2014 National Conference: ACS NSQIP celebrates 10th anniversary of improving patient outcomes

Clifford Y. Ko, MD, MS, MSHS, FACS, Director of the American College of Surgeons (ACS) Division of Research and Optimal Patient Care and National Surgical Quality Improvement Program (ACS NSQIP®), greeted attendees at the 10th National Conference of ACS NSQIP participants with numbers that convey the initiative’s achievements. According to Dr. Ko, more than 1,200 participants were at the 2014 National Conference, July 26–29, at the Midtown Hilton, New York, NY, breaking the meeting’s attendance records.

When ACS NSQIP launched in 2004, 18 hospitals had contracted with the quality improvement program. “Today we are in approximately 600 hospitals worldwide, including 59 pediatric hospitals and 43 international hospitals,” Dr. Ko said.

Studies show that each year, ACS NSQIP, a surgical quality program that began in the Veterans Affairs (VA) hospital system, has the potential to prevent, on a per-hospital average, 250 to 500 surgical complications in the U.S., save 12 to 36 lives, and reduce hospital costs by millions.1 “We have applied rigorous and believable data and taken it to new levels,” Dr. Ko said. To date, 83 percent of ACS NSQIP hospitals have been able to decrease their complications rates by statistically significant levels.1 “We know that collaboratives are a great way to learn, and we expanded our international reach.”

ACS NSQIP data allow hospitals to compare their quality improvement results with those of other institutions that report to the national database. These comparison data allow them to respond to complications that may reflect broader systemic problems. Trained reviewers collect and analyze the data, which is risk-adjusted to account for differences in patients’ ages, severity of illness, and the complexity of the operations performed.

ACS NSQIP differs from other surgical quality improvement programs in that it is a surgeon-driven program that uses clinical rather than administrative data and 30-day patient follow-up, Dr. Ko said. Dr. Ko added that while rigorous data collection is essential, it alone cannot lead to sustained improvements. “We’ve learned that you need to continue to act on the data,” he said.

Process improvement

At a preconference session on leveraging ACS NSQIP for quality improvement, John M. Morton, MD, MPH, FACS, FASMBS, chief of bariatric and minimally invasive surgery, Stanford University School of Medicine (SUSM), CA, led a discussion on robust process improvement (RPI), a performance improvement (PI) initiative of The Joint Commission. RPI comprises a set of strategies, tools, methods, and training programs that enhance the efficiency of hospital business practices. The focus is on recognizing the customer’s voice, defining factors critical to quality, using data and data analysis to improve service, and enlisting stakeholders and process owners to create and sustain solutions.

Craig T. Albanese, MD, MBA, FACS, vice-president, quality and performance improvement at Lucile Packard Children’s Hospital, SUSM, spoke on the use of “lean” concepts in health care. Lean initiatives, which focus on using fewer resources while adding more value for customers, require a long-term commitment, Dr. Albanese said.

He warned that institutions that turn away from some form of PI will be forced to respond to continual service failures. In Lucile Packard Children’s Hospital’s case, the lean method supported the institution’s efforts to view the patient as the customer and to establish high-quality service as the norm. Service to patients includes phone and office etiquette, listening to patients’ specific issues, and helping them to navigate the hospital’s complicated setting.

Where is surgery headed?

In a keynote speech during the opening session, then-ACS President-Elect Andrew L. Warshaw, MD, FACS, FRCSEd(Hon), surgeon-in-chief emeritus, Massachusetts General Hospital (MGH), and the W. Gerald Austen Distinguished Professor of Surgery at Harvard Medical School, Boston, addressed the question: Surgery—Where Are We Going?

Over the course of a surgical career that began in 1972, devoted to the “hidden organ of the pancreas,” Dr. Warshaw said he has witnessed a revolution in surgical care. “The surgeon is no longer the sole expert. Today we take care of patients in a totally multidisciplinary fashion,” he noted. Gastroenterologists, hematologists, radiologists, pathologists, oncologists, and geneticists are now part of the surgical team, and the team and patients take part in the decision-making process.

“What will surgery of the future look like?” Dr. Warshaw asked. “Technology will continue to advance, and we will see better imaging and fewer invasive procedures. Our practices will be science-based and will make better use of biological and genetic tools, organ replacement, and tissue engineering,” he predicted.

In the next 50 years, Dr. Warshaw added, science will continue to unravel a number of mysteries, including how lifestyle changes can prevent pancreatic cancer. “The future will see a continued emphasis on patient outcomes and on ACS NSQIP,” he said, noting that MGH uses ACS NSQIP every day to benchmark its performance against other leading hospitals.

