Quality Committee
Meeting
November 22, 2021
Upcoming Events
Announcements
2023 VBR New Smoking Measures
Measure Updates (PONV 05 and GLU 05)
Mercy Health St. Mary’s QI Story
Ashley Screws, MD & Kathy Scranton, ACQR
Measure Review TOC 01
Eric Davies, MD (Henry Ford Allegiance) and Alex
Bowhuis, MD (Holland Hospital)
ASPIRE Data and Joint Commission Visit
Sunny Chiao, MD, University of Virginia
Agenda
Meeting Minutes
September 2021
Roll Call – via Zoom or
contact us
Announcements
Dr. Paul Jaklitsch (Department Chair, MPOG PI and IT Champion)
Dr. Ashley Agerson (MPOG Quality Champion)
Rebecca Johnson (MPOG Anesthesiology Clinical Quality Reviewer)
Upcoming Events
ASPIRE Quality Committee Meeting: Monday, January 24, 2022
ASPIRE/MSQC Meeting: Friday April 8th, 2022
2022 Calendar is up
to date at
mpog.org/calendar/
VBR 2023
Michigan Sites
VBR
Refresher
Value Based Reimbursement (VBR) Program is a
method to increase professional fee reimbursement
based on ASPIRE measure performance
Provider must have at least 2 years of data in
ASPIRE to be eligible
Performance calculated at hospital level. Additional
reimbursement assigned at provider level (up to 5%)
Providers practicing at more than one hospital are
assigned to the hospital where they performed the
most cases
2023 VBR
Measures
Measurement Period: 12/01/2021-11/30/2022
Potential increase in fee schedule (based on
aggregate hospital performance):
● 3% - 2 out of 3 measures met threshold
● 5% - 3 out of 3 measures met threshold
Reimbursement Period: 3/1/2023 - 2/28/2024
New
additional
focus:
Smoking
Cessation
Measurement Period: 12/01/2021-11/30/2022
New additional reimbursement: 2% (on top of the
potential 5%)
Proposed* New Measures:
Improve smoking status documentation within 30
days prior to surgery. Target: 70%
Increase the proportion of smokers who receive
treatment/cessation counseling. Target: 1%
*Pending BCBSM approval
Measure
Updates
& Feedback
PONV Update
● May 2021 Quality Committee Discussion:
○ Fourth Consensus Guidelines for the Management of Postoperative Nausea and
Vomiting released August 2020 in Anesthesia and Analgesia
○ New guidelines provide updates to both risk factors and prophylaxis recommendations
for adults and pediatrics
● Pediatric PONV prophylaxis measure (PONV 04) released in August
● Adult PONV prophylaxis measure in progress - need additional guidance before
release
PONV 05 Updates
● Since the May meeting, adult prophylaxis measure has been coded and
validated
● Added criterion for cesarean delivery cases based upon SOAP guidelines:
○ At least 2 prophylactic pharmacologic antiemetic agents from different classes given preop or
intraop (regardless of risk factors)
● Removed inclusion criteria for general anesthesia - MPOG analysis of PONV
outcome and 2020 guidelines support assessment of risk factors in patients
without GA
Preliminary Data
Current PONV 05 Specification
Percentage of patients undergoing GA, aged 18 years and older administered appropriate
prophylaxis for postoperative nausea and vomiting, as defined by:
1. At least two prophylactic pharmacologic antiemetic agents of different classes
administered preoperatively or intraoperatively for patients with one or two risk
factors
2. At least three or more prophylactic pharmacologic antiemetic agents from
different classes preoperatively or intraoperatively for patients with three or
more risk factors
3. For cesarean delivery cases only: At least two prophylactic pharmacologic
antiemetic agents from different classes preoperatively or intraoperatively.
*NEW*
Limitations and Next Steps
Ignoring MAC cases with post operative nausea and vomiting
Further analysis and discussion to address these cases later
Glucose measures
Obstetric Anesthesia Subcommittee recently voted to exclude cesarean deliveries from the
glycemic management measures (labor epidurals are already excluded)
Rationale:
● The obstetrician and nursing teams often are responsible for glucose management for
these patients before and after the c-section
● Committee recommends building obstetric-specific glycemic management measures in
the future, rather than adapt existing measures to ‘fit’ this population
*Still determining implications for cesarean hysterectomies and low glucose cases (GLU 02/04)
Mercy Health St. Mary’s
Quality Improvement
Story
Ashley Screws, MD - Quality Champion
Kathy Scranton, MSN, RN - ACQR
ASPIRE
Measure:
GLU-01
MERCY HEALTH SAINT MARY’S
•ASHLEY SCREWS MD
•KATHY LEE SCRANTON, MSN, RN
11/22/2021
A little bit
about us:
•Joined ASPIRE in 2020
•New EHR January 2020 – Epic
•Data ‘go-live’ March 2021
•303 bed hospital located in Grand Rapids, MI
•Mean case volume per month: 1389
11/22/2021 21
GLU-01
Rationale
● Surgical and anesthetic stress increases hyperglycemia incidence
in both diabetics and non-diabetics.
