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Quality Measures

Surgical Care Improvement Project (SCIP)

Part of our continuing efforts at improving quality is participation in a national initiative for public reporting of quality measures promoted by the Centers for Medicare and Medicaid Services (CMS).

Process of care measures show how often hospitals give recommended treatments known to get the best results for certain surgical procedures. Information about these treatments are taken from the patients’ records and converted into a percentage. This is one way to compare the quality of care that hospitals give.

SSCBR extracts data and submits the information to CMS for the applicable process of care measures for the Surgical Care Improvement Project (SCIP). This is a specific set of guidelines in the treatment of surgical patients and preventing surgical site infections. Research has shown that following these guidelines leads to significantly better outcomes.

The results indicate how well a hospital is doing in following specific guidelines as a percentage of applicable cases and provides a comparison to the national average. Additional information regarding these measures and how other hospitals compare can be found at

The tables below display how SSCBR performed on the applicable measures compared to the national average. Only the measures with more than 25 cases are displayed.

SSCBR performs BETTER than the national average on ALL applicable measures.


Hair Removal

Percent of surgery patients needing hair removed from the surgical area before surgery, who had hair removed using a safer method (electric clippers or hair removal cream – not a razor)

  Jan 11 – Dec 11
National Average 96%

Preparation for surgery includes the appropriate method of surgical site hair removal. No hair removal, or hair removal with clippers or depilatory is considered appropriate. Shaving with a razor is considered inappropriate.

Why is this Important? Shaving can cause multiple skin abrasions that later may become infected. Studies have shown that use of clippers resulted in reduced surgical infections.


Preventing Blood Clots:

Percent of patients who got treatment at the Right Time (within 24 hours before or after their surgery) to help prevent blood clots after certain types of surgery

  Jan 11 – Dec 11
SSCBR 100%
National Average 97%


Why is this Important? Many factors influence a surgery patient's risk of developing a blood clot, including the type of surgery. When patients stay still for a long time after some types of surgery, they are more likely to develop a blood clot in the veins of the legs, thighs, or pelvis. A blood clot slows down the flow of blood, causing swelling, redness, and pain. A blood clot can also break off and travel to other parts of the body. If the blood clot gets into the lung, it is a serious problem that can sometimes cause death.

Antibiotic Received - Right Kind

Percent of outpatients having surgery who received the right kind of antibiotic

  Jan 11 – Dec 11
National Average 96%

Why is this Important?  Hospitals can prevent surgical wound infections. Medical research shows that certain antibiotics work better to prevent wound infections for certain types of surgery. Hospital staff should make sure patients get the antibiotic that works best for their type of surgery.

Antibiotic Received - Received at the Right Time

Percent of outpatients having surgery who got an antibiotic at the right time - within one hour before surgery (higher numbers are better)

  Jan 11 – Dec 11
SSCBR 100%
National Average 100%

Why is this Important? Hospitals can prevent surgical wound infections. Medical research shows that surgery patients who get antibiotics within the hours before their surgery are less likely to get wound infections. The timing is important: getting an antibiotic earlier, or after surgery begins, is not as effective.  Hospital staff should make sure patients get antibiotics at the right time.