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Core Measures Checklist

The Joint Commission for Accreditation of Healthcare Organizations developed performance measures to help compare hospitals in defined areas of performance, Acute Myocardial Infarction, Heart Failure, Pneumonia, and Surgical Infection Prevention. Mercy Hospital has included these performance measures as part of our annual Quality Plan. Here is what is being measured. Please help to improve our performance by ensuring that these recommended therapeutic goals are met.

Acute Myocardial Infarction:

Aspirin at arrival (within 24 hrs)

Aspirin prescribed at discharge

ACEI or ARB for LVSD (EF < 40%)

Smoking Cessation

Beta Blocker at arrival

Beta Blocker prescribed at discharge

LDL Cholesterol Testing

LDL Cholesterol Assessment

Surgical Infection Prevention:

Abx within one hour of incision

Abx discontinued within 24 hours of surgery end time

Case Specific Abx Selection

Applies to:

Vascular Surgery
Colon Surgery
Hysterectomy
Hip Arthroplasty
Knee Arthroplasty

Heart Failure:

LVF Assessment

ACEI or ARB for LVSD (EF < 40%)

Smoking Cessation

Heart Failure Discharge Instruction Sheet

Pneumonia:

Vaccination Screening

O2 Assessment

Pneumococcal Vaccination

Influenza Vaccination (September to March)

Antibiotic timing

Blood Cultures within 24 hours

Smoking Cessation

Antibiotic Selection Non ICU

Antibiotic Selection ICU