The National Surgical Quality Improvement Project, a growing effort run by the American College of Surgeons since 2004, reports that 83% of program participants have been able to decrease their surgical complication 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 Medical Center, talks about success in improving surgical outcomes, he inserts a joke early in the conversation.
"You know, if you ask a surgeon to name the three best surgeons they know, they have a problem coming up with two other names," he quips. Often, he says, "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 so without contradiction because for any one surgeon, procedure, or hospital, there are few ways to accurately compare results.
But the National Surgical Quality Improvement Project, a growing effort run by the American College of Surgeons, is trying to fill this gap, adopting an effort that grew out of the 44-hospital National VA Surgical Risk Study in the 1990s.
By analyzing data from all NSQIP participants, "we know the risk-adjusted infection rate, or venous thromboembolism rate, or urinary tract infection rate by surgeon, by hospital, by collaborative, or by state or region," explains Clifford Ko, MD, FACS, NSQIP director and a colorectal surgeon and professor of surgery at UCLA's department of surgery.
"We feed these back to the hospitals. They're all risk-adjusted, so someone can't say, 'Well, my patients were sicker.' That's already taken into account. And then it's up to the hospitals to figure out, if their rates are high, what 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 are participating at some level, with another 100 to 200 in the application process, Ko says.
To date, 83% of NSQIP participants have been able to decrease their complication rates by a statistically significant level, Ko says. Some hospitals have been able to prevent 250–500 complications, save 12–36 lives, and wipe away millions of dollars in costs.
"NSQIP is driven by the surgeons," Daley says. "It's data we understand, it's scientifically gathered, vetted by the VA, and now used throughout private and public hospitals across the country."
In a nutshell, hospital surgical teams participating in NSQIP allow their patients' medical records to be analyzed by an independent "data abstractor" trained and certified by NSQIP but paid by the hospital. The abstractor tracks certain outcomes for up to 30 days after the surgical procedure, a much more accurate quality measure than administrative claims and coding data now used by Medicare and other payers to evaluate quality because it measures far more actual outcomes than just readmissions and mortality.
In NSQIP, as many as 134 data points are collected, including adverse events like frequency and type of surgical site infections, unplanned intubation, the need for patients to return to the operating room, number of patients spending more than 48 hours on a ventilator, occurrence of preventable blood clots, or excessive lengths of stay, to name a few.
Hospitals and their surgeons may pick from several measurement programs, or select the "procedure targeted" option, which allows a choice of 35 operations they want reviewed, such as appendectomies or colectomies or ventral hernia repairs. Twice a year, hospitals get reports showing each surgeon's score is "exemplary," "as expected," or "needs improvement," like a golf score, Daley says. "You're at par, above par, or below par."
For surgeons at UTMC, a 581-bed hospital in Knoxville that joined NSQIP as part of a 10-hospital Tennessee collaborative in 2009, the project "has been very eye-opening because surgeons, in their heart of hearts, want the best for 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 surgeon feel much more comfortable they have real data."
And it has paid off. UTMC selected vascular and general surgery to work on. In surgical site infections, NSQIP data revealed "rates were above what we expected," Daley says. But care improvements, and minding to details, reduced infections by better than half between the first six months of 2009 and the first six months of 2012, Daley says. Thirty-day mortality rates also declined, from 7 per 1,200 surgical cases between January and June of 2009, to 5 per 1,200 cases three years later.
NSQIP makes it easier to track outcomes for surgical patients who, these days, are less likely to spend the night in the hospital, Daley says. "The majority of my patients now go home the same day. But NSQIP follows them, contacts my office, keeps track of them, and collects that 30-day outcome data. So we catch any infections, for example, that the big Centers for Medicare & Medicaid Services database doesn't," and the same is true for non-Medicare beneficiaries as well.
At 907-bed Massachusetts General Hospital in Boston, one of the original NSQIP hospitals, Matthew Hutter, MD, MPH, director of the Codman Center for Clinical Effectiveness in Surgery, has similar praise.
"We've been hooked on NSQIP," he says. There's the saying, "if you can't measure it, you can't improve on it, and that really holds true in this situation."
Take for example urinary tract infections, he says. "When we first started, we got back data showing our UTIs were much higher than the national average, 7% compared with 4.9%" in FY 2003.
That prompted introspection, he says, because back then, "surgeons weren't particularly worried about UTIs; surgeons are concerned about excess bleeding and leakage. But UTIs cause a lot of harm."
They looked in the literature to see how to prevent UTIs and decided to focus on Foley catheter necessity and duration, for starters, followed by use of impregnated catheters. "We made all these different changes, and then looked at 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 popped back up to 3% in FY 2006, which at the time was 0.4% greater than the national average. We reinstituted some of our efforts and, sure enough, brought the number back down to 1.4% by FY 2007. We wouldn't have known there was a problem if we didn't measure it, implement changes, and even after seeing improvement, track the metric over time."
