CHPPC Module 39, Section 1: Understanding Core Measures, HACs, and SCIP Protocols
MODULE 39: HOSPITAL QUALITY METRICS & THE PHARMACIST’S ROLE

Section 1: Understanding Core Measures, HACs, and SCIP Protocols

A deep dive into the foundational quality metrics all hospitals are judged by. We’ll define CMS Core Measures, Hospital-Acquired Conditions (HACs), and the Surgical Care Improvement Project (SCIP), and identify the pharmacist’s critical role in ensuring compliance with each.

SECTION 39.1

Core Measures, HACs, and SCIP Protocols

The Language of Quality: How Your Clinical Practice is Measured and Valued.

39.1.1 The “Why”: The End of Fee-for-Service, The Rise of Value-Based Care

For decades, the business model of American hospitals was straightforward: the more services they provided, the more they were paid. This “fee-for-service” model incentivized volume over value. A patient who developed a preventable complication, like a post-operative infection, generated more revenue for the hospital through the additional tests, drugs, and longer stay required to treat it. From a purely financial perspective, quality and efficiency were not rewarded. That era is definitively over. The Centers for Medicare & Medicaid Services (CMS), the largest payer for healthcare in the United States, has spearheaded a seismic shift toward a model of Value-Based Purchasing (VBP). The central premise of VBP is simple and revolutionary: hospitals are now paid based on the quality of the care they provide, not just the quantity.

This has fundamentally rewired the DNA of hospital operations and finance. Under this new paradigm, quality is not a vague aspiration; it is a portfolio of specific, publicly reported, and financially consequential metrics. These metrics, which we will deconstruct in this section—Core Measures, Hospital-Acquired Conditions (HACs), and Surgical Care Improvement Project (SCIP) protocols—are the new currency of hospital performance. Hospitals that excel in these areas receive financial bonuses from CMS. Hospitals that perform poorly not only miss out on bonuses but are hit with significant financial penalties, potentially losing millions of dollars in reimbursement annually. Furthermore, these quality scores are publicly available on websites like Medicare’s “Hospital Compare,” directly influencing a hospital’s reputation and a patient’s choice of where to seek care.

This is why your role as a hospital pharmacist has been elevated from a clinical expert to a key player in the institution’s financial health and strategic success. Nearly every major quality metric is profoundly influenced by medication use. Ensuring a heart attack patient receives the correct medications at discharge is not just good clinical practice; it is a Core Measure that determines reimbursement. Preventing an adverse drug event from an anticoagulant is not just a safety imperative; it is a HAC measure that protects the hospital from financial penalties. Your meticulous attention to detail, your proactive interventions, and your role as the medication expert on the interdisciplinary team are no longer “soft” contributions. They are hard, measurable, and financially vital activities. Understanding this framework is the key to articulating your value and becoming an indispensable leader within the modern health system.

Retail Pharmacist Analogy: From Dispensing Metrics to PQA Star Ratings

Think about the evolution of performance metrics in your retail career. Initially, your success might have been measured by simple, volume-based metrics: how many prescriptions you filled per hour, how quickly you answered the phone. This is the “fee-for-service” model. Your goal was to maximize throughput.

Then, health plans and CMS introduced the Pharmacy Quality Alliance (PQA) “Star Ratings.” Suddenly, your pharmacy was being judged—and reimbursed—on a completely new set of value-based metrics. It was no longer enough to just fill prescriptions quickly. Now, your pharmacy’s financial performance was tied to clinical outcomes: What percentage of your diabetic patients were on a statin? What was your adherence rate for patients on hypertension medications? Were you avoiding high-risk medications in the elderly?

This shift forced a change in your practice. You were no longer just a dispenser; you became a population health manager. You proactively ran reports to find diabetic patients not on a statin and worked with their doctors to get one prescribed. You implemented med-sync programs to improve adherence rates for chronic medications. Your focus shifted from volume to value. You started getting paid for the quality of your clinical interventions, not just the speed of your dispensing.

Hospital Core Measures, HACs, and SCIP are the inpatient equivalent of PQA Star Ratings, but with even higher stakes. They are the set of publicly reported, evidence-based standards that determine a hospital’s quality score and its reimbursement. Just as you learned to proactively manage your PQA measures to improve patient outcomes and pharmacy revenue, you will now apply that same data-driven, proactive mindset to ensure your patients receive the evidence-based care that defines hospital quality and financial success.