● Hyperglycemia can also be drug induced (administration of
steroids).
● Acute hyperglycemia in the perioperative period is known to
increase the incidence of wound infections, overall mortality,
length of stay, acute kidney injury, and delayed wound healing.
● Use of insulin to correct perioperative hyperglycemia decreases
the risk of hospital complications and mortality in cardiac and
general surgery patients.
https://spec.mpog.org/Spec/Public/5
11/22/2021
GLU-01
measure
•Description: The percentage of cases with intraoperative
high glucose (>200mg/dL) appropriately treated or
rechecked
•Inclusion: Patients with and without diagnosis of
diabetes who have a glucose level greater than 200 mg/dL
between Anesthesia Start and Anesthesia End.
•Success: Administration of insulin within 90 minutes
(either IV or SQ routes) or recheck of glucose level within
90 minutes
•Responsible Provider: The provider signed in at the first
glucose recheck or first administration of insulin. If neither
occurred, then the responsible provider is the one signed in
90 minutes after the high glucose measurement.
https://spec.mpog.org/Spec/Public/5
11/22/2021
2020 Dashboard
GLU-01:
High Glucose Treated Intra-op
11/22/2021
2021 Dashboard
GLU-01:
High Glucose Treated Intra-op
11/22/2021
MHSM
Glycemic
control
Surgical Services Guideline
GOAL: To decrease hyperglycemia preoperatively
and the adverse events associated with it,
including surgical site infection, while also
minimizing risk of hypoglycemia. Optimize blood
glucose of surgical patients in a target range of
100 to 150, with an acceptable range of 80 to 180
by using insulin
Recently revised February 2020
11/22/2021
MHSM
Glycemic
control
Surgical Services Guideline
• If POCT-BG on DOS is > 150 follow the Perioperative Glycemic Control
Algorithm and notify anesthesia.
• Point of Care Test- Blood Glucose (POCT-BG) performed every 2 hours on all
patients with known diabetes OR any patient treated with Insulin.
• The order to perform POCT-BG is included in the Anesthesia Preoperative
Patient Care Orders Policy.
• Anesthesia provider will treat based on the Perioperative Glycemic Control
Algorithm
• Keep Operative Team informed by recording next POCT-BG time on
whiteboard
• Anesthesia handoff includes:
• Blood glucose level
• Intervention dose and time of administration
• When next POCT-BG is due
11/22/2021
MHSM
Perioperative
Glycemic
Control
Algorithm
11/22/2021
GLU-01 –
failed case
review:
26 cases
MAR 2020 – AUG 2021
58% (15/26) - did not meet MHSM or ASPIRE
recheck time requirements (2hr|90min)
46% (12/26) – preop BG >150 – no tx
(failed our own institutional policy)
15% (4/26) – preop BG ≥ 200 – no tx
11/22/2021
GLU-01 –
other flagged
case review
findings
65% (17/26) - within 20 – 30 minutes
of out of room time
54% (14/26) - failed BG result (201-213)
35% (9/26) -had preop BG > 200 with
administration of insulin
27% (7/26) - blood source: arterial blood gas
27% (7/26) - classified as emergent -
ASA 4E (6); ASA 3E (1)
11/22/2021
GLU-01:
current
state
•Core A – 3 glucometers
•Core B – 2 glucometers – recently added 2
nd
•Preop – 2 glucometers
•Laminated cards of ASPIRE measures
available in each OR
11/22/2021
GLU-01:
interventions
began April
2021
• Staff meetings – 2
nd
and 4
th
Wednesday of each month
• Live meetings limited due to social distancing
• ASPIRE vs. MHSM requirements discussed at huddle,
via email and through individual conversations as
question arise.
• OR staff education - obtain POCT-BG if asked by
anesthesia providers despite it being prior to 2 hours as
outlined in institutional policy
• Circulating RN feels Anesthesia providers should ‘own’
glucometer access
• If Anesthesia providers are granted access, they will be
required to perform glucometer quality control.
11/22/2021
GLU-01:
Moving
forward
•No interest in changing our current policy .
