Quality Committee
Meeting
November 27, 2023
10:00am - 11:00am Eastern Time
Announcements
- Upcoming Events
- Outpatient Procedures Dashboard Available!
- OB Subcommittee Update
Measure Review
- AKI-01
- TOC-02
New Measures
- NMB 04
Measure Update: NMB-02
Agenda
Meeting Minutes
October 2023
Roll Call – via Zoom or contact
MPOG
Announcements
2024 Meetings
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
Upcoming Events
*NEW* Outpatient Procedures Dashboard
*NEW* Demographics Filter
*NEW* Multi-select Functionality
Certified Anesthesiologist Assistants (CAA)
Previously did not differentiate Certified
Anesthesiologist Assistants in QI
Reporting Tool (labeled as CRNAs)
As number of CAAs participating in
MPOG QI has increased, we want to
accurately reflect their care team roles
Will continue to combine both CAAs and
CRNAs in a single comparison group for
Provider Feedback emails.
Release Notes can be found on our website
OB Subcommittee
Met on Wednesday, November 8, 2023
Meeting Summary:
● Accepted applications for Vice-Chair position (will
announce results to OB subcommittee very soon)
● Reviewed BP:04 - Voted to continue as is
● Discussed uterotonic agent use, blood loss and
transfusions for cesarean delivery
● Minutes posted to the website
Next Meeting: Wednesday, February 7, 2024 at 1pm EST
AKI-01 Performance across MPOG
Avoiding Acute Kidney Injury 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
TOC-02 Performance across MPOG
TOC-02: Handoff to PACU 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
New Measures
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
Measure Updates
NMB-02: Appropriate Reversal
The measure was last reviewed by the Quality Committee in 2021 and the following changes were recommended:
1. Remove cardiac exclusion
2. Remove defasciculating dose exclusion
3. Remove the following success criteria: 3 hours between last dose of NMB and extubation does not require
reversal for adults (2 hours for pediatric patients)
Examples of cases that may have previously passed but are now flagged include:
1. Long spine cases where TOF ratio was measured only by neuromonitoring team and not documented in the
anesthesia record. Reversal not given based on neuromonitoring team TOF ratio measurements.
Score changes ranged from -7% to +1%. As you review cases, please contact the CC with feedback.
NMB-02: Appropriate Reversal
Thank You!
