Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)
Quality Committee Meeting Notes Monday, July 24, 2023
Attendance:
Abou Nafeh, Nancy (AUB)
Loyd, Gary (Henry Ford)
Agerson, Ashley (Spectrum)
Lewandowski, Kristyn (Corewell)
Barrios, Nicole (MPOG)
Lopacki, Kayla (Mercy Health - Muskegon)
Bauza, Diego (Weill Cornell)
Lu-Boettcher, Eva (Wisconsin)
Benitez, Julio (MyMichigan)
Mack, Patricia (Weill Cornell)
Berndt, Brad (Bronson)
Malenfant, Tiffany (MPOG)
Berris, Josh (Corewell - Farmington Hills)
McKinney, Mary (Corewell Dearborn / Taylor)
Biggs, Dan (Oklahoma)
McFarland, P (Tennessee)
Bhavsar, Shreyas
Mentz, Graciela (MPOG)
Bollini, Mara (WUSTL)
Milliken, Christopher (Sparrow)
Boutin, Jim (Henry Ford - Wyandotte)
Nanamori, Masakatsu (Henry Ford Detroit)
Bowman-Young, Cathlin (ASA)
Nurani, Shafeena (Corewell Troy)
Buehler, Kate (MPOG)
O’Conor, Katie (Johns Hopkins)
Charette, Kristin (Dartmouth)
O’Dell, Diana (MPOG)
Clark, David (MPOG)
Owens, Wendy (MyMichigan - Midland)
Cohen, Bryan (Henry Ford - West Bloomfield)
Pace, Nathan (Utah)
Coleman, Rob (MPOG)
Pantis, Rebecca (MPOG)
Collins, Kathleen (St. Mary Mercy)
Pardo, Nichole (Corewell)
Corpus, Charity (Corewell Royal Oak)
Parks, Dale (UAB)
Crump, Joyce (AUB)
Perkaj, Megan (Corewell)
Cywinski, Jacek (Cleveland Clinic)
Quinn, Cheryl (St. Joseph Oakland)
Denchev, Krassimir (St Joseph Oakland)
Reale, Sharon (BWH)
Dewhirst, Bill (Dartmouth)
Riggar, Ronnie (MPOG)
Drennan, Emily (Utah)
Rozek, Sandy (MPOG)
Ellis, Terry (Henry Ford)
Saffary, Roya (Stanford)
Esmail, Tariq (Toronto)
Sakkab, Julie (AUB)
Finch, Kim (Henry Ford Detroit)
Schwerin, Denise (Bronson)
Goatley, Jackie (Michigan)
Scranton, Kathy (Trinity Health St. Mary’s)
Goldblatt, Josh (Henry Ford Allegiance)
Shah, Nirav (MPOG)
Hall, Meredith (Bronson Battle Creek)
Smiatacz, Frances Guida (MPOG)
Harrison, Kelly (UAMS)
Spanakis, Spiro (U Mass)
Harwood, Tim (Wake Forest)
Stam, Benjamin (UMHS West)
Heiter, Jerri (St. Joseph A2)
Stewart, Alvin (UAMS)
Hubbert, Kate (Holland Hospital)
Tallarico, Roberta (UCSF)
Jervis, Karinne (Dartmouth)
Toonstra, Rachel (Spectrum Health)
Jiang, Silis (Weill Cornell)
Tyler, Pam (Corewell Farmington Hills)
Johnson, Rebecca (Spectrum & UMHS West)
VanTreese, PattiAnn (Henry Ford)
Kenron, Dan (OHSU)
Vaughn, Shelley (MPOG)
Kheterpal, Sachin (MPOG)
Vasquez, Mackenzie (Stanford)
Kumar, Sathish (Michigan)
Vitale, Katherine (Trinity Health)
Lacca, Tory (MPOG)
Woodbury, Jennifer (UCSF)
LaGorio, John (Trinity Muskegon)
Wade, Meredith (MPOG)
Langnas, Erica (UCSF)
Wedeven, Chris (Holland)
Lalonde, Heather (Trinity Health)
Zittleman, Andrew (MPOG)
Agenda & Notes
1. Roll Call: Will contact QI Champions and ACQRs directly to inquire about participation status if
missing. Other participants can review meeting minutes and contact the Coordinating Center if they
are missing from the attendance record.
