The Cutting Edge

Making the Connection between Quality and Data

Posted by Eric Nilsson on Wed, Mar 13, 2013

This is the first part of a three-part series. Part 1 provides a checklist for setting up a quality program. Part 2 will focus on how to collect and report quality measures. Part 3 will examine the role that information technology plays in quality reporting systems.

Why AIMS Now  InfographicMany practitioners have serious concerns about the reporting requirements for the Physician Quality Reporting System, or as it is better known PQRS. Beginning in 2015, eligible professionals who are not successful in reporting PRQS data will be subject to a payment adjustment (i.e. cut) of 1.5% less than the Medicare Physician Fee Schedule amount for the same services rendered in 2015. This cut increases up to 2% in 2016 and thereafter.

To avoid the payment adjustments in 2015, eligible professionals must satisfactorily report PQRS quality data during the 2013 reporting period (January 1, 2013 – December 31, 2013). That means that now is the time to develop your quality reporting methodology. 

It is very important that your practice has a quality reporting program in place, not just for PQRS, but for other initiatives such as SCIP, AQI and NACOR.

The CMS website can provide many of the answers to your questions about PQRS, for example:

  • What simple steps can I take to submit PQRS quality measures data on claims?
  • Will the remittance advice issued by CMS to providers contain any information on PRQS reporting?
  • What can I do to avoid the PQRS payment adjustment? 

More than 180 frequently asked questions on quality initiatives are posted on the website, most of the questions are related to PQRS.

This three-part primer can help you get started on the road to clinical quality reporting.

Setting up a Quality Program

At the recent ASA Practice Management conference in Las Vegas, Jay Mesrobian, MD, from the Aurora Medical Group in Milwaukee, WI, spoke about the importance of establishing a quality reporting program to help improve patient outcomes, business efficiency, and regulatory compliance. Dr. Mesrobian offered these steps for getting started:

  • Designate a champion – It is important to have one person in your department or practice that is passionate about quality and will work with key stakeholders including colleagues, surgeons, patients, and hospital leadership to establish and operate a quality program.
  • Establish a list of quality indicators – A list of indicators is published on the ASA website.
  • Gather data – The preferable method is to collect data through an automated anesthesia record that is created by an Anesthesia Information Management System (AIMS). Other methods, which are more time-consuming and less reliable, include scanned data sheets, self-reporting, and chart review.
  • Report overall data to group and stakeholders – The key here is to establish a culture of quality where people aren’t threatened by the data. The goal isn’t to blame an individual anesthesia provider but to use objective data to determine the root cause and establish new processes for improvement.
  • Review sentinel events – Sentinel events such as death, wrong-site surgery, and nerve injury call for an objective, in-depth review and discussion of what went wrong and how to prevent them from happening again. For example, a new timeout process may be implemented as a result of a wrong-site surgery.
  • Measure, improve, re-measure – Quality improvement is a continuous process that relies on data collection and measurement through surveys and other feedback mechanisms.
  • Join the AQI! The Anesthesia Quality Institute (AQI) was formed to help anesthesia practices benchmark their data against themselves and address areas of weakness. The AQI is the “measuring tape” for the anesthesia specialty. To learn more about AQI, visit

I look forward to continuing this series on quality reporting. Tune in next month for the second part of this three-part quality series, which will focus on how to collect and report quality data.

Eric Nilsson

Eric Nilsson leads development and product management as Chief Technology Officer of Surgical Information Systems (SIS). He previously served as vice president of product management at Infor, where he was responsible for leading product management for the company’s SCM, CRM, CPM and EAM solution areas within Infor’s Strategic Solutions Group. Eric grew Infor’s SCM Solutions into a supply chain software provider across multiple industries with multiple software platforms. He is well versed in open systems (solution-to-solution) integration, product life-cycle management and user interface modernization. Prior to Infor, Eric served in several key management positions overseeing product management, engineering, quality assurance and documentation.


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Anesthesia Software Adoption

Topics: quality programs, Anesthesia Providers, PQRS, clinical excellence, analytics & reporting