Quality Committee
Meeting
October 23, 2023
10:00am - 11:00am Eastern Time
Announcements
- Upcoming Events
- P4P/VBR Updates (for MI sites)
- MPOG App Suite Upgrade
Subcommittee Updates
Measure Updates
- BRAIN 01
- NMB 04
Measure Review: FLUID-01-NC (Dr. Brad Taicher, Duke)
QI Reporting Tool & DataDirect Updates
Agenda
Meeting Minutes
July 2023
Roll Call – via Zoom or contact
MPOG
Announcements
Chair: Dr. Gordon Morewood
Quality Champion: Dr. Joseph McComb
PI: Dr. Ellen Hauck
IT Champion:: Dr. Scott Schartel
Chair: Dr. Danny Muehlschlegel
Quality Champion: Dr. Nadia Hensley
PI: Dr. Tracey Stierer
IT: Champion:: Dr. Katie O’Connor
Upcoming Events
2024 Meetings
Tuesday, April 4, 2024
Virtual ACQR Retreat
Friday, April 12, 2024
MSQC/ASPIRE Collaborative Meeting
Schoolcraft College Vistatech Center
Livonia, MI
Friday, July 12, 2024
ASPIRE Collaborative Meeting
Henry Executive Center
Lansing, Michigan
Friday, September 13, 2024
ACQR Retreat
Location TBD
Friday, October 18, 2024
MPOG Retreat
Philadelphia, Pennsylvania
ACQR Annual Retreat
September 15, 2023
Thank you!
MPOG Application Suite Upgrade: Now Available!
● Upgrade package sent to each site’s IT contact (if you don’t know
who this is for your site, contact support@mpog.zendesk.com)
● Sites Using Desktop Virtualization (e.g. Citrix)
○ Your site’s IT team will upgrade the App Suite
● Users using the App Suite installed on their PC
○ Your site’s IT team will distribute the installer to all individuals
at their site after the database upgrade has been applied.
● Release Notes
Michigan Sites:
2024 P4P & 2025 VBR
2025 VBR Measures
Anesthesiologists are eligible if they meet the following criteria:
• Contracted with BCBSM’s PPO prior to the VBR effective date of 3/1/2025
• Have at least 2-years of data in MPOG
Performance calculated at hospital level. Providers practicing at more than one hospital are assigned to the
hospital where they performed the most cases. The increase in fee schedule can be:
• 3% – aggregate hospital performance met for 2 / 3 measures
• 5% – aggregate hospital performance met for 3 / 3 measures
Performance Period: 10/1/2023 - 9/30/2024
TEMP 02 Core Temperature Monitoring Target: ≥80%
PONV 05 PONV Prophylaxis, Adults Target: ≥50%
SUS 02 Global Warming Footprint, Maintenance Target: ≥40%
2025 VBR Smoking Cessation Measures
Performance Period: 10/1/2023 - 9/30/2024
SMOK-01 Smoking Tobacco Status Documentation Target: ≥70%
(12-month average)
SMOK-02 Smoking Tobacco Cessation Intervention Target: ≥10%
(12-month average)
• Standard VBR rules apply (see previous slide)
• Additional 2% for meeting threshold on both measures
Cohorts 1 - 7
SUS 02 ≥ 45%
PONV 05 ≥ 70%
Subcommittee Updates
OB Subcommittee
● Wednesday, November 8, 2023
1:00pm-2:00pm Eastern Time
Virtual
Agenda:
● Seeking OB Subcommittee Co-Chair
● Measure Review: BP-04
● Measure performance stratified by BMI
● Breakdown of administration of Uterotonic
Agents
Cardiac Subcommittee
● Last meeting: September 20, 2023
● Minutes posted to the website
● Glycemic management measures for open cardiac procedures reviewed -
GLU-07 & GLU-08 now available on Cardiac & All Measure dashboards!
