The Michigan Value Collaborative

Helping Michigan hospitals achieve their best possible patient outcomes at the lowest reasonable cost

Tag: patient outcomes (page 1 of 6)

Combating Surgical Site Infections in Michigan: Joint Replacement Workgroup Recap and Hospital Initiatives

Deby Evans

Deb Evans is the MVC Site Engagement Manager

The Michigan Value Collaborative (MVC) and the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) held a recent workgroup focused on surgical site infections (SSI) related to joint replacement. Hospitals met to discuss some of the root causes for these infections and initiatives they have implemented to help reduce them.

Below is one of the presented slides that exhibits the proportion of readmissions due to SSI’s for MVC/MARCQI hospitals based on MVC claims data:

Although many of the hospitals have done extensive analysis and in-depth review of pre-, intra- and post-operative joint conditions, few specific root causes for surgical site infections have been identified.  However, major focus areas for hospital-led initiatives that have been identified are:

  • Improving the general health of the patient especially in terms of reducing the body mass index (BMI);
  • Improving hemoglobin A1C for diabetics;
  • Improving albumin levels; and
  • Tobacco cessation

One hospital recently began an initiative aimed at helping patients become healthier and ultimately maintain an optimal weight for joint-replacement surgery. Referrals for the program come from surgeons prior to the surgery. The initiative includes a weight loss clinic and classes, which offers a refund of the cost of the program if the patient is successful in losing weight before surgery.

Most hospitals are following the Joint Commission recommendations from the Surgical Infection project (SIP) and the Surgical Care Improvement Project (SCIP). However, there are some differences in the identification and treatment of staphylococcus aureus carriers with some hospitals universally treating all joint replacement candidates and some only treating those identified as carriers through a nasal swab.  Although this workgroup only focused on SSIs related to elective joint replacement, it was mentioned that some hospitals are treating their trauma cases for staphylococcus aureus as well, while others are looking at this potential.

Other topics that prompted discussion among the group were wound closure and whether different types of closure affected SSI rates along with the type of dressing being used and the length of time the dressing stayed intact over the wound. There was some variety among surgeons and hospitals, however many are using a moisture-impervious silver based dressing that remains on for about seven days. Despite what may be considered a more expensive dressing being used the benefits of keeping the wound covered and out of contact with potentially infectious elements, i.e. pets, clothes, bed linen etc. outweigh these added costs.  In addition, when comparisons were made between these dressings and changing a dressing daily the difference in cost was negligible.

Finally, patient education was a major talking point during the workgroup. All hospitals agreed that having the patient’s cooperation is a significant factor in reducing SSI. Some hospitals have produced videos for patient viewing pre-operatively while others have an educational sheet that they provide to the patient before the surgery. Some discussion focused on the amount of information that the patients are expected to retain and ways hospitals are sharing reminders using booklets, pamphlets, a coach that is known to the patient or being seen by a discharge planner.

The Coordinating Center has put together a pre-, intra and post-operative check list of things to consider to potentially help reduce SSI, as well as a hygiene at home sheet for patients. These can be found in the resource tab on the registry along with information from our other workgroups.

If you have identified any specific root causes or have a new initiative aimed at reducing surgical site infections, then we would love to hear from you. Please contact Deb Evans ( or Abeer Yassine ( to share your story.  Preference

BCBSM Collaborative Helps Improve Joint Replacement Initiatives and Patient Outcomes in Michigan

Rochelle Igrisan

Rochelle Igrisan, MBA, MSN, RN is MARCQI’s Senior Project Manager.

Established in 2012, The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI), essentially focuses on hip and knee procedures, such as joint replacements and revisions of those procedures. MARCQI currently works with 60 member hospitals using clinical data to track the progress of these hospitals in improving patient outcomes related to joint surgery. Several of the quality initiatives initiated by MARCQI and utilized at participating hospitals have proven to be valuable and successful at improving patient outcomes while also reducing costs.

Optimize Use of Blood Transfusions Post Joint Replacement

By disseminating data on usage, sharing and promoting the American Red Cross (ARC) Guidelines for blood transfusions, and reviewing best practices regarding the standard for blood transfusions after joint replacement surgery MARCQI recognized the use of transfusions as an area to address among their member hospitals. The ARC guidelines suggest:

  1. Providing blood transfusions post joint replacement (unilateral) if the patient’s hemoglobin level is less than eight; and
  2. Only transfusing one unit of blood at a time and then testing the patient’s hemoglobin levels again to assess further treatment.

Following implementation of these guidelines, MARCQI member hospitals the use of blood transfusions after joint replacement decreased from 9.8% to 2.6%. This best practice has not only helped improve patient care by providing an appropriate and necessary amount of care for the patient, but has also helped reduce costs for hospitals. It has also reduced blood utilization throughout the state of Michigan allowing this precious commodity to be available for other occasions.

Improving Patient Care and Self-Management Post Joint Replacement

A second initiative MARCQI participants worked on has been geared towards decreasing the inappropriate use of skilled nursing facilities after joint replacement surgery. The majority of joint replacement patients have better post-operative outcomes if they are sent home. Thus, hospitals provided patients with guidance on how to better self-manage their condition post joint replacement. Prior to implementation of this quality initiative, about 33 to 50 percent of patients went to a nursing home following joint replacement surgery. However, after working on this initiative, only about 15 percent of patients are sent to nursing homes post joint replacement.

Other initiatives MARCQI is working on are better understanding of pain management post joint replacement, and reducing surgical site infections in post joint replacement candidates. Overall, the different quality initiatives that MARCQI has worked on has helped improve patient outcomes and save hospitals millions of dollars. In 2014-2015, MARCQI member hospitals saw a shared cost savings of $3,453,424. This cost savings goes hand in hand with helping improve patient experience and quality of care related to joint replacement surgery.

To promote hospital and CQI collaboration, MVC and MARCQI work on a Joint Replacement Workgroup together. If you are interested in learning more about MARCQI or the Joint Replacement Workgroup, please contact Deby (, Abeer ( or Rochelle Igrisan from MARCQI (

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