Throughout participating NSQIP hospitals nationally, quality improved, with vascular surgery UTI rates dropping from 4.9% to 2.0% over just four years, demonstrating that collective efforts raised overall quality level for all surgery "quite dramatically," says Hutter. Without comparative national NSQIP data, a hospital wouldn't know that even though it had improved, it still could 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 Boston area. "At MGH we decreased our rates from 37% during a 12-month period from July 2006 to June 2007, to 19% over a period covering calendar year 2008. We cut our complication rates in half in one year." Over that time period, the collaborative decreased colectomy complication rates from 29.1% to 22.4% from 2007 to 2008. Pancreatic resection complications decreased by one-third at MGH.
The program does cost money. NSQIP charged all hospitals $35,000 for a one-year participation, although annual fees have since been reduced between $10,000 and $25,000 depending on hospital size and extent of the program, Ko says. Each hospital also must provide a surgical-clinical reviewer who both collects data and initiates quality improvement projects, and is trained and credentialed by the NSQIP program. But still, those amounts are relatively small 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 you can reduce your number of complications, at $11,000 per complication, you more than offset the cost of the program."
Elizabeth Mort, MD, MPH, senior vice president for quality and safety for MGH and Massachusetts General Physician Organization, says she and MGH administrators "endorse this work wholeheartedly. We're all being asked to improve quality and safety while making healthcare more affordable. Reducing adverse events hits the sweet spot because you're improving patient safety and reducing cost as well."
Three of Baptist Health South Florida's hospitals based in Miami joined NSQIP about 12 years ago, says Thinh Tran, MD, corporate vice president and chief medical and quality officer, and a fourth recently came on board.
"We participate in every single measure, unless the hospital does not provide that care," he says.
Tran says that before Baptist Health started NSQIP each hospital had its own protocol. "And they were all different. The variation in that care is really a problem." After they received data on how they compared with other hospitals in Florida and across the country, they had the motivation they needed to improve.
They focused on dozens of issues, especially preventing ventilator-associated pneumonia and use of blood-thinning products to prevent blood clots. "And on adopting single protocols rather than four or five," he says.
"We actually have a full Web-based dashboard from which we share information back to our physicians, surgeons, internal medicine doctors. The benefit for me, particularly with my surgical colleagues, is that these are really meaningful outcomes" and through benchmarks, internally, regionally, and nationally, "we 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. 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 first.
"Initially, it was just a matter of education, answering questions like, 'Where is the data coming from?' and proving that the data is actually accurate—'Was the case done by Dr. X, or his or her partner?' "
But each hospital's NSQIP participation requires a "physician champion," someone whose job it is to work with surgeons to explain questions and develop plans of attack to specific problems. If physicians aren't able to improve on a certain procedure, there is more intense effort to find out why.
Tran says that though NSQIP requires considerable resources, it has the support of the hospital system's board and there hasn't been a problem getting support for its cost.
For Daley, UTMC's NSQIP "champion," one of the unexpected developments that he's seen is how willingly hospitals that compete with each other in Tennessee are sharing information and talking openly about problems.
"It shocked me that we were able to go beyond the borders of particular organizations, which had not always acted in a collegial manner, certainly within our community—da Vinci wars, helicopter wars, billboard wars, cancer center wars, and stealing high-ranking or recognized staff members that happen to be in our community," he says.
Ko says that NSQIP is seeing accelerated momentum due to surgeons' and hospitals' not seeing improved clinical results by adhering to Surgical Care Improvement Process measures currently used by CMS in pay-for-performance programs.
These measures reflect whether surgical teams performed certain steps, such as giving a patient an antibiotic within one hour of the first incision, not how well the patient did after the procedure.
"Hospitals that were scoring well on SCIP measures didn't necessarily have better outcomes, and that's consistent with what we're seeing," Ko explains. "If you get great SCIP scores, it doesn't mean you're doing everything right, and you can still have a high rate of surgical site infections.
"What the published literature has demonstrated is that the SCIP scores do not necessarily correlate with better outcomes," Ko says.
In recognition that NSQIP may offer a viable measurement tool, CMS has recently posted on Medicare's Hospital Compare website NSQIP data voluntarily uploaded by some NSQIP hospitals, showing whether hospitals are better than average, average, or worse than average in 30-day surgical complication rates for the following three procedures:
- Lower-extremity bypass surgery, in which surgeons insert a new vein to circumvent blockages in arteries and restore blood flow to the lower leg and foot
- Colon surgery, in which surgeons remove part of the colon affected by polyps, diverticula, or tumors
- Surgical complication rates for patients older than age 64
Daley says for himself, the main lesson has been that quality management must be a constant process. "The biggest thing for me is that you have to keep doing this over and over, like handwashing. You put in a program and get everyone to wash their hands, and a few weeks later they all forget. We can't do that with surgery.
"This isn't gamesmanship; it's not fancy stuff," Daley adds. "It's just someone looking someone else in the eye and asking, 'Did you wash your hands?' or 'Did we do time-outs?' and 'Does everyone agree?'
"It's been an excellent demonstration of the ability of surgeons at multiple organizations to work together for the improvement of the population as a whole," Daley says.
Cheryl Clark is senior quality editor for HealthLeaders Media. She may be contacted at cclark@healthleadersmedia.com.
Reprint HLR0413-9
This article appears in the April 2013 issue of HealthLeaders magazine.