News from MSQC - June 2018
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In this issue:
  • MSQC acts locally and thinks globally
  • Keep your feedback coming!
  • News for SCQRs 
  • A preview of our upcoming SCQR Training Day
  • QII, Education updates, new publications 
  • Update from our colleagues at Michigan OPEN
  • And so much more...

A note from MSQC Leadership

"People say think globally, act locally. Well, if you think globally, it is overwhelming and you do not have enough energy left to act locally. Just act locally and see what a difference you can make!"  - Dr. Jane Goodall

Act Local, Think Global: The influence of the singular surgeon on health care improvement

To the individual practicing surgeon, honing surgical techniques and improving patients’ lives is the first priority.  The top-down pressure of healthcare reform, despite all good intentions, adds an additional burden to patient care that relegates the surgical procedure to a simple commodity absent to the complexity of the human state. In the midst of the day-to-day, surgeons may feel helpless to influence, much less participate in, efforts to make the system (or care) better. But your voice is needed. Procedural care accounts for 40% of total healthcare expenses, however, it receives little attention in the conversation surrounding healthcare reform and improvement.

MSQC provides a unique opportunity for your voice to be heard.  From the rich clinical data we collect from our Collaborative, we are able to scrutinize surgical dogma, discover new and innovative approaches to care, and maximize patient outcomes. For example, the MSQC has been able to demonstrate:
  • Increased use of multimodal pain management strategies can help get the patient out of the hospital faster.
  • Adoption of carbohydrate nutrition preoperatively keeps glucose levels constant to enhance postoperative recovery.
  • Implementation of a ‘colectomy bundle’ can reduce surgical site infection.
  • Upstream implementation of efficient and effective postoperative prescribing practices can thwart the supply of unused opioids in the community and hopefully, opioid dependence.
With these examples, we underscore the importance of why we need more surgeons to inform surgical quality improvement. Small but important contributions at the local level, taken together, can be a strong force influencing effective healthcare reform. It goes along with the catchphrase: Act Local, Think Global.

In Michigan, we have this opportunity to extend beyond our practice and reach into the community, state and even the nation. We urge you to get involved.

Greta and Mike


A visit to the Center for Medicare and Medicaid Innovation

The commonly used phrase “act locally, think globally” certainly applies to the activities of MSQC.  No one can argue that we don’t act locally - witness the multitude of bedside QI initiatives that occur in our 70 hospitals on a daily basis.

And we have learned a lot from our efforts. But it is equally important to share what we have learned with others, not only about local QI strategies, but also about what it takes to build a successful statewide collaborative. We began the “think globally” part of our effort last fall, when we brought representatives from 10 states to northern Michigan for the Center of Excellence for Collaborative Quality Improvement (CECQI) conference.  

Then we wrote an editorial about an idea that came out of the conference. To those of us who participated it felt like a great success, but a question remained-where do we go from here?

To answer this question three of us from Michigan (myself, Jim Montie from MUSIC and Tom Leyden from BCBSM) , and four other interested doctors from other states (Prabakhar Baliga and Mark Lockett from South Carolina, David Mackey from Texas and Peter Dunbar from Washington) made a trip to the Center for Medicare and Medicaid Innovation (CMMI) headquarters in Baltimore, MD to talk about the possible next step described in the editorial.

Would the CMMI - which is a branch of CMS - be interested in partnering with states to support quality collaboratives? Specifically, would they consider making funds available for local insurers in order to help them get started, as part of a grant process? Thirteen high level CMMI employees attended the meeting and seemed engaged and interested.  So, we got our foot in the door.

What happens now is hard to say. But the point is we have a strategy to spread the word nationally. Persistence is the name of the game, and we are good at persistence. Stay tuned to this station for regular updates.


April Meeting Wrap-Up

MSQC meeting attendance is growing! The attendance at the April 20 meeting exceeded numbers at prior Collaborative meetings at 326. We hope that this reflects the value that attendees place in learning from others and sharing their hospital’s successes with others around the state.

Responding To Your Feedback 

MSQC receives many suggestions on how we can improve Collaborative and Annual Meetings, and we listen. From the Blue Cross Blue Shield of Michigan survey that many members completed, we heard that a teleconference option would be desired as a way to attend MSQC meetings, especially for those who travel a great distance. We are working to pilot a live-streaming option for the December 7 Collaborative Meeting at Schoolcraft VisTaTech Center. We value the energy and connections that result at MSQC meetings, but also aspire to make meeting topics as widely accessible as possible.

