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Annual Retreat
QI Update
October 8th 2021, Afternoon
Gratitude
Agenda
What have we accomplished
Announce and describe new
initiatives
Plans for 2022
New Measures
Released This Year
ABX 01
BP 04
GA 01
GA 02
PAIN 01
(peds)
PONV 04
(Peds)
TEMP 04
(Peds)
GLU 05
Subcommittee focused, existing domains
PAIN 02
QI
Reporting
Tool
Slowness when navigating through screens
Still working through issues
Have not been able to officially “retire” old
dashboard
We understand this is causing challenges and
are trying to resolve as soon as possible
Measure
Review
In the last year, we have matured this
process
Early communication, posting of
reviews, voting on measures
Many thanks to the Quality
Champions who took on this extra
responsibility, and produced such
excellent reviews
Thank You
September 2020
AKI 01
Mike Aziz
Mike Mathis
Bishr Haydar (peds)
January 2021
PUL 01 and 02
Avery Tung
Douglas Colquhoun
Wes Templeton (peds)
January 2021
TEMP 03
Simon Tom
Vikas O'Reilly Shah
March 2021
CARDS 02 and 03
Andrea Reidy
Michael Andrawes
May 2021
TRAN 01 and 02
Linda Liu
Masakatsu Nanamori
John Trummel
September 2021
NMB 01 and 02
Alvin Stewart
Peter Panagopoulos
Tim Dubovoy
Did we deliver
on our 2021
plan?
GLU 05 (Insulin) and GLU 06
(Preoperative Testing)
Completed GLU 05, GLU 06
on hold
Build respiratory bundle
measure
No. Progress with
phenotypes for pulmonary
complications
Peds/OB/Cardiac measures Yes
Registry outcomes on QI
reporting tool
No
Share MPOG QI stories Yes
More informational measures Yes (PAIN 01 and 02)
SUS 02 and Risk adjustment No. Progress with both
Subcommittees
2021 Pediatric
Subcommittee
• Measures Reviewed
– TOF Monitoring
– Neuromuscular Blockade Reversal
– Transfusion Vigilance
– Overtransfusion
• NEW Pediatric Measures
– Multimodal Analgesia (PAIN-01)
– PONV Prophylaxis (PONV-04)
Vikas O’Reilly Shah, MD, PhD
Seattle Children’s, University of Washington
DO, MBA
OB Anesthesia
Subcommittee
Focused on processes and
outcomes for cesarean
deliveries: antibiotic
timing, hypotension, rate
of general anesthesia, and
hypothermia
Thank you Drs. Dan Biggs and Rachel Kacmar!
Best Wishes Brooke! Congratulations on your new Nursing Supervisor role!
Cardiac
Anesthesia
Subcommittee
Focusing on temperature
management (prevention
of hypothermia and
hyperthermia on bypass)
Involving perfusion
colleagues
Helped release new
cardiac case phenotype
New QI Project to improve delirium screening in
routine clinical setting
Phillip Vlisides, MD
University of Michigan
3 phased approach
Conduct surveys and focus groups with
nursing colleagues to determine barriers to
delirium screening practices on hospital
wards.
Based on barriers identified, conduct a pilot
implementation trial with the goal of
improving delirium screening frequency and
accuracy.
Collaborate with the Michigan Value
Collaborative to determine the impact of
delirium detection on healthcare value and
costs during hospitalization
ASPIRE for Better Geriatric Care
Germaine Cuff
NYU Langone
Rob Schonberger
Yale University
Mark Neuman
U Pennsylvania
Xan Abess
Dartmouth Hitchcock
Ann Donovan
UCSF
Stacie Deiner
Dartmouth Hitchcock
Lee-Lynn Chen
UCSF
Lucy Everett
MGH
Suggested
Measures
• Percent of patients age >80 undergoing non-
cardiac GA who received a benzodiazepine
from anesthesia start to anesthesia end.
• Percent of patients age >80 undergoing GA
with ETT who received more that 1.5mg/kg of
single propofol dose for induction.
• Percent of patients age >65 without
preoperative hypotension undergoing GA for
non-cardiac surgery who had episode of MAP
< 55 mmHg within 15 minutes of induction.
• The use of rescue Sugammadex following full
reversal by neo/glycol.
23
Efforts informed by ASA Brain
Health Initiative, IHI, ACS
Geriatric Surgery Verification
Program
MPOG Delirium
Data
Delirium
Concepts
Built
Confusion Assessment Method
Cornell Assessment Pediatric Delirium - Postoperative Assessment
Clock Drawing - The patient is asked to draw a clock showing a certain time.
Used as a screen for cognitive impairment and dementia
Mini Mental Status Exam - Cognitive function test measuring orientation,
attention, memory, language, and visual-spatial skills
Mini-Cog: Used to detect cognitive impairment and consists of a 3-item recall
test and a clock drawing test
Montreal Cognitive Assessment - MoCA - 30 item, 10 minute assessment of 8
cognitive domains
4AT - Rapid Test for Delirium, AD8 - Dementia Screening Test
Hopkins Frailty
Next Steps
Programs/processes to improve delirium
screening
More sites need to map concepts
Evaluation and
Improvement of
Provider Feedback
emails
Congratulations to Zach Landis Lewis and Team
Project Title: A scalable service to improve
healthcare quality through precision audit and
feedback
Direct Sponsor: Health and Human Services,
Department of-National Institutes of Health,
1R01LM01389401
Project Dates: 9/2021 - 8/2025
Zach Landis-Lewis, PhD, MLIS
Assistant Professor of Learning Health Sciences
NLM R01 Aims and key system functions
Precision feedback: Example 3 (text only)
29
Hello Dr. Jane,
Congrats on your high performance for avoiding postoperative
nausea and vomiting (PONV-03)! You have stayed above the
peer benchmark for 6 months!
