GENERAL ELIGIBILITY AND EXPECTATIONS

MARCQI sites are invited by Blue Cross Blue Shield Michigan to join the collaborative.

Follow this link to download a copy of the Eligibility_and_Expectations list

Eligibility Requirements

To participate in the MARCQI, a site must meet the following eligibility criteria:

  • Volume requirements: See the clarification of case code lists to determine whether your facility meets eligibility requirements (MARCQI Qualifying Procedure Code List)
    • In-patient facility must perform a minimum of 200 TKA/ THA in-patient and/or out-patient procedures annually per
    • Out-patient facility must perform a minimum of 1 TKA/ THA out-patient procedure monthly per site.
  • Have an active quality improvement structure and process
  • Appoint an orthopaedic surgeon who performs THA/TKA to act as the site’s Clinical Champion (CC)
  • Appoint an administrative champion to act as the Administrative Lead
  • Appoint a clinical data abstractor (RN, LPN,), registered health information technician (RHIT) or clinical reviewer to abstract cases into the database
  • Appoint an Information Technology (IT) database lead to develop a process to pull MARCQI data and create files to upload to the MARCQI
  • Submit data to the Michigan Inpatient Database and Michigan Outpatient Database via the Michigan Health and Hospital Association
  • Access equipment and components to capture data into the web based database for the MARCQI registry:
    • Data Entry Workstation for Clinical Data Abstractor (CDA)
      • A computer with keyboard/mouse and internet access
      • Dual monitors are recommended
      • Access to EMR and/or paper chart for site and physician office records
      • Access to the site’s OR log/schedule
      • Access to the site’s billing records
  • For Operative Data
    • Ability to upload the OR log (File Based Acquisition)
    • Barcode scanner (Optional)for device stickers
  • In the Orthopaedic Clinic(s)
    • Access to office and clinic notes for 90-day event follow-up.
    • Tablet for collection of Patient Reported Outcome Surveys (PROS)(optional)
    • A computer with keyboard/mouse or tablet with internet access (Optional)  

Expectations

To successfully participate in the project, all sites (hospital or Ambulatory Surgical Center) will be expected to do the following:

I. Identify all eligible patients presenting to your facility using the following criteria:

  1. Inclusion Criteria:

    1. Patients who are 18 years of age or older at the time of
    2. All elective primary and revision TKA/THA procedures listed on the MARCQI qualifying code
    3. All emergent and urgent revisions
    4. Trauma cases that are revisions
  2. Exclusion Criteria:

    1. Patients under the age of 18 years at the time of the surgery
    2. Emergent primary cases
    3. Trauma cases – that are primary cases i.e.: (A patient admitted to the hospital with acute trauma and has a TKA/THA surgery(s) for that trauma)
    4. Hemiarthroplasty procedures
    5. Girdlestone procedures
    6. Total femur cases
    7. Arthroscopy procedures
    8. Stage 1 revisions for infection

II. Contribute case data to the MARCQI registry

  • Data collection begins when the patient is scheduled at the facility to undergo an elective hip/knee replacement procedure
  • Data Elements: Approximately 150 elements. Elements may be entered into the MARCQI database via FBA or manual
    1. Patient Registration
      1. Patient Demographics
      2. Preoperative
        1. Admission data
        2. Patient medical history
    2. Intraoperative
        1. Procedure codes
        2. Surgical data
    3. Postoperative
        1. Venous thromboembolism data
        2. Blood transfusion data
        3. Post-discharge narcotic data
    4. Implant Device Information-all devices implanted in the joint
    5. Clinical Laboratory Values
      1. Pre-operative
      2. Post-operative
      3. Screening and decolonization of Staph Aureus
    6. Patient Reported Outcome Surveys (PROS)- captured either directly in the clinic via a tablet or kiosk, an email survey, collected by a vendor or on paper
      1. Collected at the following intervals:
        1. Pre-operatively within 90 days of the
        2. Post-operatively, ideally:
          1. 5-13 weeks,
          2. 1, 2, 5 and 10 years.

