ACS NSQIP ® conference participants inspired to take QI to the next level

More than 900 surgeons and other health care professionals participated in this year’s American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) National Conference July 21–24 at the Grand America Hotel in Salt Lake City, UT. The meeting provided surgeon champions, surgical clinical reviewers (SCRs), and other health care professionals who are involved in their hospitals’ quality improvement (QI) programs with a forum to share their experiences and to learn about the tools that are available to assist them in their efforts.

During the conference, ACS NSQIP leaders and advocates issued a call to action, requesting that surgeon champions and other ACS NSQIP participants encourage their colleagues and institutions to help foster and create a quality-centered surgical culture. The following is a summary of some of the highlights of the meeting, which comprised five concurrent preconference sessions, seven general sessions, and 26 breakout sessions.

Overview of achievements

According to Clifford Y. Ko, MD, FACS, Director of the ACS Division of Research and Optimal Patient Care and ACS NSQIP, while approximately 10 percent of the nation’s hospitals now participate in ACS NSQIP, participating hospitals perform more than 50 percent of many complex procedures done in the U.S. So it can be safely said that ACS NSQIP hospitals tend to treat patients requiring operations of greater complexity. But perhaps even more meaningful is that ACS NSQIP hospitals have found the program to be an effective instrument for improving quality and reducing costs, even in the higher-complexity cases, Dr. Ko said.

Indeed, ACS Executive Director David B. Hoyt, MD, FACS, noted that 82 percent of participating hospitals have decreased complications, and 66 percent have reduced mortality. Furthermore, each of these institutions has used the program to prevent 250 to 500 complications annually.

The program’s capacity to evaluate and improve surgical outcomes has continually grown, so that today, “ACS NSQIP may be the best single source for evaluating surgical care across specialties,” Dr. Ko said.

Impact in Washington

“This message is resonating in Washington,” Dr. Hoyt noted. Legislators and policymakers have expressed considerable interest in and have taken steps to incorporate ACS NSQIP into initiatives that would move the Medicare payment system from fee for service to value-based purchasing. “We are increasing our impact,” Dr. Hoyt observed.

During his keynote address, First, Do No Harm: Professional Values Drive Business Success, Brent James, MD, MStat, chief quality officer and executive director, Institute for Health Care Delivery Research, Intermountain Healthcare, Salt Lake City, explained why surgeon-led QI programs are of such importance politically.

Dr. James noted that this year the federal government will borrow approximately 40 cents on the dollar. Two-thirds of the government’s unfunded obligations are attributable to Medicare.

Without question, the current U.S. health care system is unsustainable and needs to be reformed, Dr. James said. However, he noted that the solutions politicians offer tend to address spending alone. The Democrats are seeking to control spending through price controls, he maintained, while the Republicans say that market forces should be left to resolve the problem. “There is a third way—quality improvement,” he said. This is an approach that health care professionals can help to drive, as “quality improvement is what has made us professionals.”

A focus on quality improvement, Dr. James said, would help address the following flaws in the nation’s health care system: well-documented, massive variation in practices; high rates of inappropriate care being delivered; unacceptable rates of preventable, care-associated patient injury and death; a striking inability to “do what we know works”; and huge amounts of waste, leading to spiraling prices and limited access to care.

He told the conference attendees, “I believe that what you are doing [through ACS NSQIP] is not just the salvation of health care, but the salvation of the country.” Looking ahead five years, Dr. James anticipates massive pressure to control health care costs, increased emphasis on payment reform and transparency, and demands for “true managed care at the bedside.”

“Maintaining the status quo in American health care is not an option,” said Mark J. Ott, MD, FACS, a general surgeon in Salt Lake City, emphasizing that surgeon involvement in health care reform and quality improvement efforts is an absolute necessity. “If we don’t do it, someone will do it for us.”

Reporting

Participation in ACS NSQIP gives providers an opening to address the changes ahead. Federal agencies, including the Centers for Medicare & Medicaid Service (CMS) and the Agency for Healthcare Research and Quality, have endorsed ACS NSQIP’s efforts. In the last year, the College has partnered with CMS to invite ACS NSQIP hospitals to report surgical outcomes to Hospital Compare—the CMS website that provides quality information to patients, Dr. Ko said. The CMS Pilot Program provides ACS NSQIP hospitals with the opportunity to voluntarily publicly report on one or more of three National Quality Forum-endorsed measures: elderly surgery outcomes, colon surgery outcomes, and lower-extremity bypass outcomes.

“There is only one public reporting scorecard that matters—Hospital Compare,” said J. Michael Henderson, MD, ChB, FACS, chief quality officer, Quality and Patient Safety Institute, Cleveland Clinic, OH. “Participation in registries, such as ACS NSQIP, is going to be more prominently displayed on the Hospital Compare Web page,” he added.

