For many patients preparing for surgery, the process begins long before they enter the operating room. Blood tests, lab visits, and diagnostic screenings often become routine steps in preoperative care—even for patients undergoing low-risk procedures. In many cases, these tests add extra appointments and costs without changing how care is delivered.
Research suggests that as many as one in three patients evaluated for low-risk surgery receive tests that are not clinically necessary, and those results rarely influence clinical decisions. Improving the appropriateness of testing is therefore an important opportunity to improve the patient experience while reducing inefficiencies in surgical care.
For the last few years, the Michigan Value Collaborative has engaged its suite of offerings – from dedicated registry pages and push reports to workgroups and performance-based incentives – to support hospitals across the state in aligning their preoperative protocols with evidence-based guidelines.
Progress on the RITE-Size Trial
Another key component in the success of improved preoperative testing appropriateness in Michigan is the Right-Sizing Testing Before Elective Surgery (RITE-Size) trial, supported by the Michigan Program on Value Enhancement (MPrOVE), the Michigan Surgical Quality Collaborative (MSQC), the Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE), and MVC.
RITE-Size is an Agency for Healthcare Research and Quality (AHRQ)-funded, multi-institutional quality improvement trial. RITE-Size launched a pilot in March 2024 at three hospitals in Michigan. The study aimed to meet criteria in several areas such as feasibility (implementation in the appropriate amount of time), testing rates (reduction), and acceptability and appropriateness (results from interviews). By August 2024, the desired milestones had been achieved, showing a 68% average reduction in unnecessary testing by the three participating sites (Figure 1). All three sites saw significant decreases in their testing rates following implementation of the multi-component intervention.
Figure 1. MVC RITE-Size Pilot Program Testing Rates Over Time Across All Three Sites from March-April 2024 to July-August 2024
This was followed by a larger trial in 2025 with six new hospitals. Each site participated in a site visit, personalized coaching, and evaluation of their data in consultation with the RITE-Size team to guide on-site efforts to improve the appropriateness of their preoperative testing. In 2026, the RITE-Size partners are looking to enroll 12-15 hospitals and ambulatory surgery centers (ASCs) across Michigan.
Along the way, some of the successes, tools, and challenges from sites participating in the trial have been featured in MVC’s preoperative testing workgroups, where clinical and quality leaders have come together to learn from one another and share best practices. In one of those recent workgroups, for example, Lake Huron Medical Center shared insights into their experience in the trial and its impact on their preoperative protocols. A collated list of MVC’s preoperative testing workgroups can be found on MVC’s YouTube channel.
The work is also contributing to the broader evidence base on reducing low-value care. Nicole Mott, MD, MSCR, a National Clinician Scholar at the University of Michigan supported by the Veterans Administration and a general surgery resident at the University of Colorado, was the lead author on a recently published paper in JAMA Network Open that described the components and impact of the trial.
Leveraging Partner Operations for Recruitment
Over the past year, the RITE-Size partnership has worked to strengthen alignment between the trial’s activities with those operational activities of the partner organizations.
For instance, participation in the RITE-Size initiative is now tied to MSQC’s BCBSM P4P scorecard for preoperative testing, allowing hospitals to receive credit toward their scorecard by engaging in the initiative. MVC is also leveraging its new ambulatory surgery center (ASC) dataset to identify additional sites beyond the hospital setting that may benefit from participating in the initiative, with recruitment efforts under way with six eligible ASCs. Three new hospitals joined the trial at the start of 2026, and additional sites are engaged in conversations and related information sessions as they consider participating.
Supporting Hospitals in Practice Change
Participating hospitals are approaching preoperative testing improvement from a variety of starting points. For some, the initiative has helped validate practices that were already evolving. For others, it has created an opportunity to revisit long-standing protocols and bring them in line with current evidence.
At Lake Huron Medical Center, participation in the RITE-Size initiative helped uncover an important opportunity for improvement. While staff had already begun reducing unnecessary preoperative testing in practice, the hospital discovered that its formal documentation had not kept pace with these changes. The pre-anesthesia testing protocol used by staff still included outdated materials and handwritten updates accumulated over time.
Through the collaborative work of the RITE-Size initiative, the hospital was able to review and modernize its protocol, ensuring that documentation reflects current practice and provides clear guidance for clinical teams. This type of operational refinement—aligning written protocols, data reporting, and frontline practice—is a common step for organizations working to improve the appropriateness of preoperative testing.
The collaborative structure of the initiative has also proven valuable. Participating hospitals are able to share implementation strategies, learn from peers facing similar challenges, and access guidance from project partners as they refine their approaches.
Looking Ahead
As this work continues, MVC is also using its claims-based data to examine the broader impact of reducing unnecessary testing. The MVC Coordinating Center is currently partnering with MSQC to explore the impact and value of MSQC’s preoperative testing metric since its inclusion in their scorecard. The aims of this analysis are to better understand the statewide improvement in the measure as well as the potential financial and operational benefits associated with improvements.
Insights from this analysis will help the RITE-Size partners better understand the impact of an incentive-based measure on testing outcomes as well as related cost savings that may accompany on-the-ground improvements.
As the RITE-Size trial continues into its next phase, the trial partners remain committed to supporting hospitals through shared data, collaborative learning, and practical implementation resources. Together, these efforts aim to ensure that preoperative testing is used when it adds clinical value.
Hospitals interested in learning more about their preoperative testing rates and opportunities can contact the MVC team.