Partnering with ASPIRE to develop meetings is another means of creating an efficient and beneficial experience for both MSQC and ASPIRE members and colleagues.

Another suggestion was to incorporate more environmentally-friendly practices into the meetings, so rather than provide disposable water bottles at our meetings, going we will experiment with using water stations, and we will be providing thermal drink cups to those who attend the June 22 SCQR Training Day. The Training Day itself is also a result of requests for more SCQR-centered content.

Hearing From Patients

Finally, after hearing inspiring stories from some past patients, members asked us to include patients in more of our meetings. During the April Meeting, we had the great pleasure of hearing the presentation by Mr. Robert Miller, a surgical patient and veteran of an Enhanced Recovery Program, who told his personal story from illness to recovery.

“For me, recovery was as important as the surgery and when I was introduced to the Enhanced Recovery Program I was immediately empowered and reassured that I alone could make a significant contribution for my complete recovery,” says Mr. Miller.

His work as a photojournalist for National Geographic made his presentation even more visual and touching. His positive attitude and perspectives brought home to us the great power that Enhanced Recovery can have on surgical patients. Robert reminded us of the impact that healthcare providers can play in a patient’s entire surgical experience, as well as the important role that patients can be empowered to take in their own recovery. He used the word H-A-I-L to describe the Enhanced Recovery process: Honesty with which the open conversations with patients are conducted to give clear and simple directions that allow patients to make informed decisions about their care; Authenticity which provides realistic and attainable goals that include the patient as a partner in their recovery; Integrity assures us that the healthcare team is well-trained and reliable to address the patient’s needs in a timely manner; and Love provides a safety net before, during and after surgery. Mr. Miller’s story demonstrates how good communication between providers and patients can impact patient adherence to medical advice, better clinical outcomes and lower utilization of unnecessary health care services.

Mr. Miller says, “I am convinced patients' voices and their feedback are truly the best resource for the medical community to improve care and achieve continuous growth and advancement for patient recovery outcomes.”   

MSQC would like to include patients in more of our meetings and conferences, so if you know of a patient who is willing to share their surgical story, please send their contact information to

Now, if we could just figure out how to regulate the room temperature…

As always, meeting slides and other documents, along with video recording of the main presentations, are available on the MSQC website:

Attention SCQRs!

Another Opportunity for Case Study Review!

Based on your request for more SCQR-specific education, we released the second case review which contains commonly-asked SCQR questions and variables that are often misinterpreted.

The case study was posted on Monday, June 11th on the SCQR email Forum, and on the MSQC website, within SCQR Resources, under the FAQs and Clinical Updates 2018.  

Feel free to discuss the case and your thoughts about the answers on the Forum, so we can all learn from each other.

We will review the case and rationale for answers at the June 22 SCQR Training Day.  Hope to see you all there!


SCQR Training Day, June 22 2018

After a successful meeting last July, MSQC is once again gathering its SCQRs for a dedicated day of training, networking and sharing best of best practice.

Highlights of this year's agenda include:

  • The Secret Life of a Surgical Reviewer, tips of the trade from Anita A. Volpe, DNP, APRN, Director of Surgical Outcomes, Research and Education at New York-Presbyterian Queens
  • A3 Problem Solving in Health Care: A Template for P-D-C-A Thinking
  • Surgical Anatomy for SCQRs
  • And much, much more...
A draft of the full agenda and other information can be found on the meeting page on the MSQC website:

If you're an MSQC SCQR and you have not yet registered, please do so ASAP!


MSQC asked Dr. Sarah Shargi, a pathologist from Bronson Methodist to share the protocols and initiatives that her department developed to advance their colorectal specimen processing, and this is her response.

In the pathology department at Bronson Methodist Hospital in Kalamazoo MI, our team of pathologists and pathology assistants have been working together to enhance the quality of our gross examination and reporting of colorectal cancer resections since 2015 and we have made great strides.

The first step was educating our pathology assistants regarding the impact of gross assessment of total mesorectal excisions (TME) on recurrence risk stratification and long term survival. We are fortunate to have two skilled pathology assistants who discuss cases with one another to ensure consistent grading of the integrity of the mesorectal envelope which is incorporated into the gross description. The pathology assistants referred to images and written guidelines, found webinars helpful, and occasionally utilized pathologist input to help with TME grade assessment.

