networking meeting february 22, 2012 agenda · web-based platform for clinical data abstraction of...
TRANSCRIPT
Networking Meeting February 22, 2012
Agenda
10:00 Welcome and Introductions Dr. Joe Cofer 10:15 Patient Story Kay Loyd 10:25 Business Meeting Chris Clarke A. 2008 -2011 Final Grant Evaluation Highlights B. JACS publication and PR C. Funding 2013/14 – BCBS Meeting 3-26-12 D. TSQC Documents/Appointments 1. Leadership Committee Nominations 2013-14 2. Data Use Agreements 10:45 TSQC Data Trends and Analysis Bill Cecil A. Comparisons through July 2011 B. TSQC Leadership Reports 1. Discussion on developing ROI for CEOs C. Preoperative Risk Tool 11:45 Lunch 12:15 Quality Improvement Plans A. Colorectal SSI Project
Will Gibson and Barbara Martin
B. TSQC complication trends- UTI, Pneumonia, DVT Chris Clarke 1. Case Studies, site visits to capture best practices C. Surgical QI initiative opportunities Chris Clarke 1. SUSP – ACS /Hopkins surgical safety program 2. JC colorectal SSI pilot 3. ACS NSQIP voluntary reporting 1:30 TSQC 2012 Goals/Plans A. TN ACS / TSQC surgical care conference
Chris Clarke and Wanda Johnson
B. TSQC sites submission of posters for ACS NSQIP C. TSQC Site case studies- standard format, annual 1:45 Action Plans and Case Presentations –
Discussion UTI and Pneumonia Surgeon Champions, Clinical Reviewers, Quality Directors
3:00 Adjourn
Introduction
Welcome to the Tennessee Surgical Quality Collaborative
TSQC is a statewide collaborative among surgeons and hospitals to improve surgical care in Tennessee. The focus of this unique partnership between the Tennessee Chapter of the American College of Surgeons (TnACS), THA’s Tennessee Center for Patient Safety and participating hospitals is to utilize the ACS NSQIP and local collaboration activities to more rapidly improve surgical care and outcomes. TSQC received a $2.9 million grant from the BlueCross Blue Shield of Tennessee Health Foundation in 2008 to develop the Tennessee collaborative, which is designed to evaluate and improve surgical care delivered by general and vascular surgeons in the state of Tennessee. BlueCross BlueShield Foundation awarded TSQC a new grant for 2012 to expand the collaborative to an additional eleven hospitals. What can you expect from the ACS NSQIP?
Web-based platform for clinical data abstraction of NSQIP variables Training for surgical clinical reviewers Monthly conference calls for surgeon champions and clinical reviewers Continuous access to raw comparative data Semi-annual risk-adjusted comparison reports (SAR) Tools and Resources
o ACS NSQIP “Best Practice” guidelines o ROI Calculator o Surgeon Champion Toolkit (planned for 2012)
ACS NSQIP national conference What can you expect from the TSQC?
Local collaborative for shared learning o Action Plans o Case Studies and Presentations
Networking meetings quarterly Peer mentor for surgeon champions and clinical reviewers Aggregate evaluation and tracking of TN performance Blinded site-specific comparison reports of identified complications within
TSQC Quarterly Leadership reports for C-suite TSQC Website Quality Improvement Projects
TSQC 2012 Meeting Dates
TSQC Networking Meetings February 22, 2012 10am - 3pm CST THA Offices, Nashville May 8, 2012 10am – 5pm CST Education Session for SCRs May 9, 2012 10am – 3pm CST, THA Offices, Nashville July 22-24, 2012 ACS NSQIP National Conference, Salt Lake City, Utah August 3-5, 2012 TN ACS Meeting, Chattanooga, TN September 26, 2012 10am – 3pm CST, THA Offices, Nashville
Leadership Committee Conference Call (For Leadership Committee Members Only)
2nd Monday of each month at 4pm CST/ 5pm EST Conference Call Number: 1-866-210-1669 Passcode: 7137512
Surgical Clinical Reviewer Monthly TSQC Conference Call (For SCRs Only) 3rd Tuesday of each month at 1pm CST/ 2p EST Conference Call Number: 1-866-210-1669 Passcode: 7137512
