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Orthopedic Quality Initiatives Presenters: Erica Lemons, RN April Richmond, RN What is MARCQI? The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) is a group of orthopaedic surgeons and medical professionals dedicated to improving the quality of care for patients undergoing hip and knee replacement procedures in Michigan. More Than a Registry Collaborative Non-competitive Frequent Data Reporting Quality focused Sharing of Best Practices Feasible – efficient use of data sources Multi-year, longitudinal follow-up of cases Includes events that occur at other hospitals MARCQI Coordinating Center Team Co-Directors: Dr. Brian Hallstrom Dr. Richard Hughes Project Manager: Rochelle Igrisan Biostatistician: Dr. Bonita Singal Site Coordinators/Data Auditors: April Richmond Mary Gumtow Sherri McPhail Administrative Assistant: Anne Kagay-Lidster Providence’s MARCQI Team Clinical Champion: Dr. David Markel Clinical Data Abstractors: Erica Lemons Stephanie Jenkins www.marcqi.org What is a Hospital CQI? • Collaborative Quality Initiatives (CQI) • Funded by Blue Cross Blue Shield of Michigan • MARCQI is one of 20 CQI’s Sponsored by BCBSM • Other CQI Program examples: Angioplasty General and vascular surgery Bariatric surgery Breast cancer treatment Cardiac and thoracic surgery BCBSM P4P Program: http://www.bcbsm.com/provider/value_partnerships/hpp/index.shtml BCBSM Sponsor • CQI Participation Payment • Pay-for-Performance Incentive Payment Hospital Support • Clinical Champion • Clinical Data Abstractor(s) • IT Support • Quality Administration • Infectious Disease Performance Index 10 MARCQI Participating Sites 2012: 12 Initial Sites Two pilot sites February 2012 Gradual addition of ten more 2013: +17 additional sites joined 2014: +15 additional sites joined 2015: + 6 additional sites joined 50 MARCQI Sites to date MARCQI Sites Registered MARCQI Cases Number of Cases 68137 55867 45986 37205 30048 0 934 3160 6158 22813 18784 9896 11839 Overview of Data Process Participating hospitals collect and submit clinical data to the MARCQI Database MARCQI links data from multiple sources to track pts over time MARCQI performs risk adjustment and data validation and compiles reports Clinical Champions and Nurses come together to share data and collaborate on Quality Improvement efforts Clinical Champions and Nurses share collaborative data and goals at their hospital to implement change Levels of Data MARCQI Qualifying Cases Elective Primary Hip & Knee Arthroplasty Elective, Urgent, & Emergent Hip & Knee Revisions Levels of Data Level 1 Data Defines the procedure that starts a record Who? - Patient, Surgeon What? - Procedure, Implants Where? - Hospital When? - Procedure Date Without this the patient is not in the registry Levels of Data Level 2 Data Information about patient Demographics Co-morbidites Complications and their treatments Events of Interest ER visits or readmissions Reoperations or revision Infection, blood clot, death Levels of Data Level 3 Data Patient reported outcomes (PROS) Satisfaction & Health related quality of life questions Patients self report how they feel pre-op and again post-op PROS Collection • Pre-op • Post-op at: 3 months 1 year 2 years 5 years 10 Years PROS Collection MARCQI is currently performing a PROS collection Pilot • Goal of Pilot: Electronic capture rate of 80% in clinic/office • Surveys Utilized: HOOS PS (short form) or KOOS PS (short form) PROMIS 10 (10 questions) • Maximum number of questions: 17 • Average completion time for electronic survey: 5 minutes Make Michigan the best place in the world to have a joint replacement. Data Elements Type of Data Scheduled MARCQI Cases Data Source • • Surgery Schedule OR Schedule Possible Contact • • Entry Method Manual Entry/Case by Case -OrFBA • • OR Manager Central Scheduling Registration Office Managers Performed