Review QCDR measures, MIPS measures, and improvement activities (IA) for quality reporting as well as internal improvement measures (IIM) used for quality improvement and patient safety efforts.
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| QCDR MEAURE TITLE | MEASURE DESCRIPTION | MEASURE TYPE |
| AQI18. Coronary Artery Bypass Graft (CABG): Prolonged Intubation - Inverse Measure | Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours. | Outcome – High Priority |
| AQI48. Patient-Reported Experience with Anesthesia* | Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with anesthesia care and who reported a positive experience. | Patient-Reported Outcome - High Priority |
| AQI49. Adherence to Blood Conservation Guidelines for Cardiac Operations using Cardiopulmonary Bypass (CPB) – Composite | Percentage of patients aged 18 years and older, who undergo a cardiac operation using cardiopulmonary bypass for whom selected blood conservation strategies were used. | Composite - Process |
| AQI65. Avoidance of Cerebral Hyperthermia for Procedures Involving Cardiopulmonary Bypass | Percentage of patients, aged 18 years and older, undergoing a procedure using cardiopulmonary bypass who did not have a documented intraoperative pulmonary artery, oropharyngeal, or nasopharyngeal temperature ≥37.0 degrees Celsius during the period of cardiopulmonary bypass. | Outcome – High Priority |
| AQI67. Consultation for Frail Patients | Percentage of patients aged 70 years or older, who undergo an inpatient procedure requiring anesthesia services and have a positive frailty screening result who receive a multidisciplinary consult or care during the hospital encounter. | Process – High Priority |
| AQI71. Ambulatory Glucose Management | Percentage of diabetic patients, aged 18 years and older, who receive an office-based or ambulatory surgery whose blood glucose level is appropriately managed throughout the perioperative period. | Process |
| AQI72. Perioperative Anemia Management | Percentage of patients, aged 18 years and older, undergoing elective total joint arthroplasty who were screened for anemia preoperatively AND, if positive, have documentation that one or more of the following management strategies were used prior to PACU discharge | Process – High Priority |
| ABG44. Low Flow Inhalational General Anesthesia [NEW in 2024]* |
Percentage of patients aged 18 years or older, who undergo an elective procedure lasting 30 minutes or longer requiring inhalational general anesthesia who during the maintenance phase of the anesthetic have a total fresh gas flow less than or equal to 1 L/min (less than or equal to 2 L/min for Sevoflurane). | Process – High Priority |
| ePreop31. Intraoperative Hypotension (IOH) among Non-Emergent Noncardiac Surgical Cases* | Percentage of general anesthesia cases in which mean arterial pressure (MAP) fell below 65 mmHg for cumulative total of 15 minutes or more | Intermediate Outcome - High Priority |
* Indicates measures included in the CMS-recommended Anesthesiology Measure Set for MVP reporting. Eligible clinicians and groups are not required to report these measures towards the six measures required for the MIPS Quality Component but may find them applicable to their practice.
| MIPS MEAURE TITLE | MEASURE DESCRIPTION | MEASURE TYPE |
| QID 047. Advance Care Plan | Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan. | Process – High Priority |
| QID 130. Documentation of Current Medications in the Medical Record | Percentage of visits for patients aged 18 years and older for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. | Process – High Priority |
| QID 155. Falls: Plan of Care | Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months. | Process – High Priority |
| QID 182. Functional Outcome Assessment | Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies within two days of the date of the identified deficiencies | Process – High Priority |
| QID 226. Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user. | Process |
| QID 317. Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | Percentage of patient visits for patients aged 18 years and older seen during the measurement period who were screened for high blood pressure AND a recommended follow-up plan is documented, as indicated, if blood pressure is elevated or hypertensive. | Process |
| QID 404. Anesthesiology Smoking Abstinence* | The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure. | Intermediate Outcome – High Priority |
| QID 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 15 minutes immediately after anesthesia end time. | Outcome – High Priority |
| QID 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 anti-emetic agents of different classes preoperatively and/or intraoperatively. | Process – High Priority |
| QID 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 antiemetic agents of different classes preoperatively and/or intraoperatively. | Process – High Priority |
| QID 468. Continuity of Pharmacotherapy for Opioid Use Disorder (OUD) | Percentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment. | Process – High Priority |
| QID 477. Multimodal Pain Management* | Percentage of patients, aged 18 years and older, undergoing selected surgical procedures that were managed with multimodal pain management. | Outcome – High Priority |
| QID 487. Screening for Social Drivers of Health [NEW in 2024] |
Percent of patients 18 years and older screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety. | Process – High Priority |
* Indicates measures ncluded in the CMS-recommended Anesthesiology Measure Set for MVP reporting. Eligible clinicians and groups are not required to report these measures towards the six measures required for the MIPS Quality Component but may find them applicable to their practice.
