Quality Committee
Meeting
November 25, 2024
10:00am - 11:00am Eastern Time
Announcements
- New Sites
- Featured Member
- MPOG Retreat Wrap Up and 9/2024 QC meeting follow up
- Dissemination of Performance Data
- Pediatric Subcommittee Update
- December App Suite Upgrade
- Perioperative Blood Management Toolkit Released!
QI Reporting Tool Updates - Specialty Dashboards
2025 Measure Review Plan
Measure Updates
- ABX 03-C
- SUS 02
- TRAN 01 and TRAN 02
- TOC 02
- PONV 05
New Measures
- AKI 02-C
- ABX 04-C
- ABX 05-C
Agenda
Announcements
Upcoming Events
2025 Meetings
Friday, April 11, 2025
MSQC/ASPIRE Collaborative Meeting
Novi, MI
Friday, July 18, 2025
ASPIRE Collaborative Meeting
Henry Executive Center
Lansing, Michigan
Friday, September 2025
Specific Date TBD
ACQR Retreat
Location TBD
Friday, October 10, 2025
MPOG Retreat
San Antonio, Texas
Thanks to all that attended the 2024 Retreat
MPOG Retreat and 9/2024 QC Follow Up
1. Request for feedback: Updates to QI Reporting in 2025 to make it easier to
view data from a health equity perspective
2. Request for feedback: MPOG to propose updates that improve experience QI
for Learners
3. Reminder: Process to disseminate MPOG data
Disseminating Aggregate Multicenter Data
Aggregate Multicenter MPOG Reports – Example Scenarios:
• QI Teams - figure displaying aggregate anonymized performance for a QI measures as
part of poster presentation
• Quality Committee – Our colleagues at ASA/AQI have requested permission to use a
screenshot of MPOG QI Reporting Tool anonymized performance benchmarking
graph
• Recent Requests from Research Teams:
– Table showing the # of times ketorolac was administered for pediatric
tonsillectomies at each anonymized MPOG site
– Line graph showing monthly trend in % cases adherent to NMB-05 QI metric (use
of quantitative twitch monitoring) for all MPOG institutions
Aggregate Multicenter MPOG Reports – Example Scenarios:
Please contact the CC (mpog-quality@med.umich.edu) before
disseminating any results
Expedited Approval Pathway by DCC
Data Sensitivity Low potential for data to stigmatize patients/clinicians; or
dissemination outlet to promote misguided public perception
Data Quality Mature phenotype, QI measure, or commonly used MPOG
concept
Query Complexity No/minimal DCC programmer effort required
Analysis Complexity Descriptive statistics only (counts, %, mean/SD, median/IQR),
typically resulting in a single table or figure
Coordinating Center reviews all request and will either approve (ie expediting review) or
review at QC based on these 4 factors
Pediatric Committee Updates
Peds Cardiac Subcommittee
● Goal to build 2-3 specific metrics using a uniform peds cardiac cohort
○ In the process of refining Peds Cardiac Procedure phenotype.
○ Plan to review blinded data variation for measures of interest at next meeting in
early 2025 to inform measure build direction.
General Pediatrics Committee: PONV-04-Peds Measure Review
Proposed Modifications: will be voted upon release of the new 2025 PONV guidelines
○ Success criteria → 1 agent for low risk patients (0 risk factors), and combination therapy
of two agents for higher risk (≥ 1 risk factor).
○ Opioid risk factor → Multiple doses of any opioid intraop/postop
○ Include Infants
○ Consider Hydrocortisone IV as an antiemetic
○ Add Anticholinesterase administration intraop as a risk factor
MPOG Application Suite Upgrade: Coming Soon!
● Upgrade package will be 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 will be posted on the MPOG website
Patient Blood Management Toolkit Released!
● Blood Management for the OB Patient slide deck is now available on the MPOG
Toolkit page under ‘Patient Blood Management’
● Will soon release an updated version of the existing transfusion toolkit for the Adult
Surgical population
● Please customize and adapt the content to meet your needs.
