18 Mar 2026
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Reducing Unnecessary Preoperative Testing: Progress on RITE-Size Partnership

Reducing Unnecessary Preoperative Testing: Progress on RITE-Size Partnership

March 18, 2026 | Comments Closed | , , ,

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

line graph depicting reduction in unnecessary preoperative testing at three pilot sites

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.

Kelly Lewton, RN, BSN quote

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.

04 Dec 2024
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November Workgroups Highlight Preop Testing Project and Cardiac Rehab Access Initiative

November Workgroups Highlight Preop Testing Project and Cardiac Rehab Access Initiative

December 4, 2024 | Comments Closed | , , , ,

In November, MVC hosted two virtual workgroup presentations – the first on preoperative testing was led by a fellow Collaborative Quality Initiative (CQI), and the second on cardiac rehabilitation was delivered by an MVC member hospital. MVC hosts two virtual workgroups per month with topics rotating between post-discharge follow-up, sepsis, cardiac rehabilitation, rural health, preoperative testing, and health in action (ad hoc focused topics). Each month, the MVC Coordinating Center publishes key highlights from these presentations to support resource and best practice sharing across the state.

November Preoperative Testing Workgroup: Michigan Surgical Quality Collaborative (MSQC)

The first workgroup of November focused on preoperative testing and featured a presentation by Pamela Racchi, Clinical Site Coordinator with the Michigan Surgical Quality Collaborative (MSQC), and Susanna Fortney, Clinical Quality Specialist at ProMedica Charles and Virginia Hickman Hospital. To start, Racchi’s presentation provided an update on MSQC’s Preoperative Testing for Low-Risk Surgeries Project, including updated findings for 2024 and plans for 2025. Fortney then presented on ProMedica Charles and Virginia Hickman’s progress with reducing preoperative testing through the lens of participating in both the MSQC preop testing project and the RITE-Size pilot.

MSQC’s preoperative testing project is a continuation of a pilot started in 2022. The goals of the project include:

  1. To define the extent of routine preoperative testing in low-risk surgeries,
  2. To identify underlying reasons for overuse of preoperative testing in low-risk surgeries, and
  3. To implement interventions to heighten awareness and reduce variation among hospitals

Their project varies slightly from MVC’s preoperative testing offerings in that MSQC includes a slightly broader range of low-risk surgeries. The MSQC preop testing project includes abstraction for cases of minor hernia (abdominal hernias <3 cm and all inguinal/ femoral hernia repairs), laparoscopic cholecystectomy, and breast lumpectomy.

During the pilot, MSQC included all ASA classes in their analysis. Based on feedback from site participants, however, MSQC has since limited their evaluated cases to only ASA class I and II, elective cases, and low-risk surgeries identified as the intended primary procedure (based on CPT codes) for 2024. Patients falling into ASA classes I and II are expected to be stable with their comorbid conditions and therefore require less frequent testing.

Overall, results since September 2024 suggest ASA I and II cases are all trending in the right direction; abstracted data currently indicates preop testing rates of 18% among ASA I cases (with a goal of 25% or less) and 31% among ASA II cases (with a goal of 32% or less), as shown in Figure 1.

Figure 1.

Racchi also noted that the success of reducing preoperative testing is dependent on there being no further increases in unnecessary testing on the day of surgery. Historically, MSQC has calculated preoperative testing rates like MVC, up to 30 days prior to a surgery but not including the day of surgery. However, MSQC’s abstractors can additionally identify testing completed on the day of surgery. In 2024, MSQC abstractors are assessing cases that received testing on the day of surgery as well as those that received testing in the 30 days prior to a surgery. Preliminary performance results suggested there was an increase in day of preoperative testing when compared to baseline for both ASA I and II cases. Racchi noted that these analyses help determine whether testing was clinically necessary versus a result of physician habit.

Racchi and Fortney both spoke to the benefits of increasing engagement between surgery and anesthesiology to streamline preoperative testing protocols and processes. Between 2022 and 2023, ProMedica Charles and Virginia Hickman was able to reduce their preoperative testing rate by nearly 20% with just a few modifications to their testing protocol and additional onboarding of the anesthesiology providers.

A recent review of preoperative testing cases at ProMedica Hickman that were labeled unnecessary revealed nearly 40% were, in fact, medically justified and another 42% were due to protocol misinterpretation. Interestingly, the greatest rate of unnecessary preoperative testing was found to derive from ProMedica Hickman’s preadmission testing department. Fortney noted they had success embedding an adapted version of the RITE-Size program’s decision aid (Figure 2) within their anesthesiology preoperative protocols, and this helped to provide a more robust visual for their providers to reference when completing preop documentation.

Figure 2.

ProMedica Hickman additionally implemented a process for one-on-one training with preadmission testing (PAT) nursing staff, re-education, and the inclusion of case studies. The PAT nurses have also been included in MSQC/RITE-Size project update meetings and are given access to push reports so they can better understand their progress and impact.