2. Minutes from May 22, 2023 meeting approved - minutes and recording posted on the website for
review
3. Announcements
Featured Members - July & August
Wendy Owens, MSN, RN MyMichigan Health
Welcome New Associate QI Director, ASPIRE
Dr. Tony Edelman, MD - University of MI
4. Upcoming 2023 Meetings
July 14: ASPIRE Collaborative Meeting, Henry Executive Center, Lansing, MI
Thank you to all our speakers
Post Meeting Wrap-up on website slides, presentation recording and CME information
September 15: ACQR Retreat, DoubleTree hotel in Ann Arbor, MI
October 13: MPOG Retreat in San Francisco, CA
5. Welcome UMASS Memorial Health!
Chair: Dr. Matthias Walz
Quality Champion: Dr. Spiro Spanakis
PI: Dr. Guido Musch
IT Champion: Dr. Gregory Mitchon
6. Precision Feedback Study Update
A Scalable service to improve healthcare quality through precision audit and feedback
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-randomized trial in 2024
7. Subcommittee Updates
Cardiac Subcommittee
Next meeting: September, date TBD
o GLU-07: Hypoglycemia avoidance for open cardiac procedures - Specification & prelim
data review
o 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
Measure Review: BP-04
ABX-03-OB: Azithromycin administration for cesarean delivery
8. 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!
9. 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!
10. 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
o updates GLU 01 with new threshold of 180 mg/dL
GLU 10: Hyperglycemia Management, Periop
o updates GLU 03 with new threshold of 180 mg/dL
GLU 11: Hyperglycemia Treatment, Periop
o updates GLU 05 with a new threshold of 180 mg/dL
GLU 12: Hypoglycemia Management, Intraop
o updates GLU 02 w/ new threshold of 70 mg/dL and recheck / dextrose within 30
minutes
GLU 13: Hypoglycemia Management, Periop
o updates GLU 04 w/ new threshold of 70 mg/dL and recheck / dextrose within 30
minutes
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
o Specify and build new recheck measure (convene a small workgroup)
o Once recheck measure(s) are built, consider retiring GLU 09 and 10
o Recheck related to hyperglycemia only?
o How to deal with recheck in preop / PACU?
o How to account for insulin treatment?
DISCUSSION:
Roya Saffary (Stanford) - If these metrics have been included in provider emails, will they
automatically switch to the new measure?
o Kate Buehler (MPOG) - Hi Dr. Saffary, No - won't auto-replace the existing measures in
provider feedback emails as not all sites may opt for the new version of the measure.
However, you can now use the measure selection application within the QI Reporting
Tool to update your site measure selection for provider feedback emails pretty quickly!
Let me or Nicole know if you need help accessing the new measure selection app!
Tim Harwood (Wake Forest): I understand the technical difficulties of getting the glucose
labs in the system within 15 minutes but believe the Level 2 (BG<54) values should be
rechecked within 15 minutes for the measure. Level 1 rechecks within 30 minutes is
reasonable but would like to hear other members’ thoughts on the Level 2 recheck
timeframe.
o Josh Goldblatt (Henry Ford Allegiance): If we could have a column within the case list for
the expected time for the recheck, then we can quickly analyze the actual recheck times
and determine which opportunities exist. Also, where did we land for a decision on
formal labs as they result within 45 minutes? Did we decide to exclude those?
o Kate Buehler (MPOG) Yes, we can take a look at adding this to the measure case report
as a column.
o Nirav Shah (MPOG): We decided to include formal labs for now to allow sites the
opportunity to review those cases and determine what structural issues may need to be
addressed to allow providers to be notified timely when formal labs are resulted to
allow for proper treatment. Can revisit this as necessary after the measure is in
production and sites have had a chance to do some review.