Feedback is always welcome!
QI Reporting Tool
Update
● Currently individual providers have access to a dashboard (My Measure
Dashboard) that includes measures that are in the monthly provider feedback
emails
● They previously may have had access to the cardiac, pediatric, and OB
dashboards filtered to their own case - we removed that
● These dashboards were originally intended for quality champions and
subspecialty practice leaders, not individual providers
● Plan to add specific subspecialty measures to the “My Measure
Dashboard”
● While usage of the QI Reporting Tool is low overall among individual providers,
may generate questions to quality champions, so wanted to inform the QC
Removed individual provider access to specialty
dashboards in MPOG QI Reporting Tool
Removing individual provider access to specialty
dashboards in MPOG QI Reporting Tool
Transition for subspecialty champions with
access to departmental specialty dashboards
● Currently, it is technically possible for a subspecialty champion (ie
a Pediatric Quality Champion, or Cardiac Quality Champion) to
have access to a specific subspecialty dashboard, but not have
access to other department dashboards (ie Sustainability,
Outpatient, Opioid)
● This causes errors (and confusion) as we build out additional
dashboards and other new QI Reporting features
● So, we have removed the “feature” that grants access to only a
specific subspecialty dashboard.
Transition for those with access to departmental
specialty dashboards
● Most subspecialty champions already have access to all dashboards, so they will not
notice any difference in access.
● Several subspecialty champions only have access to a single subspecialty dashboard, and
will need to be granted access to all dashboards so they can continue to access their
subspecialty dashboard
● MPOG CC will let sites know if they have subspecialty champions who fall in this category
and will help with providing access
● MPOG is developing an “activity log” that will allow Quality Champions to view all
departmental level QI Reporting Activity.
User Name
2025 Measure Review
Plan
Measure Review 2025
Reviewers Date Measure Description
Tony Edelman, UMichigan 1/2025 NMB-01 Train of Four Monitoring
Mike Aziz, OHSU 1/2025 NMB-02 Reversal Administered
Kunal Karamchandani, UTSW 1/2025 TOC-01 Intraop Handoff
Joseph Ruiz, MD Anderson 2/2025 PONV-05 Postoperative Nausea
Sustainability Workgroup 5/2025 All SUS Sustainability Measures (All)
Sunny Chiao, UVA 7/2025 TEMP-01 Active Warming
Jonathan Kaper, Corewell Trenton 7/2025 TEMP-02 Core Temperature Monitoring
Marc Pimentel, Brigham & Women's 9/2025 BP-02 BP Monitoring Gaps
Rob Schonberger, Yale 9/2025 BP-05
Low MAP Avoidance < 55 mm Hg,
Induction
Joe McComb, Temple 11/2025 PUL-01 Median Tidal Volume <10ml/kg PBW
Ketan Chopra, HFH 11/2025 PUL-03 Administration of PEEP
Reviewers Date Measure Description
Mariya Geube, Cleveland Clinic Florida 02/2025 TEMP-06-C Hypothermia Avoidance in Cardiac Surgery
Ashan Grewal, University of Maryland 02/2025 TEMP-07-C Hyperthermia Avoidance in Cardiac Surgery
2025 Cardiac and Peds Measure Review Schedule
Reviewers Date Measure Description
Brady Still – University of Chicago Spring SUS-05-Peds Nitrous Avoidance, Induction
Charles Schrock – St. Louis Children’s Spring NMB-03-Peds NMB Dosing, Infants
TBD Fall FLUID-02-Peds Minimizing Colloid Use, Pediatrics
Jeana Havidich – Vanderbilt Winter
TRAN-03-Peds
TRAN-04-Peds
Transfusion Vigilance
Overtransfusion
Measure Updates
ABX-03-C: Antibiotic Redosing, Open Cardiac
● Description: Percentage of adult patients undergoing an open cardiac procedure
with an antibiotic redose initiated within four hours after initial antibiotic administration
(cephalosporins only)
● Three antibiotics excluded from this measure:
○ Ceftriaxone and Cefotetan are excluded due to extended half-lives relative to
other commonly used cephalosporins and therefore, re-dosing is not
recommended for a typical cardiac case (these cases are excluded NOT
flagged).
