1
Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)
Quality Committee Meeting Notes – Monday, February 23, 2015
Attendees: P=Present; A=Absent; X=Expected Absence
P
Abdallah, Arbi ‘Ben’ (Wash U)
P
Lacca, Tory (Michigan)
P
Agarwala, Aalok (MGH)
P
Lagasse, Robert (Yale)
P
Ajja, Olivia (St. Joesph)
P
LaGorio, John (Mercy Muskegon)
P
Aziz, Michael (OHSU)
P
Levy, Warren (Pennsylvania)
P
Becker, Aimee (Wisconsin)
A
Lirk, Philipp (AMC)
P
Bell, Genevieve (Michigan)
P
Louzon, Kathy (Beaumont)
A
Berman, Mitch (Columbia)
P
Mack, Patricia (Weill-Cornell)
P
Bhavsar, Shryas (MD Anderson)
A
Madden, Lawrence (Mercy Muskegon)
P
Biggs, Daniel (Oklahoma)
P
Maheshwari, Kamal (Cleveland Clinic)
A
Bonifer, Thomas (Allegiance)
A
Martin, Matt (Munson)
P
Buehler, Katie (A4)
A
Morey, Timothy (Florida)
A
Coffman, Traci (St. Joseph)
P
Naik, Bhiken (Virginia)
P
Coyle, Nina (Phy Med – Nashville)
A
Noles, Michael (OHSU)
P
Cuff, Germaine (NYU Langone)
A
O’Donnell, Steve (Vermont)
A
Cuffman, Natalie (Holland)
A
Osborne, Jaime (Michigan)
P
Dalton, John (PhyMed – Tennessee)
A
Pasma, Weize (Utrecht)
A
Dehring, Mark (Michigan)
P
Pace, Nathan (Utah
P
DeSnyder, Kathy (Beaumont)
A
Pagenelli, William (Vermont)
A
Domino, Karen (Washington)
A
Price, Matthew (Beaumont)
A
Eastman, Jaime (OHSU)
P
Ramachandran, Satya Krishna (Michigan)
P
Epps, Jerry, (Tennessee)
P
Reinhardt, Paige (Tennessee)
A
Fleisher, Lee (Pennsylania)
A
Robinowicz, David (UCSF)
A
Fleishut, Peter (Weill-Cornell)
A
Ruiz, Joe (MD Anderson)
A
Haehn, Melissa (UCSF)
P
Saager, Leif (Cleveland)
P
Harwood, Timothy (Wake Forest)
A
St. Jacques, Paul (Vanderbilt)
A
Jerri Heiter (St. Joseph)
P
Segal, Scott (Tufts)
A
Hausman, Mark (Michigan)
P
Shah, Nirav (Michigan)
A
Ianchulev, Stefan (Tufts)
P
Sharma, Anshuman (Wash U)
A
Jacobson, Cameron (Utah)
P
Skolnick, Bruce (Beaumont)
P
Jameson, Leslie (Colorado)
A
Smith, Jeffrey (McLaren)
A
Kappen, Teus (Utrecht)
A
Sommer, Richard (NYU Langone)
P
Kendale, Samir (NYU Langone)
A
Soto, Roy (Beaumont)
P
Kheterpal, Sachin (Michigan)
P
Stefanich, Lyle (Oklahoma)
P
Kiers, Gerard (St. Joseph)
A
Tom, Simon (NYU Langone)
A
King, Lisa (Oklahoma)
A
Wedeven, Chris (Holland Hospital)
A
Kooij, Fabian (AMC)
A
Wilczak, Janet (Oakwood)
P
Kuck, Kai (Utah)
A
Yasick, Tony (Holland)
A
Kuhl, Mackenzie (Marquette)
A
Lagasse, Robert (Yale)
1. Approve minutes from previous meeting: Minutes approved
2. Review feedback tool V1 – Galileo
Establish username/ passwords this week for participating institutions
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o Names and passwords are going to be established for the active sites. Please review the list
of names are on the ASPIRE website under tab Performance Measures → Quality Committee
Members. If any changes need to be made, please contact Tory Lacca.
Dashboards
o All measures are represented by a performance percentage. The performance will be
highlighted in green or red, referencing the threshold number determined in previous
discussions. The institutional number is at the bottom and is unique to each institution
nobody have access to other institutional codes for other sites.
o Each measure summary has the following:
Inclusion
Exclusions
Compliance
Responsible provider
The graph to the right indicated your performance vs. all institutions and the red bar
is the threshold.
