acs nsqip: preventing complications reducing costs improving surgical care may 17, 2014
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ACS NSQIP: Preventing complications Reducing costs Improving surgical care May 17, 2014 Scott Ellner , DO, MPH, FACS Saint Francis Hospital and Medical Center. Disclosures. No relevant disclosures related to this presentation. . Increasing Focus on Improving Quality While Reducing Costs. - PowerPoint PPT PresentationTRANSCRIPT
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ACS NSQIP:Preventing complications Reducing costsImproving surgical care
May 17, 2014
Scott Ellner, DO, MPH, FACSSaint Francis Hospital and Medical Center
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Disclosures
No relevant disclosures related to this presentation.
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Increasing Focus on Improving Quality While Reducing Costs
Decisions are being made now – and we have opportunities to get ahead of CMS actions:
• CMS readmissions penalties and value-based purchasing
• Hospital Compare and other public reporting
• Physician quality reporting
• General surgery registry rule
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Which Direction will Quality Improvement Go?
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We’ve Found Common Ground
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ACS NSQIP: What’s Different?
Developed by surgeonsClinical, not administrative, dataRisk-adjusted and case-mix adjusted National benchmarking30-Day patient follow upAuditedTrained data collector
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Clinical Data Better for Measuring Quality
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Risk and Case-Mix Adjustment Matters
To judge care fairly and understand where problems are occurring: Health of the patient must be consideredRisk of the procedure must be considered
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Following Patients After Discharge
• Half or more of all complications occur after discharge1
• Quality programs based on admin data don’t track post-discharge
• Complications after discharge can lead to readmissions2
Tracking quality can’t stop at the hospital’s door
1 Ko CY. “ACS NSQIP Conference Overview.” Presentation to the 2009 ACS NSQIP National Conference. July 2009.2 Kassin MT et al. “Risk Factors for 30-Day Hospital Readmissions among General Surgery Patients.” J Am Coll Surg. 2012; 215: 322-30. 9
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ACS NSQIP: Proven to Reduce Complications, Save Lives
2009 Annals of Surgery study: Prevent 250-500
complications annually
Save 12-36 lives annually
Leading to reduced costs
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Surgical Complications Drive Readmissions
2012 Journal of the American College of Surgeons study: • Surgical complications
key driver of 30-day readmissions
• SSIs – 22%• Gastrointestinal – 28%• Pulmonary – 8%
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ACS NSQIP: Better Care, Lower Costs
Not only will patients benefit, but hospitals see a significant return on their investment with ACS NSQIP.• Significant cost savings per year• Reduced readmissions and
reduced lengths of stay translate to better patient outcomes, better satisfaction and even more cost reduction
• Pays for itself by avoiding about a dozen surgical complications
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ACS NSQIP Meets Regulatory Requirements
CMS general surgery registry rule began this FYACS NSQIP measures reported on Hospital Compare
(voluntary) Five ACS NSQIP measures being considered for
national adoption by CMS ACS NSQIP’s SSI harmonized with CDC’s NHSN
program Joint Commission Quality Check for participationPart of SUSP program supported by AHRQ
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ACS NSQIP Meets Regulatory Requirements
CMS general surgery registry rule began this FYACS NSQIP measures reported on Hospital Compare
(voluntary) Five ACS NSQIP measures being considered for
national adoption by CMS ACS NSQIP’s SSI harmonized with CDC’s NHSN
program Joint Commission Quality Check for participationPart of SUSP program supported by AHRQ
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Why the Foley?
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Everybody gets a catheter
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Post-Operative Urinary Tract Infections
Observed Rate: 2.41%Expected Rate: 1.47%O/E Ratio: 1.64Status: Needs Improvement
2008
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The CAUTI Gang
32-40% of all nosocomial infections
Adds an average of 1-3 additional hospital days
UTIs increase a patient's hospital costs by 47 % at teaching hospitals and 35 % at community hospitals
Roberts RR Clin Infect Dis , 2009
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Next Steps
Build a guiding coalition
Drill down on data
Determine why patients developed the infection
Share key findings with key stakeholders
Surgeons
Quality
ICU/Ward Nurses
Infection Prevention
Admin
OR Staff
Share Data
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Leadership
Model the Way
Challenge the Process
Share a Vision
Empowerment
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CAUTI Sub-Committee
Goals – Time Sensitive
Drill down
Pilot Audit
Implementation
Sustainability
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ACS Clinical Guidelines
Prior to Insertion:
During Insertion:
After Insertion:
• Education
• Trained personnel• Hand hygiene
• Secured catheter• Closed Drainage• Urimeter positioning
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Nurse Driven Protocol
Automatic Order Set
Catheter Needed?
Remove by Post-op Day 2
Catheter Still In? Why?
Documentation Situational Leadership
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Nurse Driven Protocol
Patients PreIntervention
N=1,404*
PostIntervention
N=2,469*
p
UTI 36 2.6% 38 1.5% <.05
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Pre-Intervention: September 2007 – December 2008
Post-Intervention: January 2009 – December 2010
*Number of patients undergoing general surgery captured in the NSQIP database.
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C. Difficile Prevention
Derkonja DM JAMAintmed 2013
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Silver Prices
$160,000 savings/yearPickard P Lancet 2012
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Barriers
1) Complacency2) Resistance 3) Exposing failures4) Challenging years of
embedded culture5) Compliance6) Training7) Uneasy Leadership
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A Business Case for Reducing Catheter-Associated Urinary Tract Infections
A Study Using ACS National Surgical Quality Improvement Program Data
Return on Investment
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Return on Investment
General &VascularSurgery
UTI
N=74
Length of Stay (days)
Mean
Excess Costs/Patient*
Mean
CommentsPatient
Occurrences
Cases Identified
Inpatient 41 28.5 $52,384
5 deaths9 C. Diff (+)
Outpatient 33 6 $758
2 readmissions4 ED visits
29 * Variable CostsZimlichman E JAMAint 2013
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62% Reduction
Observed Rate: 1.23%Expected Rate: 1.43%O/E Ratio: 0.86Status: As Expected 2014
2008
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Surgical Checklist Verified with ACS NSQIP Data
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Take Home Points
• ACS NSQIP metrics are actionable• Share data and acknowledge need
for change• Implement a CAUTI prevention protocol• Recognize and address barriers• It’s all about leadership