○ Cefoxitin is also excluded as it is not typically used for cardiac cases and would
require more frequent dosing (these cases are excluded NOT flagged).
SUS-02: Global Warming Footprint, Maintenance
● Description: This measure analyzes the percentage of cases where carbon dioxide
equivalents normalized by hour for cases receiving inhalational anesthetic agents
(desflurane, isoflurane, or nitrous oxide) is less than CO
2
eq of 2% sevoflurane at 2 L
FGF = 2.83 kg CO
2
/hr or the Total CO
2
eq is less than 2.83 kg of CO
2
for the
maintenance period of anesthesia.
● Updated measure and code to allow MPOG to calculate Total FGF from
component FGFs. Significant score changes for 4 sites and they were notified
● Updated measure to include conversion of Nitrous Inspired % to Nitrous flow
(l/min). Minimal score changes
● Also updated for SUS 03 (GWF - Induction) and SUS 06 (FGF Induction, Peds)
● Fixed bug that temporarily improved everyone’s SUS 02 score by about 30%
TRAN-01 and TRAN-02:
● TRAN 01 - Percentage of adult patients receiving a blood transfusion with documented
hemoglobin or hematocrit value prior to administration
● TRAN 02 - Percentage of adult patients with a post transfusion hemoglobin or hematocrit
value greater than or equal to 10 g/dL or 30%, as a proxy for overtransfusion
● The approved changes are:
○ Include cardiac cases (previously excluded), as both Quality Committee and
Cardiac Subcommittee members determined that these measures apply to cardiac
procedures
○ “Ignore” autologous blood transfusion, as it is common and acceptable practice to
administer these blood products regardless of hgb/hct values.
● Scores for most sites increased modestly. However, several sites saw drops in
performance scores for both measures, based on site cardiac case transfusion practices.
New Measures
AKI-02-C: Acute Kidney Injury, Cardiac
Description: Percentage of patients undergoing an open cardiac procedure with more than a 1.5x increase in baseline
creatinine within 7 postoperative days or the baseline creatinine level increases by ≥ 0.3 mg/dL within 48 hours
postoperatively.
Measure Time Period: Up to 7 days after Anesthesia End
Exclusions:
● ASA 6 including Organ Procurement (CPT:01990)
● Cases where a baseline creatinine is not available within 60 days preoperatively
● Cases where a creatinine lab is not available within 7 postoperative days
● Patients with more than one case in a 7-day period. The first case will be excluded if a post-op creatinine is not documented for that first case. For example, a patient that
has surgery twice in a 7-day period, the first surgery is excluded if a creatinine is not drawn in between cases
● Patients with pre-existing renal (stage 4 or 5) failure based upon BSA-Indexed EGFR < 30 mL/min/1.73m
2
● Liver Transplants
● Open cardiac procedures performed in conjunction with procedures affecting the kidney, bladder, or ureter
Success: The creatinine level does not go above 1.5x the baseline creatinine within 7 days post-op and The creatinine
level does not increase by ≥0.3 mg/dL obtained within 48 hours after anesthesia end.
AKI-02-C Performance
November 2023 - September 2024, Performance Range: 0 - 67%
Threshold on agenda for next Cardiac SC meeting
Will be increasing
threshold to ~30% or
make informational
ABX-04-C: Antibiotic Selection for Open Cardiac
Procedures
Description: Percentage of adult patients undergoing open cardiac surgery with the recommended
antibiotic agents administered for surgical site infection prophylaxis.
