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Downstate Times

The Newsletter for SUNY Downstate
University Hospital of Brooklyn

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VOL. 2 ISSUE 1 star JANUARY 2014


Downstate's Latest Clinical Core Measure Scores
We Did an Outstanding Job!

Downstate's second quarter 2013 clinical core measure results have been reported out -- and Downstate posted outstanding performance results. Of 115 process-of-care measure results released on December 18, Downstate scored first among all submitters in 55 measures and "substantially better than target range" in a total of 64 measures.

"These are phenomenal results," said Michael Lucchesi, MD, Downstate's Chief Medical and Safety Officer. "They reflect the strength of Downstate's excellence in clinical care."

The data was reported by University HealthSystem Consortium (UHC), a vendor that is Joint Commission-accredited to report outcomes on core measures. UHC members include 120 of the country's 141 academic medical centers, and 300 of their affiliated hospitals. Ultimately, CMS will compare the information submitted by UHC to that of all hospitals nationwide in its hospital database, Hospital Compare.

Core measures report how often hospitals deliver recommended care processes. Measured scores include, among others, those related to acute myocardial infarction (AMI); heart failure (HF); pneumonia (PN); surgical care improvement (SCIP); and hospital-based inpatient psychiatric services (HBIPS).

Downstate also scored well on composite measures, scoring first among all submitters in 3 measures. (Composite scores are developed following Joint Commission methodology. They reflect the combination of multiple individual measures into summary scores. Scores are not weighted or risk adjusted.)

UHC also reports out "Value-Based Purchasing Clinical Process of Care Measures." These are the 12 clinical measures that CMS combines with patient satisfaction scores to determine how much incentive reimbursement, if any, a hospital will receive from Medicare. Downstate's observed performance was 100% in 9 out of 12 clinical measures.

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Downstate scored first among all UHC submitters in 55 measures and "substantially better than target range" in a total of 64 measures.

While these are excellent results, Dr. Lucchesi urges continued vigilance. "This is a single quarter's result," he explains, and of the 59 measures in which we ranked first, 33 were scored with an "interpret with caution" notation because the number of cases included in the analysis were small. And there are categories, including ED wait time and offering pneumococcal immunization, in which more work is needed.

Still, he says, "these results are worth cheering about."


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