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Surgery patients with appropriate hair removal

CBE ID
0301
Endorsement Status
1.1 New or Maintenance
Previous Endorsement Cycle
Is Under Review
No
1.3 Measure Description

Percentage of surgery patients with surgical hair site removal with clippers or depilatory or no surgical site hair removal.

        • 1.14 Numerator

          Surgery patients with surgical hair site removal with clippers or depilatory or no surgical site hair removal

        • 1.15 Denominator

          All selected surgery patients

          Include patients with an ICD-9-CM Principal Procedure Codes of selected surgeries.

        • Exclusions

          Excluded Populations:
          Patients less than 18 years of age
          Patients who have a length of Stay greater than 120 days
          Patients whose ICD-9-CM principal procedure was performed entirely by laparoscope.
          Patients enrolled in clinical trials
          Patients whose ICD-9-CM principal procedure occurred prior to the date of admission
          Patients who performed their own hair removal

        • Most Recent Endorsement Activity
          Measure Retired and Endorsement Removed Patient Safety Project 2015-2017, Phase 3
          Initial Endorsement
          Last Updated
          Removal Date
        • Steward
          Centers for Medicare & Medicaid Services
          Steward Organization POC Email
          Steward Organization Copyright

          Trend Report (BM= Benchmark, rate = national score)
          Q209
          BM: 100 Rate: 99.1
          Q309
          BM: 100 Rate 99.3
          Q409
          BM: 100 Rate 99.4
          Q110
          BM: 100 Rate 99.5
          Q210
          BM: 100 Rate 99.6