Surgeon Specific Reports What is MSQC An established Quality Improvement Initiative MSQC has been collecting and analyzing surgical data since 2005 for the purpose of improving patient care A high quality clinically collected data registry ID: 1014340
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1. Michigan Surgical Quality CollaborativeSurgeon Specific Reports
2. What is MSQC?An established Quality Improvement Initiative MSQC has been collecting and analyzing surgical data since 2005 for the purpose of improving patient care. A high quality, clinically collected data registry MSQC data is collected by a dedicated Registered Nurse employed at each hospitalAll data abstraction nurses are required to pass yearly certification exams and Inter-Rater Reliability Testing is performed by MSQC on the data collected. 2012 Results: All hospitals demonstrated greater than 95% accuracy
3. 1 Allegiance Health2 Alpena Regional Medical Center3 Beaumont Hospital – Dearborn4 Beaumont Hospital – Farmington Hills5 Beaumont Hospital – Grosse Pointe6 Beaumont Hospital – Royal Oak7 Beaumont Hospital – Taylor8 Beaumont Hospital – Trenton9 Beaumont Hospital – Troy 10 Beaumont Hospital – Wayne11 Borgess Medical Center12 Bronson Battle Creek Hospital13 Bronson Methodist Hospital14 Covenant HealthCare15 Crittenton Hospital Medical Center16 Detroit Receiving Hospital17 Dickinson County Healthcare System18 Garden City Hospital19 Genesys Regional Medical Center20 Harper University Hospital21 Henry Ford Hospital22 Henry Ford Macomb Hospital23 Henry Ford West Bloomfield Hospital24 Henry Ford Wyandotte Hospital25 Hillsdale Hospital26 Holland Hospital27 Hurley Medical Center28 Huron Medical Center29 Huron Valley Sinai Hospital30 Lake Huron Medical Center31 Lakeland HealthCare32 McLaren – Bay Region33 McLaren – Central Michigan34 McLaren – Flint35 McLaren – Greater Lansing36 McLaren – Lapeer Region37 McLaren – Macomb38 McLaren – Northern Michigan39 McLaren – Oakland40 McLaren – Port Huron41 Memorial Healthcare – Owosso42 Mercy Health Hackley43 Mercy Health Partners44 Mercy Health Saint Mary's45 Metro Health Hospital46 MidMichigan Medical Center – Clare47 MidMichigan Medical Center – Gratiot48 MidMichigan Medical Center – Midland49 Munson HealthCare Cadillac Hospital50 Munson HealthCare Grayling Hospital51 Munson Medical Center52 Oaklawn Hospital53 ProMedica Bixby Hospital54 ProMedica Monroe Regional Hospital55 Providence Hospital – Southfield56 Sinai-Grace Hospital57 Sparrow Carson Hospital58 Sparrow Hospital59 Spectrum Health Big Rapids Hospital60 Spectrum Health Butterworth Hospital61 Spectrum Health United Hospital62 St. John Hospital and Medical Center63 St. John Macomb Oakland Hospital64 St. John River District Hospital65 St. Joseph Mercy Ann Arbor66 St. Joseph Mercy Chelsea67 St. Joseph Mercy Livingston68 St. Joseph Mercy Oakland69 St. Mary Mercy Hospital, Livonia70 St. Mary’s of Michigan71 University of Michigan Health System72 UP Health System – Marquette73 West Branch Regional Medical Center
4. The MSQC Databasehttp://www.msqc.org/ Secure Web-based loginDashboard ReportingReal-time, risk adjusted benchmarking of provider performanceHospital and Surgeon level reportsIn 2015, MSQC expanded reporting capabilities to include surgeon comparisons
5. Surgeon Champion ViewDe-identified surgeon view when no surgeons selectedCompare all surgeons at a single site to other surgeons in the collaborative
6. Surgeon level ReportingFor users with hospital and surgeon level reporting privilegesSurgeons can view performance relative to both their hospital or collaborative as a wholeAvailable for surgeons with 30 or more total cases
7. Compare selected surgeon(s) to all other surgeons at a site, and to all other surgeons in the collaborative in rankings chartsSurgeon level Reporting
8. Who Can View the Reports?All Surgeon ChampionsEach surgeon champion will be able to view a de-identified comparison of surgeons at their institution vs. all other surgeons in the collaborative database.Individual SurgeonsSurgeons with 30 cases or more existing in the database will be able to view their own results.These are accessible ONLY to the surgeon identified in the reports
9. What are the intended uses of these reports?At the Hospital levelNew way to assess hospital performanceAt the Individual levelSelf-policing and motivation for improvement
10. What these reports should NOT be used for:Punitive purposesThese reports must remain separate from any other hospital or employee record.Only the individual surgeon will be able to access an identified view of his/her own reports.
11. Confidentiality and Privilege MSQC is a listed Patient Safety Organization (PSO), which provides federal protections to its data.Under the Patient Safety and Quality Improvement Act (PSQIA), Surgeon Specific Reports are considered Patient Safety Work Product (PSWP). As PSWP, these reports are considered privileged and confidential and are not subject to legal discovery.Reports will be accompanied with the following disclosure statement:
12. to access to your performance reports CONTACT:MSQC Surgeon Specific Reporting AccessMSQCCustomerSupport@med.umich.edu