Quality Committee
Meeting
February 23, 2026
10:00am - 11:00am Eastern Time
Announcements - New Subcommittee Vice Chair
Measure Review - TOC-02/03 - Alvin Stewart, MD, UAMS
Measure Updates
Agenda
Meeting Minutes
January 26, 2026
Roll Call – via Zoom or contact
MPOG
Upcoming Events
Announcements
New Cardiac Subcommittee Vice Chair
Congratulations
Dr. Ashan Grewal!
Dr. Grewal is a cardiothoracic anesthesiologist at the University of
Maryland. An active member of the MPOG Cardiac Anesthesia
Subcommittee, he has contributed to cardiac measure development and
review, including proposing the GLU-14-C measure and reviewing
TEMP-07-C, while also serving on MPOG Quality and PCRC
committees. As Associate Director of Quality in his department, he leads
efforts to translate MPOG data into meaningful clinical change.
New Measures
Key Operational
Updates
Glycemic Management Workgroup Update
Hyperglycemia Assessment, Outpatients
●Plan to develop multiple standalone assessment measures (e.g., preop diabetic
glucose check, recheck after hyperglycemia, post‑insulin monitoring) plus a
composite “hyperglycemia assessment bundle” and dashboard views.
i. Preoperative glucose check for diabetic patients
ii. Recheck after perioperative BG > 180 mg/dL
iii. Glucose check after IV insulin within 90 minutes
iv. Glucose check after SQ insulin within 120–150 minutes
v. (Tentative) PACU glucose check after intraoperative insulin
●Diabetes phenotype: Build and validate a multisource diabetes phenotype using problem list, preop
history, and diagnosis codes with site input.
●Development & validation: MPOG Coordinating Center will refine specifications and begin coding once
feedback is incorporated, then share case lists with volunteer sites for chart‑level validation.
TOC-03: Transfer of Care, ICU
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
TRAN-03-P -
Transfusion
Vigilance (peds)
Transfusion vigilance - Include cases with any PRBC
transfusion (remove 15 mL/kg rule) to catch all clinically
significant events
PUL-01 -
Protective Tidal
Volume
Exclude patients undergoing “bronchoscopy only” procedures
Measures Updated January and February
TEMP-01 - Active
Warming
Updated case start algorithm for 60-minute exclusion
Revision to use the organ procurement phenotype rather than
ASA 6 alone
2026 Anonymized
Benchmarking Plan
Anonymized Benchmarking - 2026
Based on previous QC discussion, we will be building the following additional anonymized
benchmarking visualizations in the QI Reporting Tool:
• Case volume tranche indicators
• Ambulatory Surgery Centers
• Health Systems (~ MPOG Institutions)
• Not in 2026: Academic Hospitals vs Community Hospitals (future)
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”
Plan
1. Start with May Quality Committee Meeting
2. Glucose measures
Thank you!