39.1.2 Deep Dive: CMS Hospital Inpatient Quality Reporting (IQR) Program & Core Measures

The Hospital Inpatient Quality Reporting (IQR) Program is the formal mechanism by which CMS collects quality data from hospitals. Hospitals that fail to report this data receive a 2% reduction in their annual Medicare payment update. Central to this program are the Core Measures. These are a set of evidence-based standards of care that have been shown to improve patient outcomes for common, high-volume, and high-cost conditions. They are “all-or-nothing” measures; for a patient to “pass” the measure, they must receive 100% of the indicated care elements.

As a pharmacist, you are a primary driver of compliance with the medication-related Core Measures. Your role involves screening patients for eligibility, identifying contraindications, recommending appropriate therapy to providers, and ensuring meticulous documentation.

Masterclass Table: Key Medication-Related Core Measures & The Pharmacist’s Playbook

Condition / Measure Set Specific Core Measure (Abbreviation) The Pharmacist’s Actionable Playbook
Acute Myocardial Infarction (AMI) Aspirin at Discharge (AMI-2)
All AMI patients must be prescribed aspirin at discharge unless a clear contraindication is documented.
  • Proactive Screening: Maintain a daily list of all patients with an “AMI” diagnosis. Review their discharge medication orders *before* the patient leaves.
  • Verification: If aspirin is ordered, ensure the dose is appropriate (typically 81 mg daily).
  • Intervention: If aspirin is NOT ordered, immediately investigate. Review the chart for documented contraindications (e.g., active bleeding, true hypersensitivity). If none are found, contact the prescribing provider: “Dr. Jones, I’m reviewing the discharge orders for Mr. Smith, an AMI patient in Room 302. I noticed aspirin wasn’t prescribed. Is there a contraindication I’m missing, or would you like me to add it to meet the AMI core measure?”
  • Documentation: If the provider states a valid reason (e.g., patient refusal, recent major GI bleed), ensure that reason is clearly documented in the chart. Your intervention note should read: “Spoke with Dr. Jones, aspirin held due to patient’s recent ICH. This fulfills the documentation requirement for AMI-2.”
Statin at Discharge (AMI-10)
AMI patients with an LDL-C >100 mg/dL, or with no LDL-C value available, must be prescribed a statin at discharge.
  • Same Screening Process: Use your AMI patient list.
  • Lab Review: Check the admission lipid panel. If LDL-C is >100, a statin is required. If no lipid panel was drawn during the stay, a statin is *still required by default*.
  • Dose Optimization: The standard of care is a high-intensity statin (atorvastatin 40-80 mg or rosuvastatin 20-40 mg). If a lower intensity statin is ordered, you have an opportunity to intervene: “Dr. Jones, for the AMI patient Mr. Smith, I see simvastatin 20mg is ordered. The current guidelines and core measure best practices recommend a high-intensity statin like atorvastatin 80mg post-MI. Would you like to switch?”
  • Contraindication Management: The only major contraindications are active liver disease or a history of statin-induced rhabdomyolysis. Document these clearly if they are the reason for not prescribing.
Heart Failure (HF) ACE Inhibitor or ARB for LVSD (HF-2)
HF patients with a left ventricular systolic dysfunction (LVSD), defined as an ejection fraction (EF) < 40%, must be prescribed an ACE inhibitor or an ARB at discharge.
  • Echocardiogram Review: Your screening trigger is not just the “HF” diagnosis, but the most recent echocardiogram report. Find the documented EF. If it is <40%, this measure applies.
  • Therapy Check: Review discharge orders for an ACEi (e.g., lisinopril) or an ARB (e.g., losartan).
  • Intervention for Omission: If one is missing, review for contraindications (history of angioedema, hyperkalemia, acute kidney injury, bilateral renal artery stenosis). If none, contact the provider with a specific recommendation: “Dr. Davis, the patient in 512 has an EF of 30% but isn’t on an ACEi or ARB. Her potassium and creatinine are stable. Would you like to start lisinopril 5mg daily to meet the HF core measure and guideline-directed medical therapy?”
Venous Thromboembolism (VTE) VTE Prophylaxis (VTE-1) & ICU VTE Prophylaxis (VTE-2)
All at-risk patients must receive VTE prophylaxis (pharmacologic or mechanical) within 24 hours of admission.
  • Pharmacist-Driven Protocols: This is a classic area for pharmacy-driven protocols. Many hospitals empower pharmacists to automatically assess every admitted patient for VTE risk (using a validated score like the Padua Prediction Score) and, if appropriate, order the standard prophylaxis (e.g., heparin 5000 units subcutaneously q8h or enoxaparin 40mg subcutaneously daily) per protocol.
  • Daily Review: Review the profiles of all patients. If you see a patient who is not on prophylaxis and does not have an obvious contraindication (e.g., active bleeding, therapeutic anticoagulation), it requires immediate action.
  • Clear Documentation: If a patient is not receiving prophylaxis due to a valid reason (e.g., platelet count <50,000, upcoming major procedure), that reason must be clearly documented *daily*.

