CMS-10431 Surgical Care Improvement Paper Submission

PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program
Surgical Care Improvement (SCIP) Measures
Paper Submission for FY2015 and Subsequent Years
(NQF 0218) Surgery Patients who Received Appropriate Venous Thromoembolism
Prophylaxis within 24 Hours Prior to Surgery to 24 Hours after Surgery
Q1

Q2

Q3

Q4

NUMERATOR
Surgery patients who received
appropriate Venous
Thromboembolism prophylaxis
(VTE) within 24 hours prior to
Anesthesia Start Time to 24 hours
after Anesthesia End Time

DENOMINATOR
All selected surgical patients

(NQF 0300) Cardiac Surgery Patients with Controlled 6 A.M. Postoperative Blood Glucose
Q1

Q2

Q3

Q4

NUMERATOR
Surgery patients with controlled 6
A.M. blood glucose (less than or
equal to 200/mg/dL) on
postoperative day 1 and
postoperative day 2

DENOMINATOR
Cardiac surgery patients with no
evidence of prior infection

(NQF 0453) Urinary Catheter Removed on Postoperative Day 1 or Postoperative Day 2
with Day of Surgery Being Day Zero
Q1
NUMERATOR
Number of surgical patients
whose urinary catheter is
removed on postoperative day 1
or postoperative day 2 with day
of surgery being day zero

Q2

Q3

Q4

DENOMINATOR
All selected surgical patients
with a catheter in place
postoperatively

(NQF 0527) Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision
Q1

Q2

Q3

Q4

NUMERATOR
Number of surgical patients with
prophylactic antibiotics initiated
within one hour prior to surgical
incision (two hours if receiving
vancomycin, in Appendix C, Table
3.8, or a fluroquinolone, in Appendix
C, Table 3.10)

DENOMINATOR
All selected surgical patients with no
evidence of prior infection

(NQF 0528) Prophylactic Antibiotic Selection for Surgical Patients
Q1
NUMERATOR
Number of surgical patients who
received prophylactic antibiotics
recommended for their specific
surgical procedure

DENOMINATOR
All selected surgical patients with no
evidence of prior infection

Q2

Q3

Q4

(NQF 0529) Prophylactic Antibiotics Discontinued Within 24 Hours after Surgery End
Time
Q1

Q2

Q3

Q4

NUMERATOR
Number of surgical patients whose
prophylactic antibiotics were
discontinued within 24 hours after
Anesthesia End Time (48 hours for
CABG or Other Cardiac Surgery)

DENOMINATOR
All selected surgical patients with
no evidence of prior infection

*Facility Name:
*CEO Signature:

*Date:

*CEO Email Address:
Complete and submit the Notice of Participation Agreement form using one of the following
options:
•
•
•

via My QualityNet to the Global Exchange Group “PPS Exempt Cancer Hosp. QR Support ”;
via secure FAX to Program Manager Telligen PCHQR Support (515)-558-5073, or
via mail to:

Telligen PCHQR Support
1776 West Lakes Parkway,
West Des Moines, IA 50266
Attn. Program Manager
DO NOT SEND THE COMPLETED FORM VIA E-MAIL.
Following receipt of the request form, an e-mail acknowledgement will be sent
confirming the form has been received.
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