More than 1,000 individuals who work in hospital quality improvement programs participated in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) 2013 National Conference, July 13–16, at the Bayfront Hilton San Diego, CA. This record-breaking number of attendees participated in a variety of sessions aimed at reducing surgical complications, applying quality improvement concepts to difficult surgical problems, and maximizing efficiency and resource use in health care. Many sessions also offered strategies for adapting to a changing health care environment and using evidence-based tools and case studies to improve hospital culture.
Clifford Y. Ko, MD, MSHS, FACS, Director of the ACS Division of Research and Optimal Patient Care and ACS NSQIP, told surgeon champions (SCs), surgical clinical reviewers (SCRs), and other conference attendees that ACS NSQIP, built on a foundation of strong data, is the first nationally validated, risk-adjusted program to provide external benchmarks for measuring the quality of surgical care.
In his welcoming remarks, Dr. Ko spoke of the changing definition of surgical professionalism. “There has been a shift in our definition of professionalism. We have moved from autonomy to collaboration,” he said. ACS NSQIP has taken what program participants have learned from their experiences and applied those lessons to generate optimal quality surgical standards, Dr. Ko explained. He went on to present a vision of the surgeon of the future who will be part of a high-performance team that will depend on evidence-based measurements. The College’s recently published book, Lessons Learned in the Pursuit of Quality Surgical Health Care, Dr. Ko added, reflects the commitment of ACS NSQIP participants, whose evidence-based practice gave focus to the lessons.
ACS emphasis on quality
During the opening session, ACS President A. Brent Eastman, MD, FACS, whose leadership of the College coincides with the organization’s 100-year anniversary and who has chosen “The Next 100 Years” as the theme of his presidential term, borrowed the words of former U.K. Prime Minister Winston Churchill, noting, “The further back you look, the further forward you can see.”
“The College started on a mission of quality,” Dr. Eastman said. “Care in hospitals in the early 1900s was hit or miss, and it was the ACS leaders who wanted to standardize care.” He spoke of the cycle of quality health care—that the best evidence-based practices produce high-quality surgical care, which produces better outcomes.
“The one word that surgeons agree on is ‘unsustainability’ of the current health care system,” he added. “I believe that ACS NSQIP is the best answer to the situation we face today.”
ACS Executive Director David B. Hoyt, MD, FACS, in his address to the conference attendees during the opening session, pointed to three principles that will drive health care in the future: access to care, payment reform, and delivery system redesign. “The whole idea of quality and professionalism in health care is changing in this age of accountability,” he said. “Cost and payment are the issues getting air time today.”
Surgeons may not be the drivers of reform, but they are a necessary part of the conversation, Dr. Hoyt said. He noted that at the ACS Inspiring Quality Forum in Boston, MA, on June 4, 2012, economist Stuart Altman, PhD, observed that surgeons and other physicians may not always be on the same page when it comes to health care reform, but they “are American health care” and are the right people to address issues of cost and quality of care.
“The question becomes ‘who will hold the risk?’” Dr. Hoyt said. “The priorities in surgical care today are the science of measurement, quality in surgical health, high-quality data, collaboration, and leadership—not only in the OR but on Capitol Hill.
“Quality is the future of health care,” Dr. Hoyt added. “Quality is measurable, and high-quality data are essential.”
Keynote address on promoting a safety culture
Gerald B. Hickson, MD, delivered the keynote address titled The Influence of Culture on Surgical Quality Improvement—Balancing Systems and Human Accountability in Pursuit of a Culture of Safety, and focused on professionalism.
“There is no high reliability of health systems until we know what it means to be professional. We’re not going to do that unless we have leadership, and each of us at some point becomes the leader,” said Dr. Hickson, senior vice-president for quality, safety, and risk prevention; assistant vice-chancellor for health affairs; and the Joseph C. Ross Chair of Medical Education and Administration, Vanderbilt University School of Medicine, Nashville, TN.
“That’s what happens in a safety culture,” he continued. “Whenever there is a disturbance, people must speak up. Real professionals commit to behavioral models and ask the questions: ‘How does my performance affect the people around me?’ and ‘What behavior undermines safety?’
