Great Lakes VSG Fall 2017 Regional Meeting Sept 15, 2017 12:00pm – 4:00pm ProMedica Toledo Hospital Toledo, OH

*denotes those attending remotely

Name Last Credentials Medical Center Position Robin Acino MPH ProMedica Toledo Hospital Manager *Linda Carney West Medical Center Manager *Marsha Lowrie RN, MS Hospital Admin *Amy Jackson RN, MSN Doctors Hospital Nurse Elizabeth Detschelt MD Excela Health Physician Tina Beduhn RN Lake Health Nurse Pam Estell Grant Medical Center Manager *Judi Spath LPN, CSCR Metrohealth Nurse Michelle Farneman Wexner Medical Center Manager *John Phillips MD OhioHealth Physician Brianne Gibson Summa Health System Manager Donald Logan Data Manager Wexner Medical Center Data Manager Babatunde Oriowo MD ProMedica Toledo Hospital Physician OhioHealth Marion General Amy Morris BSN, RN, CCRN Hospital Data Manager *Renee Brinker PT, MBA Summa Health System Data Manager John Moawad MD Summa Health System Physician Clinical Program Megan Pepin Manager Wexner Medical Center Nurse David Rollins West Medical Center Physician Susan Smith Riverside Methodist Hospital Manager

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Research Co- Kathy Sheridan LPN Lake West Medical Health ordinator Jean Starr MD Wexner Medical Center Physician *Elizabeth Detschelt MD Westmoreland Regional Health Physician *Matt Asbury Health Manager *Joyce Bogan Mount Carmel Hospital Manager *Barbara Pittner MetroHealth Medical Center Manager *Lori Wiseman Ohio Health Manager *Stacy O’Brien Summa Health Manager *Cathy Eveland Mount Carmel Hospital Fern Schwartz Data Coordinator UPP Vascular Surgery Data Manager John Towey West Medical Center Manager Ali Arak Data Manager UPP Vascular Surgery Data Manager

Welcome and Introduction by Dr. Jean Starr, Medical Director

Quality Physician Scorecards/reports: • Brianne Gibson from Summa Health presented their current scorecards they use and their process for creating them. Dr. Mouwad voiced how time consuming process had been and discussion was had about 30 day readmissions needing to be reportable in a timelier manner not 9-21 months later. • Donald Logan from Wexner Medical Center presented Physician Scorecards and new comparison report they created. He went through the process used to create these. Review/Discussion: • Action items from Last meeting were review. • Readdressed need to vote to unblind LTFU reporting. Need majority vote to unblind so will send out an electronic vote since not enough present at the meeting.

National VQI update by Jim Wadzinski, SVS PSO • Volume of participating centers = 431 centers in 46 states + Canada and the volume of procedures exceeds 390,000. • Highlighted the new member only website to help members to share quality improvement and best practice information more easily between and within Regional Quality Groups. The site includes a new password protected topical discussion forum for VQI members. Issue was addressed that many people did not know their login credentials so they will be sent out again. Everyone reminded to check Spam/Junk

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folder to make sure they are not being sent there.

• The VQI@VAM meeting in San Diego was on Tuesday, May 30, 2017 with a half-day session for data managers. Wednesday, May 31st is a full day session for physicians and data managers. Many of the topics for 2017 were submitted by members. The new poster session/reception on Tuesday at 5pm was highlighted and members were encouraged to submit an abstract for posters by March 15th. Posters focused on QI processes, case studies or workflow issues. • Reviewed VAM survey results. Positive feedback overall. Overall people would like to see more in depth breakout sessions, more on Analytics Engine. Idea was brought forth to try and have a Great Lakes Regional meeting for everyone attending or at least be informed who from our region will be attending. • The newsletter is now published every other month with detailed information on the annual meeting, QI projects, the participation awards and other PSO initiatives. In addition to receiving the newsletter via email, it is posted on the front page of the VQI website • Two national QI initiatives for the PSO – the first is discharge medications – slides and transcripts from the Feb webinar with Drs. DeMartino and Jackson are available on the VQI website under the Resource tab. The goal is 100% compliance. The second initiative is EVAR LTFU – a webinar will be presented in April 2017. A copy of the QI Project charter and an example using a discharge medications example is included in the regional slide deck. The QI charter will help the PSO track VQI quality projects. • Changes to the CMS physician payment program was discussed under MACRA/MIPS. Transcripts and slides from the Dec. 2016 webinar on MIPS/MACRA are available on the VQI website. The importance of submitting data IN 2017 under the ‘pick your pace’ program that allows submission of minimal data to avoid a penalty in 2019 or the full data submission that provides opportunities for bonus incentives. • Participation Award potential changes reviewed with the group and discussed. There will be a formal presentation in November.

Regional Data Review: Dr. Starr reviewed data from the Regional Reports. She reported that the region is doing very well on several key indicators including Long term follow up procedures, low hematoma rate despite low use of ultrasound guidance, high rate in the country for preop ABI/TBI rate.

• Dr. Mouwad gave update on Arterial Quality Committee • Carrie Bosela gave an update on the Venous Quality Committee and Research Advisory Committee.

Group Discussion and Feedback: • PSO will release audit tools in January

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• There is a discussion to start with annual dues to help offset costs for regional meetings.

Project Ideas for the regional group: • Questionnaire given out during lunch and also sent electronically prior to meeting to get a feel on how everyone is capturing their data and their completion rate. • Group discussion had on whether or not to pursue this as a possible regional project. Will discuss further once results are calculated and reviewed.

Anne Parker from M2S Pathways provided an update.

Presentations: • Two Fellows from ProMedica gave brief presentations.

Next Great Lakes VSG Meeting location: TBD

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