Question: Do you anticipate adding age?
o Answer: As we build out the tool, we will be adding filters and we will include
age. The filters will be on a measure-by-measure basis and will depend on the
measure.
Ranking screen include data over the last twelve months
o X-axis is the institution
o Y-axis is the compliance percentage
o The red bar is the threshold
MPOG/ASPIRE is working on determining a standardized approach to data
diagnostics to measure data quality.
o Question: Will you be categorizing institution? For example, compare a
comparing peds to peds, ambulatory centers to ambulatory centers, etc.
Answer: The measures were built so that the thresholds apply to a broad
range of institution type. We will be determining filters for institutions and
categorization.
Failure reports
Case Viewer
Notification plan
o How are you going to provide feedback to individual providers?
We will hold off on forwarding this to individual providers until we can verify the data
quality is good.
We plan to create an e-mail from Galileo that the QI Champion can forward to the
providers. We ask you to hold off on that for now, until we can get that mechanism in
place and ensure data accuracy.
Training plan
o Jaime Osborne, the ASPIRE QI Coordinator will be producing a one-page document for
training purposes. We think the tool is intuitive, but we will be making a tip-sheet for
assistance.
o Question: If we have a provider that does not do something very much, will we make a
reliability adjustment for those cases? How do we make it reliable and make it explainable?
We will come up with a way to determine this by the March Quality Committee
Meeting.
3. Review data/ measures from each institutions (from Genevieve)
Institutions who are currently providing data. See Appendix A.
4. Roll call/ Attendance/March 16, 2015 Meeting
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If you have not done so yes, please contact Tory to let her know if you will be attending the
ASPIRE Quality Meeting on Monday, March 16, 2015.
5. Documentation needs
INF 01 – antibiotic administered
o This will be recorded at the time of surgical incision. We will be tracking the exact antibiotic
being administered. Also, it is important to submit CPT codes, so we can create accurate
exclusions. If you are interested in how other sites are documenting this measure, please
contact Nirav.
o Dr. Sharma: We do not have CPT codes at Wash U, but we document the four conditions.
Dr. Evers is aware that we need your CPT data for other measures. The need for CPT codes
is necessary across all measures and we will be following up to get them.
NMB 01 - train of four counts, acceleromyography results, documentation of extubation, patients
transferred to ICU intubated
o There are variable methods in which sites document extubation and we think we found some
ways to account for this in the data. We need explicit documentation that indicates that
patients were extubated to provide feedback to your providers to ensure they document this for
all cases. We are hoping institutions will make progress in getting the extubation data by the
end of the year.
NMB 02 - documentation of extubation and patients transferred to ICU intubated
GLU 01 - preoperative glucose results, preoperative interventions, PACU glucose results, PACU
interventions
GLU 02 - preoperative glucose results, preoperative interventions, PACU glucose results, PACU
interventions
o PACU data is needed needed for both GLU 01 and 02
o Question: Which measures can use the manually documented vitals?
We need physiologic data that records minute-to-minute specific data and cannot rely on
manually entered.
PULM 01 - documentation that a patient either came with or received endotracheal tube
o We are going to be including patients transferred from the ICU and those transferred to the ICU
with an endotracheal tube. Specific documentation on this transfer will be important, so we can
provide good feedback.
6. Other Items: We have applied to be a qualified clinical data registry (QCDR) and the proposed measures
are under the ASPIRE website (https://www.aspirecqi.org/aspire-qcdr). We will find out in the next
week if we have been approved as a QCDR and will let you know. The hope is that we can report for
members in 2015 to avoid the 2017 penalty.
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Appendix A: Measures available by institutions
Institution
INF-
01
GLU-
01a
GLU-
02a
NMB-
01
NMB-
02
PUL-
01
Cornell University Health Center
X
X
Massachusetts General Hospital
X
X
X
X
University Medical Center -
Utrecht
X
X
X
X
X
University of Florida, Gainesville
X
X
X
X
X
X
University of Michigan Health
System
X
X
X
X
X
X
University of Oklahoma Health
Sciences Center
X
X
X
X
X
X
University of Tennessee Medical
Center
X
X
X
X
X
X
University of Utah Health Care
X
X
X
X
X
X
University of Vermont - Fletcher
Allen Health Care
X
X
X
X
X
X
University of Virginia Health
System
X
X
X
X
University of Washington Medical
Center
X
X
X
Washington University School of
Medicine
X
X
X
X