“At the end of the day,” he added, “safety is about team performance. Bullying is a problem, but passive-aggressive behavior is most destructive. Failure to follow up is not professional. Policies will not work if bad behaviors are not reported.”
To be professional, he added, is to be accountable. “We are not asking people to be perfect. Real professionals pursue accountability. Surgeons and the nursing staff must work together for quality.”
ACS NSQIP improves patient care
Many conference speakers echoed Dr. Hickson’s emphasis on building a culture of safety and using ACS NSQIP as the foundation for improving patient safety and quality of care.
At a session on safety, John R. Clarke, MD, FACS, professor of surgery at Drexel University, Philadelphia, and clinical director of the Pennsylvania Patient Safety Authority, said a “never event,” such as a fire in the operating room (OR), occurs rarely but is preventable. Dr. Clark went on to say that the most frequent cause of OR fires is use of electrosurgical equipment while supplemental oxygen is present. Fires must always be reported, Dr. Clarke said, and the hospital must change its practices to avoid recurrences.
To avert other types of never events, The Joint Commission developed a Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery several years ago. Linda Groah, RN, MSN, chief executive officer, Association of periOperative Registered Nurses, Denver, CO, explained that The Joint Commission’s Universal Protocol calls for OR teams to apply three steps before an operation begins: verify the relevant information about the case, mark the operative site, and take a “time out.”
Greater use of guidelines will help prevent surgical never events, which still occur with some frequency, according to a 2012 research project led by Martin A. Makary, MD, MPH, FACS, an associate professor of surgery at Johns Hopkins University School of Medicine, Baltimore, MD. The research indicates that more than 80,000 such incidents occurred between 1990 and 2010. In other words, major errors occur approximately 80 times per week and about 4,082 times per year. In the last 20 years, these incidents have resulted in medical liability payouts of more than $1.3 billion, with the payout for each event averaging $133,055.1
Champions of quality improvement
Several ACS NSQIP SCs shared best practices and lessons learned from their hospitals. Among the speakers who discussed the power of ACS NSQIP to improve surgical quality was John M. Morton, MD, FACS, quality improvement administrator, director of surgical quality, and chief of minimally invasive surgery at Stanford University Medical Center, CA. Dr. Morton said the hospital’s application of ACS NSQIP helped moved the institution’s risk-adjusted mortality ranking from average to exemplary.
In the same session, Scott J. Ellner, DO, MPH, FACS, vice-chairman of surgery and director of surgical quality at Saint Francis Hospital and Medical Center, Hartford, CT, reported that benchmark data from ACS NSQIP played a major role in the reduction of the number of urinary tract infections, saving the hospital approximately $53,000 per patient.
“It’s important to share data and recognize and address barriers,” Dr. Ellner said. “Quality improvement is about a shared vision and leadership, which is not about power.”
Joseph B. Cofer, MD, FACS, a general surgeon and program director of the department of surgery, University of Tennessee College of Medicine, Chattanooga, TN, presented highlights of the Tennessee Surgical Quality Collaborative (TSQC), the first ACS NSQIP collaborative that is a partnership between a hospital association, health plan, and ACS local chapter. TSQC has provided proven improvement in the health of Tennessee residents, Dr. Cofer said, but it takes an effective team for this to happen. “A culture of mutual trust is imperative.”
“The way we do things around here”
Elizabeth C. Wick, MD, FACS, a colorectal surgeon at Johns Hopkins, described the hospital’s Comprehensive Unit-based Safety Program (CUSP), a perioperative quality improvement program that was the outgrowth of an ACS NSQIP patient safety session. To uncover ways to reduce surgical site infections (SSI), members of the Johns Hopkins team completed an anonymous two-question survey that asked how a colorectal SSI developed, and how it could be prevented the next time. The team then developed 95 areas of concern and met monthly, using checklists and monitoring their own progress. The SSI rate for colorectal surgeries dropped 33 percent in the first 12 months of CUSP’s implementation.
Dr. Wick noted that CUSP requires an interdisciplinary team, including executive involvement, which seeks to change the culture in pursuit of patient safety. She acknowledged that in most hospitals, culture is defined as “the way we do things around here,” a mentality that impedes quality improvement. She urged the audience to approach team-building from the bottom up and not, as is most common, from the top down, and to engage all team members in patient safety.
