CMS-10431 SCIP Pop Sample paper based

PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program

Surgical Care Improvement Project (SCIP)

Paper-Based Form Content for FY 2016 and Subsequent Years

CCN Hospital Name

Instructions: (1) Please enter the Total Initial Patient Population and indicate the total Medicare and Non-Medicare populations. (2) Provide the Population and Sample size information. Note: When not sampling, provide only the Total Initial Patient Population - Not Sampled.

Strata 1 Coronary Artery Bypass Graft (CABG)

Strata 1 - Sample Frequency: Not Sampling

Not Sampled Patient Population	Number
Total Initial Patient Population
Medicare Initial Patient Population
Non-Medicare Initial Patient Population

Sample Frequency: Quarterly

Initial Inpatient Population

Initial Inpatient Population	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Total
Medicare
Non-Medicare
Total

Sample Size

Sample Size	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Total
Medicare
Non-Medicare
Total

Strata 2 Other Cardiac Surgery

Strata 2 - Sample Frequency: Not Sampled

Not Sampled Patient Population	Number
Total Initial Patient Population
Medicare Initial Patient Population
Non-Medicare Initial Patient Population

Sample Frequency: Quarterly

Initial Inpatient Population

Initial Inpatient Population	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Total
Medicare
Non-Medicare
Total

Sample Size

Sample Size	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Total
Medicare
Non-Medicare
Total

Strata 3 Hip Arthroplasty

Strata 3 - Sample Frequency: Not Sampled

Not Sampled Patient Population	Number
Total Initial Patient Population
Medicare Initial Patient Population
Non-Medicare Initial Patient Population

Sample Frequency: Quarterly

Initial Inpatient Population

Initial Inpatient Population	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Total
Medicare
Non-Medicare
Total

Sample Size

Sample Size	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Total
Medicare
Non-Medicare
Total

Strata 4 (Knee Arthroplasty)

Strata 4 - Sample Frequency: Not Sampled

Not Sampled Patient Population	Number
Total Initial Patient Population
Medicare Initial Patient Population
Non-Medicare Initial Patient Population

Sample Frequency: Quarterly

Initial Inpatient Population

Initial Inpatient Population	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Total
Medicare
Non-Medicare
Total

Sample Size

Sample Size	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Total
Medicare
Non-Medicare
Total

Strata 5 (Colon Surgery)

Strata 5 - Sample Frequency: Not Sampled

Not Sampled Patient Population	Number
Total Initial Patient Population
Medicare Initial Patient Population
Non-Medicare Initial Patient Population

Sample Frequency: Quarterly

Initial Inpatient Population

Initial Inpatient Population	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Total
Medicare
Non-Medicare
Total

Sample Size

Sample Size	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Total
Medicare
Non-Medicare
Total

Strata 6 (Hysterectomy)

Strata 6 - Sample Frequency: Not Sampled

Not Sampled Patient Population	Number
Total Initial Patient Population
Medicare Initial Patient Population
Non-Medicare Initial Patient Population

Sample Frequency: Quarterly

Initial Inpatient Population

Initial Inpatient Population	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Total
Medicare
Non-Medicare
Total

Sample Size

Sample Size	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Total
Medicare
Non-Medicare
Total

Strata 7 (Vascular Surgery)

Strata 7 - Sample Frequency: Not Sampled

Not Sampled Patient Population	Number
Total Initial Patient Population
Medicare Initial Patient Population
Non-Medicare Initial Patient Population

Sample Frequency: Quarterly

Initial Inpatient Population

Initial Inpatient Population	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Total
Medicare
Non-Medicare
Total

Sample Size

Sample Size	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Total
Medicare
Non-Medicare
Total

Strata 8 (Other Surgeries)

Strata 8 - Sample Frequency: Not Sampled

Not Sampled Patient Population	Number
Total Initial Patient Population
Medicare Initial Patient Population
Non-Medicare Initial Patient Population

Sample Frequency: Quarterly

Initial Inpatient Population

Initial Inpatient Population	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Total
Medicare
Non-Medicare
Total

Sample Size

Sample Size	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Total
Medicare
Non-Medicare
Total

Please refer to the specifications on the CMS QualityNet web site:

http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1141662756099

Complete and submit the Surgical Care Improvement Project (SCIP) Measures Paper-Based Form via

email to: [email protected].

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1175. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, il Stop C4-26-05, Baltimore, Maryland 21244-1850.

PCHQR Program 03/25/2014 Page 1 of 10