Surgical Care Improvement Project (SCIP)

Set Measures

Set Measure ID	Measure Short Name
SCIP-Card-2	Surgery Patients on Beta-Blocker Therapy Prior to Admission Who Received a Beta-Blocker During the Perioperative Period
SCIP-Inf-1	Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision
SCIP-Inf-2	Prophylactic Antibiotic Selection for Surgical Patients
SCIP-Inf-3	Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time
SCIP-Inf-4	Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Blood Glucose
SCIP-Inf-6	Surgery Patients with Appropriate Hair Removal
SCIP-Inf-7	Colorectal Surgery Patients with Immediate Postoperative Normothermia
SCIP-venous-thromboembolism-1	Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered
SCIP-venous-thromboembolism-2	Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery

General Data Elements

Element Name	Collected For
Birthdate	All Records,
Discharge Date	All Records, (used in algorithm for AMI-1, AMI-6, PN-1, PN-3a, PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b, PN-7, PR-2, SCIP-Inf-4, SCIP-VTE-1, SCIP-VTE-2)
Discharge Status	All Records, (used in algorithm for AMI-1, AMI-2, AMI-3, AMI-4, AMI-5, AMI-6, AMI-9, AMI-T1a and AMI-T2 [CMS Optional Test Measures], CAC-3 [Joint Commission Test Measure], All HF Measures, All PN Measures, PR-2)
First Name	All Records, CMS Only,
Hispanic Ethnicity	All Records, CMS Only,
Hospital Patient Identifier	All Records, CMS Only, NOTE: Refer to the Hospital Clinical Data XML File Layout in the Transmission section of this manual.
Last Name	All Records, CMS Only,
Patient HIC#	All Records, CMS Only, Collected by CMS for patients with a Payment Source - Medicare who have a standard HIC number.
Physician 1	All Records, Optional for All Records, (CMS Optional Element)
Physician 2	All Records, Optional for All Records, (CMS Optional Element)
Point of Origin for Admission or Visit	All Records, (used in algorithm for AMI-1, AMI-6, AMI-7, AMI-7a, AMI-8, AMI-8a, AMI-9, PN-1, PN-3a, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b
Postal Code	All Records, CMS Only,
Race	All Records, CMS Only,

Algorithm Output Data Elements

Element Name	Collected For
Measure Category Assignment	Joint Commission Only, Calculation, Transmission, Hospital Clinical Data File

Measure Set Specific Data Elements

Element Name	Collected For
Antibiotic Administration Date	SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3,
Antibiotic Administration Route	SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3,
Antibiotic Administration Time	SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3,
Antibiotic Allergy	SCIP-Inf-2,
Antibiotic Name	SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3,
Antibiotic Received	SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3,
Beta-Blocker Current Medication	SCIP-Card-2,
Beta-Blocker During Pregnancy	SCIP-Card-2,
Beta-Blocker Perioperative	SCIP-Card-2,
Contraindication to Beta-Blocker - Perioperative	SCIP-Card-2,
Contraindication to VTE Prophylaxis
Date of Infection	SCIP-Inf-3,
Glucose POD 1	SCIP-Inf-4,
Glucose POD 2	SCIP-Inf-4,
Infection Prior to Anesthesia	SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-Inf-7,
Joint Revision	SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3,
Laparoscope	SCIP-Card-2, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-Inf-6, SCIP-Inf-7,
Neuraxial Anesthesia
Oral Antibiotics	SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3,
Other Surgeries	SCIP-Inf-1, SCIP-Inf-3,
Perioperative Death	SCIP-Card-2, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-Inf-7,
Postoperative Infections	SCIP-Inf-3,
Preadmission Warfarin
Preoperative Hair Removal	SCIP-Inf-6,
Surgery End Date	SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4,
Surgery End Time	SCIP-Inf-2, SCIP-Inf-3,
Surgery Start Date	SCIP-Card-2, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-Inf-6, SCIP-Inf-7,
Surgical Incision Time	SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3,
Temperature Value	SCIP-Inf-7,
VTE Prophylaxis
VTE Timely
Vancomycin	SCIP-Inf-2,

---

Surgical Care Improvement Project (SCIP) Initial Patient Population

The SCIP Topic Population (common to all SCIP measures) is defined as patients admitted to the hospital for inpatient acute care with an ICD-9-CM Principal Procedure Code for SCIP as defined in Appendix A, Table 5.10, a Patient Age (Admission Date – Birthdate) >= 18 years, and a Length of Stay (Discharge Date - Admission Date) <= 120 days. There are eight distinct strata or sub-populations within the SCIP Topic Population, each identified by a specific group of procedure codes. The patients in each stratum are counted in the Initial Patient Population of multiple measures.