| Activity ID | Improvement Activity Title |
| IA_AHE_1 | Enhance Engagement of Medicaid and Other Underserved Populations |
| IA_AHE_5 | MIPS Eligible Clinician Leadership in Clinical Trials or CBPR |
| IA_AHE_6 | Provide education opportunities for new clinicians |
| IA_AHE_8* | Create and Implement an Anti-Racism Plan |
| IA_AHE_10 | Adopt Certified Health Information Technology for Security Tags for Electronic Health Record Data |
| IA_AHE_11 | Create and Implement a Plan to Improve Care for Lesbian, Gay, Bisexual, Transgender, and Queer Patients |
| IA_BE_1 | Use of certified E H R to capture patient reported outcomes |
| IA_BE_6* | Collection and follow-up on patient experience and satisfaction data on beneficiary engagement |
| IA_BE_12 | Use evidence-based decision aids to support shared decision-making |
| IA_BE_14* | Engage patients and families to guide improvement in the system of care |
| IA_BE_15 | Engagement of patients, family and caregivers in developing a plan of care |
| IA_BE_16 | Evidenced-based techniques to promote self-management into usual care |
| IA_BE_22 | Improved practices that engage patients pre-visit |
| IA_BE_25* | Drug Cost Transparency |
| IA_BMH_2 | Tobacco Use |
| IA_BMH_4 | Depression screening |
| IA_BMH_9 | Unhealthy Alcohol Use for Patients with Co-occurring Conditions of Mental Health and Substance Abuse and Ambulatory Care Patients |
| IA_BMH_11 | Implementation of a Trauma-Informed Care (TIC) Approach to Clinical Practice |
| IA_BMH_12 | Promoting Clinician Well-Being |
| IA_BMH_14 | Behavioral/Mental Health and Substance Use Screening & Referral for Pregnant and Postpartum Women |
| IA_BMH_15 | Behavioral/Mental Health and Substance Use Screening & Referral for Older Adults |
| IA_CC_2 | Implementation of improvements that contribute to more timely communication of test results |
| IA_CC_8 | Implementation of documentation improvements for practice/process improvements |
| IA_CC_15 | PSH Care Coordination |
| IA_CC_18 | Relationship-Centered Communication |
| IA_CC_19* | Tracking of clinician’s relationship to and responsibility for a patient by reporting MACRA patient relationship codes |
| IA_EPA_1* | Provide 24/7 access to eligible clinicians or groups who have real-time access to patient’s medical record |
| IA_EPA_2 | Use of telehealth services that expand practice access |
| IA_EPA_3 | Collection and use of patient experience and satisfaction data on access |
| IA_EPA_6 | Create and Implement a Language Access Plan |
| IA_ERP_1 | Participation on Disaster Medical Assistance Team, registered for 6 months |
| IA_ERP_2* | Participation in a 60-day or greater effort to support domestic or international humanitarian needs |
| IA_ERP_3* | COVID-19 Clinical Data Reporting with or without Clinical Trial |
| IA_ERP_4 | Implementation of a Personal Protective Equipment (PPE) Plan |
| IA_ERP_6 | COVID-19 Vaccine Achievement for Practice Staff |
| IA_MVP | Practice-Wide Quality Improvement in MIPS Value Pathways |
| IA_PCMH | Electronic submission of Patient Centered Medical Home accreditation |
| IA_PM_11 | Regular review practices in place on targeted patient population needs |
| IA_PM_14 | Implementation of methodologies for improvements in longitudinal care management for high risk patients |
| IA_PM_15 | Implementation of episodic care management practice improvements |
| IA_PM_16 | Implementation of medication management practice improvements |
| IA_PM_17 | Participation in population health research |
| IA_PM_18 | Provide Clinical-Community Linkages |
| IA_PM_21 | Advance care planning |
| IA_PSPA_1 | Participation in an AHRQ-listed patient safety organization |
| IA_PSPA_2 | Participation in MOC Part IV |