Measure Time Period: 120 minutes prior to Anesthesia Start through Anesthesia End
Exclusions:
● Age < 18 years
● ASA 6 including Organ Procurement
● Patients already on scheduled abx or had a documented infection prior to surgery (determined by ABX Notes
phenotype value code:2)
● Procedures:
○ Lung transplants
○ Non-cardiac, Transcatheter/Endovascular, EP/Cath, and other Cardiac cases
Success: Documentation of appropriate antibiotics administered preoperatively or intraoperatively
ABX-04-C: Acceptable Antibiotics
● Vancomycin + Cephalosporin
● Vancomycin + Aminoglycoside
● Cephalosporin Only
● Note: Only doses administered via IV route (MPOG Concept ID:2001) will be considered.
● Cases will be assigned one of the following results:
○ Passed - Vancomycin + Cephalosporin
○ Passed - Vancomycin + Aminoglycoside
○ Passed - Cephalosporin Only
○ Flagged - Non-standard antibiotic selection
○ Flagged - Prophylactic antibiotic administered (Not documented in MAR)
○ Flagged - Antibiotic not ordered/indicated per surgeon
○ Flagged - Not administered for medical reasons
○ Excluded - Scheduled antibiotics/documented infection
ABX-04-C Performance
October 2023 - September 2024
Performance Range: 0 - 100%
ABX-05-C: Composite Measure: Antibiotic Compliance
for Open Cardiac Procedures
Description: Percentage of adult patients undergoing open cardiac surgery with appropriate antibiotic
selection, timing, and re-dosing administered for surgical site infection prophylaxis
Measure Time Period: 120 minutes prior to Anesthesia Start through Anesthesia End
Exclusions:
● Age < 18 years
● ASA 6 including Organ Procurement
● Patients already on scheduled abx or had a documented infection prior to surgery (determined by ABX Notes
phenotype value code:2)
● Procedures:
○ Lung transplants
○ Non-cardiac, Transcatheter/Endovascular, EP/Cath, and other Cardiac cases
Success: Case must pass all 3 antibiotic prophylaxis for open cardiac procedure measures:
● ABX-02-C/ABX-03-C/ABX-04-C
ABX-05-C: Other Measure Build Details
● Note: Only doses administered via IV route (MPOG Concept ID:2001) will be considered.
● Cases will be assigned one of the following results:
○ Passed - Antibiotic Prophylaxis Standards Met
○ Flagged - Timing, Re-dosing, & Section Not Met (ABX-02-C, ABX-03-C, & ABX-04-C flagged)
○ Flagged - Timing & Selection Not Met (ABX-02-C & ABX-04-C flagged)
○ Flagged - Re-dosing & Selection Not Met (ABX-03-C & ABX-04-C flagged)
○ Flagged - Timing & Re-dosing (ABX-02-C & ABX-03-C flagged)
○ Flagged - Antibiotic not administered on time (ABX-02-C flagged)
○ Flagged - Antibiotics not appropriately re-dosed (ABX-03-C flagged)
○ Flagged - Non-standard antibiotic selection (ABX-04-C flagged)
○ Excluded - Scheduled antibiotics/documented infection
ABX-05-C Performance
October 2023 - September 2024
Performance Range: 0 - 100 %
NMB-02: Reversal Administered
Description: Percentage of patients administered neostigmine, sugammadex, and/or edrophonium
before extubation and after last dose of nondepolarizing neuromuscular blockade.
Inclusion criteria: All patients that have received a nondepolarizing neuromuscular blocker AND were
extubated before anesthesia End.
Exclusion criteria:
● ASA 5 & 6 including Organ Procurement
● Patients not given NMBs
● Patients that were not extubated in the immediate postoperative period
● Lung Transplant Procedures
Success Criteria: Documentation of neostigmine, sugammadex, and/or edrophonium before earliest
extubation OR an acceleromyography ratio of ? 0.9 documented after last dose of MMB and before
earliest extubation before anesthesia end.].
NMB-02 Performance across MPOG
NMB-02: Reversal Administered
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
