27 Aug 2025
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MVC Virtual Networking Event: Leveraging Claims Data for Rural & Critical Access Hospital Quality Initiatives

MVC Virtual Networking Event: Leveraging Claims Data for Rural & Critical Access Hospital Quality Initiatives

August 27, 2025 | 0 Comments | , , , ,

On August 21, 2025, MVC Coordinating Center hosted a virtual networking event providing members from rural, critical access, and acute care hospitals with an opportunity to make professional connections and discuss strategies for leveraging claims data. Twenty-three MVC members from twenty different hospitals and eight health systems participated in the ninety-minute event.

The event began with an ice breaker activity and a brief interactive quiz reviewing the number of and CMS requirements for rural and critical access hospitals (CAHs). This portion of the event concluded with a survey of MVC value metrics most relevant to quality improvement (QI) at rural and CAHs revealing most sites are focused on sepsis follow-up (Figure 1).

Figure 1. Most relevant MVC value metrics to QI at your site

The networking event continued with a presentation by MVC’s Engagement Manager Jessica Souva, MSN, RN, C-ONQS highlighting MVC’s history with critical access and rural hospitals and the addition of ED-based episodes. Starting in 2016, CAHs began joining MVC membership and today twenty-four different CAH sites are active MVC members.

Souva emphasized the need to better serve this group by understanding their unique challenges. She then shared unblinded data on hospital-level index emergency department (ED) visits with behavioral health ICD-10 code rates for 30-day ED-based episodes from January 1, 2021 to November 30, 2024. Prior to sharing the data, members were asked where they thought their hospital’s rate would fall compared to the MVC All average, most felt their rates would be higher than the average. After sharing the data, most members found their rates to be lower than expected.

Aggregate data for conditions with the highest ED episode and inpatient episode volumes across all rural and CAHs from January 1, 2022 to December 31, 2024 were also shared (Figure 2). Souva encouraged members to discuss opportunities for benchmarking and custom analytics during the breakout session with this data in mind.

Figure 2. Conditions with the highest ED and inpatient episode volumes

vertical bar graphs of conditions with the highest ED and inpatient episode volumes

The breakout discussions were structured to engage attendees in conversations about the challenges and strategies to address leveraging claims data for rural and CAHs. After breaking into two smaller groups, attendees were provided with three primary discussion prompts to reflect upon:

  1. Data Possibilities: What data sources and metrics are frequently utilized to determine outcomes and impact of process improvements in the inpatient or ED setting?

MVC members reported that various internal data platforms and benchmarking tools such as Vizient, Premiere, and Q-Centrix are used by critical access and rural health sites. They also noted frequently using metrics provided by various collaborative quality initiatives (CQIs) (e.g., HMS, MEDIC, etc.) and Medicare Beneficiary Quality Improvement Project (MBQIP) Core Measure sets to evaluate process improvements. When asked how MVC can optimize benchmarking for rural and CAHs, attendees explored options for comparing data with similar-sized sites and increased alignment between CQI pay-for-performance (P4P) metrics.

  1. Data Sharing: Which stakeholders are commonly engaged in determining strategies and indicators of successful QI initiative implementation?

The discussions in both breakout rooms highlighted the importance of involving clinical leads, physician champions, and quality improvement oversight boards for the success of QIs. One hospital noted that they additionally include an executive sponsor for each QI which they find helps to drive QI forward. Others noted a shift in culture towards encouraging ownership of QI implementation to front line staff. They noted that with adjustments to quality departments’ scope and capacity, quality leadership can focus more on the “why” versus the “how” of QI.

  1. Conditions & Follow-Up Care: Are there specific conditions currently focused on reducing ED return visits and/or inpatient readmissions?

Key conditions of focus identified by MVC members include readmissions, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), pneumonia, sepsis and diabetes. When asked if the data shared today inspired interest in new conditions or processes to investigate in the future, members noted interest in continuing to explore the utilization of behavioral health in ED-based episodes.

Feedback from members on MVC’s August Virtual Networking Event included:

  • “I enjoyed participating and sharing during this event.”
  • “This was very helpful. I would love more meetings like this specific to critical access hospitals and small rural hospitals.”
  • “These networking events are always great and provide great insight into what is happening across the state. It allows us to share ideas but there is also a validation component that we are all experiencing a lot of the same challenges and barriers.”
  • “This was a great networking event. As a member of an organization going through multiple ‘changes’, it was awesome to see how larger acute or rural hospitals tend to their QI projects.”
  • “There was a lot of great dialogs about changing culture and how we approach quality improvement.”

MVC looks forward to hosting additional networking events in the future to increase collaboration and connection with MVC’s members. The next networking opportunity will be an in-person networking dinner on October 9, 2025, the evening before MVC’s Fall Collaborative-Wide meeting. If you are interested in attending, please register for this event here. Please note that space is limited.

20 Aug 2025
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Michigan Cardiac Rehab Network Spring Meeting Recap

Michigan Cardiac Rehab Network Spring Meeting Recap

August 20, 2025 | 0 Comments | , , , , ,

Earlier this spring, the Michigan Cardiac Rehab Network (MiCR) hosted its virtual spring meeting with 74 attendees joining from cardiac rehab programs and hospitals across the state. MiCR was glad to host two guest presenters for the meeting, including Alexis Beatty, MD, MAS, Co-Director of the UCSF Cardiac Rehab and Wellness Center, and Brett Reynolds, MPH, ACSM, CEP, Supervisor of Cardiology for Corewell Health East. The primary goal of MiCR meetings is to support shared learning, practice sharing, and networking among professionals working with cardiac rehabilitation programs across Michigan.

The meeting began with MiCR team updates provided by Co-Director Mike Thompson, PhD – most notably the introduction of Dr. Jessie Golbus, MD, MS, as the new co-director of MiCR (see Figure 1). Dr. Golbus is an Assistant Professor of Internal Medicine in the Division of Cardiovascular Medicine at Michigan Medicine.

Figure 1.

Graphic depicting MiCR updates including leadership change and grant received

Dr. Thompson also announced a new grant from the University of Michigan's Frankel Cardiovascular Center awarded to Healthy Behavior Optimization for Michigan (HBOM) and MiCR for their new Heart-to-Heart initiative. Heart-to-Heart is a new initiative aiming to amplify the real, diverse voices of Michigan patients who have experienced cardiac rehabilitation. Patient stories told through compelling audio, visual, and written storytelling will foster broader conversations about the life-changing impact of cardiac rehabilitation and inspire those considering attendance. HBOM and MiCR previously partnered on the development of NewBeat materials. Following the virtual meeting, BMC2 published a blog introducing the new Heart-to-Heart initiative.

Dr. Thompson then provided insights into improvements in cardiac rehabilitation utilization in Michigan since the inception of MiCR. The network is committed to boosting enrollment to 40% across all eligible conditions except heart failure, for which it has a lower target of 10% enrollment. Dr. Thompson noted encouraging trends observed since 2020, with overall enrollment rising to 35% from just under 25%. Although heart failure patient enrollment remains low at approximately 4%, efforts are under way to improve enrollment in this population in the future.

Dr. Alexis Beatty, MD, MAS, co-director of the UCSF Cardiac Rehab and Wellness Center, delivered the first guest presentation on the transformative potential of telehealth in cardiac rehabilitation. She highlighted the advantages and potential of integrating telehealth and hybrid models with traditional center-based programming to increase accessibility and participation (see Figure 2). Since adopting a hybrid model during the COVID-19 pandemic, UCSF reported substantially improved completion rates in virtual and hybrid programs compared to exclusively in-person sessions. Furthermore, patient outcomes related to exercise capacity, risk factor management, and quality of life were consistent across all formats.