11. Multicenter QI Measure 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
Assessment:
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).
Coordinating Center should develop a process for sites to analyze registry data for QI
purposes
Recommendation:
Site completes QI proposal based on MPOG template
After presentation to MPOG Quality Committee and approval, coordinating center
generates dataset and stores at MPOG Central
Site QI team provided access to the dataset using existing approval process
Site conducts analysis based on approved proposal
Site uses results for own QI project, and must disseminate to other MPOG sites via Quality
Committee meeting
If site wishes to publish, then can develop PCRC proposal, or hand off to another interested
site
DISCUSSION:
Tariq Esmail (University Health Network- Toronto): Great proposal but by definition, when
we talk about rare cases, even if deidentified, the cases would be deidentified but would the
institutions be deidentified also?
Nirav Shah (MPOG): Great question. It would deidentified by both patient and
location perspective. Similar to how we do this for a research proposal- using an
anonymized institution ID.
Dan Kenron (OHSU) - deidentified refers both to PHI and site/location, correct?
Nirav Shah (MPOG): Correct (addressed in response to Dr. Esmail’s question)
Shafeena Nurani (Corewell East) I would support It
Josh Goldblatt (Henry Ford Health, Jackson) - QI is typically an internal process. Analysis is
typically pre-post intervention. I can't picture a case where we would need data from other
sites. Can you give an example?
Nirav Shah (MPOG) - Site example was interested in looking at compartment
syndrome and if the incidence at their site was like other MPOG sites. Similarly, this
would allow sites to analyze data for a potential new QI measure and the feasibility
of this.
Silis Jiang (Weill Cornell): Any thoughts on requiring an IRB non-human subjects
determination?
Nirav Shah (MPOG): As most QI work is usually exempt by IRB standards, I think this
would fall into that category and also be exempt but would be governed by the
Quality Committee and would seek IRB approval for studies if there was human
subject involvement beyond our current performance measurement.
Dan Biggs (University of Oklahoma) - If you identify an event that is rare enough, would that
allow us to identify the place?
Nirav Shah (MPOG) - One of the ways we would want this approved is through quality
committee to discuss and manage that risk
Kathleen Collins (Trinity Health Livonia) - This might allow sites to check the frequency of
supposed/assumed rare cases or outliers. Some might be more frequent than we expect
Tariq Esmail (University Health Network- Toronto) - On the research side, is there a
minimum case number that needs to be achieved to be revealed?
o Nirav Shah (MPOG): If you look at this in Data Direct at the cohort level, we have a
minimum threshold of cases to show up to reinforce the fact that there may be
some variation in quality
o Sachin Kheterpal (MPOG): This group is going to guide what that threshold is
o Tariq Esmail (University Health Network- Toronto): It sounds like this discussion is
just to determine if we should move forward and not the specific definition of
process but if one site has a complete outlier, we would need a process in place to
determine what to do with these types of circumstances to notify the site to let
them know. If the site has a rare event and is unaware of it, the Coordinating Center
would need to reach out to the site.
o Nirav Shah (MPOG): Yes correct. At the coordinating center we would want to know
we have approval from the quality committee to identify and reach out to the site
o Sachin Kheterpal (MPOG): What we’re discussing today is whether or not we should
allow QI project proposals. The specifics are very helpful to address any nuances.
Shreyas Bhavsar (MD Anderson) Thank you for bringing this forward. We originally were
looking at our local site data for compartment syndrome and with limited number of cases
were interested in the incidence of this complication among all MPOG sites.
Kim Finch (Henry Ford Health System) - Is compartment syndrome something that would be
identified MPOG in the data? It seems like healthcare risk reporting system is where that
info would live. Then you have to worry about discoverability
o Nirav Shah (MPOG) - Thanks, Kim. Yes it would definitely live in other places but
this proposal process would allow sites to access this data via MPOG as it may live
within the MPOG data as well.
o Sachin Kheterpal (MPOG) - this would only include data within MPOG, therefore,
already in the EHR and "discoverable"
Meeting concluded at 1057