Our pathology group also implemented mandatory synoptic reporting of the integrity of the mesorectum, even though currently TME grading is not required by the College of American Pathologists.

In addition, in working with Dr. Sam Hendren of the University of Michigan and the MSQC, we were able to identify other potential areas for improvement. We concentrated on improving lymph node recovery in our colorectal specimens by specimen reexamination and recently utilizing Carnoy’s solution when initial counts are inadequate (<12 nodes) and we have seen improvement in this area as well. The positive changes our team has made were relatively easy to implement into our daily practice.

It is encouraging to know that our focused effort to ensure high-quality colorectal cancer specimen analysis will have a positive impact on patient care.

Sarah Sharghi, M.D.
Bronson Hospital Anatomic and Clinical Pathology
Pathology Services of Kalamazoo

Notes from the MSQC Quality Improvement Team

As we enter the summer months and look forward to vacations and sunny skies, we are also nearing the halfway point of the Quality Improvement Project Year!  

We appreciate how many of you have persevered in learning to use this year, and we hope these trials and tribulations will pay off in the long run. provides safe, secure place to store and share quality improvement materials between the coordinating center and each site, and with time we are confident it will lead to better collaboration and efficiency. On June 18 you will receive an upload of your most recent data to your Box folder. Take a look at these new data files ASAP as they provide a good way to assess your project’s accomplishments to date.

Take a look at our new QI timeline, located here.  This will keep you alerted to upcoming deadlines for your QI projects, as well as let you know when we have exciting news regarding 2019.

Finally, we are looking forward to hosting  a very special event at the June meeting, called “A3 Problem Solving in Health Care: A template for PDCA thinking”. This session will be led by Dr. Jack Billi, the Medical Director of Collaborative Quality Initiatives at Michigan Medicine, and our very own Lean guru who has led Lean training for hundreds of healthcare professionals. This session will include a hands on experience during which you will be paired with other SCQRs working on the same quality improvement project this year. A3 problem solving is an extremely valuable way to structure quality improvement experiments and will be helpful not only to carrying out your project, but also in describing it to us at the end of the year.

Colectomy Bundle

MSQC has developed a data-driven process care bundle focused on SSI prevention for colectomy procedures.  Supported by numerous research findings, implementation of the bundle is associated with a decrease in SSI.  As you may recall from the Collaborative Meeting in April, Dr. Englesbe challenged the MSQC to improve our average colectomy bundle compliance score.  Current MSQC average compliance is 2.91.

Please visit our colectomy bundle webpage for implementation resources and references!

Education and Training Updates

Fourteen SCQRs completed MSQC Colorectal Cancer (CRC) data abstraction training this Spring. Training to abstract the 14 CRC variables consists of four weekly one-hour webinar sessions facilitated by Sarah Evilsizer and Dr. Hendren, project lead for the MSQC CRC project.

Each year, 140,000 cases of colorectal cancer are diagnosed, making colorectal cancer one of the most common cancers in the United States. While some MSQC hospitals may have only a few cases to abstract, each case will provide your site with important information which will lead to quality improvement in colorectal cancer care and outcomes once disparities in practice, such gaps in ostomy nurse referrals, number of lymph nodes excised and occurrence of anastomotic leaks are identified.

CRC training is conducted each Spring, so if your site is not currently participating in the MSQC CRC Project, please consider attending training in Spring 2019!

Continuing Education Requirements for Michigan Healthcare Providers

The Michigan Public Health Code and board administrative rules now require every nurse to complete 2 hours and physicians to complete 3 hours in pain and symptom management content in courses or programs approved by the Board during the 2-year (nurses) or 3-year (physicians) period prior to the renewal of the license. This is a change from pain-related content required prior to 2017.

The April 2018 Collaborative meeting included a few pain topics, such as the presentation by Dr. Melanie Simpson on Multimodal Post-Op Pain Management and the presentation by Dr. Kevin Boehnke on Cannabis for Pain-From Pills to Pot, that can be claimed for 1.25 hours of pain content. MSQC meeting agendas and CME certificates (received when meeting evaluation is completed) can be used as proof that requirements have been met if audited.