“Most surgeons do a little bit of everything, but ultimately our job is to provide the right care, at the right place, at the right time.” Patient outcomes are the essential measure, Dr. Warshaw said, and today, procedure-specific outcomes based on data guide surgical decisions. “Always remember that the outcome that matters most to patients is survival,” he said.

Lessons in improving care

Many conference speakers offered best practices for building a culture of safety and using ACS NSQIP as the foundation for quality improvement. At a session on reducing surgical site infections (SSIs), J. Michael Henderson, MB, BCh, FACS, chief quality officer, Cleveland Clinic Health System, OH, said, “What we know about SSIs is that they are still too high, and there is too much variation in monitoring and reporting them. But with ACS NSQIP data, we are moving in the right direction. Reducing SSIs is a universal goal for all surgeons, and ACS NSQIP offers the best data for action. We know now that collaboratives can accelerate the process and that national campaigns can be successful.”

Accordingly, Dr. Henderson answered “yes” to all of the following questions: Can we do better for our surgical patients? Do we know what to do? Is ACS NSQIP the best tool to drive change? Is it time for an SSI national campaign? A national campaign against SSIs would promote to the nation’s more than 6,000 hospitals an increased level of intolerance for all types of SSIs.

Erin S. DuPree, MD, FACOG, chief medical officer and vice-president of The Joint Commission Center for Transforming Healthcare, described the center’s targeted solutions tool for reducing SSIs. The Joint Commission used ACS NSQIP data in a collaborative of seven U.S. hospitals targeting colorectal SSIs in patients from preadmission to 30 days after surgery. The participating hospitals collectively and systematically defined and measured the impact of the problem and then searched for specific causes. The project involved all surgical inpatients undergoing emergency and elective colorectal surgery, with the exception of trauma and transplant patients and patients younger than age 18. The results: The hospitals reduced superficial SSIs—those infections that occur only in the area of the surgical incision—by 45 percent and reduced all types of SSIs by 32 percent, according to Dr. DuPree. Ultimately, she said, the initiative allowed the hospitals to avoid 135 SSIs and save approximately $3.7 million in treatment costs.

Written policies and procedures do not necessarily provide an accurate assessment of what is occurring at the patient level, Dr. DuPree noted. Therefore, direct observations of the process are vital. The Joint Commission also has developed modules for hand hygiene, which, according to Dr. DuPree, could potentially save one life for every 25 hospital beds; wrong-site surgery, estimated to be as high as 40 to 60 incidences per week in the U.S.; and hand-off miscommunication. Miscommunication is a key element in most adverse events. Robust process improvement, Dr. DuPree concluded, must be educational, and the tools must help the user measure the issue, determine the root problems, and implement changes.

Mark J. Ott, MD, FACS, medical director, surgical services clinical program, Intermountain Healthcare, reported that the not-for-profit health care system, composed of 22 hospitals in Utah and Idaho, 1,000 surgeons, and serving roughly 3 million patients, joined ACS NSQIP in 2011. Project leaders at the hospital trained all levels of staff, from administrators and surgeons to all other operating room (OR) personnel, in quality improvement, a process that took hundreds of hours over the course of many months. They standardized skin preparation methods and employed proper antibiotic timing and weight-based dosing, and re-dosed at three-hour intervals during the operation as needed. They allowed only hospital-supplied scrubs in the OR and stressed the need to cover up or change scrubs when entering and leaving the OR. They re-emphasized proper aseptic techniques for exchanging supplies and kept vendors away from the area.

They then measured outcomes, and today, on an ongoing basis, they feed the results back to staff and physicians. As a result of these efforts, Intermountain experienced a significant and sustained improvement in institutional SSI rates. “We keep monitoring and educating because there’s always a danger you will slide back to your old ways, and you always have new people coming into the system who need to be trained,” Dr. Ott said.

Accountability and quality care

In a keynote address on July 27, Linda Groah, MSN, RN, CNOR, NEA-BC, FAAC, chief executive officer and director of the Association of periOperative Registered Nurses, Denver, CO, spoke on Accountability and Quality Care: Are They a Match? Ms. Groah compared the U.S. health care system to that of other developed nations. She said that although the U.S. health care system is the most expensive in the world, the Commonwealth Fund 2014 Update showed that, among the 11 nations studied—Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the U.K., and the U.S.—the U.S. ranks last on most performance measures.2

The indicators of quality, she said, include safe, effective, coordinated, patient-centered care. Ms. Groah recalled two seminal events that characterize the relationship between quality and accountability. In 1982, an Air Florida Boeing 737 jet crashed into a bridge on approach at National Airport in Washington, DC, killing 78 people. The co-pilot later said he had voiced concerns about ice build-up on the wings, but when the head pilot ignored his remarks, the co-pilot, fearing the repercussions of pursuing the matter, chose to keep quiet.

