MCSQI is a non-profit consortium supported by all ten hospitals that perform cardiac surgery in the state of Maryland. The organization provides value to its stakeholders by improving the quality of care through data analysis and implementing best practice protocols led by the Board of Directors, Quality Committee and Research and Writing Committee.
Communications, Meetings and Outreach: MCSQI network of surgeons, data managers and clinical teams fosters statewide collaboration through in-person meetings, conference calls and site visits. Through dynamic communication MCSQI informs, motivates, builds trust and increases transparency; consequently, helping our quality improvement consortium affect meaningful organizational change.
Benchmarking and Reporting: MCSQI focuses on selecting quality indicators, establishing baseline data, designing scorecards, addressing privacy and confidentiality and using providers’ commentary as context to better understand trends and variations. Data managers convene regularly to standardize coding practices, allowing for timely, sound and accurate interpretations of cardiac surgery performance reports.
Quality Improvement Agenda: MCSQI members research, identify, and replicate best practices with the goal of improving the quality of patient care across the state. Pilot programs and other ‘proof-of-concept’ steps are used to develop and lead initiatives for Maryland’s cardiac surgery sites. Best practices and evidence-based guidelines are researched and validated before adoption.
Evaluating Impact: MCSQI adjusts its efforts to improve participants’ chances for success by implementing models to evaluate hospital performance. Progress is communicated to key audiences in state government, the cardiac surgery community and other external organizations.
Effective Governance: The Board of Directors represent participants’ interests, and developed a governance structure, set dues and adopted bylaws. MCSQI encourages broad participation among its member provider organizations and surgical practices.
Operational Capacity: In conjunction with the Board of Directors and other group members, the Executive Director manages the organization by facilitating development, setting agendas, encouraging participation, focusing discussion on key issues, helping the group reach
consensus and solving problems.
Informatics and Data Analytics
MCSQI’s database links clinical factors with qualitative, process-level information in order to monitor and drive quality improvements. Participants’ clinical records from the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database are submitted quarterly to a secure web-based system. An annual report and inter-hospital rankings are used to compare performance related to specific metrics for the group’s quality initiatives.
Participation is open, voluntary and non-hierarchal. Member bylaws and committee decisions guide the group’s priorities, synchronizing efforts to regularly refine the management of data.