2021 Abdominal Hernia Surgery QI - PowerPoint Presentation

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2021 Abdominal Hernia Surgery QI

Project Kickoff Session

January 2021

2021 QI Timeline

1/1/2021 OR cases – begins measurement period for:M-OPEN prescribing recommendations (hernia cases)Collaborative Wide Measure (CWM) of Intraoperative Multimodal Pain Management (all MSQC cases)3/31/2021 – must hold multidisciplinary meeting by this date4/1/2021 – measurement period for all other measures in hernia project1/17/2022 – Completed Abdominal Hernia Project Tracking Sheet and Narrative Summary Report due to MSQC

Collaborative Wide Measure (CWM)

Measure: Use

of

Intraoperative Multimodal Pain Management across all MSQC procedures*

Measurement

Period:

1/1/2021 – 12/31/2021Goal: Increase use greater than 2020 baseline of 44%

CWM ScorePoints Awarded> 60%20 points 55-59%15 points50-54%10 points45-49%5 points< 44%0 points

*Intraoperative

Multimodal Pain Management administered?



Yes selected

All surgical priorities

Preoperative Measures (elective cases only)

Goal: 80% compliance with preoperative measures (10 points)Measurement Period: 4/1/2021 – 12/31/2021Measures:Preadmission teaching includes multimodal pain managementSame measure as in the 2020 QI projectsPreadmission counseling/ teaching (ERP Tab)  Pain Management selectedGlycemic control: HgbA1C if

diabetic*; fasting

blood sugar

(or HgbA1C) if

not

diabeticDocument preoperative values in Lab Values Tab*Diabetes Mellitus = Non-insulin or Insulin

Preoperative Measures, continued

When applicable, patient education provided

on:

Smoking cessation (if

Tobacco Use within 1 month – Cigarette

= Yes)

Preadmission counseling/teaching (ERP Tab)  Tobacco Cessation selected Weight reduction (if BMI > 40) Preadmission counseling/teaching (ERP Tab)

 Weight Reduction selectedOnly the Weight Reduction option counts for this measure. The Nutrition/Diet option is not a numerator inclusionNeed to provide both written and verbal counseling (same as 2020 requirements)

Intraoperative Measures (all surgical priorities)

Goal: 80% compliance with intraoperative measures (10 points)Measurement Period: 4/1/2021 – 12/31/2021Measures:Hernia documentation includes all of the following (Hernia Tab): Hernia Size length and width (non-zero values)  entered, or diameter  enteredHernia Location 

entered

Intraoperative Measures, continued

Mesh* documentation includes all of the following (Hernia Tab):Mesh Size length and

width

(non-zero values)



entered, or diameter  enteredBrand of Mesh Used  enteredExamples: Bard (Davol), Medtronic/Covidien, etc.Hernia Mesh Resource

list in Workstation Resources Product Name  enteredExamples: Parietene, Surgipro Mesh Hernia Patch, Surgipro Hernia Plug and Patch (all Covidien products) *If Mesh used

Intraoperative Measures, continued

Mesh* documentation includes all of the following ( continued):Product

ID



entered

Manufacturer may also call this a product #, model #, catalog #, SKU, reference #. Do not enter lot #s, or internal hospital item #s, or internal charge master #s.

Mesh Location  enteredMesh Fixation  entered *If Mesh used

Intraoperative Measures, continued

Mesh documentation helpful hintsGreatly expanded Hernia Mesh Resource list containing >1000 mesh products (in Workstation Resources)

Central/Surgical

Supply, Finance, Billing dept. may be helpful if difficulty locating manufacturer product

details

Postoperative Measures (all surgical priorities)

Goal: 80% compliance with postoperative measures (10 points)Measurement Period: 4/1/2021 – 12/31/2021Measures:Order for multimodal pain managementSame measure as in the 2020 QI projectsMultimodal Pain Management ordered within the first 24 hours following surgery? (ERP Tab)  Yes selected

Postoperative Measures, continued

Discharge education includes pain management teachingSame measure as in the 2020 QI projects

Postop Teaching/Counseling (ERP Tab)



Pain Management

selectedOnly cases with Discharge Destination equal to Home, or Home with Home Health Care

Postoperative Measures, continued

Helpful Abstraction HintsToradol administered at the end of the surgery in the operating room is not

included for intraoperative or postoperative multimodal pain management. Duration of action is only 4-6 hours

.

