Quality Committee
Meeting
July 24, 2023
10:00am - 11:00am Eastern Time
Announcements
Measure Updates
- SUS-07 Released
- Glucose measures
ASPIRE Multicenter QI Data Proposal
Agenda
Meeting Minutes
May 2023
Roll Call – via Zoom or
contact us
Announcements
Welcome Tony!
Associate QI Director ASPIRE
University of Michigan
Assistant Professor Anesthesiology
Associate Chair of Adult Anesthesia
Upcoming Events
2023 Meetings
Friday, July 14, 2023
ASPIRE Collaborative Meeting
● Thank you to all our speakers
● Post Meeting Wrap-up on website:
○ Slides
○ Presentation recording
○ CME information
2023 Meetings
Friday, September 15, 2023
ACQR Retreat
DoubleTree Hotel, Ann Arbor, Michigan
Friday, October 13, 2023
MPOG Retreat
San Francisco, California
Chair: Dr. Matthias Walz
Quality Champion: Dr. Spiro Spanakis
PI: Dr. Guido Musch
IT Champion:: Dr. Gregory Mitchon
Precision Feedback Study Update
A scalable service to improve healthcare quality through
precision audit and feedback
NIH National Library of Medicine, Project #1R01LM013894-01
Zach Landis-Lewis, Allison Janda, Allen Flynn, Nirav Shah
Proposal publication: https://www.researchprotocols.org/2022/5/e34990/
Dear Alex,
You may have an opportunity to improve your
performance on measure NMB-01: Train of Four
Taken, which measures the percentage of cases
with a documented Train of Four (TOF) after last
dose of non-depolarizing neuromuscular blocker.
More information about the rationale for the
measure and how it is calculated is available here.
Below is your complete MPOG quality performance
report…
100%
80%
60%
40%
20%
0%
89%
26/29
27/30
78%
25/32
87%
26/30
87%
27/31
96% 95% 96% 97%
Nov 2021 Dec 2021 Jan 2022 Feb 2022
You Peer Average
90% Goal
Progress to date
13
Aim 1:
● 35 provider interviews, 3 design iterations of prototype messages
● Preference survey completed
Aim 2:
● Software development, performance testing, and integration of
Precision Feedback Service nearing completion
Aim 3: Assess the effects of a precision feedback service
● Preparation for pilot study in 2023, cluster-randomised trial in 2024
Subcommittee Updates
Cardiac Subcommittee
● Next meeting: September, date TBD
● Agenda:
a. GLU-07: Hypoglycemia
avoidance for open cardiac
procedures - Specification &
prelim data review
b. GLU-08: Hyperglycemia
treatment for open cardiac
procedures - Specification &
prelim data review
GLU-06: Hyperglycemia management measure currently available on ‘All Measure’ &
‘Cardiac’ dashboards!
Obstetric Subcommittee
● Next meeting: November 8th, 1pm ET
● Agenda:
a. Measure Review: BP-04
b. ABX-03-OB: Azithromycin administration for cesarean delivery
Brain Health/Geriatric Workgroup
● Interested group of MPOG participants have met virtually on an ad hoc basis over the last
couple of years
● Focus on both brain health (delirium / cognition) & geriatric measures
● Email discussions re: midazolam use in geriatric population
● Current Research project (PCRC 0170): Variation in cognition / delirium / frailty assessments
across MPOG
● Please contact Henrietta Addo (addo@med.umich.edu) via email if interested in joining this
workgroup!
QI Dashboard Updates
QI Dashboard Updates
Releases scheduled periodically over the coming
months
Starting with quirks (bug fixes), then moving to
new features
Release notes will be available on the website as
changes are pushed to Production.
Performance scores will not be impacted.
Thanks to everyone for their feedback over the
last couple of years!
Measure Updates
SUS-07: Nitrous Oxide Avoided
Description: Percentage of adult cases where nitrous oxide is avoided during
anesthesia
Inclusion: Patients ≥ 18 years old undergoing any procedure requiring anesthesia
(see SUS-05 for pediatric measure)
Now available on ‘All Measure’ & ‘Sustainability’ dashboards - if interested in
adding to Provider Feedback Emails - available in new Measure Selection Tool
New Glycemic Management Measures
Per Quality Committee approval at the May meeting, new glycemic management measures are now
available:
- GLU 09: Hyperglycemia Management, Intraop (updates GLU 01 with new threshold of 180
mg/dL)
- GLU 10: Hyperglycemia Management, Periop (updates GLU 03 with new threshold of 180
mg/dL)
- GLU 11: Hyperglycemia Treatment, Periop (updates GLU 05 with a new threshold of 180
mg/dL
- GLU 12: Hypoglycemia Management, Intraop (updates GLU 02 w/ new threshold of 70 mg/dL
and recheck / dextrose within 30 minutes)
- GLU 13: Hypoglycemia Management, Periop (updates GLU 04 w/ new threshold of 70 mg/dL
and recheck / dextrose within 30 minutes)
Existing glycemic management measures to continue through 2023
Glycemic Management Measures
● Quality Committee also requested a ‘recheck only’ measure as part of the measure review
discussion
● Peds Subcommittee also in favor of recheck only measure.
Next Steps
● Specify and build new recheck measure (convene a small workgroup)
● Once recheck measure(s) are built, consider retiring GLU 09 and 10
○ Recheck related to hyperglycemia only?
○ How to deal with recheck in preop / PACU?
○ How to account for insulin treatment?
Multicenter
QI Measure Proposal
Multicenter Data Access Proposal
Situation
● A site recently proposed a project to examine compartment syndrome related to patient
positioning in the OR
● After viewing local data, Data Direct query revealed cohort level counts, but no detailed
information
● Desire to review more granular multicenter data to benchmark and identify risk factors
Background
● MPOG Research has a well-defined process for site access to multicenter data
● Includes PCRC proposal and approval, data access, and dissemination protocols
Multicenter Measure Proposal Process
Assessment:
1. There may be demand from sites to access MPOG Registry data for QI purposes (rare diseases
or complications, or areas outside of current MPOG coordinating center focus).
2. Coordinating Center should develop a process for sites to analyse registry data for QI purposes
Recommendation:
1. Site completes QI proposal based on MPOG template
2. After presentation to MPOG Quality Committee and approval, coordinating center generates
dataset and stores at MPOG Central
3. Site QI team provided access to the dataset using existing approval process
4. Site conducts analysis based on approved proposal
5. Site uses results for own QI project, and also must disseminate to other MPOG sites via Quality
Committee meeting
6. If site wishes to publish, then can develop PCRC proposal, or hand off to another interested site
Thank You!
