SCOAP & CMS

SCOAP and CMS’ Inpatient Quality Reporting (IQR) Program Structural Measure, “Participation in a Systematic Clinical Database Registry for General Surgery.”

The SCOAP registry is a collection of clinical data for purposes of assessing clinical performance, quality of care, and opportunities for quality improvement.  Currently, there are 40 hospitals participating in the General SCOAP registry, 15 in Vascular Interventional SCOAP, and 18 in Spine SCOAP.  The SCOAP registry provides calculated measures, results, benchmarks, and quality improvement information to participants.

If a hospital participates in SCOAP, they can list the SCOAP registry to complete their requirement for the CMS FY2014 IQR Program Structural Measure, “Participation in a Systematic Clinical Database Registry for General Surgery.”  Structural Measure questions are answered through the online tool by the hospital.

Participation is defined as submitting standardized data elements applicable to at least two National Quality Forum (NQF) endorsed measures* related to the topic measured by the registry and reporting on all patients eligible for the measures. The hospital should use this definition to determine if they participate or not when answering the Structural Measures registry questions.

For the FY 2014 Hospital IQR Program, hospitals are not required to report to a registry and will not be penalized for not participating in a registry. A hospital’s Annual Payment Update (APU) is affected only when the hospital does not answer the required questions indicating they do or do not participate in the registry.

Hospitals participating in the Hospital IQR Program for CMS’ Fiscal Year (FY) 2015 are required to complete the Structural Measure questions annually between April 1, 2014, and May 15, 2014. Hospitals are required to complete Structural Measure questions with respect to participation during January 1, 2013, through December 31, 2013, for Fiscal Year (FY) 2015 Annual Payment Update (APU).

NOTE: Beginning with FY 2016, the “Safe Surgery Checklist Use” question will be added for payment determination with respect to participation during January 1, 2014 through December 31, 2014.


  

*NQF Endorsed Measures include the following:

The NQF measures that are applicable to the SCOAP population are highlighted (General=Blue; VISCOAP=Red).
  • 0134: Use of internal mammary artery (IMA) in coronary artery bypass graft (CABG) (STS)
  • 0300: Cardiac surgery patients with controlled postoperative blood glucose (CMS)
  • 0127: Preoperative beta blockade (STS)
  • 0284: Surgery patients on beta blocker therapy prior to admission who received a beta blocker during the perioperative period (CMS)
  • 0117: Beta blockade at discharge (STS)
  • 0273: Perforated appendix admission rate (PQI 2) (AHRQ)
  • 0265: Hospital transfer/admission (ASC Quality Collaboration)
  • 1519: Statin therapy at discharge after lower extremity bypass (LEB) (SVS)
  • 1540: Postoperative stroke or death in asymptomatic patients undergoing carotid endarterectomy (SVS)
  • 1543: Postoperative stroke or death in asymptomatic patients undergoing carotid artery stenting (CAS) (SVS)
  • 0339: RACHS-1 pediatric heart surgery mortality (AHRQ)
  • 0340: Pediatric heart surgery volume (PDI 7) (AHRQ)
  • 0352: Failure to rescue in-hospital mortality (risk adjusted) (CHOP)
  • 0353: Failure to rescue 30-day mortality (risk adjusted) (CHOP)
  • 0351: Death among surgical inpatients with serious, treatable complications (PSI 4) (AHRQ)
  • 0515: Ambulatory surgery patients with appropriate method of hair removal (ASC Quality Collaboration)
  • 1550: Hospital-level risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) (CMS)
  • 1551: Hospital-level 30-day all-cause risk-standardized readmission rate (RSRR) following elective primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) (CMS)
  • 1536: Cataracts: Improvement in patient’s visual function within 90 days following cataract surgery (AAO/Hoskins Center for Quality Eye Care)
  • 0528: Prophylactic antibiotic selection for surgical patients (CMS)
  • 0126: Selection of antibiotic prophylaxis for cardiac surgery patients (STS)
  • 0264: Prophylactic intravenous (IV) antibiotic timing (ASC Quality Collaboration)
  • 0527: Prophylactic antibiotic received within 1 hour prior to surgical incision (CMS)
  • 0301: Surgery patients with appropriate hair removal (CMS) (reserve status)

NQF Endorses Surgical Measures

More information regarding the CMS IQR Structural Measures here.