Skip to main content

Ambulatory Breast Procedure Surgical Site Infection (SSI) Outcome Measure

Endorsement Status
1.1 New or Maintenance
E&M Cycle
Is Under Review
Next Planned Maintenance Review
Fall 2027
E&M Cycle Comments

Effective March 27, 2023, the National Quality Forum (NQF) is no longer the consensus-based entity (CBE) funded through the Centers for Medicare & Medicaid Services (CMS) National Consensus Development and Strategic Planning for Health Care Quality Measurement Contract. Battelle has been selected to oversee the endorsement & maintenance (E&M) of clinical quality and cost/resource use measures. Since the Fall 2022 cycle launched at NQF, measures submitted to this E&M cycle continued along the prior E&M protocols that were in place at time of the Fall 2022 “Intent to Submit.” Battelle took over the E&M work for the Fall 2022 cycle after developers and/or stewards submitted their full measure information to NQF, which for CBE #3025, the most recent measure specifications can be found here:

Battelle took over the E&M work beginning with the public comment period to close the E&M committees for the post-comment meeting, convening the CSAC to render a final endorsement decision, and executing the appeals period.


1.3 Measure Description

This measure is for the risk-adjusted Standardized Infection Ratio (SIR) for all Surgical Site Infections (SSI) following breast procedures conducted at ambulatory surgery centers (ASCs) among adult patients (ages 18 - 108 years) and reported to the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN). The measure compares the reported number of surgical site infections observed at an ASC with a predicted value based on nationally aggregated data. The measure was developed collaboratively by the CDC, the Ambulatory Surgery Center Quality Collaboration (ASC QC), and the Colorado Department of Public Health and Environment. CDC is the measure steward.

        • 1.14 Numerator

          Surgical site infections (SSIs) during the 30-day (superficial SSI) and 90-day (deep and organ/space SSI) postoperative periods following breast procedures in Ambulatory Surgery Centers.

        • 1.15 Denominator

          Breast procedures, as specified by the operative codes that comprise the breast procedure category of the NHSN Patient Safety Component Protocol, performed at ambulatory surgery centers.

        • Exclusions

          Hospital inpatients and hospital outpatient department patients, pediatric patients and very elderly patients, and brain-dead patients whose organs are being removed for donor purposes

        • OLD 1.12 MAT output not attached
        • Most Recent Endorsement Activity
          Patient Safety Fall 2022
          Initial Endorsement
          Last Updated
              • Risk Adjustment
                Risk adjustment approach
                Risk adjustment approach
                Conceptual model for risk adjustment
                Conceptual model for risk adjustment