The Michigan Surgical Quality Collaborative (MSQC) is listed as a Patient Safety Organization (PSO) by the Agency for Healthcare Research and Quality (AHRQ), on behalf of the Secretary of the U.S. Department of Health and Human Services.
This designation is an important confirmation that MSQC provides all of our participating sites the most appropriate protections. MSQC is one of three patient safety organizations in Michigan and 77 nationally. This designation denotes high level quality and security in the way MSQC gathers, analyzes and shares data for each of the MSQC hospitals to use in their quality work.
MSQC PSO Documents
The following resources are available to MSQC members.
- PSO Listing Letter (2016-2019)
- MSQC PSO Patient Safety Evaluation System Model
- MSQC PSO Confidentiality and Privilege Statement for PowerPoint
MSQC PSO Resources
- Agency for Healthcare Research and Quality (AHRQ) Website
- AHRQ Patient Safety Organization: Compliance Assessment Guide
- Health and Human Services: Guidance Regarding Patient Safety
- American Medical Association: Physicians Guide to Patient Safety Organizations
- American Medical Association: Patient Safety Organization Checklist
MSQC PSO Administrative Toolkit
The MSQC PSO Administrative Toolkit contains a selection of slides explaining MSQC, its background, structure, role as a CQI, and value proposition. It contains details of MSQC's collaborative, evidence-based approach to best practice and quality improvement, some key results and achievements, and informational screenshots of MSQC’s unique data and reporting platform.
The slides may be modified for customization and reproduced for use and distribution at your site. These documents have been made available with the sole intent of assisting sites with the initiation and development of the MSQC program. In the interest of improving surgical care, favorably affecting patient outcomes, and wide promotion of best practices, MSQC has made these documents accessible with minimal restriction. Please be respectful of their use and refrain from reproducing or using these documents outside of their intended purpose.
If you have any questions, or need any further informational resources, please don't hesitate to contact MSQC Customer Support.
MSQC: A Qualified Registry for General Surgery
In August 2012 CMS announced its final IPPS rule (Inpatient Prospective Payment System) for the fiscal year 2012. This rule indicates which quality measures will be used for the value based purchasing calculations.
Beginning fiscal year 2014, hospitals will report a new measure Participation in a Systematic Clinical Database Registry for General Surgery – to be included in the 2014 payment calculation.
The measure requires hospitals to report:
- YES or No, whether they participate in a registry and
- If they do, which registry.
We have been informed by CMS that they do not regulate Registry qualification, and it is the responsibility of the reporting institution to determine whether or not regis try requireme nts are being met. So to best serve our participating hospitals, MSQC would like to announce our status as a recognized ‘Systematic Clinical Database Registry for General Surgery.’ Per Quality Net, a data collection service under CMS contract, two criteria must be met to deem MSQC a ‘qualified registry’:
- MSQC must collect standardized data elements applicable to at least two National Quality Forum (NQF) endorsed measures related to general surgery.
- MSQC must receive data from more than five hospitals and provide calculated measures, results, benchmarks, and QI information to the participant.
With 73 contributing members and growing, MSQC clearly exceeds the requirement of data collection volume and calculated measures. Furthermore, we were able to confirm with CMS that becoming a steward of our own NQF measures is not required. Following the terms of existing NQF definitions is sufficient for being deemed a ‘qualified registry’ and MSQC has determined that our data collection accommodates the following endorsed variables:
(1) NQF# 0753 American College of Surgeons – Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure
- Deep Incisional Surgical Site Infection
- Organ Space Surgical Site Infection
(2) NQF# 0528 Prophylactic antibiotic selection for surgical patients
- Prophylactic IV Antibiotics
(3) NQF# 0452 Surgery Patients with Perioperative Temperature Management
- Intraoperative Warming
- Intraoperative Temperature
- Postoperative Temperature
The above information on MSQC as a Qualified Registry for General Surgery can be downloaded here.