You achieved a performance above the peer benchmark for
the last 6 months.
Below is your MPOG quality performance report. For a case-
by-case breakdown of any measures’ result, click on the link
at left to visit your quality dashboard.
Plan for
MPOG 2022
Fix QI Reporting App performance issues
Add QI Measures to Filters and Output to
DataDirect
Continue Measure Review (OME, TEMP 01 and
02; BP 01, 02, 03; SUS 01; PONV 03)
CaseViewer for Web
Measures: SUS 02, Risk Adjustment, Registry
Outcome on QI Reporting Tool (start with MI
sites)
Continue review and validation for Length of Stay
phenotype
Thank You
Small Group
Sessions Next
1:45 - 2:15
Viewing Measure Performance: How to improve our QI
visualizations and QI Reporting Tool - Kate Buehler (Harbor C)
Self Service Data Tools: How to use the new Standardized Data
File and improve Data Direct – Dr. Douglas Colquhoun (Harbor
A/B - main room)
2:15 - 2:45
Improving our MPOG Quality Committee meetings: Time to
rethink our approach? - Nirav Shah (Harbor C)
Feedback on proposed MPOG fellowship - Sachin (Harbor A/B -
main room)
1:45 - 2:45 (Virtual)
Rapid fire feedback on your proposed research project - Dr. Mike
Mathis/Shelley Vaughn
Improving our MPOG Quality
Committee meetings: Time to
rethink our approach?
Current
features of
our QC
meetings
Participants: MI + non MI Quality
Champions
Frequency: 6x/year
Measure Review
Measure Updates
Items of Interest
MPOG QI
Coordinating
Center
Build platform
Build and validate measures
Provider feedback
MOCA
QI Toolkits
Ideas?
Focus on single/fewer QI Initiatives (ie delirium)
Adverse event reporting and workflow
Measures - certification process - MIPS/NQF. Technical Expert Panel
Measure management
QC meeting: more/less? MI only meetings? Too many people?
How to integrate/ align more closely with your sites QI efforts?
More technical services? QI services?
Appendix
38
• ASA - Brain Health Initiative - Mission: to arm anesthesiologists and other clinicians involved in
perioperative care, as well as hospitals, patients and their families caring for older surgical
patients with the tools and resources necessary to optimize the cognitive recovery and
perioperative experience for adults 65 years and older undergoing surgery.
– https://www.asahq.org/brainhealthinitiative
• IHI – Age Friendly Health Systems Initiative - is an initiative of The John A. Hartford Foundation
and the Institute for Healthcare Improvement in partnership with the American Hospital
Association and the Catholic Health Association of the United States to help deliver age-friendly
care.
– https://www.johnahartford.org/grants-strategy/current-strategies/age-friendly/age-friendly-health-systems-initiative
• ACS – Geriatric Surgery Verification Program - Developing surgical standards (2 of which are
optional) designed to systematically improve surgical care and outcomes for the aging adult
population. The standards provide a framework for hospitals to take an interdisciplinary approach
to continuously optimize surgical care for older adults.
– https://www.facs.org/quality-programs/geriatric-surgery
Clock Drawing - The patient is asked to draw a clock showing a certain
time. Used as a screen for cognitive impairment and dementia
Institutions Case Counts
Dartmouth-Hitchcock, University of Chicago, MD Anderson Cancer
Center, University of Michigan, Bronson Healthcare Group
1-14
Mini Mental Status Exam - Cognitive function test measuring orientation,
attention, memory, language, and visual-spatial skills
Institutions Case Counts
University of Michigan 20
Mini-Cog: Used to detect cognitive impairment and consists of a 3-item
recall test and a clock drawing test
Institutions Case Counts
University of Florida Health Jacksonville, Bronson Healthcare Group 3-303
Montreal Cognitive Assessment - MoCA - 30 item, 10 minute assessment
of 8 cognitive domains
Institutions Case Counts
University of Michigan Health System 2583
4AT - Rapid Test for Delirium
Institutions Case Counts
Dartmouth-Hitchcock ~520
Cornell Assessment Pediatric Delirium - Postoperative Assessment
Institutions Case Counts
University of Michigan Health System, MD Anderson Cancer Center 943-1031
Confusion Assessment Method - Delirium Screening Tool
Institutions Case Counts
Beaumont, Bronson Healthcare Group, Dartmouth-Hitchcock Medical
Center, Duke University, Holland Hospital, Trinity, UCLA Medical
Center, University of Florida Health Jacksonville, University of
Michigan Health System, University of Virginia Health System
7 - 52,000
Hopkins Frailty
Institutions Case Counts
University of Florida Health Jacksonville ~1000
AD8 - Dementia Screening Test
Institutions Case Counts
Dartmouth-Hitchcock 2
Cognition Assessment
Institutions Case Counts
Bronson, MD Anderson Cancer Center, Henry Ford, Trinity 180 - 48,000