Measures	Initial Patient Population definition
SCIP-INF-1a, 2a, 3a (overall measures)	The count of all patients in strata 1, 2, 3, 4, 5, 6, and 7
SCIP-Inf-1b, 2b, 3b	The count of all patients in stratum 1
SCIP-Inf-1c, 2c, 3c	The count of all patients in stratum 2
SCIP-Inf-1d, 2d, 3d	The count of all patients in stratum 3
SCIP-Inf-1e, 2e, 3e	The count of all patients in stratum 4
SCIP-Inf-1f, 2f, 3f	The count of all patients in stratum 5
SCIP-Inf-1g, 2g, 3g	The count of all patients in stratum 6
SCIP-Inf-1h, 2h, 3h	The count of all patients in stratum 7
SCIP-Inf-4, 6, and 7	The count of all patients in strata 1, 2, 3, 4, 5, 6, 7, and 8
SCIP-CARD-2	The count of all patients in strata 1, 2, 3, 4, 5, 6, 7, and 8
SCIP-VTE-1 and 2	The count of all patients in strata 1, 2, 3, 4, 5, 6, 7, and 8

Patients admitted to the hospital for inpatient acute care are included in one of the SCIP ICD Strata Populations and are eligible to be sampled if they have:

1 – CABG stratum – Patients with an ICD-9-CM Principal Procedure Code as defined in Appendix A, Table 5.01, a Patient Age (Admission Date – Birthdate) >= 18 years, and a Length of Stay (Discharge Date - Admission Date) <= 120 days.

2 - Other Cardiac Surgery stratum – Patients with an ICD-9-CM Principal Procedure Code as defined in Appendix A, Table 5.02, a Patient Age (Admission Date – Birthdate) >= 18 years, and a Length of Stay (Discharge Date - Admission Date) <= 120 days.

3 - Hip Arthroplasty stratum – Patients with an ICD-9-CM Principal Procedure Code as defined in Appendix A, Table 5.04, a Patient Age (Admission Date – Birthdate) >= 18 years, and a Length of Stay (Discharge Date - Admission Date) <= 120 days.

4 - Knee Arthroplasty stratum – Patients with an ICD-9-CM Principal Procedure Code as defined in Appendix A, Table 5.05, a Patient Age (Admission Date – Birthdate) >= 18 years , and a Length of Stay (Discharge Date - Admission Date) <= 120 days.

5 - Colon Surgery stratum – Patients with an ICD-9-CM Principal Procedure Code as defined in Appendix A, Table 5.03, a Patient Age (Admission Date – Birthdate) >= 18 years, and a Length of Stay (Discharge Date - Admission Date) <= 120 days.

6 - Hysterectomy stratum – Patients with an ICD-9-CM Principal Procedure Code as defined in Appendix A, on either Table 5.06 (Abdominal) or Table 5.07 (Vaginal), a Patient Age (Admission Date – Birthdate) >= 18 years, and a Length of Stay (Discharge Date - Admission Date) <= 120 days.

7 - Vascular Surgery stratum – Patients with an ICD-9-CM Principal Procedure Code as defined in Appendix A, Table 5.08, a Patient Age (Admission Date – Birthdate) >= 18 years, and a Length of Stay (Discharge Date - Admission Date) <= 120 days.

8 – Other Major Surgery stratum – Patients with an ICD-9-CM Principal Procedure Code as defined in Appendix A, Table 5.25 (Other Major Surgery for Sampling), a Patient Age (Admission Date – Birthdate) >= 18 years, and a Length of Stay (Discharge Date - Admission Date) <= 120 days.

• View the SCIP Initial Population Algorithm

---

Sample Size Requirements

Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. A hospital may choose to use a larger sample size than is required. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter for a stratum cannot sample that stratum.

Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. Because the sample for a measure set will rarely be equal to the effective sample due to exclusions and contraindications, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size.

The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual.

