1. Orthopedic Quality Initiatives
Presenters:
Erica Lemons, RN
April Richmond, RN

2. 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.

3. 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 )

4. 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

5. Providence’s MARCQI Team
Clinical Champion:
Dr. David Markel
Clinical Data Abstractors:
Erica Lemons
Stephanie Jenkins

7. 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:

8. BCBSM Sponsor CQI Participation Payment
Pay-for-Performance Incentive Payment

9. Hospital Support Clinical Champion Clinical Data Abstractor(s)
IT Support
Quality Administration
Infectious Disease

10. Performance Index

11. 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

12. MARCQI Sites

13. Registered MARCQI Cases

14. 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

15. Levels of Data MARCQI Qualifying Cases
Elective Primary Hip & Knee Arthroplasty
Elective, Urgent, & Emergent Hip & Knee Revisions

16. 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

17. 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

18. 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

19. PROS Collection Pre-op Post-op at: 3 months 1 year 2 years 5 years

20. 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

21. Make Michigan the best place in the world to have a joint replacement.

22. 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

23. Quality Improvement Cycle

24. 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

25. Why choose transfusion:
Wide range 6%-36%

26. 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

27. 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%

28. 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%

29. Estimates for 2014 676 Fewer patients transfused
1536 fewer transfusions given
$1,075,200 to $1,536,000 saved

30. 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

31. 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%

32. Readmission Data Looking at reasons for readmission
Risk adjustment for comparisons
Discharge dispositions
Providence
Manually abstracting discharge disposition
Inconsistencies
Multiple people charting/ many specialties
Where is the final dispo?

33. Infection Project
Why
Infection is devastating to patients and surgeons
Multiple admissions and operations
Rising resistant bacteria
Expensive

34. 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

35. 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

36. 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

37. Educational Links
IHI Project Joints:
AAOS:
Ortho Bullets:
HRSA Quality Improvement:
Going Lean In Healthcare:

38. Questions ?