk for Hospice Services Tutorial Texas State Reportable Infectious Diseases Tutorial Transitions of Care Management Coding (TCM Code) Tutorial	Transforming Your Practice Library Introduction to SETMA's TCPI Library Transforming Your Practice (TCPI) Summary Document of TCPI CMS Quality 12.2015 TCPI Leadership and Governance Care Coordination HIPPA and Security Data Analytics Care Transitions LESS Initiative Medical Records Clinical Decision Support Hospital Care Tools Disease Management Tools Preventive Health Tools Behavioral Health Transformation Tools New Transformation Tools Patient-Centric Care Nursing Home Medical Home Display and Explanation of SETMA's Patient-Centered Medical Home Tools	Medical Home The Story and the Ideals Introduction to Preventive Health Tools PC-MH Patient Engagement & Alternative Payment Models Preventive Care: The Best Way to Treat Illness is Don’t Get it Coordination of Care Patient-Centric Care Population Health Transition of Care - One form of Care Coordination HCAHPS - Hospital Consumer Assessment Of Healthcare Providers and Systems CAHPS - Consumer Assessment of Health Care Provider and Systems Teaching Tool for PC-MH Course – Patient Care Activation, Engagement, Shared-Decision Making Display & Explanation of PC-MH Tools SETMA's Medical Home Pilgrimage Concierge Medicine not Medical Home Medical Neighborhood Security & HIPPA Referrals Patient Web Portal Health Information Exchange Medication Reconciliation The Automated Team Coordination of Care Medical Home Description & Standards AAAHC Joint Commission NCQA Planetree URAC NCQA Interview February 14, 2014	Facebook	Letters

Public Reporting - Core Measures

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	Explanation
Inpatient
AMI measures speak to actions taken in the care of patients presenting with Acute Myocardial Infarction (AMI - commonly called “heart attack”)
AMI 1	ASA on Arrival	ASA = Aspirin.
AMI 2	ASA on Discharge	ASA = Aspirin. Patient is instructed to take aspirin daily at home following discharge.
AMI 3	ACE/ARB for LVSD	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).
AMI 5	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.
PC AMI	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	ACE/ARB for LVSD	See AMI 3 above.
PC HF	Perfect Care for Patients with Heart Failure	HF Patients received all applicable process measures.

IM=Immunizations
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.
IMM 2	Influenza Immunization	All patients who meet criteria are provided an opportunity to receive an Influenza Vaccine prior to discharge.
PC IMM	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.
PC OP CP	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.
PC OP ED	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.
PC PN	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.
SCIP Card	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.
SCIP VTE 1	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.
SCIP VTE 2	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.
PC SCIP	Perfect Care for the Surgical Patient	Surgical patients received all applicable process measures.

Stroke
STK 1	VTE Prophylaxis	Patient receives appropriate chemical or mechanical measures to prevent clots or patient is up and walking without assistance by the second day.
STK 2	Discharged on Antithrombotic Therapy	Discharged on recommended Antithrombotic medications.
STK 5	Antithrombotic Therapy by end of Hospital Day 2	Antithrombotic medications are started in the hospital as recommended.
STK 6	Discharged on Statin	Stroke patients are discharged on Statin medication as recommended.
STK 8	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.
PC STK	Stroke Perfect Care	Stroke patients received all applicable process measures.

2011 Reports

	SETMA - Core Measures for January 2011 - December 2011

About SETMA	In The News	Syllabus PC-MH Externship	Patient Information	Presentations
Governance Board	Your Life Your Health	Public Reporting	Accreditations/Awards	Diabetes Center of Excellence
EPM Tools	Transforming Your Practice Library	Medical Home	I-CARE Initiative	NextMD