Quality Committee
Meeting
September 26, 2022 @10:00 ET
Meeting Minutes
July 2022
Roll Call – via Zoom or
contact us
Announcements
Welcome Nicole and Sushma!
Software developer
Measure Spec App
QI Reporting Tool
QI Coordinator
QI Initiatives
Site liaison
ACQR Annual Retreat
September 16, 2022
MPOG Annual Retreat
October 21, 2022
New Orleans, LA
Registration Open!
In person + virtual
Michigan Sites Only:
2023 P4P & 2024 VBR
2024 VBR Measures
• Members of a Physician Organization for at least 1-year
• Provider must have at least 2 years of data in ASPIRE to be eligible
• Performance calculated at hospital level- providers practicing at more than one hospital are assigned to the hospital where
they performed the most cases
• Additional reimbursement assigned at provider level:
 2 out of 3 measures met: 3%
 3 out of 3 measures met: 5%
Performance Period: 12/1/2022-11/30/2023
PAIN 02 Multimodal Analgesia Target: ≥85%
SUS 01 Fresh Gas Flow, ≤3 L/min Target: ≥85%
GLU 03 High Glucose Treated: Preop-PACU Target: ≥78%
2024 VBR Smoking Measures
Performance Period: 12/1/2022-11/30/2023
SMOK-01 Smoking Tobacco Status Documentation Target: ≥70%
(12-month average)
SMOK-02 Smoking Tobacco Cessation Intervention Target: ≥10%
(best month)
• Standard VBR rules apply (see previous slide)
• Additional 2% for meeting threshold on both measures
2023 P4P Scorecard: Cohorts 1 – 6
P4P Scorecard: Cohorts 1 - 6
• GLU-03 ≥ 80%
• SUS-01 ≥ 95%
P4P Scorecard:
Cohort 7
New Sparrow sites
New MyMichigan sites
P4P Scorecard: Cohort 7
NMB-01 ≥ 90%
WebCaseviewer
New Web CaseViewer released August 2022
Existing Toolkits
Measure Review
BP 01 and BP 03
Dr Kamal Maheshwari
Cleveland Clinic
BP 01 and BP 03 Vote
1 vote/ site
Continue as is/ modify/ retire
Need > 50% to retire measure
Coordinating center will review all votes after
meeting to ensure no duplication
Measure
Review
PONV 03
Dr. Patricia Mack Fogarty
Weill Cornell
PONV 03 Vote
1 vote/ site
Continue as is/ modify/ retire
Need > 50% to retire measure
Coordinating center will review all votes after
meeting to ensure no duplication
SUS 02 Measure Discussion
Cardiac Subcommittee updates - Make all SUS measures consistent by
excluding cases with nitric oxide administration for all SUS measures
Threshold update - Percentage of cases where carbon dioxide equivalents (CO
2
eq) normalized by hour for cases receiving halogenated agents and/or nitrous
oxide is less than CO
2
eq of 2% sevoflurane at 2L FGF = 2.83 kg CO
2
/hr during
the maintenance period of anesthesia
Threshold Discussion - did we move too far, too fast with SUS 02?
Exclusion discussion: Are we creating noise by including short cases? For
example, a case that uses 15 mins of N0
2
will have CO
2
eq >>> 2.83 kg CO
2
/hr.
Should we be flagging these cases?
Thank You!
