Percentage of post-surgical outcomes examined by a physician's system that includes the following. •Tracking specific complications of back surgery; •Periodic analysis of surgical complications data and a plan for improving outcomes. Note: This standard is assessed as a process that applies to all patients. Evaluation is not based on documentation in individual medical records. This standard is applicable only for physicians who perform surgery.
ELEMENT A: TRACKS BACK SURGERY COMPLICATIONS Several studies have reported an increase in back surgery rates in the U.S. despite the high rate of complications associated with these surgeries. Rates of post-operative complications following procedures on the lumbar spine are significant; are associated with higher total hospital charges; and are an indication of quality problems This requirement applies to physician applicants who perform back surgeries. Back surgery-related complications within 6–12 weeks of surgery may include, but are not limited to, the following. – Infection – Wound dehiscence – Hematoma – CSF leak – Other The 6–12-week period should start the day the patient undergoes the surgical procedure.
ELEMENT B: ANALYZE SURGICAL OUTCOME DATA The physician must demonstrate that there is a process for periodically: – analyzing the surgical outcomes data to reduce the number and severity of surgical complications – improving surgical outcomes, based on the analysis. The requirement applies to physicians who perform back surgeries and should include all patients having back surgery.
Denominator
1.15 Denominator
ELEMENT A: TRACKS BACK SURGERY COMPLICATIONS Documentation requirements: To meet the requirements for this standard, the physician must submit a copy of the tracking tool used to identify the complications of back surgery.
The physician tracks the following. Yes No 1. Wound infection ? ? 2. Wound dehiscence ? ? 3. Hematoma ? ? 4. CSF leak ? ? 5. Other ? ?
ELEMENT B: ANALYZE SURGICAL OUTCOME DATA Documentation Requirements: To meet the requirements for this standard, the physician must submit a copy of the data analysis and the plan for improving outcomes. Scoring:
Yes No 1. The physician analyzes surgical outcomes data ? ? 2. The physician has a plan for improving surgical Outcome ? ?
Measure Record
Most Recent Endorsement Activity
Measure Retired and Endorsement Removed National Voluntary Consensus Standards for Ambulatory Care- Part 1 (Phase 3 Cycle 1)
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