- Quality - 70% of total score: Report 6 measures, including one Outcome or high priority measure for 12 months. To earn 1 or 3 points on a measure report at least one eligible case. To earn more than 3 points on a measure report at least 60 percent of eligible cases. Suggestions for your specialty include but are not limited to the following:
ID:044NQF:0236eMeasure ID:High Priority:No
#044: Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery
Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incisionMeasure Type
ID:076NQF:eMeasure ID:High Priority:Yes
#076: Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections
Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followedMeasure Type
ID:404NQF:eMeasure ID:High Priority:Yes
- Interventional Radiology
#404: Anesthesiology Smoking Abstinence
The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedureMeasure Type
- Intermediate Outcome
ID:424NQF:2671eMeasure ID:High Priority:Yes
#424: Perioperative temperature management
Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was achieved within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end timeMeasure Type
ID:430NQF:eMeasure ID:High Priority:Yes
#430: Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy
Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively and/or intraoperativelyMeasure Type
ID:463NQF:eMeasure ID:High Priority:Yes
#463: Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics)
Percentage of patients aged 3 through 17 years, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for post-operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperativelyMeasure Type
- *These measures comprise the Anesthesia Specialty Measures Set.
- IA: Improvement Activities - 15% of total score: Attest that you completed up to 2 high-weighted activities or 4 medium-weighted activities for a minimum of 90 days. Groups with 15 or fewer participants or if you are in a rural or health professional shortage area, attest that you completed 1 high-weighted or 2 medium-weighted activities for a minimum of 90 days. There are over 90 possible measures to choose from. The following are suggestions only:
- IA_EPA_3 - Collection and use of patient experience and satisfaction data on access (medium weighted).
- IA_PSPA_5 - Annual registration in the Prescription Drug Monitoring Program (medium weighted).
- IA_AHE_1 - Engagement of new Medicaid patients and follow-up (high weighted).
- IA_BE_14 - Engage patients and families to guide improvement in the system of care (medium weighted).
- IA_CC_8 - Implementation of documentation improvements for practice/process improvements (medium weighted).
- IA_CC_2 - Implementation of improvements that contribute to more timely communication of test results (medium weighted).
- IA_CC_5 - Participate in a CMS Partnership for Patients Hospital Engagement Network (medium weighted).
- IA_PSPA_6 - Consult a Prescription Drug Monitoring program before prescribing opiates (high weighted).
- IA_BE_15 - Engage patients, family, and caregivers in developing a plan of care (medium weighted).
- IA_PSPA_19 - Implement formal quality improvement methods, practice changes, or other practice improvement processes (medium weighted).
- IA_BE_11 - Participate in a QCDR that promotes implementation of patient self-action plans, and processes and tools that engage patients for adherence to treatment plan (medium weighted).
- IA_PSPA_1 - Participate in an Agency for Healthcare Research and Quality (AHRQ)-listed patient safety organization (medium weighted).
- IA_PSPA_11 - Participate in CAHPS or other supplemental questionnaire (high weighted).
- IA_PSPA_8 - Use patient safety tools such as surgical risk calculators (medium weighted).