Figure 2.

Graphic depicting current in-person cardiac rehab enrollment of 29% of eligible people compared to future in-person and virtual cardiac rehab enrollment goal of 70% of eligible people

Dr. Beatty also introduced an online delivery model toolkit (available at UCSF Cardiac Rehab Toolkit), crafted using human-centered design methods to aid in telehealth program development. This toolkit includes adaptable templates for exercises and safety and is already utilized by clinics in Michigan and beyond, allowing for flexibility to meet local patient needs. Dr. Beatty’s full slide presentation is available online.

In the second presentation, Brett Reynolds, MPH, ACSM, CEP, supervisor of cardiology at Corewell Health East, showcased their "Weight of Heart Failure" quality improvement initiative. Funded by a MiCR mini grant, the project sought to improve engagement and outcomes for heart failure patients. This initiative was a response to declining cardiac rehabilitation enrollments among heart failure patients. Grant funds were used to purchase 100 Corewell Health-branded scales for daily weight monitoring, accompanied by educational materials to aid in health management. The project also included follow-up calls two weeks post-discharge to verify if patients were monitoring their weight and had scheduled follow-up appointments.

Reynolds reported that of the 156 heart failure patients reached, 110 follow-up calls were completed, with 65% consistently tracking their weight and 83% scheduling follow-up appointments. This proactive approach seemed to have contributed to an increase in participation.

Despite the success, Reynolds acknowledged persistent challenges, such as referral system barriers and limited physician awareness regarding cardiac rehabilitation eligibility for heart failure. However, the initiative's efficacy in enhancing follow-up care and patient involvement highlighted the potential impact of targeted interventions in heart failure management. The full Corewell Health slide presentation is available online.

The webinar concluded with announcements of upcoming opportunities to engage with the network and collaborate to improve cardiac rehabilitation care in Michigan. Most notable among these opportunities is MiCR’s upcoming in-person fall meeting, which is set to take place on Thurs., Nov. 13 at Corewell Health Troy. Those interested in attending can register now.

13 Aug 2025
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MVC’s Updated Common Conditions Report Now Available to Hospital Members

MVC’s Updated Common Conditions Report Now Available to Hospital Members

August 13, 2025 | 0 Comments | , , ,

Last week, the Coordinating Center distributed a refreshed version of MVC’s common conditions report. This report delivers a comprehensive analysis of care episodes for eight prevalent medical and surgical conditions frequently targeted for quality improvement initiatives within MVC hospitals. It assesses hospital performance and highlights potential areas for growth. The report’s current conditions include atrial fibrillation (A-Fib), chronic obstructive pulmonary disease (COPD), colectomy (non-cancer), congestive heart failure (CHF), coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), pneumonia, and sepsis. Notably, total knee and hip (joint) replacement, which was previously included, has been replaced by A-Fib in the latest report.

MVC generated reports for 96 eligible hospitals. General acute care hospital (GACH) and Critical Access Hospital (CAH) members received tailored versions of the report, which included benchmark data specific to their respective hospital categories and tailored comparison groups. A blinded version of the general acute care hospital report is available here.

Although the provided metrics and figures vary by condition and case count, report pages generally focus on 30-day total episode payments, post-acute care and post-discharge ED utilization, readmission rates, and common reasons for readmissions. The report has been updated to feature data covering the period of January 1, 2023, through December 31, 2024, for Blue Cross Blue Shield of Michigan (BCBSM)/Blue Care Network (BCN) Commercial, BCBSM/BCN Medicare Advantage (MA), and Michigan Medicaid; Medicare FFS data covers the period of January 1, 2023, through June 30, 2024.

Upon opening the latest report, MVC members will first find a summary of patient population demographic data for each condition/procedure category their hospital was eligible to receive, facilitating a comprehensive and effective comparison across service lines for a variety of non-medical drivers of health.

On subsequent condition or procedure pages, most hospitals will have a figure displaying the breakdown of 30-day risk-adjusted, price-standardized post-acute care payments by payer categories (see Figure 1). The categories available included BCBSM/BCN Commercial, BCBSM/BCN Medicare Advantage, Medicare Only, Medicaid Only, and Dual Eligible; hospitals received data points for those payer categories with at least 11 episodes during the reporting period. As a reminder, the “Dual-Eligible” category represents patients eligible for both Medicare and Medicaid coverage, and the separate Medicare and Medicaid categories do not include those patients when the separate Dual-Eligible category is included.

Figure 1.

Bar graph of breakdown by payor of 30-day risk adjusted, price standardized, total post-acute care payments among patients hospitalized for COPD at a hospital

**Information is presented only for those payer categories that have at least 11 episodes during reporting period. Missing data labels represent less than 9% of the total.

Beyond offering insights into payments by payer and post-acute care categories, this figure can offer additional insights and context compared to the report figure that follows it for post-acute care utilization rates (see Figure 2). The two figures together serve to provide a clearer understanding of the relationship between rates of utilization and percent of episode spending for each post-acute care category, illustrating whether spending aligns with utilization frequency. The post-acute care categories for both figures includes home health care, skilled nursing facility (SNF) care, inpatient rehab, outpatient rehab, emergency department care, long-term acute care hospitals (LTACH) and outpatient services.

Figure 2.

Dot matrix of 30-day post acute care utilization among patients hospitalized for COPD

The remaining figures focus largely on ED utilization and readmissions, with some service line pages including figures for common reasons for readmission. Readmissions were generally observed to be highest across the collaborative at about 20% for patients hospitalized for CHF, followed by patients hospitalized for sepsis or COPD. Readmission rates were lowest across the collaborative at about 6% among patients who underwent a PCI procedure. There is also a visible decrease over time in 30-day readmission rates across the collaborative for all eight common conditions (see Figures 3 and 4); however, it is important to note that the 2024 Q3-Q4 data point does not include Medicare FFS patients, which is likely impacting the rate for that time interval.

Figure 3: 30-Day Readmission Rate Among Patients Hospitalized for Atrial Fibrillation, COPD, Colectomy, and CHF*

Graph of 30-Day Readmission Rate Among Patients Hospitalized for Atrial Fibrillation, COPD, Colectomy, and CHF*

Figure 4: 30-Day Readmission Rate Among Patients Hospitalized for CABG, PCI, Pneumonia, and Sepsis*

Graph of 30-Day Readmission Rate Among Patients Hospitalized for CABG, PCI, Pneumonia, and Sepsis*

*Data points are only shown for six-month intervals with 11 or more episodes. Data from 2024 Q3-Q4 excludes Medicare episodes.

MVC is dedicated to regularly updating its commons conditions report, aiming to equip collaborative partners with insightful data that can drive and reinforce meaningful advancements in healthcare quality. We hope these reports prove beneficial and welcome MVC members to contact MVC with any questions or analytic requests.

