Quality Committee
Meeting
January 26, 2026
10:00am - 11:00am Eastern Time
2026 Meeting Schedule
Announcements
●New Subcommittee Vice Chairs
●Glycemic management workgroup update
●AKI phenotype update
Measure Review - AKI 01 - Mike Mathis, MD, University of Michigan
2026 Planning
●Benchmarking graphs in QI Reporting Tool
●Best practices exchange proposal
Agenda
Meeting Minutes
November 24, 2025
Roll Call – via Zoom or contact
MPOG
Upcoming Events
2026 Meetings
Friday, March 13, 2026
MSQC / ASPIRE Collaborative Meeting
Marriott, East Lansing, MI
Friday, July 17, 2026
ASPIRE Collaborative Meeting
Weber’s Hotel, Ann Arbor, MI
Friday, October 16, 2026
MPOG Retreat, San Diego, CA
Announcements
Newest MPOG Site
Welcome to Indiana
University Health - the
newest health system to
join MPOG!
New Obstetric Subcommittee Vice Chair
Congratulations
Dr. Sharon Reale!
Dr. Sharon Reale is from Harvard Medical School's Brigham
and Women's Hospital. She is the Brigham and Women's
Hospital Obstetric Anesthesia Fellowship Program Director
and the MPOG Research Lead. She has published several
impactful obstetric anesthesia studies utilizing the MPOG
database in the areas of failed and difficult intubation in
obstetrics and management of maternal cardiac arrest.
New Pediatric Subcommittee Vice Chair
Congratulations
Dr. Eva Lu-Boettcher!
Dr. Eva Lu-Boettcher is a pediatric anesthesiologist at the
University of Wisconsin, where she holds the role of
Associate Vice Chair for Quality and Safety. She has served
as the site Principal Investigator and MPOG Quality
Champion since 2021, leading local efforts to leverage data
for quality improvement. Her current efforts emphasize
high-value, and environmentally sustainable anesthesia
care and has served as a measure reviewer for SUS-02,
SUS-03, SUS-05-Peds and SUS-06-Peds.
Key Operational
Updates
Glycemic Management Workgroup Update
Workgroup met on 12/15/25 to develop feasible, clinically meaningful metrics addressing hyperglycemia thresholds and
treatment timing in ambulatory surgery
Key Discussion Themes
● Strong consensus that patients without diabetes should be included, with recognition that a meaningful subset of
non-diabetic patients present with elevated glucose.
●Threshold debate: Extensive discussion around 180 vs 250 mg/dL as treatment thresholds, balancing clinical
ideals with operational feasibility and clinician buy-in.
●Process focus: Emphasis on measuring timely treatment and reassessment, not insulin dosing accuracy.
– consider excluding IV insulin given rarity in ambulatory settings. Analyze data
– consider excluding Capillary glucose monitors; finger-stick/arterial values only due to accuracy /
correlation with POC devices
Decision: Build two outpatient hyperglycemia treatment measures:
●GLU-15: Treatment of BG > 250 mg/dL within 60 minutes
●GLU-15b: Treatment of BG > 180 mg/dL within 60 minutes (sub-measure)
Next Meeting 1/27/26 to refine outpatient hyperglycemia assessment (blood glucose checking) measure
MPOG Phenotype - AKI Complication Update
•MPOG recently implemented some improvements to accurately capture AKI
using the MPOG Complication - AKI phenotype.
• Updates are scheduled to be released on February 2nd and AKI-01 and
AKI-02-C scores have been impacted.
• Will finalize AKI-01 risk adjustment model once these updates are released.
MPOG Phenotype - AKI Complication Update
Summary of Changes:
1. Preoperative Creatinine Source
○ Previously referenced the highest preoperative creatinine value.
○ Updated to reference the most recent preoperative creatinine value.
