2023 Quality Improvement
The 2023 MSQC Quality Initiatives are aimed at laying the foundation for future QI work. Sites will select one of three new project options: Surgical Urinary Catheter Care Enhancement Safety Study (SUCCESS), Frailty Pathway, or Appropriate Preoperative Screening for Low-Risk Surgeries. In addition, every site will select their own site-directed outcome measure. By reviewing prior year outcomes data, hospitals will identify a specific outcome where they have opportunity for improvement.
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2023 Site Directed Measure (updated 1/13/2023)
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2023 Tableau CWM Report Guide (new 3/31/2023)
Option A: SUCCESS Project
Noninfectious complications related to the trauma of catheter placement and removal are as common as urinary tract infections – and often have long-lasting consequences for patients with abnormal bladder emptying and discomfort. This project will measure perioperative urinary catheter use and duration, urinary catheter-related injury/trauma, and urinary retention. It will also focus on implementing strategies to improve the safety of perioperative urinary catheters, reduce catheter use and catheter-associated complications, and improve postoperative urinary retention management.
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SUCCESS Project Tracking Sheet (updated 1/13/2023)
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Project Resources:
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SUCCESS Data Pull Guide (from Source Data Export, updated 3/22/2023)
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Example Goal 2 and 3 (from Tracking Sheet)
Option B: Frailty Pathway Project
The focus of this project will be to implement a system for screening vulnerable patients for frailty using a validated screening tool. The goal will be to use the information gathered during the screening process to guide a discussion among patient, family, caregivers and surgeon about the risks, benefits and desired outcomes of surgical versus non-surgical interventions. Each site will check compliance with using the selected validated screening tool as well as documentation of a guided conversation between the surgeon and patient/caregivers following screening and prior to surgery. Going forward, the information gathered during the frailty pathway pilot year will inform and direct interventions for patients identified as frail in future projects.
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Frailty Project Tracking (updated 1/12/2023)
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Project Resources:
Option C: Appropriate Preoperative Screening for Low-Risk Surgeries Pilot Project
Eliminating unnecessary, routine preoperative testing before low-risk surgery represents a key opportunity to improve quality, safety, and value in surgery. The work of this project will be integral to identifying the underlying reasons for overuse of preoperative testing in low-risk surgeries, as well as interventions to heighten awareness and reduce variation among hospitals. Sites will: 1) abstract preoperative testing variables on low-risk surgical cases, 2) implement a standard protocol defining appropriate use of preoperative testing, 3) employ strategies to promote adoption of the protocol, and 4) analyze MSQC, MVC, and internal data reports to monitor progress.
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Appropriate Preoperative Screening for Low-Risk Surgeries Project Description
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Appropriate Preoperative Screening for Low-Risk Surgeries Project Tracking Sheet (updated 3/20/2023 to allow embedding of files into the document)
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QI Kickoff Webinar 1/30/2023 (PDF slides, ppt slides, recording)
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Project Resources:
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Preop Testing Decision Aid v1.3 (updated 3/9/2023)
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American Society of Anesthesiologists’ “Choosing Wisely” recommendations
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Drop the Preop! Information Sheet (Washington State Task Force)
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Appropriate Preoperative Screening for Low-risk Surgeries educational slide deck
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Waive the Workup website from MPrOVE (new 3/9/2023)
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Waive the Workup flyer (new 4/7/2023)
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Preoperative Testing Events
You can view and register for upcoming MVC Workgroups via the MVC Events calendar located on the MVC website.
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Preoperative Testing Workgroup: March 15, 2023
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Preoperative Testing Report Webinar: June 7, 2023
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Preoperative Testing Workgroup: August 1, 2023
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Presenter: Nick Berlin, MD, MPH, MS on his research in this area
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Health Equity Workgroup: August 24, 2023
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Presenter: Janée Tyus, MPH, Senior Program Director of the Mid-Michigan Community Health Access Program (CHAP)
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Preoperative Testing Workgroup: October 26, 2023
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Topic: Success stories from Michigan hospitals
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