In January, Michigan Value Collaborative (MVC) kicked off the 2026 workgroup calendar with a sepsis workgroup focused on helping members better understand how to use claims-based data to support sepsis quality improvement (QI) efforts. The session featured an overview of sepsis-related reporting available on the MVC registry followed by an example of how custom analytic reports can be used to dig deeper into areas of clinical interest. The second workgroup of the month, a health in action presentation, featured Corewell Health Farmington Hills Hospital’s multi-year QI initiative aimed at reducing surgical site infections (SSIs) in colorectal surgery. The MVC Coordinating Center hosts one to two workgroup presentations per month covering a variety of topics including post-discharge follow-up, sepsis, cardiac rehabilitation, rural health, preoperative testing, and health in action.
Sepsis Workgroup – MVC Coordinating Center
The workgroup opened with a presentation by MVC’s Site Engagement Coordinator Rachel Folk, MHA, who walked participants through the types of sepsis related data available in the MVC registry and how members can use these reports to support local QI initiatives. The presentation emphasized that MVC’s claims-based data registry allows members to examine sepsis episodes of care across multiple payers and care settings, providing a broader view of healthcare utilization and outcomes than many internal data sources alone.
Participants were introduced to several registry reports that are particularly relevant to sepsis analysis, including:
- Episode Payments Report, which shows total, price-standardized payments for 30- or 90-day episodes and can be used as a proxy for assessments of utilization across inpatient, professional, post-acute, and readmission services.
- Episode Utilization Rates Report, which breaks down where patients receive care during and after an episode, such as skilled nursing facilities, home health, inpatient rehabilitation, or emergency department visits.
- Readmissions Report, which allows members to explore readmission rates for patients by time interval and whether patients return to the index hospital or are readmitted elsewhere.
- Comorbidities Report, which highlights common coexisting conditions among patients and supports a deeper understanding of patient complexity.
- Payment by Condition Report, which compares case volume and utilization across conditions and helps contextualize sepsis relative to other medical episodes.
The presentation also included a review of sepsis-related Pay for Performance (P4P) reports available in the MVC registry including a Value Metric Summary Report and Value Metric Trends Report, which allow users to assess their current performance, improvement and achievement baselines and trends over time (Figures 1 and 2). Folk explained how these reports can help teams visualize progress relative to peer hospitals and MVC-wide averages.
Figure 1. MVC Data Registry Value Metric Summary – Blinded Report
Figure 2. MVC Data Registry Value Metric Trends – Blinded Report
Throughout the presentation, Folk additionally highlighted key registry features such as filtering by hospital type, payer, episode length, patient demographics, and episode time frame. She also reviewed case suppression thresholds and reminded participants that MVC’s data are risk adjusted, allowing for fairer comparisons across hospitals with differing patient populations.
Using Claims Data to Support Improvement
A recurring theme of the discussion was the importance of approaching the registry with curiosity. Participants were encouraged to consider the “five W’s” when reviewing their data and to use the available benchmarking opportunities to compare their hospital’s performance against similar hospitals to help identify realistic opportunities for improvement.
Polling during the session revealed that many participants had limited or no prior experience with an MVC registry review. Registry reviews are a dedicated opportunity for MVC staff to walk members through their site-specific data, focusing on the reports and metrics most relevant to their individual goals. These reviews can help teams move beyond high-level trends to more actionable questions about variation, utilization, and outcomes.
If you’re interested in setting up a time to complete a registry review, please email MVC.
Applying Custom Analytics to Sepsis Care
The workgroup concluded with a second presentation by MVC Analyst Janet Zhang, MPH, highlighting how custom analytic reports can be used to explore specific questions not fully addressed by standard registry reports. Using a recent example focused on sepsis patients and the impact of palliative care, Zang demonstrated how tailored analyses can provide deeper insight into care patterns, outcomes, and opportunities for improvement.
MVC encourages members interested in deeper analyses via custom report to submit a request through the Coordinating Center [Link].
