From: "Saved by Windows Internet Explorer 8" Subject: Surgeon-Driven Quality Effort Slashes Complications, Costs - HealthLeaders Media Date: Wed, 15 May 2013 13:22:49 -0500 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0000_01CE516F.4C124AD0" X-MimeOLE: Produced By Microsoft MimeOLE V6.1.7601.17609 This is a multi-part message in MIME format. ------=_NextPart_000_0000_01CE516F.4C124AD0 Content-Type: text/html; charset="utf-8" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.healthleadersmedia.com/print/QUA-292043/SurgeonDriven-Quality-Effort-Slashes-Complications-Costs =EF=BB=BF
The National Surgical Quality Improvement Project, a = growing=20 effort run by the American College of Surgeons since 2004, reports that = 83% of=20 program participants have been able to decrease their surgical = complication=20 rates by a statistically significant level.
This article appears in the April 2013 issue of HealthLeaders magazine.
When Brian J. Daley, MD, FACS, chief of trauma at University of = Tennessee=20 Medical Center, talks about success in improving surgical outcomes, he = inserts a=20 joke early in the conversation.
"You know, if you ask a surgeon to name the three best surgeons they = know,=20 they have a problem coming up with two other names," he quips. Often, he = says,=20 "surgeons think everyone else is having a complication, but not = them."
Hospitals and doctors often say they're better than their peers, and = they do=20 so without contradiction because for any one surgeon, procedure, or = hospital,=20 there are few ways to accurately compare results.
But the National Surgical Quality Improvement Project, a growing = effort run=20 by the American College of Surgeons, is trying to fill this gap, = adopting an=20 effort that grew out of the 44-hospital National VA Surgical Risk Study = in the=20 1990s.
By analyzing data from all NSQIP participants, "we know the = risk-adjusted=20 infection rate, or venous thromboembolism rate, or urinary tract = infection rate=20 by surgeon, by hospital, by collaborative, or by state or region," = explains=20 Clifford Ko, MD, FACS, NSQIP director and a colorectal surgeon and = professor of=20 surgery at UCLA's department of surgery.
"We feed these back to the hospitals. They're all risk-adjusted, so = someone=20 can't say, 'Well, my patients were sicker.' That's already taken into = account.=20 And then it's up to the hospitals to figure out, if their rates are = high, what=20 factors in the hospital lead to that and fix it."
At its start in 2004, some 18 hospitals had signed up; today, more = than 500=20 are participating at some level, with another 100 to 200 in the = application=20 process, Ko says.
To date, 83% of NSQIP participants have been able to decrease their=20 complication rates by a statistically significant level, Ko says. Some = hospitals=20 have been able to prevent 250=E2=80=93500 complications, save = 12=E2=80=9336 lives, and wipe away=20 millions of dollars in costs.
"NSQIP is driven by the surgeons," Daley says. "It's data we = understand, it's=20 scientifically gathered, vetted by the VA, and now used throughout = private and=20 public hospitals across the country."
In a nutshell, hospital surgical teams participating in NSQIP allow = their=20 patients' medical records to be analyzed by an independent "data = abstractor"=20 trained and certified by NSQIP but paid by the hospital. The abstractor = tracks=20 certain outcomes for up to 30 days after the surgical procedure, a much = more=20 accurate quality measure than administrative claims and coding data now = used by=20 Medicare and other payers to evaluate quality because it measures far = more=20 actual outcomes than just readmissions and mortality.
In NSQIP, as many as 134 data points are collected, including adverse = events=20 like frequency and type of surgical site infections, unplanned = intubation, the=20 need for patients to return to the operating room, number of patients = spending=20 more than 48 hours on a ventilator, occurrence of preventable blood = clots, or=20 excessive lengths of stay, to name a few.
Hospitals and their surgeons may pick from several measurement = programs, or=20 select the "procedure targeted" option, which allows a choice of 35 = operations=20 they want reviewed, such as appendectomies or colectomies or ventral = hernia=20 repairs. Twice a year, hospitals get reports showing each surgeon's = score is=20 "exemplary," "as expected," or "needs improvement," like a golf score, = Daley=20 says. "You're at par, above par, or below par."
For surgeons at UTMC, a 581-bed hospital in Knoxville that joined = NSQIP as=20 part of a 10-hospital Tennessee collaborative in 2009, the project "has = been=20 very eye-opening because surgeons, in their heart of hearts, want the = best for=20 their patients, but they also know that they have problems," Daley = says.
