Quality - QCDR

Are you struggling with submitting MIPS data to CMS?  We can help. ASPIRE, MPOG’s QI initiative, is an approved Qualified Clinical Data Registry (QCDR). With this designation, ASPIRE can report approved quality measures to CMS (Center for Medicare and Medicaid Services)  on behalf of eligible professionals (EPs) and group practices for participation in the MIPS (Merit-based Incentive Payment System).

For 2017, ASPIRE can submit information in the Quality and Improvement Activities categories.  For more information about the ASPIRE QCDR program for 2017, please refer to the Participation Guide. If your site is interested in participating, please complete the Non-Binding Letter of Intent to begin the registration process.  Only MPOG sites submitting the the Minimum Data Requirement on a monthly basis are eligible to participate.

Please note:

Approved Measures for QCDR Reporting- 2017

QCDR Measure ASPIRE Measure Abbreviation Measure Description Measure Domain
ASPIRE 2 NMB 01 Train of four monitor documented after last dose of non-depolarizing neuromuscular blocker Effective Clinical Care
ASPIRE 3 NMB 02 Administration of Neostigmine before extubation for cases with nondepolarizing neuromuscular blockade Effective Clinical Care
ASPIRE 4 GLU 01 Administration of insulin or glucose recheck for patients with hyperglycemia Effective Clinical Care
ASPIRE 6* PUL 01 Avoiding excessively high tidal volumes during positive pressure ventilation Patient Safety
ASPIRE 8 TEMP 02 Core temperature measurement for all general anesthetics Effective Clinical Care
ASPIRE 13* TRAN 02 Transfusion goal of hematocrit less than 30 Efficiency and Cost Reduction
ASPIRE 16* BP 01 Avoiding intraoperative hypotension Patient Safety
ASPIRE 18* CARD 01 Avoiding myocardial injury Effective Clinical Care
ASPIRE 19* AKI 01 Avoiding acute kidney injury Effective Clinical Care
ASPIRE 22* MED 01 Avoiding medication overdose Patient Safety
MIPS 424* TEMP 03 Perioperative temperature management Patient Safety
MIPS 426* TOC 02 Post-anesthetic transfer of care measure: procedure room to a PACU Communication and Care Coordination
MIPS 430* PONV 01 Prevention of postoperative nausea and vomiting (PONV)- combination therapy Patient Safety

For complete measure specifications, please go to the Quality Measures Webpage.

*Those measures with an (*) are considered High Priority measures per CMS.

Bold: Risk adjusted outcome measures. Risk adjustment methodology provided by the MPOG statistics team.

IMPROVEMENT ACTIVITIES

ASPIRE recommends that you review the list of improvement activities posted on the CMS website: https://qpp.cms.gov/mips/improvement-activities and select the activities most applicable to your providers.

Anesthesia providers are required to attest to 2 medium-weighted or 1 high-weighted activity for full participation in 2017.  There are 13 activities related to QCDR activity however, the five (5) activities listed below are most relevant to your participation in ASPIRE.  As we near the submission deadline, ASPIRE will send a form to each site to request information about the activities selected/performed.

  1. IA_BE_8: Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive (Medium)
  2. IA_PSPA_7: Use of QCDR data for ongoing practice assessment and improvements (Medium)
  3. IA_PM_7: Use of QCDR for feedback reports that incorporate population health (High)
  4. IA_CC_6: Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination (Medium)
  5. IA_BE_2: Use of QCDR to support clinical decision making (Medium)

Contact Katie Buehler with any questions regarding ASPIRE QCDR.