06 Aug 2025
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July Workgroups Highlight Sepsis Compliance Process Improvements and Patient Satisfaction Excellence

July Workgroups Highlight Sepsis Compliance Process Improvements and Patient Satisfaction Excellence

August 6, 2025 | 0 Comments | , , , ,

In July, MVC hosted two virtual workgroup presentations – the first, a rural health workgroup focused on how a sepsis compliance initiative was developed and implemented in a critical access hospital setting. The second, a post-discharge follow-up workgroup, presented a small acute care hospital’s journey to patient satisfaction excellence. The MVC Coordinating Center hosts workgroup presentations twice per month, covering a variety of topics including post-discharge follow-up, sepsis, cardiac rehab, rural health, preoperative testing and health in action.

Rural Health Workgroup July 8, 2025

MVC hosted a rural health workgroup with a presentation by Victoria Durr, BSN, RN, Infection Prevention Coordinator from Scheurer Health. The presentation spotlighted a targeted sepsis compliance initiative and shared key strategies, lessons learned, and outcomes tailored to rural healthcare.

Meeting sepsis bundle compliance requirements set by the Centers for Medicare & Medicaid (CMS) is not only vital for reimbursement and regulatory alignment but also directly tied to improved patient mortality outcomes. As Durr explained, rural hospitals face unique challenges to improving sepsis compliance including agency coverage, fewer staff, and limited diagnostic tools.

As a part of her initial assessment of SEP-1 bundle compliance at Scheurer Health, Durr evaluated her staff’s understanding of the sepsis bundle components and found significant knowledge gaps. Other challenges faced by Schurer Health included limited space to admit directly from the emergency department (ED), an inconsistent sepsis census, and changing admitting privileges. These challenges contribute to downstream impacts to sepsis compliance including limited staff awareness and training, changes to lab orders, and transitions in continuity of care.

In July of 2024, Durr began working through each issue one-by-one with the help of department leadership. She outlined specific strategies Scheurer Health has used to improve compliance including:

  1. Implementation of structured training and process changes to standardize sepsis detection across emergency, inpatient, and inpatient care units
  2. Employed a team-based strategy, pairing clinicians and quality improvement leads to reinforce consistent sepsis protocols across inpatient workflows
  3. Leveraged data analytics to identify gaps and monitor compliance in real time

One key proactive tool Durr developed was a step-wise sepsis worksheet for nursing staff to follow in the case of a sepsis patient (see Figure 1, access PDF here). While this form is not required, in those cases when it has been utilized, Durr has found 100% SEP-1 compliance. A similar summary guide was created for physicians to optimize work flows (see PDF here).

Figure 1. Step-Wise Sepsis Worksheet for Nursing

While Durr notes she has only evaluated data for sepsis cases dating back to July of 2024, she has seen a shift in the areas of SEP-1 non-compliance over time. Analysis revealed that some areas of non-compliance have improved while others have worsened (Figure 2). For example, between Q3 2024 and Q4 2024, non-compliance with antibiotic delivery within a three-hour window significantly declined, while non-compliance with blood cultures being drawn after antibiotic administration increased. However, by Q1 2025 when almost all the strategies outlined above had been implemented, the distribution of SEP-1 non-compliance areas became relatively even. Durr notes that real-time tracking has allowed her team to pinpoint manageable areas of improvement and inform their next steps.

Figure 2. Tracking Areas of SEP-1 Non-Compliance

In the future, Durr notes Scheurer Health will continue to improve SEP-1 compliance through the implementation of a SEP-1 orientation with newly hired ED and acute care unit nurses, the creation of a standardized nurse handoff report, and continued tracking and team report outs on various metrics including length of stay (LOS), mortality, and sepsis related readmissions.

The workgroup presentation and follow-up discussion not only emphasized specific challenges to improving SEP-1 compliance at a rural health center but also offered solutions. Some of the solutions shared with attendees included recommendations to:

  1. Standardize workflows and checklists to build consistency across units
  2. Create on-demand education modules
  3. Utilize checklists available through the electronic medical records (EMR)
  4. Optimize nursing and physician champions
  5. Use data dashboards for real-time feedback

Rural Health Workgroup July 8, 2025 Recording

Post Discharge Follow Up Workgroup July 24, 2025

MVC’s second workgroup in July featured a presentation by Sara Hagerman BSN, RN, Quality Performance Improvement Specialist for University of Michigan Health-Sparrow at the Clinton, Carson, and Lansing sites. The presentation outlined the various pathways UMH Sparrow Carson has taken to improve their Hospital Consumer Assessment of Healthcare Providers and Systems survey (HCAHPS) scores.

HCAHPS is a tool developed by CMS that measures patient satisfaction. The survey consists of 27 questions that measure different aspects of patient care, including communication with providers, hospital environment, medication management, transitions from hospital to home care, and discharge planning. The survey is administered at various points throughout a patient’s stay, and results are used to compare hospitals on a national level.

Hagerman explains that starting about one year ago, the University of Michigan Health-Sparrow Carson devised a plan to not only improve HCAHPS scores but also to decrease readmissions. To do this, they focused on three primary areas:

  1. Evaluation of social determinates of health (SDoH)
  2. Individualized discharge planning
  3. Care facilitator follow-up

After collecting SDoH metrics in the Electronic Health Record (EHR) for about a year, the team aggregated this data to determine the greatest needs within their patient population. They also specifically looked for corresponding readmission cases to determine if readmissions were contributed to by social needs. Hagerman notes they found food insecurity (3.9%), housing instability (4.2%), and transportation needs (3.9%) to be the most common social factors impacting their community.

Transitioning from a micro to a macro-level, University of Michigan Health-Sparrow Carson senior executives next worked with their community partners to support improved transportation and food assistance resources at the local level. They collaborated with local programs to identify new resources for transportation and food assistance and developed pathways to connect patients directly with these resources prior to discharge.

With these resources in place, the team turned to tailoring individualized patient discharge plans. At UMH Sparrow Carson, nearly 90% of patients discharged have a scheduled follow-up appointment with their primary care provider (PCP) prior to leaving the hospital. And for those without a confirmed PCP, teams set a goal to follow-up within 3-7 days or less. Other components of the individualized discharge plans include:

  • Review of SDoH screening and arrangement for appropriate support services
  • Review of home care instructions, medications, and patient education
  • Post-discharge contact information and call-back within 72 hours

Lastly, Hagerman described the third component of their program triad: care facilitators. Care facilitators are nurses embedded in primary care offices whose primary goal is to identify and support chronically ill patients. They can support care transitions, medication management, patient education, and enhance overall experience. Care facilitators can also enroll patients in UMH Sparrow’s Chronic Care Management Program.

Benefits to enrollment in the Chronic Care Management Program include improved care coordination, increased patient engagement, and reduced hospitalizations. Hagerman points to a readmission rate of 5.9% thus far in 2025, compared to a readmission rate in 2024 of 6.95% as evidence of the positive impact this program has had. However, Hagerman notes there are limitations to the availability of this program to patients due to the cost of patient copays.

When it comes to improving HCAHPS scores, Hagerman noted that perhaps the most important lesson learned in this process has been to ensure team members are aware of the content of HCAHPS surveys. “It’s important to understand what patients will be asked about in order to better address potential issues up front”, noted Hagerman and she’s encouraged her team to become more knowledgeable about the survey. Additionally, engaging an interdisciplinary team and sharing data is especially useful to ensure communication and continued progress. The UMH Sparrow Carson leadership team meets in person at their strategy huddle board every other week to discuss progress and next steps (Figure 3).

Figure 3. Tier 2 Strategy Huddle Board

Post Discharge Follow Up Workgroup July 24, 2025 Recording

MVC’s July workgroups specifically highlighted successful quality initiatives at small rural and acute care hospitals in Michigan. Their insights provide a basic understanding of the unique struggles these hospitals face to implement and maintain quality improvement.

