2024 MSQC Quality Initiatives

2024 Quality Improvement

The 2024 MSQC Quality Initiatives are aimed at continuing the work started in 2023 for three projects, the Surgical Urinary Catheter Care Enhancement Safety Study (SUCCESS), Preoperative Testing for Low-Risk Surgeries, and Frailty. In 2024 we will offer a new project option, Breast Surgery Quality. Sites will select from one of these four options. In addition, MSQC will continue to focus on Hernia surgery and appropriateness, as a collaborative-wide measure, and focus on improving documentation of selected cancer variables.

P4P Resources

Final P4P Scorecard (updated 2/27/2024) [CWM goals were updated and new bonus point option added]
- In 2024, the SCQR and SC will participate in participation and engagement activity(s) as part of the P4P. See the SCQR/SC Participation/Engagement document for acceptable activities and requirements for Measure 4 (new 12/22/2023)
- Measure 7: Documentation of cancer variables measure requirements (updated 6/11/2024)

2023-2024 QI timeline (new 12/22/2023)
2024 QI Project Details and Requirements (new 3/7/2024) this document contains QI project submission requirements and other information (e.g., deadlines, file requirements/content/naming, and multidisciplinary meeting requirements)

Option A: SUCCESS Project

The 2024 SUCCESS project will build on the work begun in 2023. This intervention aims to (1) reduce inappropriate perioperative urinary catheter use, (2) reduce catheter-associated trauma, and (3) improve the management of postoperative urinary retention. The project focuses on common general surgery procedures: appendectomy, cholecystectomy, colorectal surgery, and hernia repair. This project will include the implementation and/or evaluation of toolkit elements that will address clinician knowledge and urinary catheterization skills, as well as communication and implementation challenges anticipated to affect catheter use in different types of perioperative clinical settings, and meet process/outcome measures, and develop or refine the urinary care pathway.

Final SUCCESS Project QII Summary (updated 12/7/2023, revision date 10/19/2023)
2024 SUCCESS QI Kickoff meeting – 1/24/2024 [slides, recording]
SUCCESS QI Tracking Sheet (new 3/7/2024)

Project Resources:

See the SUCCESS webpage for Toolkit elements and more details
SUCCESS Project Year 2 FAQs
SUCCESS Date Pull Guide (using source data export, from 2023)
SUCCESS Categories by CPT code, 2024 Process Measure Specs and SUCCESS data dictionary (updated 7/30/2024)
Urinary Care Pathway Templates (new 4/23/2024)

Option B: Frailty Pathway Project

The 2024 frailty project will build on the work begun in 2023 which introduced a system to assess vulnerable patients for frailty using a validated screening tool with an informed discussion regarding the results of frailty screening during the surgical planning phase. For 2024, the goal is to improve the surgical experience for patients identified as frail through interventions shown to potentially improve outcomes. This year will see an enhanced informed decision-making discussion with surgical candidates and caregivers and add interventions aimed at improving the surgical experience for candidates identified as frail.

Final Frailty Project QII Summary (updated 12/7/2023, revision date 10/17/2023)
2024 Frailty QI Kickoff meeting – 1/16/2024 [slides, recording]
Frailty QI Tracking Sheet [new sites, returning sites] (new 3/7/2024)

Project Resources:

Option C: Breast Surgery Quality

This project focuses on improving the performance of evidence-based quality measures for patients undergoing partial mastectomy and mastectomy. MSQC began capturing breast surgery data in 2023, so this project will lay the groundwork and encourage engagement from the multidisciplinary team to promote high-quality treatment to improve short- and long-term outcomes.

Final Breast Surgery QII Summary (updated 2/27/2024) [cancer measure goals were revised]
2024 Breast Surgery QI Kickoff meeting – 1/22/2024 [slides, recording]
Breast Surgery QI Tracking Sheet (new 3/7/2024)

Project Resources:

Option D: Preoperative Testing for Low-Risk Surgeries (invited sites ONLY)

In collaboration with MVC and MPrOVE, this project will continue to work toward reducing unnecessary, routine preoperative testing for low-risk surgeries, as well as implement interventions to heighten awareness and reduce variation among hospitals. Through a multi-faceted approach, invited 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. Continuing sites who participated in the pilot project in 2023 are eligible if their average rate of preoperative testing is >20% from 4/1/2023 to 6/30/2023, and sites who did not select preoperative testing as their QII in 2023 will be eligible to participate.