The RITE-Size project is a collaboration between several CQI organizations – the Michigan Program on Value Enhancement (MPrOVE), the Michigan Value Collaborative (MVC), MSQC, and the Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE). Each organization has individual projects underway to address unnecessary preoperative testing, but also collaborate under the umbrella of RITE-Size to support de-implementation with additional customized support and coaching. Learn more about RITE-Size by visiting the program website here.

November 5 Preoperative Testing Workgroup

November Cardiac Rehab Workgroup: Marshfield Medical Center – Dickinson

The second November workgroup focused on cardiac rehabilitation – another of MVC’s value-based initiatives. This workgroup featured a joint presentation by Carolyn Hoy, BSN, Director of Quality; Courtney Swanson, BSN, RN, Heart Care Clinic and Cardiopulmonary Rehab Manager; and Lacey Schjoth, BS, Cardiac Rehab Coordinator at Marshfield Medical Center – Dickinson. Hoy, Swanson, and Schjoth’s presentation introduced Marshfield – Dickinson’s cardiac rehab Patient Access Improvement Project, an initiative rooted in one of their core values of patient-centered care.

Although part of a much larger system, Marshfield Medical Center – Dickinson is a relatively small hospital with about 49 general med/surgical beds. To support a significantly rural population in the Upper Peninsula, the Marshfield – Dickinson team identified the need to modify their cardiac rehab program to improve access. Their three main goals included:

  • Increase the volume of patients seen,
  • Accurately track referrals,
  • Expand services to include a supervised exercise therapy (SET) peripheral artery disease (PAD) program

Swanson and Schjoth described how the Northern Michigan landscape and weather contributed to some of the barriers patients faced in accessing cardiac rehab care. Outside of Marshfield – Dickinson’s cardiac rehab center, the next rehabilitation facility is nearly 45 miles away. To support patients driving a long distance to receive cardiac rehab, the team worked to coordinate with their patient’s other appointments. They also flexed their schedules to accommodate earlier or later availability and were willing to shift the appointment times as needed pending weather conditions.

Ultimately, the team was able to increase their class size to five patients per class and increased their class offerings by one cardiac rehab (and one pulmonary rehab) class per day by December 2023. They saw a nearly 27% increase in patient enrollment between 2022 and 2023 (Figure 3). Thus far in 2024, their patient volumes are on track to match or exceed 2023.

Figure 3.

Since Marshfield – Dickinson is unable to support a Phase 1 cardiac rehab program, most of their referrals come from outside facilities located in Wisconsin. Connecting with patients quickly after referrals are received is helpful to reduce the duration of time between referral and enrollment. With adjustments to their workflow, the team was able to reduce the average time from referral to initial contact to an average of just 3.5 days as of November 2024. The team also observed a corresponding reduction in the time to first cardiac rehab visit of just 16.5 days on average.

However, rectifying referral documentation from multiple outside sources can slow down this process. Additionally, surveyed patients reported that one of the largest barriers to starting cardiac rehab was a lack of insurance coverage or high copays, with nearly 9% of patients identifying this as the primary reason they did not schedule their initial cardiac rehab appointment in 2024.  The team has recently brought on a financial counselor to assist in contacting insurance companies and ensuring adequate and accurate referrals documentation.

Lastly, the Marshfield – Dickinson cardiac rehab team worked to develop close partnerships with local cardiology providers. Ensuring local cardiology providers are aware of and supportive of cardiac rehab is a critical step that generates additional opportunities for program endorsement and patient education by the provider. Marshfield – Dickinson has additionally added Dr. Massabni, an interventional cardiologist specializing in peripheral artery disease, to their staff. This allowed them to further develop their SET PAD program in January 2024 and they are seeing increasing enrollment in this specialized vascular program.

Much of MVC’s work with its members and partners in the space of cardiac rehab is delivered under the umbrella of the Michigan Cardiac Rehab network (MiCR), a collaborative partnership with the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2). You can see the MiCR website and offerings here. MVC also offers a robust registry of medical insurance claims data and data specialists that can help navigate and create custom analytic reports on cardiac rehab utilization metrics. Please reach out to the Coordinating Center by email if you would like to learn more about MVC data or engagement offerings.

November 21 Cardiac Rehab Workgroup

To learn more about the efforts showcased by November’s workgroup presenters, or other past workgroup presentations, please visit MVC’s YouTube Channel here.

December’s workgroups will feature a post-discharge follow-up presentation on December 3 led by Crystal Young of Corewell Health Trenton and Natalie Holland of MDHHS. Additionally, on December 12, Toni Moriarty-Smith of McLaren Northern Michigan will present a rural health presentation. The complete 2024 and 2025 MVC event calendars and workgroup registration links are available here.