SIP measures now available to public

Momentum growing with health care consumers

Surgical infection prevention (SIP) performance measure sets are now available on the Joint Commission’s Quality Check web site ( The evidence-based measures assess the overall use of antibiotics for surgical infection prevention.

SIP measure data are displayed only for hospitals that collect and submit SIP measure data to the Joint Commission through their selected performance measurement vendor.

The measure results that are posted cover the reporting period from October 2004 to June 2005. The comparative check, plus or minus symbol will be added when 12 months of data have been reported.

SIP measures data can be reported on seven surgical procedures: Blood vessel surgery; colon/large intestine surgery; coronary artery bypass graft surgery; hip joint replacement surgery; hysterectomy; knee joint replacement surgery; and open heart surgery other than coronary artery bypass graft.

SIP-2 measures, which cover patients having surgery who received the appropriate antibiotic which is shown to be effective for the type of surgery performed, will be added at a later date.

Beginning in mid-2004, the Joint Commission adopted the three antibiotic prophylaxis performance measures from the National Surgical Infection Prevention Project. "CMS and JCAHO are completely aligned on this important effort to reduce the incidence of surgical site infections in the United States," says Dale W. Bratzler, DO, MPH, medical director for the Oklahoma Foundation for Medical Quality, based in Oklahoma City.

Participation in the SIP project remains voluntary at this point, but more than 1,000 hospitals now are collecting and reporting these measures, Bratzler says. "There has been an increasing number of hospitals collecting this data and submitting it," he adds. "In addition, there is growing public pressure for hospitals to report infection rates. Improving performance on these measures represents a way to prevent infections."

Now that SIP measures are included on Quality Check, it raises the profile of the Surgical Care Improvement Project (SCIP), says Bratzler. (For more information on SCIP, go to

"Public reporting of quality measures often provides incentive for quality improvement activities," he says. "There is good data that show that when performance measures are reported in the public domain, they garner the attention of hospital leadership. That is essential for assuring appropriate resources for quality improvement activities."

Presenting publicly available data is a powerful was to get attention of hospital leaders, adds Jill Garrett, RN, CPHQ, perioperative care manager at Memorial Hospital in Colorado Springs, CO. "There are many valuable health initiatives, but when data is offered on a consistent basis for patients, clinicians, and family members to view, the driving force begins and the measure becomes meaningful," she says.

Patients are better educated about their medical conditions than ever before, adds Garrett. "The public domain reflects performance comparison and brings these valuable measures to the forefront," she says. "Publicized measures which are shown to impact patient outcomes and are evidence-based are a great place to start."

The organization’s medical quality chair challenged section chiefs to undertake a process improvement project for the year, she reports. "Our surgery section chief has taken on the prophylactic antibiotic SIP measures. What better way to make improvements but by a physician leader?"

Garrett points to a just-published study demonstrating that physician involvement is a significant factor for successful quality improvement.1 "At our institution, the directive of our medical quality chair and the commitment of our surgical chief are creating a successful quality improvement project with the SIP measures," she reports.


  1. Weiner BJ, Alexander JA, Baker LC, et al. Quality improvement implementation and hospital performance on patient safety indicators. Med Care Res Rev 2006; 63:29-57.

[For more information, contact:

Dale W. Bratzler, DO, MPH, QIOSC Medical Director, Oklahoma Foundation for Medical Quality, 14000 Quail Springs Parkway, Suite 400, Oklahoma City, OK 73134. Telephone: (405) 840-2891, Ext. 209. Fax: (405) 840-1343. E-mail:

Jill Garrett, RN, CPHQ, Perioperative Care Manager, Memorial Hospital, 1400 East Boulder, Colorado Springs, CO 80909. Telephone: (719) 365-2786. E-mail:]