Networking Meetings Education Sessions ACS NSQIP National Conference TN ACS Meeting
Leadership Committee Conference Call Surgical Clinical Reviewer Monthly TSQC Conference Call (4:00 pm Central Time) (1:00 pm Central Time)
Underwritten by a grant from the BCBS Tennessee Health Foundation
January July S M T W T F S 9 - Leadership Committee S M T W T F S 9 - Leadership Committee 1 2 3 4 5 6 7 Conference Call 1 2 3 4 5 6 7 Conference Call 8 9 10 11 12 13 14 17 – SCR Conference Call 8 9 10 11 12 13 14 17 – SCR Conference Call
15 16 17 18 19 20 21 15 16 17 18 19 20 21 22 – 24 - ACS NSQIP National 22 23 24 25 26 27 28 22 23 24 25 26 27 28 Conference 29 30 31 29 30 31
February August
S M T W T F S 13 - Leadership Committee S M T W T F S 3 – 5 - TN ACS Meeting 1 2 3 4 Conference Call 1 2 3 4 13 - Leadership Committee
5 6 7 8 9 10 11 21 – SCR Conference Call 5 6 7 8 9 10 11 Conference Call 12 13 14 15 16 17 18 22 – Networking Meeting 12 13 14 15 16 17 18 21 – SCR Conference Call 19 20 21 22 23 24 25 19 20 21 22 23 24 25 26 27 28 29 26 27 28 29 30 31
March September
S M T W T F S 12 - Leadership Committee S M T W T F S 10 - Leadership Committee 1 2 3 Conference Call 1 Conference Call
4 5 6 7 8 9 10 20 – SCR Conference Call 2 3 4 5 6 7 8 18 – SCR Conference Call 11 12 13 14 15 16 17 9 10 11 12 13 14 15 26 – Networking Meeting 18 19 20 21 22 23 24 16 17 18 19 20 21 22 25 26 27 28 29 30 31 23 24 25 26 27 28 29
30
April October
S M T W T F S 9 - Leadership Committee S M T W T F S 8 - Leadership Committee 1 2 3 4 5 6 7 Conference Call 1 2 3 4 5 6 Conference Call
8 9 10 11 12 13 14 17 – SCR Conference Call 7 8 9 10 11 12 13 16 – SCR Conference Call
15 16 17 18 19 20 21 14 15 16 17 18 19 20 22 23 24 25 26 27 28 21 22 23 24 25 26 27 29 30 28 29 30 31
May November
S M T W T F S 8 – SCR Education Session S M T W T F S 12 - Leadership Committee 1 2 3 4 5 9 – Networking Meeting 1 2 3 Conference Call
6 7 8 9 10 11 12 14 - Leadership Committee 4 5 6 7 8 9 10 20 – SCR Conference Call 13 14 15 16 17 18 19 Conference Call 11 12 13 14 15 16 17 20 21 22 23 24 25 26 15 – SCR Conference Call 18 19 20 21 22 23 24 27 28 29 30 31 25 26 27 28 29 30
June December
S M T W T F S 11 - Leadership Committee S M T W T F S 10 - Leadership Committee 1 2 Conference Call 1 Conference Call
3 4 5 6 7 8 9 19 – SCR Conference Call 2 3 4 5 6 7 8 18 – SCR Conference Call 10 11 12 13 14 15 16 9 10 11 12 13 14 15 17 18 19 20 21 22 23 16 17 18 19 20 21 22 24 25 26 27 28 29 30 23 24 25 26 27 28 29
30 31
2012 Tennessee Surgical Quality Collaborative Calendar
Contact Sheet TSQC Project Director Chris Clarke, R.N Sr. Vice President, Clinical Services TN Center for Patient Safety Tennessee Hospital Association Phone: 615-401-7437 [email protected] TSQC Project Coordinator Rebecca Carroll Executive Assistant & Project Coordinator TN Center for Patient Safety Tennessee Hospital Association Phone: 615-401-7427 [email protected] ACS Collaborative Associate Laura Meyer ACS NSQIP American College of Surgeons Phone: 312-202-5528|Fax: 312-202-5063 Email: [email protected] ACS Business Development Representative Tresha Russell ACS NSQIP American College of Surgeons Phone: 312-202-5441 Email: [email protected] Chair, TN Collaborative Leadership Committee Joe Cofer, M.D., F.A.C.S. Professor of Surgery UT College of Medicine Chattanooga Campus Phone: 423-778-7695 [email protected]
Hospital Contact List