MVC Sepsis Workgroup: Jan. 13, 2026
Health in Action Workgroup – Corewell Health Farmington Hills Hospital
MVC’s second workgroup of January featured Jennifer Hengy, BSN, RN, Internal Quality Improvement Specialist, Dr. Eugene Laveroni, Chief of Surgery, and Leslie Smith, RPh, JD, BCPS, BCIDP, Clinical Pharmacist Specialist from Corewell Health Farmington Hills. Together they showcased how a multidisciplinary team used data, evidence-based guidelines, and workflow redesign to drive meaningful improvements in patients’ safety by reducing SSIs in colorectal surgery.
SSIs remain a significant source of patient harm and financial penalty for hospitals nationwide. Despite advances in sterile technique and surgical technology, data from the Centers for Disease Control and Prevention (CDC) continue to show SSIs occur at alarming rates. As Hengy explained, their local data mirrored this challenge with an SSI rate of 9.6% in colorectal surgeries in 2023. This signaled an urgent need for targeted improvement. For Farmington Hills, this started with building the right team.
Building a Team
The initial improvement committee included surgical leadership, quality improvement specialists, pharmacy, nursing education, and anesthesia, with additional stakeholders added as new insights emerged. This diverse group ensured that clinical expertise, frontline workers, and data review were all represented throughout the project. Another key principle of the initiative was fostering a non-punitive culture. Chart reviews and peer discussion focused on learning and system improvement rather than individual blame, helping to sustain engagement across disciplines.
The Discovery Phase: Identifying Key Gaps
The discovery phase proved to be the most challenging but ultimately the most impactful, Hengy shared. The team conducted detailed chart reviews of SSI cases to better understand contributing factors, examining elements including:
- Use of clean closing gloves, gowns, and closing packs
- Skin preparation and closure techniques
- Antibiotic selection, timing, and infusion duration
- Documentation of infections present at the time of surgery (or PATOS)
Early interventions focused on education about documentation, standardized closing packs, and surgical techniques. While these steps led to modest improvements, they did not produce the level of change the team was seeking so they turned to the experts in antibiotics.
Optimizing Antibiotic Selection and Timing
A deeper dive into perioperative antibiotic practices at Farmington Hills revealed variability in both the antibiotics chosen and their infusion timing. The team identified frequent use of second-line antibiotics in patients with reported penicillin allergies, as well as inconsistencies ensuring antibiotics were fully infused prior to surgical incision.
Smith, a clinical pharmacist specializing in antimicrobial stewardship and a member of Corewell Health Farmington Hills’ SSI workgroup explained that cefazolin remains the preferred first-line prophylactic antibiotic for colorectal surgery and can be safely administered to most patients with reported penicillin allergies. Pharmacy-led education highlighted Cefazolin’s uniquely low risk of cross-reactivity and proven lower SSI rates compared to non-beta-lactam alternatives. Education was delivered through multiple channels, including surgical quality meetings, residents and provider training, newsletters, and real-time feedback to reinforce adherence to standardized protocols.
In addition, the team redesigned workflows to address infusion timing. New processes ensured that antibiotics requiring longer infusion times were started earlier in the preoperative phase. The use of visual job aids, memory tools, and Omnicell alerts reinforced these changes at the point of care (Figures 3 and 4).
Figure 3. Timing of Preoperative Antibiotic Infusion Flyer
Figure 4. Recommended Antibiotic Re-Dosing Interval Guideline Table for Patients Currently Receiving Antibiotics
Outcomes and Impact
Following implementation of these antibiotic-focused interventions and revised workflows, Corewell Health Farmington Hills observed a substantial reduction in colorectal SSIs with an infection ratio (SIR) of 0% between February 2024 and August 2024. In conclusion, the presenters emphasized that while zero harm is an aspirational goal, the consistency of guideline adherence and the sustainability of improved practices represented their major successes.
