Genesis Health System Quality Reports
Glossary of Definitions for Core Measures/Inpatient Satisfaction
All definitions are supplied by The Center for Medicare and Medicaid Services (CMS)
Acute Myocardial infarction Indicator (AMI) Core Measures
ACE Inhibitor or ARB for LVSD - Heart attack patients who receive either a prescription for a medicine called an “ACE inhibitor” or a medicine called an angiotensin receptor blocker (ARB) when they are discharged from the hospital. Most patients who have heart failure and who take ACE inhibitor medicine have fewer symptoms, are physically better, and reduce their risk of returning to the hospital. The number of patients prescribed this drug is measured.
Adult Smoking cessation advice/counseling - Heart attack patients who are given advice about stopping smoking while they are in the hospital. This measure reports what percent of adult heart attack patients are provided advice and/or counseling to quit smoking. Smoking harms the heart, lungs and blood vessels and makes existing heart disease worse.
Aspirin at arrival - Heart attack patients receiving aspirin when arriving at the hospital. This measure reports what percent of heart attack patients receive aspirin within 24 hours before or after they arrive at the hospital. Aspirin is beneficial because it reduces the tendency of blood to clot in blood vessels of the heart and improves survival rates.
Aspirin prescribed at discharge - Heart attack patients who receive a prescription for aspirin when being discharged from the hospital. This measure reports how often aspirin was prescribed to heart attack patients when they are leaving a hospital. Aspirin is beneficial because it reduces the tendency of blood to clot in blood vessels of the heart and improves survival rates.
Beta blocker at arrival - Heart attack patients who receive a medicine called a “beta blocker” when they arrive at the hospital. This measure reports what percent of heart attack patients – within 24 hours after arrival were prescribed special type of medicine that reduces heart damage.
Beta blocker prescribed at discharge - heart attack patients who have a medicine called a “beta blocker” prescribed when they are discharged from the hospital. This measure reports what percent of heart attack patients were prescribed a special type of medicine when leaving the hospital that has been shown to reduce further heart damage.
Inpatient mortality - Death of a patient with a heart attack during a hospital stay. This measure reports heart attack patients who die during their hospital stay. This measure accounts for the fact that some patients are sicker or have other preexisting conditions that make death more likely. This is called “risk adjustment."
Primary PCI received within 90 minutes of hospital arrival - Heart attack patient with a clogged artery in the heart that is opened with a balloon therapy called PCI within 90 minutes of hospital arrival. This measure reports how quickly heart attack patients had a clogged artery in the heart opened with a balloon therapy called PCI to increase blood flow to the heart and reduce heart damage. Lack of blood supply to heart muscle can cause lasting heart damage. In certain types of heart attacks, a small balloon is threaded into a blood vessel in the heart to open up a clogged artery that keeps the blood from flowing to the heart muscle. It is important that this therapy be given quickly after a heart attack is diagnosed.
Heart Failure (HF) Core Measures
ACE inhibitor or ARB for LVSD - Heart failure patients who receive a prescription for a medicine called an “ACE inhibitor” or a medicine called an angiotensin receptor blocker (ARB) when they are discharged from the hospital. Most patients who have heart failure and who take ACE inhibitor medicine have fewer symptoms, are physically better, and reduce their risk of returning to the hospital. The number of patients prescribed this drug is measured.
Adult smoking cessation advice/counseling - Heart failure patients who are given advice about stopping smoking while they are in the hospital. This measure reports what percent of adult heart failure patients are provided advice and/or counseling to quit smoking. Smoking harms the heart, lungs and blood vessels and makes existing heart disease worse.
Discharge Instructions - Heart failure patients who receive all specific discharge instructions about their condition. This measure reports what percent of patients with heart failure are given all information about their condition and care when they leave the hospital. Patient education about medicines, diet, activities, and signs to watch for is important in order to prevent further hospitalization.
LVF assessment - Heart failure patients who have had the function of the main pumping chamber of the heart (i.e. ventricle) checked during their hospitalization. This measure reports what percent of patients with heart failure receive an in-depth evaluation of heart muscle function in order to receive the right treatments for their heart failure.
Community Acquired Pneumonia (CAP) Core Measures
Adult smoking cessation advice/counseling - Pneumonia patients who are given advice about stopping smoking while they are in the hospital. This measure reports what percent of adult pneumonia patients are provided advice and/or counseling to quit smoking. Smoking harms the heart, lungs and blood vessels and makes existing disease worse.
Blood cultures for pneumonia patents admitted through the Emergency Department –
Pneumonia patients who were admitted through the Emergency Department who had a blood test in the Emergency Department for the presence of bacteria in their blood. Before antibiotics are given, blood samples are taken to test for the type of infection. This measure reports the percent of pneumonia patients admitted through the Emergency Department who receive this test before antibiotics were given.
Blood cultures for pneumonia patients in intensive care - Pneumonia patients cared for in an intensive care unit who had a blood test for the presence of bacteria in their blood within 24 hours of hospital arrival. This measure reports the percent of pneumonia patients in intensive care units who had a blood culture with 24 hours prior to or after hospital arrival.