MVC welcomes workgroup presenters from across Michigan to share their expertise, successes, initiatives and solution-focused ideas with fellow MVC members. Interested in presenting? Please reach out to us by email or submit a presentation proposal here.

30 Jul 2025
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MVC Thanks Presenters from the First Half of 2025

MVC Thanks Presenters from the First Half of 2025

July 30, 2025 | 0 Comments | , ,

The MVC Coordinating Center wishes to express our deep appreciation for the thirty-four dedicated professionals who stepped forward to present at MVC’s first and second quarter 2025 virtual workgroups and spring collaborative-wide meeting. We know that members have many demands on their time, competing priorities, and requests from other Collaborative Quality Initiatives (CQIs) and professional organizations to present. By sharing their current data, innovative approaches to persistent challenges, best practices, and lessons learned with MVC members, these 34 presenters made important contributions to our shared goals to improve both access to and the quality of healthcare for all Michigan patients. We celebrate you for contributing in this high-value way. You DO make a difference!

Join the MVC Coordinating Center in giving these folks a well-deserved round of applause!

Cardiac Rehab Workgroup

  • Steven Keteyian, PhD, Director of Cardiac Rehabilitation & Preventive Cardiology, Henry Ford Health
  • Greg Scharf, BS, ACSM-CEP, AACVPR-CCRP, Cardiopulmonary Rehab System Manager, MyMichigan Health

Preoperative Testing Workgroup

  • Jennifer Bennett, MBA, BSN, RN, Lead Quality and Patient Safety Coordinator, Henry Ford Health

Sepsis Workgroup

  • Diane Barton, MSN/MHA, RN, CPHQ, CPPS, Director of Organizational/Clinical Quality, Munson Medical Center
  • Alex Callaway, MBA, CPHQ, CPPS, Director of Quality and Patient Safety, Munson Health System
  • Jennifer Bentley, RN, BSN, Nursing Quality Coordinator, Munson Health System
  • Stephanie Bowen, RN, BSN, Nursing Quality Coordinator, Munson Health System
  • Amy Lorenz, RN, BAS, MPA, Lead QI Specialist II Patient Safety & Quality Department, Covenant Healthcare

Post-Discharge Follow-Up Workgroup

  • Zachary Chapman, MHA, Executive Director, Oaklawn Medical Group
  • Morgan Albright, BSN-RN, Director Case/Care Management Population Health, Oaklawn Hospital

Rural Health Workgroup

  • Mary Wozniak, MPH, CHES, Program Manager, Health Systems Interventions, National Kidney Foundation
  • Jill Oesterle, Director of Provider Solutions, Michigan Center for Rural Health, Michigan State University

Health in Action Workgroup

  • Mary Nowlin, PA-C, Physician Assistant, Michigan Medicine
  • Niki Farquhar, MSE, Project Management Lead for Delays in Care Progression Project Workstream, Michigan Medicine
  • Heidi O’Neill, MS, Project Manager Lead for Continuous Improvement Division of Quality, Michigan Medicine
  • Amanda Biskner, RN, Paramedic, CP-C, Community Paramedicine Coordinator, Tri-Hospital EMS, CP/MIH & File of L.I.F.E. Program

MVC’s spring collaborative-wide meeting:

Roundtables

  • Vani Patterson, MPH, FNAP, Administrative Director, Michigan Center for Interprofessional Education, Michigan Medicine
  • Chloe Miwa, MPH, Administrative Fellow, Michigan Medicine
  • Cyndie Bates, Administrative Services for Access & Referral Management and Mobile Health Clinic, University of Michigan Health-Sparrow
  • Whitney Soule, BSN, Nursing Quality Coordinator, Munson Healthcare Cadillac Hospital
  • Keli K. DeVries, LMSW, Program Manager, MOQC
  • Natalia Simon, MBA, MA, Senior Project Manager, MOQC
  • Ashley Bowen, MS, RDN, CHC, Clinical Nutrition Services Manager, Michigan Medicine
  • Amanda Saint Martin, Hospital Programs Manager, Michigan Center for Rural Health
  • Larrea Young, MDes, Multimedia Design Project Manager, Human-Centered Design Project Manager, HBOM, MCT2D
  • Danielle Fergin, LMSW-C, Manager of Integrated Behavioral Health, MyMichigan Medical Group

Poster Session

  • Leslie Johnson, RN, Clinical Quality Improvement Lead, MIMiND
  • Larrea Young, MDes, Multimedia Design Project Manager, Human-Centered Design Project Manager, HBOM, MCT2D
  • Jennifer Bennett, MBA, BSN, RN, Lead Patient and Safety Coordinator, Ascension Macomb-Oakland, River District, and St. John Hospitals
  • Dawn Johnson, BSN, RN, CCM-R, VP, ACO Performance and Growth, Commonwealth Care Alliance
  • Catie Guarnaccia, MSN, RN, CPEN, Quality Initiatives and Operations Specialist, MEDIC
  • Sam Kesterson, LMSW, Project Coordinator, MEDIC
  • Emma Steppe, MPH, Project Manager, MSHIELD
  • Bradley Lott, PhD, MPH, MS, Content Expert, Health Informatics and Social Care Integration, MSHIELD
  • Keli DeVries, LMSW, Program Manager, MOQC
  • Natalia Simon, MBA, MA, Senior Project Manager, MOQC
Image of thank you note in the palms of two hands

Attendees of workgroups and MVC’s spring collaborative-wide meeting appreciate presenters, too! Here are just a few of the many glowing survey responses MVC has received about presenters and their content in 2025.

Attendee testimonials graphic

As a reminder, past workgroups and virtual networking event recordings can be viewed on MVC’s YouTube channel, and presentation slides and materials from MVC’s spring 2025 collaborative-wide meeting can be viewed here.

Do you have valuable information to share?

Whether you are new to presenting or a seasoned pro, MVC’s Engagement team is here to support you every step of the way. From exploring topic ideas, to preparing information, to managing event logistics, our team makes the experience of presenting easy and comfortable. The P4P points you can earn as a presenter are a great benefit to your organization, too! For more information about presenting, contact the MVC’s Engagement team.

23 Jul 2025
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MVC Welcomes Manager of Data Analytics Ian Raxter, MPH

MVC Welcomes Manager of Data Analytics Ian Raxter, MPH

July 23, 2025 | 0 Comments | , ,

I am excited to be joining the Michigan Value Collaborative (MVC) team as Manager of Data Analytics! I look forward to working more closely with this great team to improve the quality of care across the state of Michigan.

Since receiving my Master of Public Health in general epidemiology from the University of Michigan in 2012, I have spent my career in the healthcare data world, working in particular with claims data and the CQIs. After graduate school I worked at Blue Cross Blue Shield of Michigan in the Department of Clinical Epidemiology and Biostatistics, working with Value Partnerships to support the Physician Group Incentive Program. After five years there I joined ArborMetrix where I worked as a Data Scientist with several of the CQIs, specifically the Michigan Emergency Department Improvement Collaborative (MEDIC), Michigan Surgical Quality Collaborative (MSQC), Obstetrics Initiative (OBI), and MVC. Following ArborMetrix, I joined Mathematica Policy Research where I worked on a variety of healthcare research projects for federal, state, and other clients.