“Guide the process so that everybody on the team comes to the conclusion by themselves that a cultural change is needed,” Dr. Wick said. “This requires communication at every level, disseminating information, setting forth expectations, and holding everyone accountable to the same standards.”
According to Charles L. Bosk, PhD, a medical sociologist at the University of Pennsylvania, Philadelphia, CUSP encourages change at the local level and “creates a culture of high reliability through distributed responsibility. The beauty of CUSP is that it calls forth our better angels,” he added. “The work is never done, the team never stops talking, the staff find value in their work, there is a respect for knowledge, and work becomes a calling.”
At a session on the Top 10 List for Reducing Surgical Complications, John F. Sweeney, MD, FACS, the W. Dean Warren Distinguished Professor of Surgery and chief, division of general and gastrointestinal surgery, department of surgery, Emory University School of Medicine, Atlanta, GA, spoke about readmissions, calling them “a vital performance metric.” Readmissions are expensive, he said. They consume associated opportunity cost—as the readmitted patient takes up a bed—and they have a major adverse effect on the patient.
Most general surgery patients who return to the hospital within 30 days of discharge are readmitted due to postoperative complications, Dr. Sweeney said. Decreasing complications improves the quality of care and benefits the patient, the hospital, and the payor. ACS NSQIP data allow participating hospitals to review clinical patient data, compare themselves with other hospitals, learn the reasons for the readmissions, and determine whether the readmission was planned or unplanned, he added.
“The estimated cost to Medicare for rehospitalization is more than $17.4 billion a year,” Dr. Sweeney said, “a number that has caught the attention of Capitol Hill.” The Centers for Medicare & Medicaid Services (CMS), in October 2012, began to penalize hospitals with high readmission rates.
Pascal R. Fuchshuber, MD, PhD, FACS, The Permanente Medical Group, Inc. and the Permanente Medical Group’s lead ACS NSQIP Surgeon Champion for 21 Northern California Kaiser Medical Centers, noted that complications are a major factor in postoperative respiratory failure and mortality. Using ACS NSQIP data of surgical outcomes, Kaiser collaborative participants identified a number of problems related to system failures and not to the individual performance of a surgeon, nurse, or respiratory therapist, he said. The lack of efficient communication between the treatment team and the respiratory therapy team and the relative absence of respiratory care during postoperative recovery of patients because of staffing issues were discussed and presented to the individual department and the hospital leadership.
Each year, ACS NSQIP issues a call for abstracts to allow participating hospitals to submit presentation topics on how they have used ACS NSQIP to improve patient care. This year, participating sites received a record 125 abstracts, with topics ranging from pediatric-specific quality improvement, to reducing SSI and readmissions and team building. Authors presented their winning abstracts during 24 sessions held throughout the conference. The authors also displayed posters of their abstract topics and were available to answer questions about their work.
Awards honored the authors in four abstract categories:
Resident Abstract Winner: Michael Cassidy, MD, Boston University Medical Center, MA, Challenges of Sustaining Momentum in Quality Improvement—Lessons from a Multidisciplinary Postoperative Pulmonary Care Program
Clinical Abstract Winner: Cynthia G. Segal, MSN, PhD, MD Anderson Cancer Center, University of Texas, Houston, Risk Factors Differ by Type of Surgical Site Infection
SCR Abstract Winner: Peggy K. Jeanneault, RN, MAOM, Kaiser Foundation Hospitals, Fresno, CA, Team—Together Everyone Achieves More—The Story of the Kaiser Northern California ACS NSQIP Collaborative
Abstract Poster Winner: Dan W. Gates, Vanderbilt University, Nashville, TN, Is Pediatric ACS NSQIP Review Representative of Total Institutional Experience for Children with Appendicitis?
Access to experts to help improve patient care at the local level
Through many educational and networking events, the ACS NSQIP National Conference provided attendees with opportunities to meet with and learn from experts in their field. Special pre-conference workshops allowed attendees to learn firsthand from leaders in surgical quality improvement.