Recently revised February 2020
•Begin by reviewing cases not meeting our own
guidelines/policy – timing of POCT-BG recheck and
following treatment algorithm
•Identify trends
•Continue to educate and encourage staff
11/22/2021
TOC-01: Intraoperative
Transfer of Care Review
Alex Bouwhuis, MD
Amy Poindexter
Holland Hospital / Holland, MI
What is TOC-01?
● Percentage of patients who undergo a procedure under anesthesia in
which a permanent anesthesia staff change occurred, who have a
documented use of a checklist or protocol for the transfer of care from the
responsible anesthesia practitioner to the next responsible anesthesia
provider.
● Exclusions: OB non-operative care, labor epidurals, handovers between
supervising anesthesiologists.
● Threshold: 90%
Checklist Items
● Identification of patient
● Age
● Gender
● Weight
● Allergies
● Discussion of pertinent/attainable medical history/preop meds
● Surgical procedure and course
● Anesthetic management and issues or concerns
● Expectations / Plan
● Introduction of new provider to surgical team
Why TOC-01?
● Communication errors are a leading cause of iatrogenic injury/death
○ Joint commission reports that the number one cause of anesthesia-related sentinel events
is breakdown in communication. 1
● Perioperative period is high stakes–mistakes can lead to rapid
deterioration
Intraoperative Hand Overs
● Have you ever played the game “telephone”?
● Opportunity for information loss and misinformation with every handover
○ One 2014 study showed that anesthesia care transitions were significantly associated with
higher odds of experiencing major in-hospital mortality/morbidity–8.8, 11.6, 14.2, 17,
21.2% with increasing # handovers. 2
● Unrealistic to eliminate provider exchanges in the OR (practicality, lunch
breaks, restroom).
○ Practical to limit them
○ Improve communication to minimize mistakes
Utility of Checklists
● To nobody’s surprise, a standardized checklist or protocol minimizes data loss / misinformation
during transfers.
● Studied ad nauseum, mostly re: OR -> PACU transfers
○ Less recent studies
● 2014 study in NEJM showed that the rate of medical-errors decreased by 23% (p<0.0001) and
preventable adverse events deceased by 30% (p<0.0001) after implementation of a checklist.
There was no negative effect on workflow. 3
● 2015 study in A&A showed significant improvements in information exchange when a checklist
was used (vasopressor use, antiemetics, EBL, and info about areas of concern, p<.003). Clinician
satisfaction with communication higher in checklist group. 4
● 2017 study in the EJA showed that intraoperative handover training and display of a checklist in
the OR improved information transfer by 43% between anesthesia providers (p<0.001). 5
TOC-01 Modifications
● Pretty simple logic here… information loss occurs during handovers, the
more handovers the worse it is, and in the periop period this can lead to
catastrophe.
● Holland Hospital has our checklist built into cerner.
○ Click on it to enter it into the record and the checklist pops up for us to go through
○ ASPIRE is able to capture this data easily
● Are any of you limited by operations issues or technological issues that are
site specific?
● What is causing poor performing sites to fail?
Final Recommendations
● We recommend to continue the measure as is…
● There are many causes of iatrogenic harm, but prominent among them are
communication-related.
● It’s relatively easy to make a checklist…
● It’s relatively easy to implement a checklist…
● Harder to change provider behavior but the juice is worth the squeeze.
References
1. Joint Commission. Sentinel event data—event type by year (The Joint Commission) 2016. Available at:
www.jointcommission.org/se_data_event_type_by_year_/. Accessed November 1.
2. Saager, L., Hesler, B. D., You, J., Turan, A., Mascha, E. J., Sessler, D. I., & Kurz, A. (2014). Intraoperative transitions of
anesthesia care and postoperative adverse outcomes. Anesthesiology, 121(4), 695–706.
https://doi.org/10.1097/aln.0000000000000401
3. Changes in medical errors with a handoff program. (2015). New England Journal of Medicine, 372(5), 490–491.
https://doi.org/10.1056/nejmc1414788
4. Agarwala, A. V., Firth, P. G., Albrecht, M. A., Warren, L., & Musch, G. (2015). An electronic checklist improves transfer and
retention of critical information at intraoperative handoff of care. Anesthesia & Analgesia, 120(1), 96–104.
https://doi.org/10.1213/ane.0000000000000506
5. Jullia, M., Tronet, A., Fraumar, F., Minville, V., Fourcade, O., Alacoque, X., LeManach, Y., & Kurrek, M. M. (2017). Training
in intraoperative handover and display of a checklist improve communication during transfer of care. European Journal of
Anaesthesiology, 34(7), 471–476. https://doi.org/10.1097/eja.0000000000000636
Poll - 1) keep as is, 2) modify, 3) retire