Partnering

In recent months, ACS NSQIP has also been partnering with other agencies and groups to develop higher standards of care for surgical patients. More specifically, the College has been working with the Centers for Disease Control and Prevention (CDC) and The Joint Commission to develop protocols for the prevention of surgical site infections (SSIs).

Earlier this year, the ACS and the CDC entered into an agreement to work together to address SSIs and related complications that afflict approximately 2 million Americans annually. Bruce Hall, MD, PhD, FACS, professor of surgery, division of general surgery, cancer and endocrine surgery section, Washington University, St. Louis, MO, said that in 2010, both ACS NSQIP and the CDC developed and submitted measures related to SSIs to the National Quality Forum for consideration and possible approval. One of the primary goals of the new initiative is to harmonize the measures that ACS NSQIP currently uses with the metrics that the CDC’s National Healthcare Safety Network applies. “The two-way exchange with the CDC has been very useful and appears to have benefitted both organizations,” Dr. Hall said.

Sandra I. Berrios-Torres, MD, orthopaedic surgeon, medical officer, and SSI subject matter expert in the CDC’s Division of Healthcare Quality Promotion (DHQP) at the CDC, outlined challenges and opportunities in the development of these guidelines, including: absence of evidence, issues inherent to complex systemic reviews, difficulty using meta-analyses given the heterogeneity of the existing evidence, and the role of cost analyses in making the recommendations. Other challenges included balancing guideline development and updates with expert and public input.

E. Patchen Dellinger, MD, FACS, chief of the division of general surgery at the University of Washington, Seattle, identified several factors that influence the likelihood of a patient developing an SSI, including: the use of prophylactic antibiotics, wound oxygenation, glucose control, teamwork, communication, discipline, and surgical technique.

“The implications of SSI are enormous,” leading to greater costs, more readmissions, higher morbidity rates, and significant risks to other patients, said Robert R. Cima, MD, FACS, a colon and rectal surgeon at the Mayo Clinic, Rochester, MN. Dr. Cima gave an overview of The Joint Commission’s work with regard to SSIs in colon-rectal surgery patients, who experience these complications with the greatest frequency. The goal of The Joint Commission’s project is to reduce SSI in colon-rectal patients by 50 percent.

The College also collaborated with the American Geriatrics Society to develop soon-to-be-released guidelines for surgery in elderly patients. A general session at the meeting featured presentations from the following surgeons who have researched key issues of concern:

  • Warren B. Chow, MD, MS, a general surgeon in Los Angeles, CA, and a former ACS Clinical Scholar, discussed issues related to cognitive impairment and dementia, including the risks of overmedication and postoperative delirium.
  • Emily V.A. Finlayson, MD, FACS, assistant professor of surgery at the Institute of Health Policy Studies at the University of California, San Francisco, said, “Frailty predicts outcome.” However, surgeons can modify the effects of frailty through nutrition, she added.
  • Sandhya A. Lagoo-Deendaylan, MD, PhD, FACS, a general surgeon at Duke University Medical Center, Durham, NC, said the two factors that clearly affect outcomes in older patients are comorbidities and the need for emergency surgical care.

In addition, ACS NSQIP participant hospitals have reached out to other institutions in their region to form collaboratives. Dr. Ko said that ACS NSQIP collaborative programs should lead to long-term improvements at participating institutions because, “This is how we believe people learn best—by working with each other.”

Several speakers provided updates on ACS NSQIP regional collaboratives:

  • Joseph B. Cofer, MD, FACS, the Tennessee Surgical Quality Collaborative
  • Joseph J. Tepas III, MD, FACS, the Florida Surgical Care Initiative
  • Pascal R. Fuchshuber, MD, PhD, FACS, the Kaiser Permanente Collaborative
  • Marlies van Dijk, RN, MSc, Surgical Quality Action Network, British Columbia, Canada

Call to action

Given QI’s potential to truly transform the nation’s health care system and improve the quality of life for patients, a central theme of this year’s conference focused on taking ACS NSQIP to the next level. ACS leaders encouraged attendees to look beyond the data and foster a culture of quality improvement.

During a lecture titled Raising the Collective Consciousness: A Program for the Public Trust, Dr. Hoyt said, “We need to start channeling our ‘inner Codman.’” Ernest Amory Codman, MD, FACS, is best known for his advocacy of the then-controversial “end result idea.” More specifically, Dr. Codman called upon hospital staffs to follow every patient to whom they provided medical and surgical services long enough to see whether the treatment was successful, to learn from any failures, and to determine how to avoid complications in the future.

Dr. Hoyt said a national goal should be to create “a learning health care system” and quality-focused surgical culture rooted in the College’s four core principles: setting standards, creating the right infrastructure, generating and analyzing rigorous data, and verifying that the standards are being met.

