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Disclaimer

In the Downloads section, the ‘Prior Submission’ file reflects the most recent measure submission to the former CBE. This file is provided for transparency. For any questions or clarification, please contact the designated measure steward.

Surgery patients with appropriate hair removal

CBE ID
0301
1.5 Project
Patient Safety, Phase 3
Endorsement Status
Endorsement Removed
1.0 New or Maintenance
Maintenance
1.1 Measure Structure
Single Measure
Previous Endorsement Cycle
Full Year 2015
Is Under Review
No
1.6 Description

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

Measure Specs
General Information
1.7 Measure Type
Process
1.3 Electronic Clinical Quality Measure (eCQM)
No
1.8 Level of Analysis
Facility
Other
Population: Regional and State
1.9 Care Setting
Inpatient/Hospital
1.20 Types of Data Sources
Claims Data
Other
Paper Patient Medical Records
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 Organization
Centers for Medicare & Medicaid Services
Steward POC email
[email protected]
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

Risk Adjustment
No risk adjustment or risk stratification
Use
Planned Use
Payment Program
6.1.2 Current or Planned Use(s)
Payment Program
Public Comments