Michael J. Englesbe, MD

MSQC Program Director

QI initiative

Year Initiated

2012 Baseline

Rate

2016 Baseline

Rate

Current Rate

(2020)

Target

Reduce Morbidity Rates (all

procedures)

2012 11.8% 10.9% 6.26% 9%

Reduce Sepsis Rates (all

procedures)

2012 2.63% 2.58% 2.30% 2%

Reduce SSI Rates (all procedures)

2012 3.67% 3.23% 3.05% 2.5%

Reduce Readmissions (all

procedures)

2014 6.74% 6.49% 5.61% 5.8%

Reduce ED Visits (all procedures)

2014 9.45% 8.36% 7.09% 7.3%

Reduce LOS (all procedures)

2014 3.87 days 3.18 days 2.89 days* 4.2 days

Reduce Opioid Prescribing

(average OME prescribed for all

procedures)

2017 N/A

N/A (2017

baseline = 193)

80.7 OME <180 OME

Hernia

Lap Chole

Colectomy

Hysterectom

Whipple

New quality metrics needed

POSITIVE MARGIN

FOLLOWING COLORECTAL

CANCER SURGERY

What contributes to health?

PILOT

MAR 8 – MAR 26

20 (29.4%)

REFERRED TCS

14 (82.4%)

REFERRED GAP

68 (8.4%)

SMOKING

17 (2.1%) FOOD

INSECURITY

809 (71%) SCREENED

1144 PATIENT H&P

New quality metrics needed

•Stakeholder Advisory Board meeting at 1pm today – Members, please use the

Zoom link in your calendar invite

•We are still looking for volunteers to serve on this board which guides this

important project. Please contact Jessica Ameling if you are interested:

jameling@umich.edu

SUCCESS Study:

Surgical Urinary Catheter Care

Enhancement Safety Study

Nirav Shah, MD

ASPIRE Quality Improvement Program

Director

2021 Michigan Sites

Welcome

Current measure list on our new QI reporting tool

Your challenge is to pick measures that are

relevant to your site and providers

Our challenge is to pick measures that are

relevant across site and providers

Multimodal Analgesia across MI

Use of non-opioid adjunct (acetaminophen, nsaids, ketamine, dexmedetomidine

Sustainability across Michigan

Low fresh gas flow across when using inhalational agent

Association of race or ethnicity with QI measure performance

Still working on an automated linked dataset

Thank you