| IA_PSPA_3 | Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS® or other similar activity |
| IA_PSPA_4 | Administration of the AHRQ Survey of Patient Safety Culture |
| IA_PSPA_7 | Use of QCDR data for ongoing practice assessment and improvements (QCDR reporting only) |
| IA_PSPA_8 | Use of patient safety tools |
| IA_PSPA_9 | Completion of the AMA STEPS Forward program |
| IA_PSPA_12 | Participation in private payer CPIA |
| IA_PSPA_13 | Participation in Joint Commission Evaluation Initiative |
| IA_PSPA_16 | Use decision support—ideally platform-agnostic, interoperable clinical decision support (CDS) tools — and standardized treatment protocols to manage workflow on the care team to meet patient needs |
| IA_PSPA_18 | Measurement and improvement at the practice and panel level |
| IA_PSPA_19 | Implementation of formal quality improvement methods, practice changes or other practice improvement processes |
| IA_PSPA_21 | Implementation of fall screening and assessment programs |
| IA_PSPA_22* | CDC Training on CDC's Guideline for Prescribing Opioids for Chronic Pain |
| IA_PSPA_23* | Completion of CDC Training on Antibiotic Stewardship |
| IA_PSPA_25 | Cost Display for Laboratory and Radiographic Orders |
| IA_PSPA_27 | Invasive Procedure or Surgery Anticoagulation Medication Management |
| IA_PSPA_28 | Completion of an Accredited Safety or Quality Improvement Program |
| IA_PSPA_31* | Patient Medication Risk Education |
| IA_PSPA_32* | Use of CDC Guideline for Clinical Decision Support to Prescribe Opioids for Chronic Pain via Clinical Decision Support |
| Measure ID | Internal Improvement Measure (IIM) Title |
| IIM001 | Assessment of Acute Postoperative Pain |
| IIM002* | Patient Education on Safe Opioid Storage and Disposal |
| IIM003 | Perioperative Cardiac Arrest |
| IIM004 | Perioperative Care: Timing of Prophylactic Antibiotic – Administering Physician |
| IIM005** | Perioperative Mortality Rate |
| IIM006*** | Postanesthesia Care Unit (PACU) Re-intubation Rate |
| IIM007 | Postdural Puncture Headache after Epidural Anesthesia/Analgesia |
| IIM008* | Pre-Procedural Timeout Checklist |
| IIM009*** | Procedural Safety for Central Line Placement |
| IIM010 | Surgical Safety Checklist – Applicable Safety Checks Completed before Induction of Anesthesia |
| IIM011 | Treatment of Hyperglycemia with Insulin |
| IIM012 | Unplanned Transfer or Admission to Hospital |
| IIM013 | Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU) |
| IIM014 | Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU) |
| IIM015 | Coronary Artery Bypass Graft (CABG): Stroke – Inverse Measure |
| IIM016 | Coronary Artery Bypass Graft (CABG): Post-Operative Renal Failure– Inverse Measure |
| IIM017 | Lung-Protective Ventilation during General Anesthesia |
| IIM018 | New Corneal Injury Not Diagnosed Prior to Discharge |
| IIM019 | Geriatric Cognitive Assessment |
| IIM020 | Ambulatory Point-of-Care Glucose Testing |
| IIM021 | Ambulatory Hyperglycemia Control |
| IIM022 | Discharge to a Responsible Patient Escort |
| IIM023 | Neuromuscular Blockade: Documented Assessment of Neuromuscular Function Prior to Extubation |
| IIM024 | Neuromuscular Blockade: Reversal Administered |
| IIM026 | Infection Control Practices for Open Interventional Pain Procedures |
| IIM027 | Ambulatory Post-Discharge Patient Follow-Up |
| IIM028 | Team-Based Implementation of a Care-and-Communication Bundle for ICU Patients |
| IIM029* | Use of Neuraxial Techniques and/or Peripheral Nerve Blocks for Total Knee Arthroplasty (TKA) |
| IIM030 | Obstructive Sleep Apnea: Mitigation Strategies |
| IIM031 | Intraoperative Antibiotic Redosing |
| IIM032 | Prevention of Arterial Line-Related Bloodstream Infections |
Date of last update: September 4, 2024