It was always a pleasure to work with the MVC team during my time at ArborMetrix, and I’m happy to now join the other side of the table to help lead MVC’s analytic team! Please feel free to connect with me at iraxter@med.umich.edu.

16 Jul 2025
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MVC Updates Registry with New Claims Across All Payers

MVC Updates Registry with New Claims Across All Payers

July 16, 2025 | 0 Comments | , , ,

This week MVC updated its registry with new claims from its included payers. This most recent update included the addition of three new months of Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network (BCN) claims, one new quarter of Medicaid claims, and one new quarter of Medicare Fee-for-Service (FFS) claims. Following these updates, the MVC registry now has the following data ranges for its data:

  • BCBSM PPO (Commercial and Medicare Advantage): 01/01/2015 – 03/31/2025 (index events through 12/31/2024)
  • BCN (Commercial and Medicare Advantage): 01/01/2015 – 03/31/2025 (index events through 12/31/2024)
  • Medicaid: 01/01/2015 – 03/31/2025 (index events through 12/31/2024)
  • Medicare FFS: 01/01/2015 – 09/30/2024 (index events through 06/30/2024)

Anytime MVC publishes new data on its registry, the newest claims for each payer are incorporated throughout the various reports and dashboards where that payer’s data is present, including the interactive multi-payer reports for cardiac rehabilitation utilization and preoperative testing.

Refreshed Multi-Payer Cardiac Rehabilitation Reports

The multi-payer cardiac rehabilitation utilization reports were added to the registry in the first half of 2024 and have replaced the static PDF hospital-level push reports MVC previously distributed biannually to its members as well as BMC2 and MSTCVS contacts. The regular release of new data on the registry, therefore, gives members opportunities throughout the year to check progress on cardiac rehabilitation metrics more regularly and find opportunities for improvement. For example, available 2024 data on cardiac rehabilitation enrollment for all eligible patients (excluding heart failure patients) with episode start dates between Jan. 1, 2024, and Dec. 31, 2024, indicates wide variability among hospitals; the statewide average utilization rate is 34%, with the majority of sites observing rates below the Million Hearts recommended 70% rate as well as below the Michigan Cardiac Rehab Network goal rate of 40% (Figure 1).

Figure 1. Statewide Rankings for Cardiac Rehab Utilization within 90 Days After Discharge from AMI, CABG, PCI, SAVR, and TAVR, 1/1/2024-12/31/2024*

*Index events 1/1/24-12/31/24 for BCBSM Commercial and Medicare Advantage (MA), BCN Commercial and MA, and Medicaid; index events 1/1/24-6/30/24 for Medicare FFS

Similarly, there is significant variation between hospitals in their mean days to a patient’s first cardiac rehab appointment, with some hospital patients attending their first session 31 days after discharge and some waiting as long as 68 days. However, MVC has observed a steady yearly decrease over time in this metric, with a collaborative-wide average of 59 days in 2020 compared to 47 days in 2024.

These data along with metrics for mean number of visits and utilization rates for specific service lines and payers can be accessed via the multi-payer tab on the registry under the cardiac rehab heading.

Refreshed Multi-Payer Preoperative Testing Reports

The multi-payer preoperative testing utilization reports were added to the registry at the end of 2024 and have also replaced static hospital-level push reports that were previously distributed as biannual PDF reports to members as well as MSQC contacts. Looking at all available 2024 claims across payers, there is evidence of a small decrease in the MVC All rate of preoperative testing prior to low-risk surgery beginning in late 2022 through 2024 (Figure 2). The average testing rate in 2020 was 46.8% and the average rate in 2024 was 39.9%. Members whose rates are 40% overall or higher are eligible to participate in the RIght-sizing Testing before Elective Surgery (RITE-Size) program, which offers participating sites consultation and coaching, templates, best practice guidance, and other resources to help coordinate decreases in unnecessary testing across their institutions. MVC is also able to supplement registry data with custom analytics by an MVC analyst to meet the needs of members. One such site recently utilized MVC’s custom analytics to identify differences in preoperative testing rates by physician NPI to support conversations about intra-hospital variation by provider and service line.

Figure 2. Statewide Rate of Preoperative Testing and Relative Difference in Preoperative Testing by Quarter, 01/01/2020-12/31/2024*

*Index events 1/1/24-12/31/24 for BCBSM Commercial and Medicare Advantage, BCN Commercial and MA, and Medicaid; index events 1/1/24-6/30/24 for Medicare FFS

MVC’s registry contains an extensive collection of report views for multi-payer, P4P, and payer-specific metrics with select patient-level drilldown capabilities. If you are newer to the registry or would like a refresher on how best to leverage the information, reach out to the MVC Coordinating Center for information about a tailored registry training.

09 Jul 2025
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June Workgroups Highlight Organizational Structure Impacts on Cardiac Rehab and Measuring System Quality

June Workgroups Highlight Organizational Structure Impacts on Cardiac Rehab and Measuring System Quality

July 9, 2025 | 0 Comments | , , ,

In June, MVC hosted two virtual workgroup presentations – the first, a cardiac rehab workgroup focused on how healthcare organizational structures impact the effectiveness of cardiac rehab operations. The second workgroup, health in action, was a continuation of the recent MVC spring collaborative-wide meeting (CWM) presentation and discussion on How Should We Measure System Quality? The MVC Coordinating Center hosts workgroup presentations twice per month, covering a variety of topics including post-discharge follow-up, sepsis, cardiac rehab, rural health, preoperative testing and health in action.

Cardiac Rehab Workgroup June 10, 2025

MVC hosted a cardiac rehab workgroup with a presentation by Gregory Scharf, BS, ACSM-CEP, AACVPR-CCRP from MyMichigan Health System. Scharf is the Cardiopulmonary Rehab System Manager for nine cardiac rehab and eight pulmonary rehab programs that serve 25 counties in Michigan. In addition to his role with MyMichigan, Scharf is also the vice president of the northern region of the Michigan Society for Cardiovascular and Pulmonary Rehabilitation (MSCVPR). With his experience and knowledge, Scharf shared detailed insight into how healthcare organizational structure impacts the effectiveness of cardiac rehabilitation operations.

Organizational Structures & Impact

Many cardiac and pulmonary rehabilitation programs experience disjointed connections within healthcare organization structures.  According to a recent MSCVPR state poll, up to 20% of the state’s cardiac rehab (CR) programs were structured under a non-cardiovascular related service. Scharf polled the MVC workgroup audience to see where their cardiac rehab programs fell within their organizational structure and found that out of the 21 responses, 11 sites had their CR program under Cardiology/Cardiovascular service, three under respiratory service, four under cardiopulmonary service, one under diagnostic imaging, one under cardiovascular/neurology, and one did not have an onsite CR program.

Scharf noted that in his experience, many of the structures and managerial roles of cardiac rehab programs varied across sites. Cardiac rehab managers included an obstetrics/emergency room nurse manager, physical therapy manager, respiratory services supervisor, and a cardiovascular services manager who was also the echocardiogram technician. The lack of consistency in who should manage a cardiac rehabilitation program adds to the challenges within the healthcare organizational structure.

