Team # 924 -- Surgical Care Improvement Team (SCIP)
College of Medicine

September 2007


To improve the quality of patient care and reporting of the improvements through National Hospital Quality Measure Reporting(NHQM), which started out in 2002 as the Joint Commission’s Core Measures project as an effort to improve the quality of patient care by implementing a national standardized performance measurement system that focuses on the results of the care provided. In 2003 CMS initiated their Hospital Quality Initiative (HQI) – designed to stimulate improvements in hospital care by standardizing hospital performance measures and data transmission to ensure that all payers, hospitals, and oversight & accrediting entities use the same measures when publicly reporting on hospital performance. Beginning FY2007 hospitals received a 2% reduction in their annual payment update (APU) if they did not participate. The NHQM measure sets include SCIP, but also AMI, CHF and Pneumonia care.

10 SCIP measures for 8 categories of adult surgical inpatient and hospital outpatient procedures:
- Coronary artery bypass grafting (CABG)
- Other cardiac surgery
- Hip arthroplasty
- Knee arthroplasty
- Colon surgery
- Hysterectomy
- Vascular Surgery
- Random sampling of all other surgeries

Team Membership

  • Lucille Andersen, Orthopedics Rep
  • April Armstrong, Orthopedics Rep
  • Linda Burgess, NSQIP Rep
  • Nicholas Cavarocchi, Heart/Vascular Rep
  • Virginia Hall, OB/GYN Rep
  • David Han, Vascular Surg Rep
  • Carol Houlihan, Data Collection/Process Expert
  • Kathy Law, Periop Rep
  • Kevin McKenna, Physician Lead
  • Margaret Miller, Infection Control
  • Gail Ortenzi, NSQIP Rep
  • Walter Pae, Heart/Vascular Rep
  • Sally Plesic, Data Quality Abstractor
  • Sirkantha Rao, Anesthesia Rep
  • Christine Straw, Same Day Unit Rep
  • Greg Swope, Dept of Surg Admin Rep
  • Thomas Verbeek, Anesthesia Rep
  • Kathy Williams, Quality Services Rep
  • Jackie Lamendola, Project Manager

Results Achieved to Date

  • ExpectedResults: All results are available to the public at and at

    Measures of performance include:
    1)Antibiotic within 1 hr of incision
    2)Antibiotic selection
    3)Antibiotic disc. within 24 hrs
    4)Card pts 6am postop serum glucose
    5)Appropropriate hair removal
    6)Urin cath removed POD1 or 2
    7)Periop temperature management
    8)Beta-blocker prior to admission and periop
    9)VTE prophylaxis ordered
    10)VTE prophylaxis timing




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