Quality Committee Meeting Minutes 11.22.21

Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)

Quality Committee Meeting Notes – Monday, November 22, 2021

Attendance:

Abess, Alex (Dartmouth)

Khan, Meraj (Henry Ford Macomb)

Agerson, Ashley (Spectrum)

Kheterpal, Sachin (MPOG)

Ahmad, Dennis (UofM Health-West)

Koltun, Ksenia (Beaumont Royal Oak)

Andrae, Michael (Utah)

LaGorio, John (Mercy Muskegon)

Angel, Alan (Bronson)

Lewandowski, Kristyn (Beaumont)

Applefield, Daniel (St. Joseph Oakland)

Lins, Steve (Bronson)

Aziz, Mike (OHSU)

Liu, Linda (UCSF)

Bailey, Meridith (MPOG)

Loyd, Gary (Henry Ford)

Berndt, Brad (Borgess)

Mack, Patricia (Weill Cornell)

Biggs, Dan (Oklahoma)

Malenfant, Tiffany (MPOG)

Bodas, Alina (Cleveland Clinic)

Mathis, Mike (MPOG)

Boutin, Jimmy (Henry Ford Wyandotte)

McKinney, Mary (Beaumont Dearborn / Taylor)

Bouwhuis, Alex (Holland Hospital)

Mentz, Graciela (MPOG)

Buehler, Kate (MPOG)

Milliken, Christopher (Sparrow)

Charette, Kristin (Dartmouth)

Nanamori, Masakatsu (Henry Ford Detroit)

Chen, Lee-Lynn (UCSF)

Nurani, Shafeena (Beaumont Troy)

Chiao, Sunny (Virginia)

Obembe, Samson (Weill Cornell)

Clark, David (MPOG)

Overmyer, Colleen (Chicago)

Cloyd, Ben (Michigan)

Owens, Wendy (MidMichigan - Midland)

Collins, Kathleen (St. Mary Mercy Livonia)

Pardo, Nichole (Beaumont)

Coleman, Rob (MPOG)

Payne, Gloria (Beaumont Dearborn)

Coons, Denise (Bronson)

Percha, Tina (Beaumont Dearborn)

Corpus, Charity (Beaumont Royal Oak)

Ping Yu, Shao (Weill Cornell)

Cuff, Germaine (NYU Langone)

Poindexter, Amy (Holland)

Davies, Eric (Henry Ford Allegiance)

Pywell, Carol (Beaumont Troy)

Dewhirst, Bill (Dartmouth)

Qazi, Aisha (Beaumont Troy)

Doney, Allison

Quinn, Cheryl (St. Joseph Oakland)

Drennan, Emily (University of Utah)

Reidy, Andrea (WUSTL)

Esmail, Tariq (University Health Network)

Riggar, Ronnie (MPOG)

Everett, Lucy (MGH)

Saad, Manal (MPOG)

Finch, Kim (Henry Ford Detroit)

Schonberger, Rob (Yale)

Fisher, Garrett (MidMichigan)

Scranton, Kathy (Mercy St. Mary)

Ginnebaugh, Nadia (St. Mary Mercy Livonia)

Screws, Ashley (Mercy Health St. Mary)

Goatley, Jackie (Michigan Medicine)

Shah, Nirav (MPOG)

Goorin, Patty (Sparrow)

Tyler, Pam (Beaumont Farmington Hills)

Harwood, Timothy (Wake Forest)

Vaughn, Shelley (MPOG)

Heiter, Jerri (St. Joseph A2)

Vishneski, Susan (Wake Forest)

Hubbert, Kate (Holland Hospital)

Wren, Jessica (Henry Ford Wyandotte/Macomb)

Janda, Allison (MPOG)

Zittleman, Andrew (MPOG)

Johnson, Rebecca (Spectrum & Metro)

Agenda & Notes

1) Roll Call: Will contact QI Champions and ACQRs directly to inquire about participation status if

missing. Other participants can review meeting minutes and contact the Coordinating Center if they

are missing from the attendance record.