Supporting Cardiac & Pulmonary Rehab Programs

How can cardiac rehab be strategically aligned within a system? Main organizational connections for CR programs can be successful if placed under the umbrella of cardiovascular services (testing, heart failure clinic, open heart surgery, structural heart surgery, electrophysiology, and vascular), and rehabilitation services (occupational/physical therapy, etc.). Misalignment may occur if the organization’s strategies and objectives are disconnected between service areas, for example:

  1. Communication breaking down across the system
  2. Advocates for the CR service lack authority for change
  3. There are conflicts between service resources and access to space based on organizational leadership structure (OT/PT/CR)

A challenge for smaller sites may be that their organization is not large enough to support the typical structure of large health systems. At MyMichigan the CR program functions with 30 clinical staff for all sites whereas PT has more than 1,000 clinicians. These kinds of discrepancies may cause programs like cardiac rehab to be placed under misaligned service structures due to convenience (staff availability, resource availability) versus a more appropriate setting.

Important questions to ask about your site’s cardiac rehab program structure:

  1. Who is responsible for your cardiac rehab operations?
  2. Are they responsible for non-cardiac rehab departments as well?
  3. Who are the cardiac rehab subject matter experts (SME) and do they have authority to make changes?

SMEs may vary in experience and knowledge, especially when looking at smaller healthcare sites. These SMEs may only have secondary or limited experience with cardiac rehab services, which can impact how successful the program is. One way to help support staff in these positions is to encourage continuing education programs and certifications related to cardiac rehabilitation.

Understanding the Anatomy of the Referral

Over the past 10 years, MyMichigan has seen a significant increase in referral rates for cardiac rehab. Unfortunately, an increase in referrals does not always equate to an increase in patient participation. Some examples of why this may happen include referral delays, missing referral information (no qualifying diagnosis, or no co-signing MD/DO), or a referral being sent with the patient information but no signed order (inactionable).

Figure 1. Common Referral Delay Examples

When referrals are completed incorrectly, CR program staff must do the leg work to reconnect with the referring provider and make sure they receive a complete referral for their patient. MyMichigan faxes a Cardiac Rehabilitation (CR) Referral & Evaluation Order back to the referring provider to complete and return before the patient can be seen for cardiac rehab. This extra step can impact patient recovery and create added strain on the workforce for multiple healthcare sites.

MVC Data Analytics Resources & Support

Wanting to take a deeper look at cardiac rehab claims data, MyMichigan Health System collaborated with the MVC team including Emily Bair, Site Engagement Coordinator, Julia Mantey, Sr. Data Analyst, and Jiaying Zhang, Data Analyst. The MVC analysts created custom reports that helped visualize where MyMichigan’s CR patients were being referred to and which patients were being referred to their CR program from external sites.

Looking at MyMichigan sites they found that approximately 94% of the patients that discharged from the MyMichigan Midland Medical Center for any of the Michigan Cardiac Rehab Network (MiCR) Main five Conditions (AMI, PCI, CABG, SAVR, TAVR) ended up staying within the MyMichigan system cardiac rehab program. Additionally, they looked at what locations MyMichigan cardiac rehab patients come from across the state. Approximately 58% of CR patients are internal referrals and 41% are from external referrals, almost doubling patient population in MyMichigan’s cardiac rehab program. This also put a spotlight on how much this system’s cardiac rehab program impacted patient populations of external healthcare sites/systems in the state.

Key Take Aways

  • What internal barriers exist due to your organizational structure?
  • Is communication getting to those that impact change?
  • Understand what steps need to be completed between referral and scheduling the patient appointment
  • Understand the process for referrals that leave the system/site

Health in Action Workgroup 6.26.25

In late June MVC Director Hari Nathan, MD, PhD presented on how quality could be measured at a system level. This was a continuation from his interactive presentation at our spring CWM earlier this year, How Should We Measure System Quality? This “Part 2” workgroup included breakout groups and focused topics for discussion.

Advantages of Health Systems

Dr. Nathan shared several advantages that health systems have in the world of quality improvement that could be utilized, such as being able to right-size care and services at sites, having internal selective referrals as an option, avoiding low-volume surgeries, creating “focused factories,” disseminating best practices, and being able to have a big impact on attributed populations.

Health systems have the ability to address barriers to care on a larger scale, for example improving electronic health record integration between sites and being able to integrate telehealth across the system. Or by collecting data on various patient populations, a system has the potential to develop and expand its population health program. Utilizing the strengths of a system can benefit individual healthcare sites and improve patient care.

It is important to begin challenging systems to become more than just a sum of their parts – rather, to function as a cohesive unit. How do we create the right incentives for hospital systems to improve quality and costs? What metrics should be measured? These are just a few of the questions posed by Dr. Nathan as the workgroup audience prepared to go into breakout session discussions.

At MVC’s spring CWM in May of this year, audience members were asked “What is your organization doing at a system-level that you would want to be measured on and/or receive credit for improving?”. The most popular responses included: CMS 5 Star Measures, balancing length of stay (LOS) and readmissions, infection prevention, and sepsis outcomes (LOS, readmissions, mortality/end of life care).

Based on the CWM responses, four breakout session topics were chosen (readmissions & balancing LOS, safety, infection prevention, sepsis outcomes), and participants were asked to think about and discuss “What is YOUR organization working on at a system level that you would want to be measured on and/or receive credit for improving?”. Based on their poll responses, participants were sent into breakout groups to discuss their topic more in depth.

Readmissions & Balancing LOS

Members expressed great interest in identifying opportunities to incentivize process measures. Currently tracked metrics that were shared included order set utilization, care coordination, evaluating daily readmission risk reports, and transitions to home care. It was noted however, that these metrics may be difficult to track via claims data. Another system-wide metric discussed was the percentage of patients being seen by their primary care physician one week post discharge. The measure of success could be either achievement (outperform MVC All) or improvement (improve on system metric compared to previous measure).

Some barriers to implementing these processes as a system would be system-wide financial support for care coordination and nurse navigators. These positions are typically site specific and funded through the site’s individual budget.

Safety

During this breakout session members discussed some of the interests their sites/systems had around tracking safety metrics across the system. Sometimes a system can be different than just multiple hospitals under the same umbrella. Oaklawn Hospital, for example, is a single hospital site, but their goal is to align better with their primary care offices which requires a systems approach.

When looking at safety measures, Henry Ford Health shared ideas on how measuring or tracking a patient’s nutritional status might be valuable, as well as physical or occupational therapy consults for falls. Patients with a hip fracture from a fall tend to have longer hospital stays, this could be tracked by LOS codes such as weakness or loss of balance.

Infection Prevention

Members discussed some of the successful methods they have been implementing so far with their infection prevention initiatives. ProMedica Charles & Virginia Hickman shared they use a hub and spoke model where the sites have a system level clinical risk department that helps oversee essential hospital acquired infection data (using PowerBI, a data visualization program). This program enables a drill down for the different hospital leaders to design and implement quality improvement initiatives at their site.

At the system level leaders review data to identify opportunities and coordinate with hospital quality leads to implement improvement strategies, maintaining an upstream and downstream approach. In the UP Health system, they use a collaborative model involving regular reporting and discussion of quality markers among hospitals under the LifePoint organization, with resource sharing and active discussion facilitated by calls that include Duke University Health System partners.

Sepsis Outcomes

Members shared that their health systems have hospital level sepsis committees that meet once per month to review sepsis cases, as well as system level sepsis committees that include a representative from each site that meet monthly or quarterly to review sepsis cases. One of the ways that members are tracking their sepsis cases across the system is by tracking when sepsis patients go from “door to initial antibiotic received,” since research has shown this to be the biggest impact on reducing sepsis related mortality.

