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Measure 358


Patient-Centered Surgical Risk Assessment and Communication

Description: The percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed and discussed prior to surgery.

Measure ID: 358

Type: Process

CMS Derm Specialty Set: No

High priority: Yes

Topped out: Yes

Reporting methods: Registry/QCDR

Maximum points: 7

Measure purpose: This measure encourages physicians to use standardized tools to assess patient risk for postoperative complications and to discuss those findings with patients. The use of risk calculators encourages greater consistency in risk assessment.  

Calculation

The numerator: The number of patients who received empirical, personalized risk assessment with a validated risk calculator, and who discussed the findings with the physician prior to surgery.

÷

The denominator: The total number of adult patients who had non-emergency surgery during the reporting period.

Measure calculation example

Dr. Crocker saw 28 patients who have non-emergency surgery during the reporting period. This is the denominator.

Dr. Crocker used a validated calculator to assess risk and discusses the assessment with the patient or their family in 26 of these encounters. This is the numerator.

Quality of patient care = 26/28. Dr. Crocker has a score of 92.9% for this measure. This translates to 5.0 to 5.9 points.

Important note:

Because this measure is topped out, there is a gap between performance scores and the number of points earned. A physician who reports on only one patient encounter earns 3 points. Physicians must achieve a performance score higher than 91.4% to earn 5 points. A score of 99.99% earns 6.9 points, while physicians must score a perfect 100% to earn the full 7 points available.


Click on the image to download PDF.

Quality measure score benchmark

CMS will award points based on a comparison of your performance rate to CMS benchmarks listed below. Reach the performance rate listed to achieve the corresponding points per measure. The maximum points you can achieve for the quality score is 45 points.

Below 3
Decile 3Decile 4Decile 5Decile 6Decile 7
Performance rate  1 patient 17.29 - 61.78
61.79 - 91.42
 91.43 - 97.63  97.64 - 99.99 100.00
Points  3 - 3.9  4 - 4.9  5 - 5.9 6 - 6.9 7

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