In 1986, after the Space Shuttle Challenger broke into pieces on take-off, ground staff admitted that they had been concerned that below-freezing temperatures might affect the integrity of the solid rockets’ O-rings. Staff members admitted after the disaster that they didn’t speak up out of fear of reproach from their superiors.

“Do you have an elephant in your surgical unit?” Ms. Groah asked. “Do you work with anyone that you do not hold accountable because it is too dangerous to speak up?” A “just” culture, Ms. Groah said, is not a blame-free culture. The culture defines what is acceptable behavior, and errors are evaluated in terms of contributing factors, and accountability is determined in relation to actions.

Accountability needs to be the norm, Ms. Groah told the gathering. “In a positive, healthy environment, leadership strongly promotes accountability, and it is a core value for all employees,” she said. Accountability is patient-centric, and team members have an intrinsic obligation to one another. “There is ongoing education on the culture of safety, a just culture, and continual efforts to sustain the gains.”

“Without accountability, there are missed treatments and medication delays,” Ms. Groah added. “There is reduced productivity, lack of follow-through, poor coordination of care, failure in hand-offs, untoward patient events, clinical changes that are not sustained, and ultimately, an increase in the cost of health care.

“It is important to consider if an individual knowingly violated a policy or procedure, and if the policy and procedures in place were actually workable and correct,” she noted. “In a just culture, there is recognition that human beings make mistakes and that even professionals may develop unhealthy norms. But there is also a fierce intolerance of reckless conduct,” Ms. Groah said.

ACS: Commitment to quality

The ACS has always been committed to quality care. “Throughout our history, when something worked, it became obvious that it should become the standard of care,” David B. Hoyt, MD, FACS, ACS Executive Director, told attendees. “ACS NSQIP is that kind of initiative.”

He noted that the Affordable Care Act (ACA) encompasses a range of regulatory requirements aimed at increasing access to care, reducing costs, and redesigning the delivery system.

“Any discussion of cost and payment in health care is really a discussion of who will assume the risk,” Dr. Hoyt said. Noting that U.S. health care costs are forecast to climb to $4.5 trillion and consume 19.3 percent of the nation’s gross domestic product by the year 2019, Dr. Hoyt stressed the importance of curtailing costs.3 He noted, however, that surgical costs have remained relatively flat in recent years, with the exception of knee and hip operations.

Dr. Hoyt acknowledged the triple-aim theory of Donald Berwick, MD, former Administrator of the Centers for Medicare & Medicaid Services (CMS), which emphasizes quality and professionalism: (1) improve the experience of care; (2) improve the health of populations; and (3) reduce the per capita costs of health care.4

“Quality improvement is the future of medicine,” Dr. Hoyt said. “Quality is measurable, and health care data are essential to the process.” He noted that health care professionals need standards, individualized for patients and backed by research. “It requires the right infrastructure, the right staff levels, specialists, equipment, and checklists,” he said, adding that rigorous data must come from medical charts, supported by research, and verified through external peer review.

Collecting data will be critical for working with the accountable care organizations (ACOs) established in the ACA, Dr. Hoyt said, and will help surgical practices meet emerging trends, such as maintenance of certification and pay for performance mandates. ACOs consist of doctors, medical groups, hospitals, and other health care professionals who work together to deliver high-quality, coordinated patient care.

Best practices

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. Awards honored authors in three abstract areas:

  • Resident Abstract: Lindsay A. Bliss, MD—Perioperative Culture, Organizational Behavior, and Patient Outcomes
  • Surgical Clinical Reviewer Abstract: Christine Solis, BSN, CLSSBB—Engaging the Hearts and Minds of the Frontline Team in Continuous Daily Surgical Performance Improvement Initiatives: The Journey of One Medical Center
  • Clinical Abstract: Brian J. Daley, MD, MBA, FACS—Participation in a Statewide Collaborative of Surgeons, Hospitals, and Insurers Leads to Improved Patient Outcomes and Financial Savings in Surgical Care

Dr. Daley reported that the Tennessee Surgical Quality Collaborative has reduced surgical complications by 19.7 percent since 2009, saving at least 533 lives and $75.2 million. The hospital collaborative was formed in 2009 as a partnership of the ACS Tennessee Chapter and the Tennessee Hospital Association’s Center for Patient Safety, with support from Blue Cross Blue Shield’s Tennessee Health Foundation. “Our results show that not only have Tennessee hospitals improved care, but we’ve been able to sustain these improvements over time,” Dr. Daley said. “Our collaborative approach and use of robust clinical outcomes data through ACS NSQIP is an effective model for quality improvement across our state and nationally.”

