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

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

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

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 Data Source Possible Contact Entry Method Scheduled MARCQI Cases Surgery Schedule OR Schedule OR Manager Central Scheduling Registration Office Managers Manual Entry/Case by Case -Or- FBA Performed MARCQI cases Billing/Coding OR Log 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 -Or- Combination FBA & Manual Post-Op Events after discharge Admitting/Registration Billing Surgeons’ Office Surgeons’ Office Managers Manual Entry Only Implant Data Medical Record OR Scanner System Orthopaedic News Network (ONN) files ONN administrator Manual Entry -Or- FBA -Or- Barcode Scanner in OR

Quality Improvement Cycle

MARCQI QI Projects #1 Transfusions #2 Readmissions #3 Infections 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

Then and Now Transfusion Project 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 MIDB Readmissions All sites are statistically the same MIDB Readmissions 1/1/2013 – 12/31/2013 MARCQI 30 Day 90 Day 3.3% 5.3% MIDB 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/Pages/default.aspx   AAOS: http://www.aaos.org/ Ortho Bullets: http://www.orthobullets.com/ HRSA Quality Improvement: http://www.hrsa.gov/healthit/toolbox/HealthITAdoptiontoolbox/QualityImprovement/whatisqi.html Going Lean In Healthcare: http://www.ihi.org/resources/Pages/IHIWhitePapers/GoingLeaninHealthCare.aspx

Questions ?