Reporting Quality Measures

One of the quality measures reported by hospitals to the Centers for Medicare and Medicaid Services (CMS) that is published on the Hospital Compare website  is statistics on “surgery patients who were given an antibiotic at the right time (within one hour of surgery) to help prevent infection.” Answer the following questions to reflect on your understanding of this quality measure addressing the following:

  • Why is it clinically important for patients to receive antibiotics within one hour of surgery?
  • In clinical documentation what would be reviewed to report on hospital performance of this quality measure or which portion of the record would provide the most accurate information to confirm the administration of antibiotics and its time?
  • If hospital consistently scores low on this measure, what does this indicate?
  • If a hospital is scoring low on this quality measure, which clinical quality management process could be used to help the hospital understand why the performance is low?

Your initial post comprising a minimum of 450 words should have at least 3-4 peer-reviewed references.

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Source:, Hospital Compare. (n.d.). Measures and current data collection periods. Retrieved from