Mercy Health Muskegon
Managing Change: On-Boarding
Dr. John LaGorio, Physician Champion
Joan Crawford, ACQR
ASPIRE QI STORY
About our facilities…
• Member of Trinity Health
• Presently 2 Muskegon campuses, Hackley and Mercy,
with a combined total of 21 ORs
• Currently under construction is a new facility to
consolidate both campuses
• Completion is scheduled for the fall of 2019 with the ED
and ORs opening in late fall of this year
• New building will have 20 ORs
• Currently 409 beds between the two campuses, most of
which are semi-private
• Consolidation will give us 267 private rooms
• Will change to Epic EMR in 2020
About our providers…
• American Anesthesiology of Michigan-Lakeshore (AAMU)
• Our group provides services at 3 hospitals and 2
ambulatory surgical services centers in West Michigan
• 32 anesthesiologists and 23 CRNAs
• Perform about 30,000 cases/yr between Hackley and
Mercy
About MPOG/ASPIRE…
• Cohort 1, started in 2015
• Since 2015: Significant staffing adjustments
– 38 new providers (temp or permanent) were brought on-board
– ACQR turned over 4 times
– 29 providers activated their email
– 3 providers enrolled in MOCA4 through MPOG
• MPOG has had new measures developed
• MPOG has had some specification changes with
measures
• 2018 P4P site directed measure – TEMP 01
About all that change…
• Using the Provider list in Galileo we determined
– PUL 01: new staff comprised 44% of all of providers in this measure and were
responsible for 51% of the measure fails
– TRAN 02: new staff comprised 43% of all providers in this measure and were
responsible for 55% of the measure fails
– TEMP 01: new staff comprised 45% of all providers in this measure and were
responsible for 36% of the measure fails
• Using this Galileo tool we were able to drill down and determine one long-term provider
had 23% of the institutional fails
• The provider did not document Bair huggers in the anesthesia record although the peri-
op nursing record contained this information
About improvements…
• In April 2018 (borrowing Jerri’s template) we updated the
pocket measure card and distributed it to both new-hires
and long term providers.
• The card is a tri-fold measuring approximately 5”x5”
• Contained all the measures current at that time
– Inclusions
– Exclusions
– Compliance
• Included a link to the MPOG site for full specifications
Pocket Measure Card
About Improvements (cont)
• Each new provider receives a welcome letter from the
anesthesia practice’s QA Manager outlining her role in the
practice’s compliance, risk metrics and MPOG
• The one-pagers for the 3 MPOG measures (PUL 01,
TRAN 02 and TEMP 01) were included
• A monthly score card goes out as well
• New providers are clinically on boarded with a mentor
– ASPIRE metrics reviewed
Score Card
PUL 01: Low Tidal Volume <10 mL/kg
The four new providers:
Our institutional compliance for the past 12 months:
TRAN 02: Post transfusion monitoring
*low denominator
Our institutional compliance for the past 12 months:
The four new providers (no included cases):
TEMP 01: Active Warming
Our institutional compliance for the past 12 months:
The four new providers:
About the future…
• Surgical Review Committee – ACQR to begin presenting
at these staff meetings, first presentation in December
• Revise Welcome Letter to include
– links to MPOG
– sign up for provider emails
– link to MOCA4 participation
THANK YOU!
QUESTIONS?
