The outcome of interest is a hospital-specific assessment of risk-adjusted Urinary Tract Infection (UTI: as defined by American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP)defined below) within 30 days of any listed (CPT) surgical procedure: the list of eligible CPT codes is attached separately.
Denominator
1.15 Denominator
Patients undergoing any of the listed (CPT) surgical procedures- list is attached separately. Specifically excluded are certain CPTs involving the urinary tract (excluded: 50220, 50545, 50400, 50205, 51040, 54640, 53852, 55866, 52450, 52234). See attached submitted list of eligible CPT codes.
Exclusions
Exclusions
Major trauma and transplant surgeries are excluded as are surgeries not on the supplied CPT list as eligible for selection. Patients who are ASA 6 (brain-death organ donor) are not eligible surgical cases. A patient who has a second surgical procedure performed within 30 days after an index procedure cannot be accrued into the measure as a new (second) index procedure since the measure is based on 30 day outcomes.
Measure Record
Most Recent Endorsement Activity
Measure Retired and Endorsement Removed Patient Safety Spring Cycle 2018
Initial Endorsement
Last Updated
Removal Date
Point of Contact
Steward Organization
American College of Surgeons
Steward POC email
krichards@facs.org
Steward Organization Copyright
UPDATED CONDITIONS SECTION: Type of measure * Outcome Four conditions must be met before a proposed measure may be considered and evaluated for suitability as voluntary consensus standards: A. The measure steward is a governmental organization or a Measure Steward Agreement is signed. Public domain only applies to governmental organizations. All non-government organizations must sign a Measure Steward Agreement even if measures are made publicly and freely available. Do you attest that the measure steward holds intellectual property rights to the measure and the right to use aspects of the measure owned by another entity (e.g., risk model, code set)? * Yes Please check if either of the following apply Proprietary measure Measure Steward Agreement * Agreement will be signed and submitted prior to or at the time of measure submission B. The measure owner/steward verifies there is an identified responsible entity and process to maintain and update the measure on a schedule that is commensurate with the rate of clinical innovation, but at least every 3 years. * Yes, information will be provided in the contact section (in the Additional tab) C. The intended use of the measure includes both public reporting and quality improvement. Purpose * Public reporting Internal quality improvement Additional purposes None D. The requested measure submission information is complete. Generally, measures should be fully developed and tested so that all the evaluation criteria have been addressed and information needed to evaluate the measure is provided. Measures that have not been tested are only potentially eligible for a time-limited endorsement and in that case, measure owners must verify that testing will be completed within 24 months of endorsement. Testing * Yes, tested, as reported above.
Have NQF-endorsed® measures been reviewed to identify if there are similar or related measures? * If there are similar or related measures, be sure to address those items in the Usability tab. Yes, as above.
Public Comments