Nestor F. Esnaola, MD, MPH, MBA, FACS, Co-Principal Investigator, National Center on Minority Health and Health Disparities/National Institutes of Health, Washington, DC; and chief, division of surgical oncology; and vice-chair, clinical and academic affairs, Temple University School of Medicine/Fox Chase Center, Philadelphia, PA, led a pre-conference session on a pathway to improvement that incorporates Lean Six Sigma. Lean Six Sigma is a managerial process that helps identify sources of waste and activities that do not add value in the pursuit of maximum productivity.†
Attendees learned how to combine Lean Six knowledge with ACS NSQIP reports and resources to generate successful quality improvement projects and successful change management. “Communicate your strategy for change,” Dr. Esnaola said. “Be concrete in your communication, but don’t attempt to tackle everything. There must be a shared ownership of a change initiative.”
In another pre-conference session, Joe H. Patton, MD, FACS, associate chief medical officer and chief of surgical services at Henry Ford Hospital, Detroit, MI, and Jennifer Ritz, RN, BSN, Manager of Quality Improvement at Henry Ford Hospital, focused on teamwork and improving culture to engage leadership and surgeons in the quality improvement process. The limited number of attendees in the pre-conference workshops allowed for a collaborative environment focused on sharing and learning from fellow attendees.
New to this year’s conference were “Ask the Expert” sessions, which allowed attendees to meet in small groups with surgical leaders from around the country to discuss areas of interest. Ask the Expert sessions emphasized the sharing of ideas and involved individuals with expertise in a variety of surgical fields, government regulation, culture and safety, and team building.
New tools to improve care
At the conference, ACS NSQIP introduced two new quality improvement tools to help attendees with their local quality improvement efforts, including the ACS NSQIP Surgical Risk Calculator. This instrument uses information from more than 400 hospitals and 1.4 million ACS NSQIP patient records to provide accurate, patient-specific risk information to guide both surgical decision making and informed consent. The risk calculator provides predictions for 10 outcomes, including mortality, any morbidity, serious morbidity, pneumonia, cardiac complications, SSI, urinary tract infection, venous thromboembolism, renal failure, and length of stay. The Surgeon Adjustment Score that the Risk Calculator generates allows surgeons to adjust the predicted risks if a patient has significant risk factors not already included in the instrument-provided variables. The risk calculator is available for use. (Read corresponding article for more details.)
Attendees also learned that they will receive Interim Semiannual Reports (ISAR) starting in October. Previously, ACS NSQIP hospitals received their risk-adjusted outcomes on a semiannual basis only. The ISAR, in addition to real-time risk-adjusted reports for measures endorsed by the National Quality Forum, will enable hospitals to monitor quality efforts and act on the results more quickly.
Evidence-based measurements improve quality
Hospitals that participate in ACS NSQIP have the opportunity to avoid complications and enhance performance by using evidence-based measurements, assessing outcomes, and learning from past experiences—a lesson that was repeated throughout the conference. Maher A. Abbas, MD, FACS, FASCRS, chair of the Center for Minimally Invasive Surgery at Kaiser Permanente, Los Angeles, director of the Permanente National Center of Excellence for Colon and Rectal Surgery, and associate professor of surgery, University of California, invoked the memory of a historical event—the sinking of the RMS Titanic in 1912, a catastrophe that resulted in the death of 1,502 passengers and crew.
“The outcome was very different than expected,” Dr. Abbas said, but there were warnings that should have been heeded. The ship was equipped with the minimum number of required lifeboats and the ship’s captain had been advised of icebergs in the area, he said. As with surgical deaths, he said, the Titanic deaths were preventable. The captain of the Titanic went down with the ship, a fate that fortunately does not await surgeons who participate in ACS NSQIP. “The beauty of ACS NSQIP is that you can compare results to national standards and propose intervention,” Dr. Abbas concluded.
* Harman K. Scientific American. Jan. 8, 2013. Surgical “never” events happen nevertheless. Available at: www.scientificamerican.com/podcast/episode.cfm?id=surgical-never-events-happen-nevert-13-01-08. Accessed August 5, 2013.
† Lean Six Sigma and process excellence. International Institute for Learning, Inc. New York, NY. Available at: www.iil.com/catalog.asp?cat=4&parent=4. Accessed September 2, 2013.
All photos Baumann Photography, San Diego