TJC - CMS Core Measures Dashboard in Excel

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Jay Arthur
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The Joint Commission - CMS Core Measures

Need a better way to report your TJC Core Measures to your leadership team? Does your monthly reporting process take too much time?

Nancy Keenan and I attended the NDNQI conference with a poster on the nursing dashboard. We had crowds of people asking about the dashboard and we raved about your great work! - Jean Dols PhD, RN

With our new TJC - CMS Core Measures dashboard in Excel, just input your data directly into the pre-formatted data entry sheet and color coded scorecards and a dashboard of control charts are automatically created.

This system consists of four parts:

1. A pre-populated spreadsheet listing all measures and their definitions. This sheet can be updated to meet your needs.
2. A data input sheet to record your results.
3. A color-coded (green, yellow, red -- good, poor, bad) scorecard that shows how well you're performing against targets.
4. A control chart for each measurement that shows actual performance as a graph.

Here are examples of each sheet:

Core Measures Definitions Sheet

Core Measures Data Input Sheet

Color Coded Scorecard showing your results against targets.

Automatically populates from your data entry sheet. Also, contains a column to the left for data analysis notes and action plans.

Dashboard of Control Charts

Automatically creates control charts for each of your measures.

Core Measures included in the TJC - CMS Core Measures dashboard include:

Acute Myocardial Infarction (AMI)

• AMI-1 Aspirin at Arrival
• AMI-2 Aspirin Prescribed at Discharge
• AMI-3 ACEI or ARB for LVSD
• AMI-4 Adult Smoking Cessation Advice/Counseling
• AMI-5 Beta Blocker Prescribed at Discharge
• AMI-6 Beta Blocker at Arrival
• AMI-7 Median Time to Thrombolysis
• AMI-7a Thrombolytic Agent Received Within 30 Minutes of Hospital Arrival
• AMI-8 Median Time to PTCA
• AMI-8a PCI received within 120 minutes of hospital arrival
• AMI-9 TJC Only Inpatient mortality

Heart Failure (HF)

• HF-1 Discharge Instructions
• HF-2 LVF Assessment
• HF-3 ACEI or ARB for LVSD
• HF-4 Adult Smoking Cessation Advice/Counseling
  

Pneumonia (PN)

• PN-1 Oxygenation assessment
• PN-2 Pneumococcal screening and/or vaccination
• PN-3a Blood Cultures for ICU
• PN-3b Blood Culture Before First Antibiotic
• PN-4 Adult smoking cessation advice/counseling
• PN-5 Antibiotic timing
• PN-5a Initial antibiotic received within 8 hours of hospital arrival
• PN-5b Initial antibiotic received within 4 hours of hospital arrival
• PN-6 Immunocompetent patients with Community-Acquired Pneumonia who receive an initial antibiotic regimen during the first 24 hours.
• PN-6a Immunocompetent ICU patients with Community-Acquired Pneumonia who receive an initial antibiotic regimen during the first 24 hours.
• PN-6b Immunocompetent non-Intensive Care Unit (ICU) patients with Community-Acquired Pneumonia who receive an initial antibiotic regimen during the first 24 hours.
• PN-7 Influenza vaccination

Pregnancy and related conditions (PRC)

• PRC-1 VBAC
• PRC-2 Neonatal Mortality
• PRC-3 Third or Fourth Degree Laceration

Surgical Infection Prevention (SIP)

• SIP-1 Prophylactic Antibiotic Received Within 1 Hour Prior to Surgical Incision
• SIP-2 Prophylactic Antibiotic Selection for Surgical Patients
• SIP-3 Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time
  

TJC - CMS Core Measures Dashboard

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