Sepsis compliance is also an important metric that systems are tracking to meet CMS standards. Sites within a system track sepsis compliance metrics and review them monthly both site by site and system wide. Through the group discussion, the idea of tracking the associated order sets for sepsis cases through MVC claims data may be interesting to view at a system level (though singling out order sets in claims data may be difficult).

Wrap Up

The breakout sessions not only helped to highlight what health systems are currently doing to track quality across their sites but also gave some insight into what metrics could be utilized as performance-based incentives in the future.

MVC welcomes workgroup presenters from across Michigan to share their expertise, success stories, initiatives, and solution-focused ideas with MVC members. Please reach out to us by email if you are interested in being a workgroup presenter or submit a presentation proposal here.

18 Jun 2025
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CQI Spotlight: Michigan Surgical Quality Collaborative (MSQC)

CQI Spotlight: Michigan Surgical Quality Collaborative (MSQC)

June 18, 2025 | 0 Comments | ,

Surgical quality improvement is essential for enhancing patient outcomes, ensuring safety, optimizing healthcare costs, and strengthening overall healthcare system performance. To build patient trust, reduce disparities, and drive continuous advancements in surgical practices, the Michigan Surgical Quality Collaborative (MSQC) was established in 2005. Originally created through a partnership between Blue Cross Blue Shield of Michigan (BCBSM), Blue Care Network (BCN), the American College of Surgeons, and 17 participating hospitals, MSQC aimed to foster collaboration in advancing surgical quality. Today, the collaborative includes 70 Michigan hospitals, all committed to improving care delivery through the promotion of evidence-based, best practices in general surgery.

MSQC Achievements

Over the past two decades, MSQC has made a profound and lasting impact on surgical quality, achieving milestones that have significantly advanced the field. The following are highlights of those success stories.

Postoperative Opioid Prescribing Recommendations

Post-procedural pain management is a crucial component of surgical care, and yet the ongoing opioid epidemic posed a pressing question: How much prescription pain medication should be prescribed after surgery? Recognizing the absence of a standardized, evidence-based approach to opioid prescribing, MSQC partnered with Michigan Overdose Prevention Engagement Network (OPEN) in 2016 to develop and implement new guidelines for general surgery and hysterectomy patients. A range of quantitative measures were employed to inform these recommendations, including the number of pills prescribed, patient-reported outcomes on pill usage, and pain levels post-surgery.

Since the guidelines were introduced, opioid prescriptions across Michigan have dropped by 50% over the course of a few years. Follow-up data showed that patients did not report higher pain levels, reductions in satisfaction with their care, or the need for additional prescriptions. This initiative has had a significant impact on public health in Michigan, helping to reduce the availability of unused opioids in the community and mitigate their potential for misuse.

MSQC Care Pathways

In the surgical field, the absence of standardized procedures often results in variation in practice, as demonstrated by the previously mentioned lack of opioid prescribing guidelines. MSQC is dedicated to fostering consistency by standardizing approaches and ensuring the adoption of evidence-based practices. Through collaboration with multidisciplinary teams across member hospitals statewide, MSQC developed the MSQC Care Pathways (Figure 1). These standardized care pathways, which cover surgeries such as colon surgery, hernia repair, laparoscopic cholecystectomy, hysterectomy, Whipple procedures, and outpatient mastectomies, are helping to improve patient outcomes and reduce care variation across Michigan.

Figure 1. MSQC Hernia Care Pathways

Current Initiatives

Building on its past successes, MSQC is advancing several key initiatives to further enhance surgical care. This includes focuses on surgical quality measures for specific procedures, including colorectal cancer, abdominal hernia, and breast surgery, for which MSQC intends to improve both short- and long-term outcomes. Additionally, MSQC is working to identify patient frailty before surgery and implement targeted interventions to enhance overall surgical experiences and outcomes.

In collaboration with ASPIRE/MPOG, MVC, and MPrOVE, MSQC is also supporting the de-implementation of unnecessary preoperative testing before low-risk surgery. As such, MSQC offered metrics in 2023 and 2024, with 33 MSQC hospitals participating in the initiative and observing a 20% reduction in testing. MSQC continues this partnership via the RIght-Sizing Testing before Elective Surgery (RITE-Size) grant, which aims to support hospitals across Michigan in reducing unnecessary testing via a multi-component intervention first piloted at Michigan Medicine. Several of the resources used in the RITE-Size program (Figure 2) were developed in partnership with MSQC and its hospital abstractors, such as the decision aid, sample testing protocol, and engagement package for primary care physician partners.

Figure 2. RITE-Size Resources

A recent survey of surgeons identified postoperative urinary retention as one of the most common challenges in their practices. In response, MSQC has partnered with the Surgical Urinary Catheter Care Enhancement Safety Study (SUCCESS) team to develop a comprehensive toolkit. Created and tested in collaboration with a pilot group of MSQC hospitals, surgeons, and nurses, the toolkit aims to reduce inappropriate perioperative urinary catheter use, prevent complications such as infections and trauma, and improve the management of postoperative urinary retention. By 2024, over 35 MSQC hospitals had implemented these tools, significantly enhancing patient safety, particularly for the most vulnerable populations.

Services and Benefits for MSQC Members

MSQC offers a unique opportunity for hospitals and surgeons to improve surgical care through reliable, real-time, risk- and reliability-adjusted data. By leveraging data collected from trained nurse data abstractors, MSQC helps hospitals statewide with benchmarking, meeting quality standards, and driving continuous improvement in surgical care. In collaboration with surgeon leaders across Michigan, MSQC develops robust variables not captured by other organizations, offering valuable insights into a variety of surgical procedures. Additionally, MSQC provides participating surgeons with personalized reports, empowering them to assess their own performance and identify opportunities for improvement at the individual level. When asked what makes MSQC’s work within the CQI community unique, Dr. Michael Englesbe, MD, FACS, MSQC Program Director explained, “What makes us unique is the quality of clinical data that we have access to. Issues that matter the most to patients such as ‘Did I get the right cancer care’ or ‘Will this hernia repair last me a long time’ are the focus of the MSQC. Again, the high-quality clinical data enables high-quality and impactful efforts to transform care in Michigan.”

MVC is proud to partner with MSQC in advancing surgical quality improvement across Michigan. The BCBSM-funded CQIs play a crucial role in driving healthcare quality improvement, and MVC is excited to continue showcasing the innovative contributions of individual CQIs and the ways in which MVC’s data analytics are supporting high-value care initiatives across the portfolio. Please reach out to us by email if you are interested in learning more about MVC data and collaboration offerings.

11 Jun 2025
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May Workgroups Highlight Sepsis Predictive Models and Post-Surgical Early Ambulation

May Workgroups Highlight Sepsis Predictive Models and Post-Surgical Early Ambulation

June 11, 2025 | 0 Comments | , , ,

In May, MVC hosted two virtual workgroup presentations – the first, a sepsis workgroup focused on Covenant Health’s strategies and successes in improving sepsis bundle compliance under Centers for Medicare and Medicaid Services (CMS) reporting standards. The second, a health in action workgroup, focused on Michigan Medicine’s efforts to advance post-surgical recovery through early ambulation with the help of care path and command center supported real-time notifications. The MVC Coordinating Center hosts workgroup presentations twice per month covering a variety of topics including post-discharge follow-up, sepsis, cardiac rehab, rural health, preoperative testing, and health in action.

