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Home > Mercy Quality > Service Quality 

National Voluntary Measures

 

Mercy hospitals are among more than 3,800 acute care hospitals across the United States that have pledged to participate in “The Quality Initiative: A Public Resource on Hospital Performance.” This voluntary
initiative is an effort to advance quality of care and improve patient safety by collecting and sharing standardized hospital measures with the public. Participating hospitals voluntarily report on a starter set of 10 hospital quality measures.


Initially, the data includes various aspects of treatment of heart failure, heart attack and pneumonia. The Web site of the Centers for Medicare and Medicaid Services (CMS) provides more information on this initiative and the results by all participating hospitals.

Information on Mercy's performance related to the measures is provided below.

10 Measures for Hospital Quality
The starter set of 10 quality measures has been tested for validity and reliability by the Centers for Medicare and Medicaid Services (CMS) and its Quality Improvement Organizations, the Joint Commission on Accreditation of Healthcare Organizations and independent researchers. The hospital quality measures also are endorsed by the National Quality Forum, a national standards setting organization. The measures include:

Heart Attack
Acute myocardial infarction (AMI) is a priority focus area for quality measurement due to disease prevalence. Cardiovascular disease is the leading cause of death in the United States and is the primary disease category for patient discharges. Annually, 900,000 people are diagnosed with AMI and approximately 225,000 cases result in death.

There are specific measures that reduce the probability of further heart complications or death for heart attack patients. For example, early treatment with aspirin and beta blocker medications upon patient arrival at the hospital has been proven to prevent clotting, restore blood flow to the heart, and prevent additional damage to the heart muscle. Beta blocker medication can also reduce high blood pressure and should be considered for all eligible heart patients when they leave the hospital.

Initially, the data includes various aspects of treatment of heart failure, heart attack and pneumonia. The Web site of the Centers for Medicare and Medicaid Services (CMS) provides more information on this initiative and the results by all participating hospitals.

Information on Mercy's performance related to the measures is provided below.

10 Measures for Hospital Quality
The starter set of 10 quality measures has been tested for validity and reliability by the Centers for Medicare and Medicaid Services (CMS) and its Quality Improvement Organizations, the Joint Commission on Accreditation of Healthcare Organizations and independent researchers. The hospital quality measures also are endorsed by the National Quality Forum, a national standards setting organization. The measures include:

Heart Attack
Acute myocardial infarction (AMI) is a priority focus area for quality measurement due to disease prevalence. Cardiovascular disease is the leading cause of death in the United States and is the primary disease category for patient discharges. Annually, 900,000 people are diagnosed with AMI and approximately 225,000 cases result in death.

There are specific measures that reduce the probability of further heart complications or death for heart attack patients. For example, early treatment with aspirin and beta blocker medications upon patient arrival at the hospital has been proven to prevent clotting, restore blood flow to the heart, and prevent additional damage to the heart muscle. Beta blocker medication can also reduce high blood pressure and should be considered for all eligible heart patients when they leave the hospital.

 

1. Aspirin was administered on arrival to the hospital
Rationale: The use of aspirin for treatment of a heart attack within 24 hours of hospital arrival is associated with better outcomes, markedly reducing mortality from acute myocardial infarction (AMI).
2. Aspirin was prescribed at hospital discharge
Rationale: Heart patients prescribed aspirin at discharge experience better outcomes, markedly reducing the probability of experiencing another heart attack.
3. ACE inhibitor for left ventricular systolic dysfunction (LVSD)
Rationale: Prescribing ACE inhibitor medication to eligible patients upon their hospital discharge has proven to reduce the likelihood of additional heart problems.
4. Beta blocker was administered when patient was admitted to the hospital
Rationale: Giving beta blockers to AMI patients (patients without contraindications to the medicine) during the initial hours of presentation reduces the risk of death.
5. Beta blocker was prescribed at hospital discharge
Rationale: Prescribing beta blocker medication to eligible heart attack patients upon their hospital discharge reduces their risk of experiencing future heart attacks.
6. Inpatient Mortality (AMI)
Rationale: While mortality is inherent in heart disease, our efforts are focused in reducing inpatient mortality. (back to top)
 

Congestive Heart Failure
Nearly five million Americans have congestive heart failure. Every year, approximately 500,000 to 900,000 new cases are diagnosed. More Medicare dollars are devoted to the diagnosis and treatment of CHF than for any other diagnosis.

Research reveals that there are several key measures health care professionals can implement that will improve the quality of CHF patient outcomes. Specifically, individuals with CHF require assessments of their left ventricular function to determine the progression or severity of their disease. ACE inhibitors should be prescribed to eligible patients upon their hospital dismissal.

Smoking is a known contributing factor to causation of cardiovascular disease and it is vital that those CHF patients with a history of smoking receive smoking cessation advice or counseling during their hospital stay.

 
1. Assessment of left-ventricular function was completed
Rationale: A left ventricular function (LVF) test guides the physician in treatment options and discussion of potential outcomes of a patient’s condition.
2. ACE inhibitor was prescribed at hospital discharge
Rationale: Angiotension converting enzyme (ACE) inhibitor medications have been proven to help reduce problems associated with congestive heart failure and should be prescribed to eligible patients upon their hospital dismissal. (back to top)
 

Pneumonia
Community-acquired pneumonia is America’s sixth most common cause of death. From 1970-1994, the overall death rates due to pneumonia and influenza increased by 59%. Annually, 2-3 million cases of CAP result in 100,000 physician visits, 500,000 hospitalizations and 45,000 deaths.

Specific measures to combat the complication and morbidity rates associated with CAP include oxygenation assessment measures that allow a patient’s treatment to be altered to maximize their recovery. Individuals hospitalized with pneumonia frequently have complicating diseases. These individuals are at risk of develop future pneumoncoccal infections. A vaccine exists which effectively reduces the risk of developing future pneumonia. Individuals diagnosed with pneumonia need to receive antibiotics as soon as possible. Efforts are focused on minimizing the time to both diagnose the condition and receive the appropriate antibiotic.

Smoking accounts for one out of every five deaths in the United States. Hospitalization is an ideal opportunity for a patient to receive tobacco cessation counseling. Studies show that patients who receive even brief smoking-cessation advice are more likely to quit smoking.

 
1. Oxygenation assessment was completed on admission
Rationale: This measure tracks the percentage of patients who received oxygenation assessment with arterial blood gas or pulse oximetry within 24 hours of hospital arrival.
2. Pneumococcal vaccination was administered if appropriate
Rationale: This measure represents the percentage of eligible pneumonia inpatients (age 65+ that did not refuse or have contraindications) that were screened for vaccine status and received it prior to discharge.
3. Antibiotic was administered at least four hours after admission
Rationale: This measure represents the time, in minutes, from hospital arrival to administration of first antibiotic for inpatients with pneumonia. (back to top)