2) Minutes from September 27, 2021 meeting approved- minutes and recording posted on the

website for review

3) Announcements & Updates

a) Welcome Spectrum Health! Newest site to join MPOG

i) Dr. Paul Jaklitsch- Department Chair

ii) Dr. Ashley Agerson - Quality Champion

iii) Rebecca Johnson- ACQR

b) Featured Member November and December 2021 – Eric Sun, University of California- San

Francisco

4) Upcoming Events

a) Quality Committee Meetings via Zoom: 2022 calendar is posted on website

i) Monday, January 24, 2022

ii) ASPIRE/MSQC meeting: Friday, April 8, 2022

5) VBR 2023: Michigan Sites Only

a) Value Based Reimbursement Refresher

i) Value Based Reimbursement (VBR) Program is a method to increase professional fee

reimbursement based on ASPIRE measure performance

ii) Provider must have at least 2 years of data in ASPIRE to be eligible

iii) Performance calculated at hospital level. Additional reimbursement assigned at provider

level (up to 5%)

iv) Providers practicing at more than one hospital are assigned to the hospital where they

performed the most cases

b) 2023 VBR Measures

i) Measurement Period: 12/1/2021-11/30/2022

ii) Potential increase in fee schedule (based on aggregate hospital performance):

(1) 3% - 2/3 measures met threshold

(2) 5% - 3/3 measures met threshold

iii) Reimbursement Period: 3/1/2023-2/28/2024

iv) Measures:

(1) GLU 03: Threshold of 65%

(2) PAIN 02: Threshold of 70%

(3) SUS 01: Threshold of 80%

c) New Additional VBR focus area: Smoking Cessation

i) Measurement period: 12/1/2021-11/30/2022

ii) New additional reimbursement: 2% (on top of the potential 5%)

iii) Proposed New Measures (not yet approved by BCBSM):

iv) Improve smoking status documentation within 30 days prior to surgery. Target: 70%

v) Increase the proportion of smokers who receive treatment/cessation counseling. Target: 1%

6) Measure Updates and Feedback

a) PONV Update

i) May 2021 Quality Committee Discussion

(1) 4th Consensus Guidelines for the Management of PONV released August 2020 in

Anesthesia and Analgesia

(2) New guidelines provide updates to both risk factors and prophylaxis recommendations

for adult and pediatrics

(3) Pediatric PONV prophylaxis measure (PONV 04) released in August

(4) Adult PONV prophylaxis measure in progress- need additional guidance before release

ii) PONV 05 - Adult Prophylaxis measure updates

(1) Since the May meeting, adult prophylaxis measure has been coded and validated

(2) Added criterion for cesarean delivery cases based upon SOAP guidelines:

(a) At least 2 prophylactic pharmacologic antiemetic agents from different classes given

preop or intraop (regardless of risk factors)

(3) Initially removed inclusion criteria for general anesthesia as MPOG analysis and 2020

guidelines support assessment of risk factors in patients without GA. However, PONV 05

performance across sites ranges 10-60%. Several MAC cases are currently flagged for

only having 1 risk factor and not receiving 2 antiemetics as prophylaxis

(4) MPOG Coordinating Center proposes updating the specification to only include GA cases

for the updated version of the new measure. New specification would read as follows:

(a) Percentage of patients, aged 18 years and older undergoing a procedure requiring

general anesthesia and administered appropriate prophylaxis for postoperative

nausea and vomiting, as defined by:

(i) At least two prophylactic pharmacologic antiemetic agents of different classes

administered preoperatively or intraoperatively for patients with one or two risk

factors

(ii) At least three or more prophylactic pharmacologic antiemetic agents from

different classes preoperatively or intraoperatively for patients with three or

more risk factors

(iii) For cesarean delivery cases only: At least two prophylactic pharmacologic

antiemetic agents from different classes preoperatively or intraoperatively.