Sepsis Workgroup 5/13/25

Improving CMS sepsis compliance is a national priority; hospitals that succeed not only avoid penalties but – more importantly – save patient lives. In her presentation, Amy Lorenz, RN, BAS, MPA, Lead QI Specialist and Sepsis Team Leader for Covenant Healthcare pointed out that a CMS compliance score review in January 2021 of just 64% predicated their site’s interest in pursuing methods to improve sepsis compliance.

To start, Covenant Healthcare reviewed the number of sepsis Best Practices Advisory (BPA) alerts (or OurPractice Advisory or OPAs) firing in the background of their Electronic Medical Records (EMR) based on Modified Systemic Inflammatory Response Syndrome (SIRS) Criteria. The numerous alerts lead to interruptions in workflow, alert fatigue, and frustration.

With the help of their EMR and IT teams, Covenant Health decided to research and validate the use of a predictive model available through EPIC called BPA Level 8. The predictive model is a ruled based, logical scoring system that relies on various criteria such as patient medication orders, lab values, age, and comorbidities to assess the risk of sepsis development for any patient. The predictive model also incorporates non-specific SIRS criteria and additional exclusion criteria (Figure 1).

Figure 1. Covenant Healthcare Base Sepsis Care Path Level 8 Criterion for Exclusion

With the replacement of the SIRS Criteria with the Predictive Model in Q3 of 2023, Covenant Health saw the number of interruptive alerts drop from 90-100,000 to just 30,000 per month in 2024. Lorenz notes that this reduction in interruptive alerts alone was a relief to staff. However, they have additionally seen other positive outcomes including:

  • A climbing RN action rate (10% to 24.5%),
  • An increase in accuracy in sepsis diagnosis (9-18% to 50-60%), and
  • A reduction in the number of sepsis flags missed by the model (only 1-2 per month)

These outcomes together suggest that in addition to reducing inefficient alerts, patients are increasingly receiving optimal and appropriate care. Additional outcomes of this initiative highlighted in the presentation included the development of a linked automatic blood culture and/or lactate level order set within the EMR. Additionally, with support from medical leadership, this order set can now be approved by RNs eliminating a common stopgap in care.

A multidisciplinary approach with regular staff feedback, education, and leadership support further drove engagement and compliance of staff. Another Covenant Healthcare team member on the call, Beth Turnbull, Lead Senior EMR Applications Analyst pointed out that nursing leadership was involved in the implementation of this predictive model from the beginning. Nursing also engaged in evaluating data dashboards, routine compliance audits, and collaborative huddles to monitor sepsis bundle adherence and maintain accountability.

While Covenant Healthcare’s predictive model is specific to their EMR program EPIC, attendees noted that there are other predictive model options available. Ultimately, the key takeaways from this presentation used to improve sepsis bundle compliance include:

  1. Identify and analyze fall outs: to prioritize and target education
  2. Deploy an easy-to-access knowledge base to support clinical decision-making: by creating a one-page resource or visual dashboards
  3. Promote transparency: by increasing access to real-time data and routine collaborative huddles to help keep teams accountable
  4. Secure leadership backing: but also empower front-line workers to make quality efforts stick
  5. Measure and validate interventions: based on data and compliance trends

Health in Action Workgroup 5/29/25

The health in action workgroup featured a joint presentation by Heidi O’Neill, MS, Project Manager Lead; Mary Nowlin, PA-C; and Niki Farquhar, MSE, Project Management Lead from Michigan Medicine. Their presentation centered on the power of interdisciplinary collaboration, data-driven processes, and scalable strategies to embed post-surgical real-time notifications for delayed post-operative ambulation into Michigan Medicine’s post-surgical clinical pathways.

In 2019, Michigan Medicine started a multidisciplinary quality initiative supporting teams across the site to improve outcomes called Advancing Care, Treatment Efficiency, Innovation, Value and Teamwork for Surgical Episodes (or ACTIVATE). O’Neill explained that ACTIVATE places emphasis on teamwork, innovation, and communication to drive patient experience and outcomes. By focusing on units/ services with high observed/expected (O/E) length of stay (LOS >1.0), high surgical volume, and positive leadership engagement; the ACTIVATE team ensured that each unit they invested in had room to improve and support to achieve their goals.

Post-surgical early ambulation, or getting patients up and walking as soon as possible after surgery, has been shown to decrease the length of hospital stay. Common ACTIVATE interventions to promote early ambulation include patient education videos, transport triggers for ambulation from stretcher to bed, documentation of ambulation within four hours, and the development of detailed clinical pathways (see Figure 2).

Figure 2. Common ACTIVATE Interventions to Promote Post-Surgical Early Ambulation

Additionally, Nowlin explained that as the ACTIVATE team spread their interventions across various services, from colorectal to spine then to more general surgical units (4B and the 5th floor) they noticed that there wasn’t a consistent order set for early or sustained ambulation. To ensure consistent documentation, the ACTIVATE team developed an early ambulation order set to be used across all units and started tracking their impact.

ACTIVATE’s efforts to outline post-surgical clinical pathways and optimization of documentation of ambulation eventually led to their collaboration with Michigan Medicine’s Capacity Operations Real Time Engagement Center (or M2C2), launched in November 2022. M2C2 is a state-of-the-art command center designed to act as the hub for Michigan Medicine operations and innovation by leveraging real-time visualization of patient milestone achievement based on EPIC data. Their goal is to not only improve LOS but to ultimately increase the percentage of patients who achieve post-surgical milestones (e.g., early ambulation) in a timely manner. Farquhar explained, M2C2’s integration of care paths and responsive actions when patients deviate from their expected progression are paving the way to reduced LOS, safe discharge, and increased bed capacity.

Figure 3. M2C2 Post-Surgical Procedure Care Path Framework

To develop the post-surgical care path framework (Figure 3), Nowlin and Farquhar met with other key stakeholders to ensure that ACTIVATE and M2C2 efforts to optimally progress patients through the early ambulation node of the post-surgical path were synced. Understanding the goal ACTIVATE had previously set for ambulation within four hours of exiting the OR, M2C2 set alerts for patients that had no documented ambulation by three hours post-surgery to allow for a one-hour intervention window. During this period, M2C2 clinical expeditors (CEs) conduct a patient chart review and then contact the nurse and medical provider to discuss barriers to ambulation.

Within the first quarter of the new M2C2 alert for ambulation going live, nearly 1280 alerts were logged: 559 resulting in contact with the care team to assess barriers to ambulation. When compared to baseline data, a 23.1% decrease in median time to first ambulation was observed for ICU post op patients. For non-ICU post-op patients, a 7.1% decrease was observed. Additionally, a 0.34 day decrease in average LOS was observed. These results indicate opportunities for enhanced patient recovery, shorter LOS, and better overall patient outcomes.

Lastly, Farquhar outlined opportunities to continue to progress with early ambulation including:

  1. Refine exclusions for patients that are not appropriate for early ambulation
  2. Improve visibility of ambulation status and timeline in EPIC
  3. Explore improved capture of ambulation in clinical notes
  4. Enhance alert communication to support nursing
  5. Continue to work on nurse-to-nurse APS consult orders for pain management control

MVC’s May workgroups exemplify efforts from two different sites to place value on interdisciplinary teams, the importance of data visibility, and alignment across clinical, operational, and administrative units to ensure optimal quality improvement.

If you are interested in pursuing a healthcare improvement program, MVC has data specialists available to help navigate and create custom analytics reports. Please reach out to us by email if you would like to learn more about MVC data or engagement offerings!