● Next Meeting: December, 8, 2023 from 1-2pm ET
○ Next measure focus area - Antibiotic selection, timing, re-dosing
○ Unblinded review of GLU-06-CARD, GLU-07-CARD & GLU-08-CARD
Pediatric Subcommittee
● Monday, December 4, 2023
Pediatric Subcommittee Meeting
3:00pm-4:00pm Eastern Time
Virtual
Tentative Agenda
● PAIN-01-Peds Measure Review
○ Dr. Lisa Einhorn (Duke University)
● MPOG Peds Research Update
● Gestational Age at Birth
○ Best practice documentation and phenotype discussion
Performance across MPOG
Fluid Management Voting
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
New Measures
Brain Health/Geriatric Workgroup Update
BRAIN-01: Percentage of patients > 70 years old who did not receive any benzodiazepine
perioperatively. Informational only - No threshold
● Measure Time Period: Pre-op Start - PACU End
● Exclusions:
○ Age < 70 years
○ ASA 5&6 including Organ Harvest (CPT: 01990)
○ Floor/ICU emergent intubation only cases
○ ICU transfer postoperatively
● Success: Avoiding administration of benzodiazepines for patients > 70 years old
Draft specification also shared with Dr. Vilma Joseph & the ASA Committee on Performance and
Outcomes Measurement (CPOM).
NMB-04: Variation in Sugammadex Dosing
Description: Percentage of cases with sugammadex administration where cumulative
sugammadex dose ≤ 200 mg OR ≤ 3 mg/kg.
Measure Time period: Anesthesia Start to Earliest Extubation (if none, PACU end)
Exclusion:
● Age <= 2yrs
● ASA 5 and 6 cases including Organ Harvest (CPT: 01990)
● Cases <30 min
● Patients that were not extubated in the immediate postoperative period (as defined by the Postoperative
Destination phenotype). This excludes: patient transported to ICU, patient transported to another destination
and intraoperative mortality (phenotype values 0, 2 and 3).
Success: Cases where cumulative sugammadex dose was ≤ 200 mg or ≤ 3 mg/kg.
NMB-04: Variation in Sugammadex Dosing
Will be published to
“All Measures”
dashboard this week
Measure Updates
Measure Update
ABX-01 Updated to use Emergency Status phenotype- will include Emergency cases for ABX timing
BP-02 Exclude Block (only) procedures
CARD-02/03 Exclude Age < 18yrs
FLUID-01 NC/FLUID-01-C Exclude Age < 3yrs
NMB-01/02/03/04 Exclude Organ Harvest (CPT: 01990) if ASA=6
PAIN-02 Exclude cases with only diagnostic imaging (no additional procedure performed) using the Diagnostic Imaging phenotype
PONV-04 Exclude MAC cases using Anesthesia Technique: Sedation phenotype
PONV-05 Exclude bronchoscopy using the new Bronchoscopy phenotype
Updated exclusion to use Diagnostic Imaging phenotype rather than excluding only MRIs
SMOK-01/02 Exclude Organ Harvest (CPT: 01990) if ASA=6
Exclude Block (only) procedures
TEMP-03 Exclude MAC cases using Anesthesia Technique: Sedation phenotype
TRAN-01/02 Hematocrit values < 1 reported in L/L (liters of blood cells per liter of blood volume) are multiplied by 100 to convert from decimal to percentage
QI Reporting Tool
Updates
QI Dashboard Updates
Benchmark Graph
● Each hospital displayed as separate blue bar. Hovering shows hospital name
and measure score
● New info icon with graph description
QI Dashboard Updates
Location Filter
● Alert if time period includes more than one
database instance (ie Legacy Data Alert)
● Duplicate locations removed
● Tree structure display
Case List
● Faster Load Time!
● Default view is Flagged cases only
● Passed/Flagged/Excluded Filters
○ Locked until case list loads
○ Remain when switching between
measures
QI Dashboard Updates
Find a Provider Filter
● Duplicate provider names (legacy/IM) fixed
● Hospital entity added next to provider name
● Spinning wheel added to search bar to indicate loading
Data Direct Updates
New Filter Options
Starting Population
Added option for the Standardized Data File - filter updated annually as SDF is updated
New Filters
Starting Population
● Added surgery type
presets
● Auto-adds filters to
narrow the starting
population to the selected
surgery type
New Filters
Cases
● Added Surgical Service
Procedures
● Added Diagnostic
Imaging filter
● Group Procedure Type
phenotypes in
sub-category
*NEW* Medications Filter
Outputs
Reorganized output options a bit, hopefully more intuitive now!
Removed Case Types category
Bug Fixes
Corrected Institution count error when creating a new query
Date/time results now export in date/time format to Excel (downloads
only)
Thank You!