MSQC provides CMEs as an added benefits for its members. CMEs are offered for every MSQC meeting and conference, which may be used by physicians, nurses and other meeting attendees to fulfill state requirements for continuing education. In addition, because MSQC data reports are available for access, surgeons can claim Maintenance of Certification (MOC) Part 4 points for participating in MSQC.

CMEs are also available for surgeons who submit and review surgical videos as part of the Surgeon Video Review Project.

Coming soon to a browser near you...

MSQC is revamping its website with a planned relaunch in the fall. Watch this space!


Updates from the Michigan Opioid Prescribing Engagement Network

Statewide Drug Takeback Event Brings in Over One Ton of Unused Medications

On Saturday, April 28, Michigan residents in 17 counties had a chance to get opioids and other unused and expired prescription medicines out of their medicine cabinets through 27 simultaneous events held around the state. The collective effort resulted in hundreds of families safely removing a total of 2000+ pounds of medication, including approximately 54,000 opioids from their homes while also increasing awareness in the community about safe medication disposal.

Michigan OPEN works with partners to hold community opioid and medication take-back events twice a year. These events provide a safe process for disposing of unused medications in order to protect communities, children and the environment. When Take Back Event participants were asked how they disposed of medications prior to coming to the Event, more than 50% answered, “did not dispose,” highlighting the need for these community events.

We will be announcing the date of our Fall Take Back Event soon, please consider joining us!

MICHIGAN OPIOID LAWS - Start Talking Consent became the law on June 1, 2018.

In December of 2017, Lt. Governor Brian Calley signed into law, as passed by the Michigan Legislature, a 10-bill package of legislation aimed to curb Michigan’s persistent and increasing substance abuse and drug diversion problem.  PA 246 of 2017  mandates prescribers to provide specific patient education regarding risks involved in opioid use and disposal, upon issuing a new, outpatient prescription for any controlled substance, containing an opioid.  The patient, or guardian (for minors) must attest to receipt of this education by signing the state’s Start Talking Consent form.  Organizations can create their own form, provided it contains all regulatory requirements. The signed form must be saved to the patient’s medical record at the onset of each treatment episode involving a new outpatient opioid prescription only.

The “Start Talking Consent” form is located on the DHHS website:; click on <Prescribers> and you will see the MDHHS-5730, Opioid Start Talking link.  It is also available in Arabic and Spanish.

The following is a very useful link outlining all the Michigan Opioid laws, with FAQs beginning on page 5. Click here to download.

Michigan OPEN’s patient education brochures cover all the regulatory requirements and we will customize the brochures with your organization’s logo. For more information

Recent Articles of Interest

Association Between Hospital Staffing Models and Failure to Rescue
Annals of Surgery. Publish Ahead of Print, MAR 2018
Sarah T. Ward; Justin B. Dimick; Wenying Zhang; Darrell A. Campbell; Amir A. Ghaferi

Practice Patterns and Complications of Benign Hysterectomy Following the FDA Statement Warning Against the Use of Power Morcellation
JAMA Surg. Published online April 11, 2018.
Francesco Multinu; Jvan Casarin; Kristine T. Hanson; Stefano Angioni; Andrea Mariani; Elizabeth B. Habermann; Shannon K. Laughlin-Tommaso

Harnessing the Power of Peer Influence to Improve Quality
American Journal of Medical Quality 1–3
Christina T. Yuan; Peter J. Pronovost; and Jill A. Marsteller

Outcomes after Laparoscopic or Robotic Colectomy and Open Colectomy When Compared by Operative Duration for The Procedure
The American Journal of Surgery, Volume 215, Issue 4, April 2018,  577-580
Sunu Philip, Nancy Jackson, Vijay Mittal

Development and Validation of a Scoring System to Predict Surgical Site Infection after Ventral Hernia Repair: A Michigan Surgical Quality Collaborative Study
E. Karamanos, P. Kandagatla, J. Watson et al. World J Surg (2017) 41: 914.
Population-based evaluation of implementation of an enhanced recovery protocol in Michigan,
E George, GL Krapohl, SE Regenbogen,Surgery, (2018) 163: 6, 1189-1190,

Upcoming Meetings and Calls

MSQC Collaborative Meetings

September 14th 2018 - Meijer Gardens, Grand Rapids
December 7th 2018 - Schoolcraft College, Livonia (will be live-streamed)

SCQR and Surgeon Champion Conference Calls

August 2nd 2018
November 1st 2018

Full details on all the above will be made available here, closer to the dates:

And finally...

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