Influenza vaccination - Pneumonia patients in the hospital during flu season (October through February) who were given the influenza vaccination prior to leaving the hospital. This measure reports how often pneumonia patients in the hospital during the flu season were given flu vaccine if needed, prior to leaving the hospital.
Initial antibiotic received within 4 hours of hospital arrival - Pneumonia patients who are given an antibiotic within 4 hours of arriving at the hospital. This measure reports the percent of adult pneumonia patients who are given an antibiotic within 4 hours of arriving at the hospital.
Initial antibiotic received within 8 hours of hospital arrival – Pneumonia patients who are given an antibiotic within 8 hours of arriving at the hospital. This measure reports the percent of adult pneumonia patients who are given an antibiotic within 8 hours of arriving at the hospital.
Initial antibiotic selection for pneumonia ICU patients - Patients in intensive care units that have community-acquired pneumonia who received the appropriate medicine (antibiotic) that has been shown to be effective for community-acquired pneumonia. This measure reports how often patients in intensive care units with community acquired pneumonia were given the correct antibiotic within 24 hours of hospital arrival, based on recommendations from written guidelines for the treatment of pneumonia.
Initial antibiotic for non ICU patients - Patients not in intensive care units who have community – acquired pneumonia who receive the appropriate medicine (antibiotic) that has been shown to be effective for community-acquired pneumonia. This measure reports how often patients with community-acquired pneumonia not cared for in intensive care units, were given the correct antibiotic within 24 hours of hospital arrival based on recommendations from written guidelines for the treatment of pneumonia.
Oxygenation Assessment - Patients with pneumonia in which the amount of oxygen in the blood stream was measured. This measure reports how many patients with pneumonia had their blood/oxygen level measured. Pneumonia reduces the amount of oxygen carried in a patient’s blood.
Pneumococcal vaccination - Pneumonia vaccination. This measure reports how many patients 65 years and older were screened and vaccinated to prevent pneumonia.
Patient Satisfaction (HCAHPS) Measures
Communication with Nurses - Patients reported how often their nurses communicated well with them during their hospital stay. "Communicated well' means nurses explained things clearly, listened carefully to the patient, and treated the patient with courtesy and respect.
Communication with Doctors - Patients reported how often their doctors communicated well with them during their hospital stay. "Communicated well" means doctors explained things clearly, listened carefully to the patient, and treated the patient with courtesy and respect.
Respnsiveness of Hospital Staff - Patients reported how often they were helped quickly when they used the call button or needed help in getting to the bathroom or using a bedpan.
Pain Management - If patients needed medicine for pain during their hospital stay, the survey asked how often their pain was well controlled. "Well controlled" means their pain was well controlled and that the hospital staff did everything they could to help patients with their pain.
Communication about Medicines - If patients were given medicine that they had not taken before, the survey asked how often staff explained about the medicine. "Explained" means that hospital staff told what the medicine was for and what side effects it might have before they gave it to the patient.
Cleanliness of Hospital Environment - Patients reported how often their hospital room and bathroom were kept clean.
Quietness of Hospital Environment - Patients reported how often the area around their room was quiet at night.
Discharge Information - The survey asked patients about information they were given when they were ready to leave the hospital. Patients reported whether hospital staff had discussed the help they would need at home. Patients also reported whether they were given written information about symptoms or health problems to watch for during their recovery.
Overall Rating of this Hospital - After answering all other questions on the survey, patients answered a separate question that asked for an overall rating of the hospital. Ratings were on a scale from 0 to 10, where "0" means "worst hospital possible" and "10" means "best hospital possible."
Willingness to Recommend this Hospital - The survey asked patients whether they would recommend the hospital to their friends and family.
Surgical Care Improvement / Surgical Infections Prevention (SCIP)
Process of Care Measures
Receive Antibiotics One Hour Prior to Surgery - Research shows that surgery patients who get antibiotics within the hour before their operation are less likely to get wound infections. Getting an antibiotic earlier, or after surgery begins, is not as effective. This measure shows how often a surgery patient gets antibiotics at the right time.
Receive Appropriate Antibiotics - Certain antibiotics are recommended to help prevent wound infection for particular types of surgery. This measure looks at how often surgical patients get the appropriate antibiotic in order to prevent a surgical wound infection.
Discontinue Antibiotics 24 Hours After Surgery - While the likelihood of infection after surgery can be reduced by giving patients preventative antibiotics, taking these antibiotics for more than 24 hours after routine surgery is usually not necessary and can increase the risk of side effects such as diarrhea, and antibiotic resistance (when antibiotics are used too much, they will not work anymore.)
Receive Treatement to Prevent Blood Clots 24 Hours Before/After Selective Surgeries - A number of factors can increase a patient's risk of developing blood clots, but doctors can order preventive treatments called prophylaxis to reduce the risk. Prophylaxis may include blood thinning medications, elastic support stockings, or mechanical air stockings that promote circulation in the legs.
Ordered Treatement to Prevent Blood Clots After Selective Surgeries - Certain types of surgery can increase the risk of blood clots forming in the veins. This is because patients don't move much during and, usually, after some surgeries.