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Anesthesia Measures and Improvement Activities that Contribute to Facility Measures

ASA Committee on Performance and Outcomes Measurement

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Background:
As part of the ASA strategy for quality performance measures and utilizing the CMS Value-Based Purchasing Program, the Committee on Performance and Outcomes Measurement (“CPOM”) was tasked with identifying hospital-based measures that anesthesiologists directly or indirectly influence.   A dedicated work group was established to evaluate Hospital Value-Based Purchasing measures and identify the three most significantly impacted by anesthesiologist-led care.  This work group prioritized in order of priority as follows:

1. COMP-THA/TKA Complication Rate for THA/TKA, Clinical Outcomes
2. NHSN-HAI HAI Measures (CLABSI, CAUTI, SSI, MRSA, C. diff), Clinical Outcomes
3. PSI 90 PSI 90 Composite

  • PSI 03 – Pressure Ulcer Rate
  • PSI 06 – Iatrogenic Pneumothorax Rate
  • PSI 08 – In-Hospital Fall-Associated Fracture Rate
  • PSI 09 – Postoperative Hemorrhage or Hematoma Rate
  • PSI 10 – Postoperative Acute Kidney Injury Requiring Dialysis Rate
  • PSI 11 – Postoperative Respiratory Failure Rate
  • PSI 12 – Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate
  • PSI 13 – Postoperative Sepsis Rate
  • PSI 14 – Postoperative Wound Dehiscence Rate
  • PSI 15 – Abdominopelvic Accidental Puncture or Laceration Rate

Building on this work, staff conducted a thorough review of AQI NACOR-supported Merit-based Incentive Payment System (MIPS) Clinical Quality Measures (CQMs), Improvement Activities, Qualified Clinical Data Registry (QCDR) measures, and Internal Improvement measures. Based on this analysis, they developed potential product bundles for evaluation by the work group. The measures and activities within these bundles are intended for inclusion in NACOR and through the integration with the Anesthesia Community Registry (ACR) powered by Epic. These bundles are designed to advance anesthesia quality measures that focus on hospital-based patient outcomes and to encourage broader adoption of NACOR and the ACR within institutional practice settings.

These bundles include Improvement Activities and quality performance measures aligned with the three hospital-based payment measures. It is anticipated that these recommendations will help anesthesiologists close care gaps, support quality improvement efforts, and facilitate reporting within their practices.

Below are proposed product bundles for each of the top three hospital-based measures identified and reviewed by CPOM.

COMP-THA/TKA Complication Rate for THA/TKA, Clinical Outcomes
Quality Measures Improvement Activities
  1. AQI 71: Ambulatory Glucose Management
  2. AQI 81: Use of Peripheral Nerve Blocks for Pain Management in Hip Fracture Patients
  3. IIM026: Infection Control Practices for Open Interventional Pain Procedures 
  4. IIM031: Intraoperative Antibiotic Redosing
  5. Q477: Multimodal Pain Management
  1. IA_BE_6 Regularly Assess Patient Experience of Care and Follow Up on Findings
  2. IA_BE_12 Use evidence-based decision aids to support shared decision-making.
  3. IA_PSPA_8 Use of Patient Safety Tools

 

NHSN-HAI HAI Measures (CLABSI, CAUTI, SSI, MRSA, C. diff), Clinical Outcomes
Quality Measures Improvement Activities
  1. AQI 48: Patient Reported Experience with Anesthesia
  2. AQI 81: Use of Peripheral Nerve Blocks for Pain Management in Hip Fracture Patients
  3. IIM026: Infection Control Practices for Open Interventional Pain Procedures 
  4. IIM029: Use of Neuraxial Techniques and/or Peripheral Nerve Blocks for Total Knee Arthroplasty (TKA)
  5. IIM031: Intraoperative Antibiotic Redosing 
  6. IIM032: Prevention of Arterial Line-Related Bloodstream Infections 
  1. IA_BE_6 Regularly Assess Patient Experience of Care and Follow Up on Findings
  2. IA_BE_12 Use evidence-based decision aids to support shared decision-making.
  3. IA_PSPA_8 Use of Patient Safety Tools

 

PSI 90 PSI 90 Composite
  • PSI 03 – Pressure Ulcer Rate
  • PSI 06 – Iatrogenic Pneumothorax Rate
  • PSI 08 – In-Hospital Fall-Associated Fracture Rate
  • PSI 09 – Postoperative Hemorrhage or Hematoma Rate
  • PSI 10 – Postoperative Acute Kidney Injury Requiring Dialysis Rate
  • PSI 11 – Postoperative Respiratory Failure Rate
  • PSI 12 – Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate
  • PSI 13 – Postoperative Sepsis Rate
  • PSI 14 – Postoperative Wound Dehiscence Rate
  • PSI 15 – Abdominopelvic Accidental Puncture or Laceration Rate
Quality Measures Improvement Activities
  1. AQI 71: Ambulatory Glucose Management
  2. AQI79. Neuromuscular Blockade and Quantitative Train-of-Four
  3. IIM009: Procedural Safety for Central Line Placement
  4. IIM010: Surgical Safety Checklist – Applicable Safety Checks Completed before Induction of Anesthesia 
  5. Q404: Anesthesiology Smoking Abstinence

Measures Collected in Cardiac and Orthopedic Surgery MVPs: Future…

  1. Q480: Risk-standardized complication rate following elective primary THA and/or TKA (Outcome measure)
  1. IA_BE_6 Regularly Assess Patient Experience of Care and Follow Up on Findings
  2. IA_PSPA_1 Participation in an AHRQ-listed patient safety organization
  3. IA_PSPA_8 Use of Patient Safety Tools
  4. IA_PSPA_34 Patient Safety Use of Artificial Intelligence

Date of last update: February 11, 2026