39.1.3 Deep Dive: The Hospital-Acquired Condition (HAC) Reduction Program

If Core Measures reward hospitals for providing evidence-based care, the HAC Reduction Program penalizes them for causing preventable harm. A Hospital-Acquired Condition is a condition (like an infection or an injury) that a patient develops during their hospital stay that was not present on admission. CMS views these as indicators of poor quality and safety.

The financial stakes are high. Each year, CMS evaluates hospitals based on their rates of several HACs. Those hospitals that fall into the worst-performing quartile (the bottom 25%) are penalized with a 1% reduction in all Medicare payments for the entire fiscal year. For a large hospital, this can amount to millions of dollars in lost revenue. Pharmacy plays a central role in preventing many of these medication-related HACs.

Masterclass Table: Key Medication-Related HACs & The Pharmacist’s Prevention Playbook

Hospital-Acquired Condition The Link to Medication Safety The Pharmacist’s Proactive Prevention Playbook
Central Line-Associated Bloodstream Infection (CLABSI) Contamination of parenteral nutrition (PN) solutions, improper aseptic technique during IV preparation, and prolonged, unnecessary use of central lines all increase infection risk.
  • IV Room Excellence: Ensure strict adherence to USP <797> standards for sterile compounding to prevent contamination at the source.
  • Parenteral Nutrition Stewardship: As the PN expert on the nutrition support team, continually re-evaluate the need for central nutrition. Advocate for transitioning to enteral nutrition as soon as clinically feasible to allow for central line removal.
  • Line Necessity Reviews: During daily clinical rounds, ask the simple question: “Does this patient still need their central line?” If the only reason for the line is for IV antibiotics that could be given peripherally or converted to oral, you can advocate for its removal, directly reducing CLABSI risk.
Catheter-Associated Urinary Tract Infection (CAUTI) While not directly medication-related, the treatment of CAUTIs contributes to antibiotic overuse and resistance. The pharmacist’s role is primarily one of antibiotic stewardship.
  • Distinguish Asymptomatic Bacteriuria (ASB) from true CAUTI: A positive urinalysis in a patient with a catheter but no symptoms is often ASB and does not require treatment. You must be the guardian against treating a lab value.
  • Intervention Script: When you see an order for antibiotics for a patient with a Foley catheter, review the chart for signs and symptoms of infection (fever, leukocytosis, altered mental status). If none are present, contact the provider: “Dr. Miller, I see the order for ciprofloxacin for the positive UA on Mrs. Davis. In reviewing her chart, I don’t see any documented symptoms of a UTI. Per our stewardship guidelines, this may be asymptomatic bacteriuria, and treating it may not be beneficial. Are you seeing clinical signs of infection I might have missed?”
Surgical Site Infection (SSI) This is directly linked to the SCIP measures. Failure to administer the correct antibiotic at the correct time, or continuing it for too long post-operatively, increases SSI risk.
  • (See SCIP Section Below for Full Detail)
  • Ensure correct pre-operative antibiotic selection and timing.
  • Police the 24-hour post-operative discontinuation of prophylactic antibiotics to prevent resistance and secondary infections like C. difficile.
Adverse Drug Events (ADE) / Harm from High-Risk Medications This is the HAC category where pharmacists have the most direct and profound impact. CMS specifically tracks patient harm from anticoagulants, hypoglycemics, and opioids.
Anticoagulant Stewardship Playbook:
  • Implement pharmacist-managed dosing protocols for warfarin and heparin infusions.
  • Utilize EMR alerts and order sets to promote appropriate DOAC dosing based on renal function, age, and weight.
  • Lead efforts to ensure appropriate reversal agents (e.g., andexanet alfa, idarucizumab, Kcentra) are available and that clear protocols for their use exist.
  • Perform daily monitoring of all patients on therapeutic anticoagulation for signs of bleeding (dropping hemoglobin) or thrombosis (subtherapeutic INR/aPTT).
Hypoglycemia Prevention Playbook:
  • Champion the elimination of sliding scale insulin (SSI) as monotherapy, promoting instead the use of evidence-based basal-bolus-correctional insulin regimens.
  • Develop and manage protocols for IV insulin infusions in critically ill patients.
  • Create EMR alerts to warn prescribers when initiating sulfonylureas (especially glyburide) in elderly or renally impaired patients.
  • Lead the P&T initiative to remove high-risk agents like glyburide from the formulary.