"This just gives them an easier way to put a number on that and makes = the=20 surgeon feel much more comfortable they have real data."
And it has paid off. UTMC selected vascular and general surgery to = work on.=20 In surgical site infections, NSQIP data revealed "rates were above what = we=20 expected," Daley says. But care improvements, and minding to details, = reduced=20 infections by better than half between the first six months of 2009 and = the=20 first six months of 2012, Daley says. Thirty-day mortality rates also = declined,=20 from 7 per 1,200 surgical cases between January and June of 2009, to 5 = per 1,200=20 cases three years later.
NSQIP makes it easier to track outcomes for surgical patients who, = these=20 days, are less likely to spend the night in the hospital, Daley says. = "The=20 majority of my patients now go home the same day. But NSQIP follows = them,=20 contacts my office, keeps track of them, and collects that 30-day = outcome data.=20 So we catch any infections, for example, that the big Centers for = Medicare &=20 Medicaid Services database doesn't," and the same is true for = non-Medicare=20 beneficiaries as well.
At 907-bed Massachusetts General Hospital in Boston, one of the = original=20 NSQIP hospitals, Matthew Hutter, MD, MPH, director of the Codman Center = for=20 Clinical Effectiveness in Surgery, has similar praise.
"We've been hooked on NSQIP," he says. There's the saying, "if you = can't=20 measure it, you can't improve on it, and that really holds true in this=20 situation."
Take for example urinary tract infections, he says. "When we first = started,=20 we got back data showing our UTIs were much higher than the national = average, 7%=20 compared with 4.9%" in FY 2003.
That prompted introspection, he says, because back then, "surgeons = weren't=20 particularly worried about UTIs; surgeons are concerned about excess = bleeding=20 and leakage. But UTIs cause a lot of harm."
They looked in the literature to see how to prevent UTIs and decided = to focus=20 on Foley catheter necessity and duration, for starters, followed by use = of=20 impregnated catheters. "We made all these different changes, and then = looked at=20 our UTI rates again. They went from 7% to 1.8% the next year."
They didn't stop with that success; they kept looking.
As time passed, they noticed that without ongoing focus on the = problem "UTIs=20 popped back up to 3% in FY 2006, which at the time was 0.4% greater than = the=20 national average. We reinstituted some of our efforts and, sure enough, = brought=20 the number back down to 1.4% by FY 2007. We wouldn't have known there = was a=20 problem if we didn't measure it, implement changes, and even after = seeing=20 improvement, track the metric over time."
Throughout participating NSQIP hospitals nationally, quality = improved, with=20 vascular surgery UTI rates dropping from 4.9% to 2.0% over just four = years,=20 demonstrating that collective efforts raised overall quality level for = all=20 surgery "quite dramatically," says Hutter. Without comparative national = NSQIP=20 data, a hospital wouldn't know that even though it had improved, it = still could=20 be worse than other hospitals.
Hutter says MGH also took on overall complication rates for colectomy = procedures as part of a surgical collaborative of the Partners hospitals = in the=20 Boston area. "At MGH we decreased our rates from 37% during a 12-month = period=20 from July 2006 to June 2007, to 19% over a period covering calendar year = 2008.=20 We cut our complication rates in half in one year." Over that time = period, the=20 collaborative decreased colectomy complication rates from 29.1% to 22.4% = from=20 2007 to 2008. Pancreatic resection complications decreased by one-third = at=20 MGH.
The program does cost money. NSQIP charged all hospitals = $35,000 for a=20 one-year participation, although annual fees have since been reduced = between=20 $10,000 and $25,000 depending on hospital size and extent of the = program, Ko=20 says. Each hospital also must provide a surgical-clinical reviewer who = both=20 collects data and initiates quality improvement projects, and is trained = and=20 credentialed by the NSQIP program. But still, those amounts are = relatively small=20 enough to make an attractive business case for the program.
Hutter points out that each complication costs on average $11,000, as = determined by Justin Demick and colleagues at the University of = Michigan. "So if=20 you can reduce your number of complications, at $11,000 per = complication, you=20 more than offset the cost of the program."
Elizabeth Mort, MD, MPH, senior vice president for quality and safety = for MGH=20 and Massachusetts General Physician Organization, says she and MGH=20 administrators "endorse this work wholeheartedly. We're all being asked = to=20 improve quality and safety while making healthcare more affordable.=20 Reducing adverse events hits the sweet spot because you're = improving=20 patient safety and reducing cost as well."