EXPAREL wound infiltration has a duration of action of up to 72 hours. EXPAREL placed in the beginning of the surgery is included as one type of intraoperative and

postoperative multimodal

pain management. EXPAREL placed at the end of surgery will only count as postoperative multimodal pain management.

Postoperative Measures, continued

Helpful Abstraction Hints, continuedMultimodal Interventions – Administration Timing Comparisons

Goal

: 90 % of abdominal hernia surgery cases (5 points)Measurement Period: 1/1/2021 – 12/31/2021Measure:Opioid type (Opioid Tab)  “No opioid prescribed at discharge” selected, OR amount prescribed was at or below Michigan OPEN prescribing

recommendations*

Recommendation for all hernia repairs: 0 – 10 pills

Measure includes pts

DC to home or home with home

careData found on Opioid Dashboard report in WorkstationMeet M-OPEN opioid prescribing recommendations*based on oxycodone 5 mg tablets

Conduct and document at least one multidisciplinary meeting by

3/31/2021 (5 points)Meeting can be in-person, virtual, or hybrid formatAttendees to include surgeons, nurses, quality, pharmacy and other relevant staffDiscuss and establish the following:comprehensive hernia care pathwaystandardized template for charting on abdominal hernia repair patients

Submit meeting documentation to MSQC with 2021

QI project

report (due 1/17/2022)

Preadmission

teaching done Hernia occurrence (initial or recurrent)Hernia type (reducible, incarcerated or strangulated)Hernia location (epigastric, umbilical, etc.)Hernia measurements (length & width, or circumference)Mesh

measurements (length & width, or circumference)

Mesh product brand, product name

and

product ID

Mesh placement locationFixation technique/deviceMyofascial/component release (if applicable)Create template for standardized charting that includes:

Submit template to MSQC with 2021 QI project due 1/17/2022

Include summary of template development/implementation process, successes, barriers, challenges to implementation in QI reportPossible approaches to creating template:Synoptic operative note in EMRHernia synoptic OP note information posted on the MSQC website. Will require modification to include all required project elements and to adapt to your EMR

Preoperative H&P template, operative report template

Create prompts, headers, and standardized field value options for required elements

Other options that will work at your site?

Template

for standardized charting, continued

QI Tracking

Sheet and Narrative Summary ReportDue to MSQC by 1/17/2022 (10 points)Take credit for QI work on project measures, standardized documentation development and implementationDocument throughout year to track progress on measure performance, capture QI implementation effortsMeetings, communications, process changes, key dates

Describe improvement

efforts, successes, barriers, challenges

Report due earlier than in prior

years

Conform to BCBSM Collaborative time frames

Resources

QI measure reports available in MSQC Workstation and via Box account.CWM & Abdominal Hernia

Care Pathway Measures Reference Sheet (“one-pager”)

Hernia Repair Care Pathway

Virtual QI site visits during 2021

June 2020 SCQR Training Day

recorded sessions available on MSQC websiteSurgical Pain Management: Procedure Specific EvidenceSCQR and Hernia Surgery: Everything you wanted to know….

Resources, continued

Sample hernia synoptic note posted MSQC websiteHernia Test cases/answers

for review on website

April 23 MSQC/ASPIRE Collaborative Meeting (virtual) – session on multimodal anesthesia, other content pertinent to your QI work

Qualitative analysis of 2019 pain management pathways submitted by sites for 2019 QI project; loaded into your Box account in November

Q & A