(5) Limitations and Next Steps

(a) The measure will ignore MAC cases that could potentially result in postop nausea

and vomiting for this initial version of PONV 05

(b) Further analysis and discussion to address MAC cases can be done later

(6) Chat comments:

(a) Lucy Everett: I agree but what about PONV 04

(i) Nirav Shah: Will add PONV 04 inclusion criteria (to consider only GA cases) for

the pediatric subcommittee agenda in December

(b) Michael Andreae (University of Utah): Should TIVA be considered a prophylactic

intervention?

(i) Nirav Shah (MPOG Quality Director): Yes- propofol infusion is considered an

approved antiemetic agent for this measure

there is no IV placed?

(i) Nirav Shah: Great question- defer to the pediatric subcommittee for non-IV

antiemetic recommendations; will add to the December peds subcommittee

agenda. Not too many pediatric anesthesiologists on this call

(d) Eric Davies: Can we get separate outcome measures for PONV 03 for general

anesthesia cases only?

(i) Nirav Shah: Great idea- will figure out how to break out GA only cases for the

PONV 03 and 03b measures at the coordinating center.

iii) Glucose Measures

(1) Obstetric Anesthesia Subcommittee recently voted to exclude cesarean deliveries from

the glycemic management measures (labor epidurals are already excluded)

(2) Rationale:

(a) The obstetrician and nursing teams often are responsible for glucose management

for these patients before and after the c-section

(b) Committee recommends building obstetric-specific glycemic management measures

in the future, rather than adapt existing measures to ‘fit’ this population

(GLU 02/04)

b) Mercy Health St. Mary’s Quality Improvement Story: Kathy Scranton, ACQR & Dr. Ashley

Screws, Quality Champion presented QI story on GLU 01 (see slides posted on website for more

information)

c) Measure Review- TOC 01 (Dr. Alex Bouwhuis, Holland Hospital & Eric Davies, Henry Ford

Allegiance)

i) Feedback from Measure Reviewers

ii) See slides with presentation from Dr. Bouwhuis regarding TOC 01 with recommendation to

continue the measure as is

iii) Zoom Recording available to hear full discussion

iv) Recommendations from reviewers:

(1) Alex Bouwhuis (Holland) recommends continuing the measure as is

(2) Eric Davies (Henry Ford Allegiance) recommends retiring the measure

v) Chat comments:

(1) Emily Drennan (University of Utah): How are people documenting handoffs in Epic?

(a) Lucy Everett (MGH): What is mapped from our Epic build is the “handoff event”

intraoperatively. What we find is that people have done it but not clicked that

button

(i) Emily Drennan (University of Utah): The button is there but nothing behind it in

Epic

(b) Kathleen Collins (St. Mary’s Livonia): We had >90% on TOC-01 with Cerner. Epic has

been an abysmal failure with TOC-01 performance. After repeated reviews, we're

only at 60%. People are performing a handoff, but the documentation is convoluted

and failing. Clicking the correct box will help you pass, but I agree it's the content

that's critical. Computer issues are causing our failure, not the lack of handoff.

intraop. And you can also free text in it if you want

(2) Bill Dewhirst (Dartmouth): We had a handoff event that presented an ETX checklist, then

converted to the Epic-released build (sidebar report with links) when it became

available. Even though it takes one to the Staffing window, we still find that many just go

directly there. Frustratingly, our TOC-1 performance is stalled at around 70%- not sure

that I’d support discarding the measure though.

(3) Alex Abess (Dartmouth): Do Dr. Bouwhuis or Davies have thoughts about why

supervising anesthesiologists are excluded?

vi) Vote:

(1) Continue as is (13/33) 39%

(2) Modify (6/33) 18%

(3) Retire (14/33) 42%

vii) Conclusion:

(1) Nirav Shah (MPOG Quality Director): Given that the majority of responses (19/33) would

vote to either continue as is or modify, I think we need to better understand what the

requested modifications would be before we retire. The Coordinating Center will reach

out to those 6 voters individually and report back with next steps.

Meeting concluded at 11:03 am