At an abstract session on vascular surgery and venous thromboembolism (VTE), a surgical team from the department of surgery at Carilion Clinic Roanoke Memorial Hospital, VA, reported their complicated but ultimately successful experience using ACS NSQIP data. The Carilion team determined which patients had VTE and queried the electronic health records to find patients placed in postoperative isolation. Data revealed a predisposition for patients in isolation to develop VTE. The researchers, who noted that VTE rates were low in 2008 but went up sharply in 2010, discovered that a hospital-wide focus on methicillin-resistant staphylococcus aureus (MRSA), a contagious bacteria that can lead to pneumonia and infections of the skin and bloodstream, resulted in several readmissions. The hospital began a universal program of screening and isolating patients who tested positive for MRSA. The rates of MRSA infection dropped, but VTE rates unexpectedly rose, an occurrence that researchers attributed to the absence of movement and lung exercises among isolated patients.

Using ACS NSQIP data, Carilion administrators established designated ambulation areas for isolated patients. They also hired a nurse specialist to gather daily reports on the VTE patients, and they educated patients’ families on the condition.

ABCs of government regulation

Frank G. Opelka, MD, FACS, Medical Director of Quality and Health Policy, ACS Division of Advocacy and Health Policy, described the new realities of regulation, key among them that performance measures have become integral to payment. In a session titled Regulatory Update: The Alphabet Soup of Programs and Reporting—Basic Understanding of How ACS NSQIP and ACS Can Help You and Your Hospital, Dr. Opelka noted that CMS, the Office of the National Coordinator for Health Information Technology, the Patient-Centered Outcomes Research Institute, and the Agency for Healthcare Research and Quality are quickly shifting to new data sources.

Performance measurement is changing, Dr. Opelka noted. Pay-for-reporting is evolving into pay-for-performance, administrative claims are being replaced with clinical data, and process measures replaced by outcome measures. The Physician Quality Reporting System (PQRS) uses a combination of incentives and payments to promote reporting of quality information by eligible professionals (EPs). The creation of the pay-for-reporting program in 2012 allows EPs to qualify for two incentive payments—one for e-prescribing and one for the PQRS. CMS’ Electronic Prescribing (eRx) incentive program was authorized under the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), and CMS implemented a separate pay-for-reporting incentive program in 2009, to advance quality through safer, more coordinated prescription writing.

Dr. Opelka noted that starting in 2015, the ACA will require the CMS to develop a value-based payment program (VBP) in an attempt to move physician reimbursement toward a system that rewards value of care over volume. With the goal of improving efficiency of care, the VBP program will provide performance information to physicians so they can benchmark themselves against a national standard.

Changing environment

ACS NSQIP may help to resolve many problems associated with an expensive, overburdened U.S. health care system that continues to underperform, in comparison with systems in other developed nations. Ultimately, health care professionals worldwide strive to save lives and improve patient outcomes. ACS NSQIP provides a path for transforming health care into a reliable, measurable enterprise. Quality improvement is a gradual, deliberate process that requires strong, disciplined leaders and surgeon champions, dedicated team members, and collaboratives that work together to promote quality care and sustain the goals of continuous quality improvement.

Commit to change early, and commit to it often, conference speakers urged attendees. In his keynote address, Dr. Warshaw stressed the point succinctly with a quote from retired Chief of Staff of the U.S. Army, Gen. Eric Shinseki: “If you don’t like change, you’re going to like irrelevance even less.”


References

  1. Hall BL, Hamilton BH, Richards K, Bilimoria CY, Cohen ME, Ko C. Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program? Ann Surg. 2009;250(3):363-376.
  2. Davis K, Stremikis K, Squires D, Schoen C. The Commonwealth Fund. Mirror, mirror on the wall, 2014 Update: How the U.S. health care system compares internationally. June 16, 2014. Available at: http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror. Accessed August 11, 2014.
  3. Centers for Medicare & Medicaid Services. National health expenditure projections 2009–2019: Forecast summary. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/proj2009.pdf. Accessed August 11, 2014.
  4. Berwick DM, Nolan TW, Whittington J. The triple aim: Care, health, and cost. Health Aff. 2008;27(3):3759-3769.

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