Three of Baptist Health South Florida's hospitals based in Miami = joined NSQIP=20 about 12 years ago, says Thinh Tran, MD, corporate vice president and = chief=20 medical and quality officer, and a fourth recently came on=20 board.
"We participate in every single measure, unless the hospital does not = provide=20 that care," he says.
Tran says that before Baptist Health started NSQIP each hospital had = its own=20 protocol. "And they were all different. The variation in that care is = really a=20 problem." After they received data on how they compared with other = hospitals in=20 Florida and across the country, they had the motivation they needed to=20 improve.
They focused on dozens of issues, especially preventing = ventilator-associated=20 pneumonia and use of blood-thinning products to prevent blood clots. = "And on=20 adopting single protocols rather than four or five," he says.
"We actually have a full Web-based dashboard from which we share = information=20 back to our physicians, surgeons, internal medicine doctors. The benefit = for me,=20 particularly with my surgical colleagues, is that these are really = meaningful=20 outcomes" and through benchmarks, internally, regionally, and = nationally, "we=20 can learn from others' best practices," Tran says.
Based on NSQIP's risk-adjustment algorithm, which adjusts for patient = comorbidities, Tran says Baptist would have had 64 more deaths and 1,061 = complications throughout 2011 if it hadn't been for the changes it = implemented.=20 And that saved Baptist $21.3 million in care it didn't have to = provide.
Asked if surgeons resisted the project, Tran says there were some at=20 first.
"Initially, it was just a matter of education, answering questions = like,=20 'Where is the data coming from?' and proving that the data is actually=20 accurate=E2=80=94'Was the case done by Dr. X, or his or her partner?' = "
But each hospital's NSQIP participation requires a "physician = champion,"=20 someone whose job it is to work with surgeons to explain questions and = develop=20 plans of attack to specific problems. If physicians aren't able to = improve on a=20 certain procedure, there is more intense effort to find out why.
Tran says that though NSQIP requires considerable resources, it has = the=20 support of the hospital system's board and there hasn't been a problem = getting=20 support for its cost.
For Daley, UTMC's NSQIP "champion," one of the unexpected = developments that=20 he's seen is how willingly hospitals that compete with each other in = Tennessee=20 are sharing information and talking openly about problems.
"It shocked me that we were able to go beyond the borders of = particular=20 organizations, which had not always acted in a collegial manner, = certainly=20 within our community=E2=80=94da Vinci wars, helicopter wars, billboard = wars, cancer=20 center wars, and stealing high-ranking or recognized staff members that = happen=20 to be in our community," he says.
Ko says that NSQIP is seeing accelerated momentum due to surgeons' = and=20 hospitals' not seeing improved clinical results by adhering to Surgical = Care=20 Improvement Process measures currently used by CMS in = pay-for-performance=20 programs.
These measures reflect whether surgical teams performed certain = steps, such=20 as giving a patient an antibiotic within one hour of the first incision, = not how=20 well the patient did after the procedure.
"Hospitals that were scoring well on SCIP measures didn't necessarily = have=20 better outcomes, and that's consistent with what we're seeing," Ko = explains. "If=20 you get great SCIP scores, it doesn't mean you're doing everything = right, and=20 you can still have a high rate of surgical site infections.
"What the published literature has demonstrated is that the SCIP = scores do=20 not necessarily correlate with better outcomes," Ko says.
In recognition that NSQIP may offer a viable measurement tool, CMS = has=20 recently posted on Medicare's Hospital Compare website NSQIP data = voluntarily=20 uploaded by some NSQIP hospitals, showing whether hospitals are better = than=20 average, average, or worse than average in 30-day surgical complication = rates=20 for the following three procedures:
Daley says for himself, the main lesson has been that quality = management must=20 be a constant process. "The biggest thing for me is that you have to = keep doing=20 this over and over, like handwashing. You put in a program and get = everyone to=20 wash their hands, and a few weeks later they all forget. We can't do = that with=20 surgery.
"This isn't gamesmanship; it's not fancy stuff," Daley adds. "It's = just=20 someone looking someone else in the eye and asking, 'Did you wash your = hands?'=20 or 'Did we do time-outs?' and 'Does everyone agree?'
"It's been an excellent demonstration of the ability of surgeons at = multiple=20 organizations to work together for the improvement of the population as = a=20 whole," Daley says.
Cheryl Clark is senior quality editor for HealthLeaders Media. She =
may be=20
contacted at cclark@healthleadersmedia.com.
Reprint HLR0413-9
This article appears in the April 2013 issue of HealthLeaders magazine.