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122, 39%
191, 61%
International Hospitals Selections of Library Measures (36 measures) Top 6 Measures Selected to Date
46, 6%
37, 5% 37, 5%
70, 9% I-AMI-1 ASA on arrival I-AMI-2 ASA on discharge 439, 59% 44, 6%
75, 10%
Other
QPS.3.1 Standard, Measurable Element (ME) 2, requires JCI accredited hospitals to select at least 5 of 36 measures from the Library of Measures.
Example: Prevention of Surgical Site Infections Guidelines Antimicrobial Prophylaxis Recommendations of Antimicrobial Prophylaxis Administer prophylactic antimicrobial agents only when indicated, and select in accordance with published recommendations as delineated in national guidelines Administer by the intravenous route the initial dose of prophylactic antimicrobial agent
o Prophylactic antibiotic should be received within one hour prior to surgical incision
Joint Commission International
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Rationale
A goal of prophylaxis with antibiotics is to establish bactericidal tissue and serum levels at the time of skin incision
Numerator
Number of surgical patients (hip arthroplasty) with prophylactic antibiotics initiated within one hour prior to surgical incision
Joint Commission International
I-SCIP-Inf-1d
Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Hip Arthroplasty
START
Run inpatient cases with a Principal Procedure Code or Principal Procedure of Hip Arthroplasty on Appendix A, Table 5.04
NO
YES
Patient Age (in years ) = Admission Date Birthdate Run case for patients = >18 years old
Patient Age
<18 years
= >18 years
ICD Principal Diagnosis Code or Principal Diagnosis on Appendix A, Table 5.09, Infections
YES
NO
Check if there is documentation that the patient had an infection prior to the Principal Procedure
YES
NO
Documentation that Other procedures requiring general or spinal/epidural anesthesia that occurred within three days prior to or after the principal procedure during this hospital stay.
Other Surgeries
YES
NO
Unable to determine
Unable to determine
Valid Time
Documentation that the intravenous antibiotic that the patient received perioperatively was on the Appendix C, Antibiotic Medications Table 2.1
Antibiotic Name
NO
YES
Documentation of the date the patient received intravenous antibiotics (IVAB) closest to and before the principal procedure incision time dd/mm/yyyy
Unable to determine
Valid date
Documentation of the time the patient received intravenous antibiotics (IVAB) closest to and before the prinicipal procedure incision time Hour and minutes
Unable to determine
Valid time
Antibiotic Timing 1 = Surgical Incision Date and Surgical Incision Time (minus) Antibiotic Administration Date and Antibiotic Administration Time
Check if the documented antibiotic was received within one hour (or 2 hours if Vancomycin, Appendix C, Table 3.8) prior to Surgical Incision Time: Answer Yes
YES = > 0 minutes and =< 60 minutes for at least one antibiotic
The organization granted an authorized exception from a Library measure, is NOT exempt from selecting and gathering data for the relevant QPS.3.1 clinical measures.
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Data Validation
What dose it mean? Data validation is most important when:
A new measure is implemented Data will be made public
Just an example
Benchmark
Target
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collection !
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