2. Postoperative Creatinine Selection
○ Previously the logic didn’t check for a ≥0.3 mg/dL rise from the 0-2 day creatinine if the 3-7
day creatinine was higher. Now even if the 3-7 day creatinine higher it will still evaluate a
0-2 day creatinine for a ≥0.3 mg/dL rise and assign AKI 1 accordingly.
3. Significant score changes due to evaluating day 2 increase in creatinine
○AKI-01: ~2-3 percentage points increase in AKI across MPOG
○AKI-02-C: percentage point changes more significant due to low open cardiac case
volumes. ~2-13 percentage point increase in AKI
2026 Measure Review
Plan
2026 Quality Committee Review Plan
Date ID Topic Presenter Organization
1/26/2026 AKI-01 Acute Kidney Injury Mike Mathis, MD University of Michigan Health
2/23/2026 TOC-02 PACU Handoff Alvin Stewart, MD University of Arkansas for Medical
Sciences (UAMS) Medical Center
2/23/2026 TOC-03 ICU Handoff Alvin Stewart, MD University of Arkansas for Medical
Sciences (UAMS) Medical Center
5/18/2026 GLU-09 Hyperglycemia management,
Intraop Patrick Henson, MD Vanderbilt Health
5/18/2026 GLU-10 Hyperglycemia management,
Periop Patrick Henson, MD Vanderbilt Health
5/18/2026 GLU-11 Hyperglycemia treatment, Periop Patrick Henson, MD Vanderbilt Health
5/18/2026 GLU-12 Hypoglycemia management,
Intraop TBD
2026 Quality Committee Review Plan
Date ID Topic Presenter Organization
7/27/2026 OME Opioid Equivalency Clark Fisher, MD, PhD Yale New Haven Health
7/27/2026 PONV-03 Postoperative Nausea or Vomiting
Outcome Tariq Esmail, MB Bch University Health Network
9/28/2026 BP-01 Low MAP Prevention <55 (20
minutes) Jonathan Paul, MD Columbia University Medical Center
9/28/2026 BP-03 Low MAP Prevention <65 (15
minutes) Jonathan Paul, MD Columbia University Medical Center
9/28/2026 BP-06 Low MAP Prevention <55 (10
minutes) Jonathan Paul, MD Columbia University Medical Center
11/23/2026 FLUID-01-NC Minimizing Colloids Ayesha Bryant, MD, MPH University of Alabama Birmingham
Health System
11/23/2026 NMB-04 NMB-04 Variation in Sugammadex
Dosing Megan Anders, MD University of Maryland
2026 Anonymized
Benchmarking Plan
Anonymized Benchmarking - 2026
Based on your feedback, we are investigating building additional anonymized benchmarking
visualizations in the QI Reporting Tool:
• Case volume
• Ambulatory Surgery Centers
• Health Systems
• Academic Hospitals vs Community Hospitals (future)
Discussion Points / Areas of Feedback
Have (or will need to determine) definitions for each location type (ie what is a
community hospital?)
Planning on exposing these visualizations to all sites. Sites that have a location
included in the visualization with be able to identify their own site (the blue bar),
but others will be anonymized
Other subgroups that folks are interested in? Small hospitals, large hospitals?
2026 Best-Practices
Exchange Proposal
Concept
• Identify high performers during measure review
• Add short, low-prep “how we do it” spotlights during Quality Committee (or adjacent
forums) where a high-performing site or a “big mover” briefly shares
workflow/policies/culture that drove success on a measure
• Consider two lenses: (1) always-high performers (culture/process) and (2) intentional QI
improvers (PDSA, reminders, education).
• Interested sites can connect offline for deeper dives
Why?
• May be useful especially for newer sites or areas with stalled traction
Proposal
• Format: less than 10 minutes. Slides optional, but some material encouraged
• Cadence: aim for ~2x/year to start, at Quality Committee meeting
• Topic pipeline: align with measure review + call for topics (site initiated) + coordinating center
• Who: quality champion or designee
Vote
1. Should we identify high performers during measure review?
2. Should we create a new QC segment “Best Practice Xchange”
Thank you!
