Quality Improvement Through the Lens of the Multicenter Perioperative Outcomes Group

Introduction

An early titan in healthcare quality improvement (QI), Avedis Donabedian, once said, “The secret to quality is love.” Although it is difficult to disagree with that statement, many would agree that the secret to success additionally includes collaboration, persistence, and high-quality data ( Fig. 43.1 ). The previously described Collaborative Quality Initiatives (CQIs) in Michigan are exemplars of how these factors, supported by financial incentives, have resulted in tremendous improvements in care.

In this chapter, we will focus on the process by which the Multicenter Perioperative Outcomes Group (MPOG) conducts its QI efforts to enable anesthesiologists and nurse anesthetists to reduce perioperative complications and improve outcomes.

Specifically, we will describe how MPOG infrastructure overcomes barriers to accessing information needed for practice analysis and reflection. We will demonstrate how tools developed by MPOG can be a catalyst for practice improvement. Finally, we will share examples of QI initiatives and the result of such efforts across participating sites.

Context

Founded in 2008, MPOG ( https://mpog.org/ ) is a consortium of hospitals and healthcare systems focused on improving perioperative care and includes sites from around the United States and the Netherlands. MPOG has developed automated processes to extract and validate hospital data before submitting the data to its coordinating center at the University of Michigan. In 2014, with funding provided in part from Blue Cross Blue Shield of Michigan's (BCBSM) CQI program, MPOG launched a quality improvement program called the Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE). Over 50 hospitals around the United States participate in ASPIRE, including over 25 hospitals within the state of Michigan.

ASPIRE fulfills its mission to prevent complications and reduce unexplained variation in care by:

• 1.

  Using data from the MPOG registry to develop measures based on electronic health records (EHRs) and supplementary data sources.

• 2.

  Creating dashboards and visualizations to enable quality champions and practice leaders to view measure performance data, benchmarked with other institutions and filtered down to specific providers and cases ( Fig. 43.2 ).

  

• 3.

  Sending performance feedback emails to providers that enable visualization of measure performance data, including benchmarks and links to specific cases that contributed to the provider's score ( Fig. 43.3 ).

  

• 4.

  Creating supplementary tools, such as QI toolkits. ASPIRE toolkits contain a collection of educational resources, articles, and reference guides. Materials within are intended for use across the collaborative to facilitate the sharing of best practices ( https://mpog.org/toolkits/ ). These toolkits enable local projects to implement practice change and support efforts by anesthesiology departmental quality champions ( Fig. 43.4 ).

  

Importantly, this infrastructure is governed by the ASPIRE Quality Committee, which develops and approves all measure criteria to ensure the appropriate level of evidence or expert consensus is met. In addition, the committee reviews measures at regular intervals to determine whether the measure should be: (1) modified to incorporate recent evidence or (2) retired. The ASPIRE Quality Committee is composed of practice leaders from member institutions and quality champions (a practicing anesthesiologist who has been designated as a quality leader within the department, responsible for communicating measure updates and championing local improvement efforts).

The process by which practice change occurs across ASPIRE sites and providers is varied and tailored to the goal of each institution and individual. Nevertheless, there are several mechanisms that ASPIRE encourages to spark practice change:

• 1.

  Attendance and participation in unblinded performance review sessions by quality champions and QI staff

• 2.

  Review of cases flagged as not meeting criteria for successful performance for measures of interest (ASPIRE enables this review using software applications developed at the coordinating center at both the institutional and provider levels)

• 3.

  Sharing site QI initiatives or projects with the rest of the collaborative to disseminate best practices and lessons learned

• 4.

  Linking these QI efforts with the Maintenance of Certification in Anesthesiology (MOCA) program sponsored by the American Board of Anesthesiology

The factors leading to successful outcomes as a result of implementing a QI initiative include strong evidence to suggest the recommended change in process will improve outcomes, a significant gap between desired and actual behavior, variation in performance across providers and institutions, and the ability to measure change over time.

Example A: Perioperative Transfusion Stewardship