For Physicians at Banner Gateway Medical Center  

2012 CMS Publicly Reported Hospital Performance Measures


By David Edwards, MD, Chief Medical Officer

New Inpatient Global Sampling Measures
Global sampling is a new CMS defined process for data abstraction.  Global Sampling will impact our ability to reverse core measure outliers by effectively eliminating the 30-day window of opportunity for documentation revision/addendum.   To prevent core measure outliers, documentation must be accurate the first time, every time.   Global Sampling Measures are the first measures to be abstracted, followed by other applicable measures (HF, AMI, PN, SCIP):

Inpatient ED throughput

  • ED-1  Median time from ED arrival to ED departure for admitted patients
  • ED 2  Admit decision time to ED departure time for admitted patients

Influenza and Pneumococcal vaccination status

  • IMM-1a  Overall rate
  • IMM-1b  Patients 65 years and over
  • IMM-1c  Patients 6-64 years with high risk conditions:  Diabetes, nephritic syndrome, ESRD, CHF, COPD, HIV, asplenia, patients 19-64 with asthma

New Outpatient Core Measures CMS outpatient measures:
Acute MI and Chest Pain

  • OP-16  Troponin results received within 60 minutes of arrival

ED Throughput

  • OP-18  Median time from ED arrival to departure for discharged patients
  • OP-19  ED discharge instructions given to the patient must include all major procedures and tests that were done

Pain Management

  • OP-21  Time to pain meds for long bone fractures for ages 2 and above


  • OP-23  Head CT or MRI results within 45 minutes of arrival time for TIA or hemorrhagic stroke patients with a definable “last known well” time

If you would like additional information, please contact Michael Coston, Quality Management director at 543-2813, Jo Steffi Cunningham, RN QM specialist at 543-2818 or Gail Quirin, RN QM specialist at 543-2437. Thank you for supporting Banner Gateway’s pursuit of clinical excellence.

Banner Gateway Medical Center
Higley Road and US 60
1900 N. Higley Road
Gilbert, Arizona 85234
(480) 543-2000
Follow Us:  
Facebook IconPinterestTwitter IconBlogYouTube Icon
Jump to top links