39.1.4 Deep Dive: The Surgical Care Improvement Project (SCIP)

The Surgical Care Improvement Project, or SCIP, was a national quality partnership that aimed to reduce preventable surgical complications. While the formal SCIP program has been retired by CMS, its principles were so successful that they have become the accepted standard of care and are now incorporated into other quality and payment programs. Hospitals are still intensely focused on these measures because they are proven to reduce surgical site infections (SSIs) and post-operative VTE, both of which are now tracked as HACs. Your role in the timely and appropriate use of prophylactic medications is central to the success of the surgical service line.

The Unforgiving Clock of Pre-Operative Antibiotics

For SCIP-Inf-1, the timing is everything. The goal is to have bactericidal concentrations of the antibiotic in the tissue *at the time of incision*. For most IV antibiotics (like cefazolin), this means the infusion must be completed within the 60 minutes prior to incision. For vancomycin and fluoroquinolones, which have longer infusion times, the infusion must be started within 120 minutes prior to incision. An antibiotic given too early (e.g., 90 minutes before incision) will have declining tissue levels. An antibiotic given too late (e.g., 10 minutes after incision) is not prophylactic; it’s a failed measure. This requires tight coordination between pharmacy, anesthesia, and the operating room staff, a process you will be instrumental in managing.

Masterclass Table: Core Medication-Related SCIP Measures & The Pharmacist’s Workflow

SCIP Measure The Rationale (The “Why”) The Pharmacist’s Tactical Workflow
Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision
(SCIP-Inf-1)		 To ensure adequate antibiotic concentrations in the tissue at the moment of incision to prevent bacterial colonization of the wound.
  • Pre-Op Screening: Review the OR schedule for the next day. Cross-reference each patient’s planned procedure with the hospital’s surgical prophylaxis guidelines.
  • Order Verification: Verify the pre-op antibiotic order for the correct drug, dose, and timing. Ensure it is scheduled correctly in the EMR relative to the planned incision time.
  • Logistical Coordination: Work with OR satellite pharmacists or central pharmacy to ensure the right antibiotic is delivered to the correct pre-op holding area or OR room at the right time. For “first case of the day” surgeries, this may mean preparing the IV bag the night before.
  • Real-Time Problem Solving: Be available to the OR team. If a case is delayed, you may need to advise on re-dosing the antibiotic. If a patient has an allergy, you must be able to rapidly recommend a safe and effective alternative.
Prophylactic Antibiotic Selection for Surgical Patients
(SCIP-Inf-2)		 To ensure the chosen antibiotic is effective against the most likely pathogens to cause an SSI for that specific type of surgery, while also being narrow-spectrum enough to avoid unnecessary side effects and resistance.
  • Guideline Mastery: You must be an expert in your hospital’s surgical prophylaxis guidelines. The standard is often Cefazolin for many procedures due to its ideal spectrum against skin flora. More complex procedures (e.g., colorectal surgery) will require broader coverage (e.g., ceftriaxone + metronidazole).
  • Intervention for Incorrect Selection: When you see a pre-op antibiotic ordered that deviates from the guideline without a clear reason (like an allergy), you must intervene. “Dr. Evans, I see you ordered Unasyn for this patient’s knee replacement. Our institutional guideline and the national recommendations suggest cefazolin to best cover skin flora. Is there a reason for the broader spectrum agent, or can we switch to cefazolin to align with the SCIP measure?”
Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time
(SCIP-Inf-3)		 Continuing prophylactic antibiotics beyond 24 hours provides no additional benefit in preventing SSI and significantly increases the risk of antibiotic resistance, C. difficile infection, and other adverse effects.
  • Post-Op Order Review: This is a core daily activity for unit-based pharmacists. Generate a list of all post-operative patients. Review their medication profiles specifically for surgical prophylactic antibiotics.
  • The Hard Stop: The best practice is to have CPOE order sets that automatically set a 24-hour stop time for these antibiotics. Your role is to advocate for and help build these order sets.
  • Manual Intervention: If no hard stop exists, you must manually intervene. Find the “surgery end time” in the anesthesia record. If the antibiotic is still running more than 24 hours later, and there is no clear evidence of an active infection being treated, you must contact the provider. “Hi Dr. Lee, I’m calling about your post-op patient in Room 621. The prophylactic cefazolin is still scheduled. The SCIP guidelines recommend stopping it within 24 hours to reduce C. diff risk. Can I go ahead and discontinue that order for you?”