MARCQI cases • • Billing/Coding OR Log • • OR Manager Billing Manager FBA Only Pre-Op Risk Factors, Hospital Data, Post-Op events prior to D/C • Medical Records • • • HIM Manager Your Director Infection Control All Manual Entry/Case by Case -OrCombination FBA & Manual Post-Op Events after discharge • • Medical Records Admitting/Registrati on Billing Surgeons’ Office • • • HIM Manager Your Director Surgeons’ Office Managers Infection Control Manual Entry Only Medical Record OR Scanner System Orthopaedic News Network (ONN) files • • • HIM Manager OR Manager ONN administrator Manual Entry -OrFBA -OrBarcode Scanner in OR • • Implant Data • • • • Quality Improvement Cycle MARCQI QI Projects #1 Transfusions Reduce PRBC transfusions #2 Readmissions What are the largest primary diagnosis reasons for readmissions ? #3 Infections Infection Prevention Bundle #3 VTE Make recommendation Why choose transfusion: Wide range 6%-36% Transfusion Guidelines Red Cross Transfusion Guideline post operative patients Indicators for transfusion Threshold of HGB < 8g/dl Clinically Significant symptoms of anemia Unresponsive to fluid resuscitation Clinical judgment in patients with HGB < 10g/dl and increased risk factors Providence: Then and Now Transfusion Project 5/1/2012 – 11/5/2013 1/1/2014 – 9/30/2014 Received Transfusion 13.9% 5.6% Blood Transfusion w/ post-op HGB > 8 33.3% 8.9% Hips with Transfusion 22.5% 10.7% Knees with Transfusion 10.0% 3.0% MARCQI: Then and Now Transfusion Project 2/15/2012 – 11/5/2013 7/1/2013 – 6/30/2014 Received transfusion 8.3% 6.4% Blood Transfusion w/ post-op HGB > 8 28.7% 21.6% Hips with Transfusion 11.7% 9.4% Knees with Transfusion 6.0% 4.5% Estimates for 2014 676 Fewer patients transfused 1536 fewer transfusions given $1,075,200 to $1,536,000 saved Transfusion: Going Forward High transfusion rates at hospitals Review recommendations and current practices Collaboration between hospitals Visits from MARCQI Coordinating Center Staff Meeting with QI staff Meeting with blood bank Readmission Project All sites are statistically the same MIDB Readmissions 1/1/2013 – 12/31/2013 MARCQI MIDB 30 Day 90 Day 3.3% 5.3% 3.3% 5.6% Readmission Data Looking at reasons for readmission Risk adjustment for comparisons Discharge dispositions Barriers @ Providence Manually abstracting discharge disposition Inconsistencies Multiple people charting/ many specialties Where is the final dispo? Infection Project Why Infection is devastating to patients and surgeons Multiple admissions and operations Rising resistant bacteria Expensive Infection Prevention Bundle •Preoperative Methods •Patient education of SSI •Cleanse with CHG-containing product •Screen for MRSA/MSSA and treat those positive results •Decolonize for MRSA/MSSA with Skin and Nasal Antiseptic •Intraoperative Methods •Do not remove hair unless necessary •Prep with an alcohol based agent •SCIP- Administer ABX •Minimize intraoperative foot traffic •Postoperative Methods •Apply sterile dressing •SCIP- Discontinue ABX per protocol Where does Providence Stand? < 0.2 % infection rate for 2014 (deep infections) Information shared with NHSN Gathered by the Infectious Disease team Goal < 0.5% We have implemented a decolonization process for the orthopedic patients qualifying for MARCQI VTE Project Collecting data phase Not enough information to make recommendations Multiple protocols X surgeons 50 + hospitals Many practices Importance of Documentation Mechanical and Chemical Educational Links IHI Project Joints: http://www.ihi.org/Engage/Initiatives/Completed/ProjectJOINTS/Page s/default.aspx AAOS: http://www.aaos.org/ Ortho Bullets: http://www.orthobullets.com/ HRSA Quality Improvement: http://www.hrsa.gov/healthit/toolbox/HealthITAdoptiontoolbox/Quali tyImprovement/whatisqi.html Going Lean In Healthcare: http://www.ihi.org/resources/Pages/IHIWhitePapers/GoingLeaninHea lthCare.aspx Questions ?