SCIP Surgical Care Improvement Project A National Quality Partnership Summary and Measures and Tools

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SCIP Surgical Care Improvement ProjectA National
Quality PartnershipSummary and
MeasuresandTools from Premier to support
SCIP
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What is SCIP

• National quality partnership of organizations
  focused on improving surgical care by
  significantly reducing surgical complications

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SCIP Steering Committee

• American College of Surgeons (ACS)
• American Hospital Association (AHA)
• American Society of Anesthesiologists (ASA)
• Association of peri- Operative Registered Nurses
  (AORN)
• Agency for Healthcare Research and Quality (AHRQ)

• Centers for Medicare Medicaid Services (CMS)
• Centers for Disease Control and Prevention (CDC)
• Department of Veterans Affairs
• Institute for Healthcare Improvement (IHI)
• Joint Commission on Accreditation of Healthcare
  Organizations (JCAHO)

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SCIP National Goal

• To reduce preventable surgical morbidity and
  mortality by 25 percent by the year 2010

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What happened to SIP

• The three SIP measures transitioned to the SCIP
  Infection Module
• Renamed
• SIP-1 is now SCIP Infection-1
• SIP-2 is now SCIP Infection-2
• SIP-3 is now SCIP Infection-3
• Measure(s) population and definition will remain
  the same

Surgical Infection Prevention (SIP) previous CMS
initiative focusing on surgical antibiotic
prophylaxis focusing on appropriate selection and
timing of administration and discontinuation.
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Final SCIP Modules/Measures

• SCIP has four modules
• Infection
• 7 Infection Prevention Process Measures
• Venous Thromboembolus (VTE)
• 2 VTE Prevention Process Measures
• Cardiac Prevention Module
• 1 Cardiovascular Prevention Measure
• Respiratory
• Delayed implementation to use these measure in
  expanding the ICU Core Measure Set

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SCIP Infection Module

• SCIP INF 1
• Prophylactic antibiotic received within one hour
  prior to surgical incision
• SCIP INF 2
• Prophylactic antibiotic selection for surgical
  patients
• SCIP INF 3
• Prophylactic antibiotics discontinued within 24
  hours after surgery end time (48 hours for
  cardiac patients)
• SCIP INF 4
• Cardiac surgery patients with controlled 6 a.m.
  postoperative serum glucose
• SCIP INF 6
• Surgery patients with appropriate hair removal
• SCIP INF 7
• Colorectal surgery patients with immediate
  postoperative normothermia

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SCIP VTE Module

• SCIP VTE 1
• Surgery patients with recommended venous
  thromboembolism prophylaxis ordered
• SCIP VTE 2
• Surgery patients who received appropriate venous
  thromboembolism prophylaxis within 24 hours prior
  to surgery to 24 hours after surgery

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SCIP Cardiac Module

• SCIP Card 2
• Surgery patients on a beta-blocker prior to
  arrival that received a betablocker during the
  perioperative period

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Premiers Quality Measures ReporterTM

• Premiers Quality Measure Reporter TM tool fully
  supports abstraction and reporting of the
  Surgical Care Improvement Project. 

Quality Measure Reporter TM tool is part of
Premiers Advisor Suite of comparative data
tools powered by Perspective TM the largest
clinical and operational comparative database in
the U.S.
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Premiers Quality Measures Reporter TM

• For submission and analysis of data required for
  national and state regulatory compliance and
  insurance plan initiatives including
• Abstracting and reporting of the Surgical Care
  Improvement Project
• JCAHO Core Measures
• CMS Scope of Work
• APU and HQA
• CMS/Premier Hospital Quality Incentive
  Demonstration
• Leapfrog Hospital Rewards Program
• Multiple state initiatives including CHART (CA)
  and ACHA (FL)
• More
• Premiers Quality Measure Reporter
• Captures and reports quality information and ties
  it back to the physician or nursing unit level.
• Simplifies abstraction with immediate error
  correction ability and an efficient concurrent
  abstraction option.
• Tracks performance against national benchmarks
  including practices from the CMS/Premier Hospital
  Quality Incentive Demonstration (HQID)
• Provides drillable reports to analyze areas for
  improvement.

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SCIP Implementation Schedule
Individual Participant Group- Selected set of
hospitals that volunteer to work with their state
Quality Improvement Organization (QIO) on
defined quality improvement projects
Scope of Work QIO measures
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Premiers Implementation

• Align SCIP module implementation with National
  Hospital Quality Measure (NHQM) schedule
• Infection Module
• July 1 2006 Discharges
• VTE and Cardiac Modules
• October 1 2006 Discharges

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Requirements
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SCIP Reporting Requirements

• JCAHO
• If SCIP is a Core Measure Set
• For Calendar year 2006 collect and submit SCIP
  Infection -1 2 and 3
• Additional SCIP measures will not be implemented
  for accreditation requirements until approved by
  NQF

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SCIP Reporting Requirements

• CMS
• Scope of Work
• All measures following NHQM schedule
• SCIP IPG participant
• Infection VTE measures starting with 1/1/2006
  discharges
• APU
• SCIP Infection 1 2 and 3 beginning with July
  1 2006 discharges

APU Appropriateness of Care measures composite
score