Developing surgeon champions

Underscoring his assertion that, “Because we can improve care, we should,” Dr. Hoyt called upon surgeon champions to take QI to the next level by fostering a culture of quality improvement in their institutions and sought their assistance in expanding ACS NSQIP’s reach.

“There are two things you can do this year: (1) contact three surgeons you know and invite them to learn more about and participate in ACS NSQIP; and (2) give an ACS NSQIP presentation at a chapter or health care association meeting,” he said. The College is assisting surgeons who want to carry out these activities by offering the following programs: Web-based training and a presenter’s guide, new marketing materials, template e-mails and letters, and a PowerPoint presentation. Surgeon champions also may schedule a one-on-one strategy session with an ACS NSQIP expert.

Surgeon champions are the lifeblood of establishing and sustaining ACS NSQIP-driven quality improvement programs in hospitals and health systems. “Without the surgeons’ involvement, it doesn’t go very far,” Leigh Neumeyer, MD, FACS, an ACS Regent and professor of surgery at the University of Utah, said in a presentation titled Lessons Learned in ACS NSQIP. Dr. Neumeyer was a Veterans Affairs surgeon when ACS NSQIP was introduced into that health care system in the 1990s and was on the executive committee charged with implementing it.

Dr. Ott noted that surgeon involvement is imperative because, “Surgery matters to hospitals. Surgical services dwarf everything else in terms of income and contribution to the bottom line.”

Joe Patton, MD, FACS, a general and acute care surgeon with Henry Ford Health Care System, Detroit, MI, also emphasized that participating hospitals need to cultivate surgeon champions to encourage other members of the profession to participate. To encourage surgeon involvement and leadership, Dr. Patton encouraged approaching surgeons with data and an understanding of the data’s meaning. “Physicians are data-driven. Show them their numbers. Ask them, ‘How can we make this better?’”

Ninh T. Nguyen, MD, FACS, chief, division of gastrointestinal surgery, University of California, Irvine, shared his experience as a novice surgeon champion. He said surgeon champions need to get buy-in from their departments, commitment for a SCR, and educational resources.

Creating a culture of QI

Surgeon champions must take responsibility not only for reviewing and analyzing the data they receive from ACS NSQIP, but also for fostering an overall culture of quality improvement. “Culture, communication, and teamwork in the operating room have an enormous amount to do with patient outcomes,” Dr. Dellinger said.

Elizabeth C. Wick, MD, FACS, a colon-rectal surgeon at Johns Hopkins Medicine, Baltimore, MD, discussed how the Comprehensive Unit-based Safety Program (CUSP) has been implemented in units of that institution to help change the workplace culture. CUSP is designed to get each unit involved with and committed to safety improvement—and national-level safety goals.

“Change cannot be top-down,” Dr. Wick said, noting that CUSP is effective because it recognizes the importance of culture in effecting sustainable patient safety improvements. “Better teamwork leads to better outcomes, and a better culture leads to better teamwork,” she added.

Most errors that occur in the operating room are due to lack of communication, according to Jennifer Ritz, RN, SCR for Henry Ford Health Care. “The strongest predictor of clinical excellence is [creating an environment where] caregivers feel free to speak up when they perceive there is a problem in patient care,” she said.

Other factors that seem to lead to better outcomes are medical team training and the use of checklists. “The checklist ensures everyone knows what they’re doing throughout the operation,” Ms. Ritz said.

Of course, changing an institution’s culture is no easy task and must be managed very carefully. Nestor F. Esnaola, MD, MPH, FACS, assistant professor of surgery, division of surgical oncology, Medical University of South Carolina, Charleston, defined change management as “a structured, proactive coordinated approach to transforming individuals and organizations from their current state to their desired future state.” This process is usually guided by strong models and guidelines, he said, adding that change leaders need to make sure that the rest of the people in the organization understand the need for change, develop a team of people who guide the change process, and create a vision strategy.

To implement real, sustained change, Dr. Esnaola said it is necessary to create a sense of urgency. “Sometimes, you have to shock people out of the status quo,” Dr. Esnaola said. Change leaders need to communicate their vision and “empower broad-based action,” he said. He also advised that change leaders listen to and respond to resistors.

Ms. Ritz also offered a list of suggestions for creating a successful surgical QI culture (see table).

Creating a successful surgical QI culture

  • Always put the patient first
  • Get leadership commitment
  • Establish buy-in, collaboration, and partnerships
  • Educate about quality
  • Garner necessary resources
  • Be transparent/share everything
  • Use data to drive and measure change
  • Influence change; use emotional intelligence and situational awareness to determine who can help; and lead across silos
  • Incorporate quality into everything you do
  • Focus on the “big picture”

This year’s ACS NSQIP conference provided attendees with a clear understanding of how much progress they, their colleagues, and the program as a whole are making and helped them set their sights on taking ACS NSQIP to the next level. For more information about ACS NSQIP activities, go to www.acsnsqip.org.

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