Safety and Quality Key

Performance Indicators
Mark Reiter MD MBA FAAEM
St. Lukes Hospital Bethlehem, PA

Objective

To evaluate the utility of select safety

and quality performance indicators

Disclosure

Dedicated to Emergency Medicine performance excellence

through benchmarking and process improvement

Ideal Performance Indicators

Relevant
Measurable
Meaningful
Evidence-based
Leads to performance improvement
opportunities

Hospital Compare
Collaboration between CMS and TJC
Endorsed by the National Quality Forum, Hospital Quality Alliance
Hospital data is published on consumer website and advertised in
the media
Hospital participation is near universal to avoid 2% penalty

Hospital Compare. DHHS website. www.hospitalcompare.hhs.gov.

Facts about ORYX for Hospitals (National Hospital Quality Measures). TJC website.
www.jointcommission.org/AccreditationPrograms/Hospitals/ORYX.
Specifications Manual for National Hospital Quality Measures. HQA website. www.qualitynet.org.
National Quality Measures Clearinghouse. AHRQ website. www.qualitymeasures.ahrq.gov.

Hospital Compare Measures

AMI

Acute Myocardial Infarction

Aspirin at Arrival

Beta Blocker at Arrival (
recently removed)

Median Time to Fibrinolysis

7a

Fibrinolytic Therapy Within 30 Minutes of Arrival

Median Time to Primary PCI

8a

Primary PCI Within 90 Minutes of Arrival

PN

Pneumonia

Oxygenation Assessment

3b

Blood Cultures Performed Prior to Initial Antibiotic

5*

Antibiotic Timing (Median)

5b*

Initial Antibiotic Within 6 Hours of Arrival

Initial Antibiotic(s) for Immunocompetent Patient

6a*

Initial Antibiotic(s) for Immunocompetent ICU Patient

6b*

Initial Antibiotic(s) for Immunocompetent Non-ICU

Patient

* TJC only
CMS only

AMI-6: ASA at Arrival for AMI

Relevant  Yes
Measurable  ??? Documentation omissions
Meaningful  Yes
Evidence-based  Yes
Leads to performance improvement opportunities  ???
Minimal opportunity for improvement

AMI-8a: Primary PCI Within 90

Minutes of Arrival
Relevant  Yes
Measurable  Yes
Meaningful  Yes
Evidence-based  Yes
Leads to performance improvement opportunities  Yes

PN-1: Oxygenation Assessment

Relevant  Yes
Measurable  ??? Documentation omissions
Meaningful  Yes
Evidence-based  Yes
Leads to performance improvement opportunities 
??? Minimal opportunity for improvement

PN-3b: Blood Cultures Before

Abx
Relevant  Yes
Measurable  Yes
Meaningful  No
Evidence-based  No
Leads to performance improvement opportunities  ???

Benenson RS , Kepner AM, Pyle DN 2nd, Cavanaugh S, et al. Selective use of blood cultures in
emergency department pneumonia patients. J Emerg Med. 2007;33(1):1-8.

PN-5b: Initial Abx Within 6

Hours
Relevant  Yes
Measurable  Yes
Meaningful  ???
Evidence-based  No
Leads to performance improvement opportunities  ???

Fee C, Weber E. Identification of 90% of Patients Ultimately Diagnosed With Community-Acquired

Pneumonia Within Four Hours of Emergency Department Arrival May Not Be Feasible. Ann Emerg
Med. 2007;49(5):553-559.

Hospital Compare Concerns

Pressure to meet certain Hospital Compare goals may lead to
unforeseen and negative consequences:
- Poor choices may be made to hit the benchmark (i.e.
unnecessary abx)
- Exaggerated attention on a limited group of diagnoses leads to
time and resources directed away from other serious cases.
- The ED may become the preferred setting for other Hospital
Compare processes (i.e. initiation of ACE inhibitors, smoking
cessation counseling, influenza/pneumococcal vaccination), further
detracting resources and attention from the care of emergent
patients. This may be especially tempting when private physicians
are indifferent towards compliance with these measures.

NHS 4 Hour Target

(Goal > 98%)

Relevant  Yes
Measurable  ???
(opportunities to game the
system)
Meaningful  ???
Evidence-based  Variable
Leads to performance improvement opportunities  Yes

The good, the bad, and the 4 hour target. BMJ 2008;337:a195
UK Emergency Department Doctors Warn They Are Struggling To Cope, Says BMA.
http://www.medicalnewstoday.com/articles/60997.php

Recommendation
Government and quality organizations should work closely with
EM professional organizations to develop meaningful benchmarks
that truly promote excellence in emergency medicine.
Relevant
Measurable
Meaningful
Evidence-based
Lead to performance improvement opportunities
There should be enough performance indicators across a wide
range of medical conditions to minimize exaggerated attention on
patients with a limited group of conditions at the expense of other
patients

Questions?