7 Lessons from Michigan’s Pioneering Trauma Quality Collaborative

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What is the right “scale” for a trauma quality program? Four years ago, the Michigan trauma community launched a region-level quality collaborative. Leaders say a regional collaborative is large enough to provide meaningful comparative data, but small enough to allow trauma teams to meet, build mutual trust and work together effectively on quality improvement.

The Michigan Trauma Quality Improvement Program (M-TQIP) is a statewide collaborative of 27 Level I and Level II trauma centers. Participating hospitals share data on trauma care, with the goals of measuring care quality, identifying best practices and improving patient outcomes. The collaborative is funded by Blue Cross Blue Shield of Michigan and Blue Care Network of Michigan.

Since the collaborative’s launch in 2011, M-TQIP hospitals have achieved significant improvements in trauma care quality and safety. Recently, program leaders discussed how the collaborative works. Seven lessons stand out:

1. Start with the basics, then branch out
M-TQIP hospitals are enrolled in the national American College of Surgeons Trauma Quality Improvement Program (TQIP). But TQIP measures are just the starting point for participating hospitals.

“Initially, we focused on the usual measures of mortality and complications,” said Judy Mikhail, Program Manager of the collaborative. “But as we made progress, we branched out into process measures. We started to look at different aspects of trauma care and try to drill down to see what was happening.”

M-TQIP tracks more than 50 custom data points. Areas of special focus include traumatic brain injury, use of blood products and cerebral monitoring. One major interest is venous thromboembolism prophylaxis. “The literature says you need to give VTE prophylaxis as close to the time of admission as possible,” Mikhail said. “The group wanted to see whether we were doing this in a timely manner. This is not a traditional trauma data point, but the group decided they wanted to tackle it.”

2. Face-to-face meetings are powerful
Much of M-TQIP’s work takes place during quarterly review meetings. Trauma medical directors, program managers and other team members gather to review up-to-date performance data. “It’s important for hospital teams to get together, discuss performance openly and learn best practices from high-performance centers,” Mikhail said. “There is something about face-to-face meetings that is quite genuine in helping people talk about performance issues openly.”

At last October’s meeting, for example, participants reviewed data on massive transfusion. Hospitals were ranked in terms of their PRBC/FFP ratio. Participants then discussed the results and talked about ways to improve performance.

“We might start out the discussion by asking the whole group what institutional barriers are making it harder to meet the target ratio,” Mikhail said. “There will be a discussion, then we will turn to the high performers and ask what they are doing to overcome these problems. It really is a great open discussion and we have a robust sharing of ideas.”

3. One size does not fit all
Discussions generally show that there is not one perfect way to solve a problem. “A discussion might generate seven different ideas about how to tackle a problem,” Mikhail said. “Maybe a particular program can only use two of them, but those are two ideas that program leaders can take back home and attempt to put in place.”

“An important thing we found is that no trauma center is good at everything,” she said. “Often, a hospital may be the best performer in the state on a certain measure, but then three slides later they are on the other side of the screen.”

4. The starting point is clean data
No quality improvement effort can succeed if participants do not trust the data. “During the early years of the collaborative, we really focused on developing standard data definitions and creating a strong audit process,” Mikhail said. Independent M-TQIP auditors visit each participating hospital at least once a year. The auditors re-abstract charts and compare them to the registrar’s original reports. Results and feedback are shared immediately.

“The fact that we have a robust process for validating data really sets us apart from possibly most state trauma registries,” she said. “This data is as clean as you can get, and we’re constantly working to make sure it is as strong as possible.”

5. Analytics drive insight
“One of the things that make trauma ripe for data-driven quality improvement is the fact that most states mandate some kind of trauma data collection already,” said Paul Henchey, MS, Senior Vice President of Product Strategy at ArborMetrix. “Trauma programs are already putting in a significant effort to collect data, and there is an opportunity to leverage that data better.”

ArborMetrix provides a cloud-based platform for capturing, analyzing and reporting clinical data. M-TQIP hospitals submit clinical and administrative data to ArborMetrix, which then applies several analytic filters.

“One important part of what we do is provide some pretty sophisticated risk adjustment to outcome measures. That lets collaborative members know they are comparing ‘apples to apples’ when comparing hospital performance,” Henchey said. “We also do reliability adjustment to make sure we are not jumping to conclusions around a small sample size.”

6. Tailor reports for clinicians
“Often, hospital reporting tools are kind of finance- or administration-oriented. The information is put together from an accounting perspective,” Henchey said. “But when you have IT pushing performance reports, physicians end up poking holes in them. We tailor our information to be very meaningful to a clinical audience. It’s important to use statistically rigorous methods. If the data are credible, clinicians will buy in.”

M-TQIP participants access data through a web-based dashboard. “The ArborMetrix platform lets you drill down and compare your hospital to other centers in the state,” Mikhail said. “You can look at data on certain types of injuries, compare your performance to Level I centers or Level II centers or both, and tease the data out in so many ways. It is so much richer and more robust than other reporting tools.”

(Note: Paul Henchey presented a webinar entitled “Data Driven Improvements to Trauma Care – A Regional Approach” on January 22, 2015. The webinar addressed strategies for creating a regional quality collaborative, leveraging your program’s existing data and using analytics to drive trauma quality improvement. To replay the webinar, click here.)

7. Collaboration accelerates improvement
Henchey believes region-level collaboration is effective. “National quality programs can provide a good database for researchers and policymakers, but they are not necessarily usable and actionable by local providers,” he said. “M-TQIP is taking data and making it available to participants in a way that proves more meaningful and more usable to help them improve care in local facilities.”

One focus of the Michigan collaborative is tracking the cost of trauma care. A study published recently in the Journal of Trauma and Acute Care Surgery showed that M-TQIP hospitals reduced trauma episode payments by $6.5 million over one year. The cost savings were driven by cutting the rate of serious complications from 14.9% to 9.1%.

“As complications came down, cost came down,” Mikhail said. “Our ability to work together moved the needle faster.”

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