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Clinic performs well in heart surgery site audit

Marshfield Clinic and Saint Joseph’s Hospital achieved exceptional results in a first-ever Adult Cardiac Surgery Site Validation Audit conducted last summer by the Society of Thoracic Surgeons (STS).

“Since the Adult Cardiac Surgery Database is a national database, it is important to verify that data entered into it is accurate. We achieved a 97.3 percent accuracy rate, which exceeded STS’s expectations,” said Julie Uebel, Heart Care Registry Data manager at Marshfield Clinic and Saint Joseph’s Hospital. “We use the database for process improvement – to decrease length of stay, decrease patient ventilator hours and improve patient outcomes.”

The Heart Care Registry is a combined effort of Marshfield Clinic and Ministry Health Care / Saint Joseph’s Hospital.

“The STS database, which began in 1989, is the largest clinical database in the world. It holds more than 3 million records,” said Hope Maki, M.D., Marshfield Clinic cardiovascular surgeon. “The national database was started to help individual surgeons and institutions compare outcomes against a larger group of patients. It helps the surgeons see how they are doing, in terms of patient care.”

“Saint Joseph’s Hospital was named a Solucient Top 100 Heart Hospital for its fifth consecutive year, the only Wisconsin hospital to do so,” said Andrew Weier, director, Quality and Strategic Analysis, Saint Joseph’s Hospital. “In part, this is because of the effort with STS to track and improve heart surgeries.”

During their visit, auditors interviewed Heart Care Registry and other staff members, reviewed random medical records of patients who have undergone coronary artery bypass grafts and compared coronary artery bypass graft records with hospital case log documents. They reviewed data for demographics, hospitalization, pre-operative risk factors, pre-operative cardiac status, pre-operative medications, previous interventions, complications, mortality, discharge and other variables.

“This speaks very well about the cooperation between Marshfield Clinic and Saint Joseph’s Hospital, as well as between medical personnel. Everyone must participate to make the database a success,” said Roxann Rokey, M.D., cardiologist and medical director of Marshfield Clinic’s cardiac database. “We have a core of people who collect and review data. It is very important to Saint Joseph’s Hospital and Marshfield Clinic.”

“It’s a team effort between the Heart Care Registry staff, perfusionists and surgical physician assistants to abstract data accurately,” Uebel explained.

“Our highest priority is the accuracy of the data,” Dr. Maki said. “Once data forms are completed they are then further reviewed by the Heart Care Registry staff, perfusionists and surgical physician assistants to ensure completeness and eliminate even the potential for biased information.”

Auditors noted that Marshfield Clinic surgeons know data definitions and many checks and balances between departments are in place to ensure data accuracy. For training and quality purposes, all cases for new cardiology providers are reviewed for the first three months.

Information Systems infrastructure was a critical component to the audit result.

“Our institution is one of very few in the nation with this high of a level of Information Systems support,” Dr. Rokey said. “All fields for these database elements have been developed by our Information Systems staff. Because of programs developed by Information Systems, it is easy to gather data as well as customize and run reports as needed.”

Chuck Berger, Information Systems, programmed the database software, and this site is one of five across the country that has designed its own database software.

The combined medical record was also essential to the exceptional outcome.

“Data was readily accessible and well organized. Hospital staff members were able to pull only data auditors needed to review,” Uebel said. “They didn’t need to look at any extra data from patient visits, which made their work faster and easier.”

“There is a 20-year-plus record of database usage on this campus,” Dr. Maki said. “Dr. William Myers, a retired Marshfield Clinic cardiovascular surgeon, began a home-grown database at Marshfield Clinic in 1983 and when the STS database became available Marshfield Clinic joined it.”

According to Dr. Rokey, in addition to the STS database, Marshfield Clinic and Saint Joseph’s Hospital also have participated in the American College of Cardiology National Database Registry since its inception. This flagship national database is similar to the one maintained by STS.

The registry contains more than 2 million patient records. It is recognized as the gold standard for measuring quality in the heart catheterization lab by the Centers for Medicare and Medicaid Services, Joint Commission on Accreditation of Healthcare Organizations and U.S. Food and Drug Administration.

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