Surgical Site Infection (SSI)

Measure Specification

This is an adverse surgical outcome, which is often a preventable cause of harm, thus it is important to measure and report. It is feasible to collect the data and produce reliable and valid results about the quality of care. It is useful and understandable to stakeholders. This measure was developed in a collaborative effort by the American College of Surgeons and the American Board of Surgery.

This measure addresses the National Quality Strategy Priorities and was identified by an expert panel of physician providers to be a critical outcome for this procedure. This measure addresses a high-impact condition as it is one of the most common procedures performed in the U.S. The measure aligns well with the intended use. The care settings include Acute Care Facilities/Hospitals.

Data are being collected in a clinical registry that has been in existence for over 10 years, with over 5500 current, active users. Thus, we are requesting consideration of this measure in the MIPS CQM reporting option. The level of analysis is the clinician/individual. All populations are included, except children. The measure allows measurement across the person-centered episode of care out to 30 days after the procedure whether an inpatient, outpatient, or readmitted.

The measure addresses disparities in care. The risk adjustment is performed with a parsimonious dataset and aims to allow efficient data collection resources and data reporting. The measure has been harmonized when possible.

A modified-Delphi methodology using an expert panel of surgeons who are Directors of the American Board of Surgery identified this to be a critical outcome for this surgical procedure (Surgeon Specific Registry Report on Project for ABS MOC Part IV. Unpublished study by the American College of Surgeons in conjunction with the American Board of Surgery, 2011).

This measure contains one strata defined by a single submission criteria. This measure produces a single performance rate. For the purposes of MIPS implementation, this procedure measure is submitted each time a procedure is performed for the performance period. There is no diagnosis associated with this measure. All sites of the primary procedure and integral procedures performed during that trip to the operating room should be evaluated as part of this measure for possible wound occurrences.

If more than one SSI is observed, assign the SSI at the deepest level (superficial, deep or organ/space) that occurs within a 30-day postoperative timeframe. Include only patients that have procedures through November 30th of the performance period. This will allow the evaluation of at least 30 days after the surgical procedure within the performance period.

This is an inverse measure which means a lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases.

For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.