Quarterly Sampling

For hospitals selecting sample cases for SCIP, a modified sampling procedure is required. Hospitals selecting sample cases for this set must ensure that each individual stratum’s population and effective quarterly sample size meets the following conditions:

• Select within each of the seven individual measure stratum (e.g., colorectal surgery, hip arthoplasty, etc.) and the 8th SCIP stratum (Table 5.25 in Appendix A). The effective quarterly sample size within a stratum is at least 16 cases per quarter.
• The required quarterly sample size is at least 10% of the stratum population for the quarter.

Quarterly Sample Size
Based on Initial Patient Population for the SCIP Measure Set

Hospital's Measures
Average Quarterly Stratum Initial Patient Population Size “N”	Minimum Required Stratum Sample Size “n”
> 470	48
161 - 470	10% of the Initial Patient Population
16 - 160	16
< 16	No sampling; 100% of the Initial Patient Population is required

Monthly Sampling

For hospitals selecting sample cases for SCIP, a modified sampling procedure is required. Hospitals selecting sample cases for this set must ensure that each individual strata population and effective monthly sample size meets the following conditions:

• Select within each of the seven individual measure stratum (e.g., colorectal surgery, hip arthoplasty, etc.) and the 8th SCIP stratum (Table 5.25 in Appendix A). The effective monthly sample size within a stratum is at least 6 cases per month.
• The required monthly sample size is at least 10% of the strata population for the month.

Monthly Sample Size
Based on Initial Patient Population for the SCIP Measure Set

Hospital's Measures
Average Monthly Stratum Initial Patient Population Size “N”	Minimum Required Stratum Sample Size “n”
> 150	16
61 - 150	10% of the Initial Patient Population
6 - 60	6
< 6	No sampling; 100% of the Initial Patient Population is required

Sample Size Examples

Note: All sampled strata in SCIP should be used in the calculation of all SCIP Infection, Venous Thromboembolism (VTE), and Cardiac measures, including the several surgery-specific measures (e.g., SCIP-Inf-7, Colorectal Surgery Patients with Immediate Postoperative Normothermia). All of the SCIP measures' specific exclusion criteria are used to filter out cases that do not belong in the measure denominator. Using SCIP-Inf-7 as an example, include cases covering all sampled strata, although the measure-specific exclusion criteria would only allow cases in the colorectal stratum to be included in the denominator.

• Quarterly sampling:
  When applicable, larger hospitals must also abide by the required quarterly sample sizes for the seven individual measure stratum and the 8th SCIP strata (Table 5.25 in Appendix A) a minimum of 16 required sample cases per strata when Initial Patient Population size is 16 or greater.
  
  • The SCIP Initial Patient Population sizes for a hospital are 5, 50, 15, 140, 35, 201, 3, and 481 patients respectively per quarter. The required quarterly sample sizes would be 5, 16, 15, 16, 16, 21, 3, and 48.
    • The 1st, 3rd, and 7th strata are less than the minimum required quarterly sample size, so 100% of each of these strata are sampled.
    • The 2nd, 4th, and 5th strata each require 16 cases to be sampled.
    • The 6th stratum has 201 patients per quarter, which requires a 10% sample size, or 21 cases (ten percent of 201 equals 20.1 rounded to the next highest whole number = 21).
    • The 8th stratum is more than the maximum required quarterly sample size, so this stratum requires 48 cases to be sampled.

• Monthly sampling:
  When applicable, larger hospitals must also abide by the required monthly sample sizes for the seven individual measure stratum and the 8th SCIP strata (Table 5.25 in Appendix A) a minimum of 6 required sample cases per strata when Initial Patient Population size is 6 or greater.
  
  • The SCIP Initial Patient Population sizes for a hospital are 5, 50, 15, 141, 35, 201, 3, and 481 patients respectively in June. The required monthly sample sizes would be 5, 6, 6, 15, 6, 16, 3, and 16.
    • The 1st and 7th strata are less than the minimum required monthly sample size, so 100% of each of these strata are sampled.
    • The 2nd, 3rd, and 5th strata each require 6 cases to be sampled.
    • The 4th stratum has 141 patients per month, which requires a 10% sample size, or 15 cases (ten percent of 141 equals 14.1 rounded to the next highest whole number = 15).
    • The 6th and 8th strata are each more than the maximum required monthly sample size, so each of these strata requires 16 cases to be sampled.