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MVP: Patient Safety and Support of
Positive Experiences with Anesthesia 

Most applicable medical specialty: Anesthesiology


The Patient Safety and Support of Positive Experiences with Anesthesia MVP focuses on increasing quality of anesthesia care, improving postoperative outcomes, promoting patient safety, and enhancing satisfaction for patients receiving anesthesia. The measures are used for a variety of surgical procedures that anesthesiologists deliver care for, and are broadly applicable to anesthesiologists practicing within ambulatory, outpatient, and inpatient hospital settings.

Quality

To fulfill quality requirements:

  1. You must select 4 quality measures from the list below

  2. At least 1 measure must be an outcome measure

    • If no outcome measures are available, you may report a high priority measure.
  3. You must collect data for each measure for the 12-month performance period of the associated performance year (e.g., January 1, 2023 - December 31, 2023).

    TIP: Make sure that you select measures that are appropriate to your patient population. Measures that don't meet case minimum or data completeness criteria will earn zero points.

Quality Measures (MVP ID: G0059)

ID

Title

Specs

404

Anesthesiology Smoking Abstinence

   Details

424

Perioperative Temperature Management

430

Prevention of Post-Operative Nausea and
Vomiting (PONV) - Combination Therapy

463

Prevention of Post-Operative Vomiting
(POV) - Combination Therapy (Pediatrics)

477

Multimodal Pain Management

AQI48*

Patient-Reported
Experience with Anesthesia

AQI69*

Intraoperative Antibiotic Re-dosing

Improvement Activities

You must report 1 of the following 3 options:

1. Two medium weighted improvement activities from the list below, or

2. One high weighted improvement activity from the list below, or

3. The IA_PCMH activity (participation in a certified or recognized patient-centered medical home
or a comparable specialty practice).

Improvement Activities (MVP ID: G0059)

ID

Title

IA_BE_6

Regularly Assess Patient Experience
of Care and Follow

IA_BE_22

Improved Practices that Engage
Patients Pre-Visit

 IA_BMH_2

Tobacco use

IA_CC_2

Implementation of improvements that contribute to more timely communication of test results

IA_CC_15

PSH Care Coordination

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 MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record

 IA_PCMH

Electronic submission of Patient Centered Medical Home accreditation

IA_PSPA_1

Participation in an AHRQ-listed patient
safety organization.

IA_PSPA_7

Use of QCDR data for ongoing practice assessment and improvements

IA_PSPA_16

Use of decision support and standardized treatment protocols

Cost

Important information to consider:

  1. You don’t have to submit any data for this performance category. We'll use Medicare claims data to
    calculate your cost measure performance.

    (You don't select cost measures during MVP registration. CMS will calculate your performance
    on all the cost measures included in the MVP based on available Medicare claims data.)

  2. You'll only be scored on the cost measures in this MVP for which you meet or exceed the established
    case minimum.

Cost Measures (MVP ID: G0059)

ID

Title

Specs

MSPB_1

Medicare Spending Per
Beneficiary (MSPB) Clinician

Foundational Layer - Promoting Interoperability

To fulfill Promoting Interoperability requirements:

  1. Submit the required Promoting Interoperability measures (the same as under traditional MIPS) listed below. Bonus points are available for reporting measures that aren't required.

    • If you're reporting as a subgroup, you'll submit your affiliated group's data for the Promoting Interoperability performance category.
  2. Review if you qualify for automatic reweighting of the Promoting Interoperability performance category based on your clinician type, special status, or an approved Promoting Interoperability Performance Category Hardship Exception Application.

Clinician Types for Automatic Reweighting:

  • Physical therapist (PT)
  • Occupational therapist (OT)
  • Qualified speech-language pathologist (SLP)
  • Qualified audiologist (AuD)
  • Clinical psychologist
  • Registered dietitian (RD) or nutrition professional
  • Clinical social worker

Special Status for Automatic Reweighting:

    • Ambulatory Surgical Center (ASC)-based
    • Hospital-based
    • Non-patient facing
    • Small practice

Promoting Interoperability Performance Category Hardship Exception Qualifications:

    • Decertified EHR technology
    • Insufficient internet connectivity
    • Experience extreme and uncontrollable circumstances (e.g., disaster, practice closure, severe financial distress, vendor issues)
    • Lack control over availability of CEHRT (Certified Electronic Health Record Technology)

Note: Promoting Interoperability requirements are the same in MVPs as they are in traditional MIPS. Learn more about Promoting Interoperability requirements.

Promoting Interoperability Measures (All MVPs)

ID

Title

PI_EP_1

e-prescribing

PI_EP_2

Query of the Prescription Drug
Monitoring Program (PDMP)

PI_HEI_1

Support Electronic Referral Loops By Sending Health Information

PI_HEI_4

Support Electronic Referral Loops By Receiving and Reconciling Health Information

PI_HEI_5

Health Information Exchange (HIE)
Bi-Directional Exchange

PI_HEI_6

Enabling Exchange Under TEFCA

PI_PEA_1

Provide Patients Electronic Access to
Their Health Information

PI_PHCDRR_1

Immunization Registry Reporting

PI_PHCDRR_2

Syndromic Surveillance Reporting

PI_PHCDRR_3

Electronic Case Reporting

PI_PHCDRR_4

Public Health Registry Reporting

PI_PHCDRR_5

Clinical Data Registry Reporting

PI_PPHI_1

Security Risk Analysis

PI_PPHI_2

High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides

PI_INFBLO_1

Actions to Limit or Restrict the
Compatibility of CEHRT

PI_ONCDIR_1

ONC Direct Review  Attestation

Foundational Layer - Population Health

You must select 1 population health measure at the time of MVP registration.

  • You don't have to submit any data for this measure, CMS will calculate the population health measures for you using administrative claims data.

  • This measure will be excluded from scoring if the measure doesn't have a benchmark or meet the case minimum.

  • Population health isn't a new performance category. The population health measure you select during MVP registration will be scored as part of the quality performance category provided you meet the case minimum.

  • Subgroups will be evaluated at the affiliated group level.

Improvement Activities (All MVPs)

ID

Title

Specs

479 (2022)

Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups

484 (2022)

Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions

*2023 versions will be available once updated from CMS.

Looking for a different MVP? Head back to our complete listing of MVPs.

Begin your MVP journey today.