Quality Committee
Meeting
January 22, 2024
10:00am - 11:00am Eastern Time
Announcements
- Upcoming Events
- QI Reporting Tool Updates
Measure Review
- TEMP 03 - Dr. Simon Tom, NYU
- MORT 01 - Dr. Kathryn Lauer, MCW
Measure Update
- PAIN 02 - Dr. Patricia Mack, Weill Cornell
- NMB 02
New Measures
- NMB 04
- BRAIN 01
Agenda
Meeting Minutes
November 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
Henry Executive Center
Lansing, Michigan
Friday, October 18, 2024
MPOG Retreat
Philadelphia, Pennsylvania
Upcoming Events
Central Data Processing: Current State
MPOG Coordinating Center processes uploaded data to provide QI measure
performance and access to computed phenotypes for research and QI.
Currently, most recent data prioritized to process first. For example, if a site
uploads data from January - December 2022, then December 2022 will process first
working backwards to January 2022.
Issue: There are significant delays in processing “older” data as “new” data is
continuously uploaded & prioritized.
Central Data Processing: Change
● For the first 2 weeks of the month: will process data in the order it is
uploaded.
● The week before provider feedback emails, will prioritize the previous
month’s data, to prevent any impact on our monthly provider
feedback emails.
What does this mean?
1. If you upload data to MPOG more frequently than listed in the MPOG
2024 Maintenance Schedule, then you may not see the most recent
month’s data in QI Reporting Tool or DataDirect the Monday after the
upload.
2. You will be able to see the most recent month’s data in DataDirect and
QI Reporting tool by the third Monday of each month.
3. Benefit: Older data uploaded to the MPOG Coordinating Center will now
be processed with fewer delays and be available in QI Reporting Tool
and DataDirect more consistently.
Pediatric Subcommittee
Met December 4
th
● Congratulations to our new subcommittee leadership team!
○ Chair - Dr. Vikas O’Reilly-Shah (Seattle Children’s)
○ Vice Chair – Dr. Morgan Brown (Boston Children’s)
● New MPOG peds cardiac workgroup meeting February 13, 2024.
○ If interested in joining or learning more, please complete this brief form:
https://umich.qualtrics.com/jfe/form/SV_3DzhM5tU6mSZROK
● PAIN-01 Measure Review by Dr. Lisa Einhorn (Duke University). The subcommittee voted to
modify the following measure criteria:
○ Add performance threshold of 90%
○ Exclude Block Only cases
○ Exclude Myringotomy & Tube cases
○ Exclude cases that received no analgesia
Next Meeting: March 2024
Cardiac Subcommittee
Met December 8
th
● Discussed new antibiotic measure drafts for open cardiac procedures: Antibiotic timing
(ABX-02), redosing (ABX-03), selection (ABX-04), and overall composite measures (ABX-05)
○ Shared preliminary data for ABX-02 and ABX-03
○ Continuing to develop ABX-04 (antibiotic selection) and ABX-05 (composite) measures
with input from pharmacists
○ Will notify the group once these measures are available on your dashboards
● Reviewed unblinded performance data for glucose management measures (GLU-06, GLU-07
and GLU-08)
● The recording, minutes, and slides from the December 8th meeting are posted
● New MPOG peds cardiac workgroup meeting February 13, 2024.
○ If interested in joining or learning more, please complete this brief form:
https://umich.qualtrics.com/jfe/form/SV_3DzhM5tU6mSZROK
Next Meeting: April 2024
OB Subcommittee
Announcement:
● Congrats to Brandon Togioka, MD - New Chair OB
Subcommittee!
● Thank you to Monica Servin, MD!
Meeting Summary (11/8/2023):
● Reviewed BP:04: Voted to continue as is
● Discussed uterotonic agent use, blood loss and
transfusions for cesarean delivery
Next Meeting: Wednesday, February 7, 2024 at 1pm EST
MORT-01 Performance (Inverse)
January - December 2023
Performance Range: 0.4-1.4%
MORT-01: 30-day In Hospital Mortality
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
TEMP-03 Performance (Inverse)
January - December 2023
Performance Range: 0.4-42.2%
TEMP-03: Postoperative Hypothermia
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 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. Cases where defasciculating doses were administered, but no reversal administered.
2. Long spine cases where TOF ratio was measured only by neuromonitoring team and not documented in the
anesthesia record.
Score changes ranged from -7% to +1%. As you review cases, please contact the CC with feedback.
NMB-02 Performance
January - December 2023
Performance Range: 76-100%
QI Reporting Tool
Update
Request from sites to add denominator counts to institution comparison
graphs (departmental view only). Feedback?
*NEW*
Provider
Summary
Page
*NEW* Case Attribute Filters
*NEW* Case Attribute Filters
*NEW* Multi-select Functionality
Release Notes can be found on our website
New Measures
NMB-04: Sugammadex Dosing
NMB-04: Percentage of adult and pediatric (> 3 years) cases with sugammadex administration where
cumulative sugammadex dose is < 200 mg OR < 3 mg/kg
● Measure Time Period: Anesthesia Start to Earliest Extubation
● Exclusions:
○ Age < 2 years
○ ASA 5 & 6
○ Cases < 30 minutes
○ Patients that were not extubated in the immediate postoperative period
● Success: Cases where cumulative sugammadex dose was < 200 mg OR < 3 mg/kg
NMB-04 Performance
January - December 2023
Performance Range: 51-100%
BRAIN-01 Released!
BRAIN-01: Percentage of patients > 70 years old who received a benzodiazepine perioperatively.
Informational only - No threshold
● Measure Time Period: Pre-op Start - PACU End
● Exclusions:
○ Age < 70 years
○ ASA 5 & 6
○ Floor/ICU emergent intubation only cases
○ ICU transfer postoperatively
● Success: Avoiding administration of benzodiazepines for patients > 70 years old
BRAIN-01 Performance (Inverse)
January - December 2023
Performance Range: 1.5-75%
Thank You!