III. Sites must have an active Quality Improvement Committee

    1. Participating sites shall sign and return a Participation Agreement, Data Use Agreement (DUA), and Business Associate Agreement (BAA) within 3 months of application approval. Data collection must start within 60 days of paperwork completion.
    2. The Quality Improvement Committee can meet as frequently as needed, but at least quarterly, depending on the needs of the facility. A Site Based Quality Meeting is required after each MARCQI Collaborative meeting (Three times a year) and before the next collaborative meeting.
    3. Members of the committee can include (but are not limited to) the Clinical Champion, Clinical Data Abstractor/Reviewer, orthopaedic surgeons, anesthesia providers, operating room personnel, nurses, and other staff involved in the care of surgical patients.
    4. The committee will review data from the site as well as aggregate Michigan registry data for the purposes of quality improvement in surgical care.

IV. Sites need to appoint a Clinical Champion (CC)

    1. The CC will be an orthopaedic surgeon interested and active in the care of patients undergoing a total hip/knee replacement procedure. The clinical champion will participate in the Quality Improvement Committee and lead the site in QI efforts, and will attend all MARCQI collaborative meetings, provide oversight and leadership at your site
    2. The CC must perform THA or TKA at the site.

V. All sites identify an Administrative Lead

    1. The Administrative Lead will be the administrative contact for the MARCQI registry at the facility (hospital or ASC), provide institutional support for full project participation, and is welcome to participate in the MARCQI collaborative meetings.

VI. Access to records: Sites must identify an Information Technology (IT) database lead

    1. The IT Lead will be the IT contact for the MARCQI registry at the facility, provides institutional support for full project participation, and will participate in the MARCQI new site Kick-Off meeting and annual IT webinar conference calls.
    2. The IT Lead will ensure active communication and collaboration with the MARCQI registry data management center and database vendor to establish electronic data exchange/upload of site data directly into the MARCQI registry in the appropriate data format in a timely manner.
    3. Sites must provide an OR log that is uploaded electronically to the MARCQI database.

VII. Site must hire or contract with an appropriate Clinical Data Abstractor (CDA)/Clinical Reviewer (CR)

    1. A FTE model for hospitals is provided annually following discussions between the MARCQI coordinating center and BCBSM.
    2. The data abstractor(s) will be responsible for the timely and accurate collection of data and entry/upload into the web-based database.
    3. The trained and certified MARCQI data abstractor(s) will participate in project training sessions, the MARCQI collaborative meetings (3 times a year), and maintain regular contact (email, phone, conference calls, webinars, etc.) with the Coordinating Center.
    4. Only a trained and certified MARCQI CDA will be able to represent a site at a MARCQI collaborative-wide meeting.
    5. If a separate person is assigned to do performance improvement vs the person who does data abstraction, both people are expected to attend the collaborative meetings.

VIII. Collaborate with Coordinating Center

    1. The participating staff is expected to respond to Coordinating Center queries and requests in a timely manner, but no more than 5 business days.
    2. The facility should actively participate in reporting progress and outcomes.
    3. The institution will work closely with the Coordinating Center and the other sites to develop a Quality Improvement (QI) Agenda for the MARCQI program using the aggregate Michigan registry data.
    4. The institution will work closely with the Coordinating Center to develop a site-specific QI Agenda using data from their facility’s data in comparison to the aggregate Michigan registry data.

IX. Collaborate with other participating sites

    1. Participation of each site in quality process improvement is essential to the success of the program, including sharing of and learning from best practices.
    2. Sites must be willing to share de-identified data.

X. MARCQI data and reports are privileged and confidential and should only be used for quality improvement purposes.

    1. MARCQI data is not to be shared with any device manufacturers or the device/pharmaceutical industry.
    2. MARCQI data is not to be used for marketing or making comparisons to any surgeon or MARCQI site.
    3. MARCQI data is not be used for surgeon credentialing or Ongoing Professional Practice Evaluation (OPPE).
    4. Any internal site based research involving MARCQI data must have internal IRB approval.

 

Revised 09.2020