Baptist Hospital Surgeon Champion: Dr. George Lynch ([email protected]) Surgical Clinical Reviewer: Quality: Debbie Roberts ([email protected]) Claiborne County Hospital Surgeon Champion: Dr. Robert Wilmoth ([email protected]) Surgical Clinical Reviewer: Tracy Nutt ([email protected]) Quality: Linda VanLandingham ([email protected]) Other: Jodi Whitaker ([email protected]) Cumberland Medical Center Surgeon Champion: Dr. Rick Gibbs ([email protected]) Surgical Clinical Reviewer: Quality: Rebecca Foster ([email protected]) Other: Perry Lynn Capps ([email protected]) Other: Villa Edwards ([email protected]) Ft. Sanders Regional Medical Center Surgeon Champion: Dr. Richard Brinner ([email protected]) Surgical Clinical Reviewer: Quality: Jenny Hanson ([email protected]) Henry County Medical Center Surgeon Champion: Dr. Ray Compton ([email protected]) Surgical Clinical Reviewer: Michelle Thompson, RN ([email protected]) Quality: Judy Farris ([email protected]) Maury Regional Medical Center Surgeon Champion: Dr. Mark S. Hinson ([email protected]) Surgical Clinical Reviewer: Quality: Brenda Totty ([email protected]) Memorial Health Care System Surgeon Champion: Dr. Charles Portera, Jr. ([email protected]) Surgical Clinical Reviewer: Quality: Gale Fellowes ([email protected]) Other: Nan Payne ([email protected])
NorthCrest Medical Center Surgeon Champion: Dr. Keith Goldberg ([email protected]) Surgical Clinical Reviewer: Quality: Joseph Mollohan ([email protected]) Saint Thomas Hospital Surgeon Champion: Dr. Raymond S. Martin, III ([email protected]) Surgical Clinical Reviewer: Quality: Julie Farmer ([email protected]) Baptist Memorial Hospital - Memphis Surgeon Champion: Dr. Stephen Behrman ([email protected]) Surgical Clinical Reviewer: Kay Loyd ([email protected]) Quality: Darla Belt ([email protected]) Cookeville Regional Medical Center - Cookeville Surgeon Champion: Dr. Scott Copeland ([email protected]) Surgical Clinical Reviewer: Melissa McCollough ([email protected]) Quality: Buffy Key ([email protected]) Erlanger Health System - Chattanooga Surgeon Champion: Dr. Joe Cofer ([email protected]) Surgical Clinical Reviewer: Patti Spangler ([email protected]) Quality: Lynne Marks ([email protected]) Jackson Madison Co General Hospital Surgeon Champion: Dr. Kamran Mahalati ([email protected]) Surgical Clinical Reviewer: Lisa Twyman /Julie Robbins ([email protected]) Quality: Amy Matthis ([email protected]) Johnson City Medical Center Surgeon Champion: Dr. Tony Haley ([email protected]) Surgical Clinical Reviewer: Sheryl Holmes ([email protected]) Quality: Tamera A.Fields ([email protected]) Methodist University Hospital - Memphis Surgeon Champion: Dr. Martin Fleming ([email protected];[email protected]) Surgical Clinical Reviewer: Bobbie Hale ([email protected]) Quality: Bret Sanders ([email protected];[email protected]) Parkwest Medical Center - Knoxville Surgeon Champion: Dr. Christopher W. Pollock;Dr. Will Gibson ([email protected];[email protected]) Surgical Clinical Reviewer: Cheri Cole-Jenkins ([email protected]) Quality: Missy Sanford & Sheryl Hiers ([email protected]; [email protected])
Saint Francis Hospital - Memphis Surgeon Champion: Dr. Norma Edwards ([email protected]) Surgical Clinical Reviewer: Jackie Cibulka ([email protected]) Quality: University of Tennessee Medical Center -Knoxville Surgeon Champion: Dr. Brian Daley and Dr. Blane Enderson ([email protected]; [email protected]) Surgical Clinical Reviewer: Debra Vittetoe ([email protected].) Quality: John Lacey MD; Heather Creason ([email protected];[email protected]) Vanderbilt University Medical Center- Nashville Surgeon Champion: Dr. Oscar Guillamondegui ([email protected]) Surgical Clinical Reviewer: Barbara Martin;Sherree Levering ([email protected];[email protected]) Quality:
Background Documents
MISSION
To improve the care of the surgical patient by supporting an open discussion and
transfer of information through a collaborative team effort.
VISION
To identify best surgical practices, examine how the surgical team obtains best
outcomes and teach other surgical teams how to improve outcomes.
The surgeon champion provides a critical role in fulfilling the mission and vision of the collaborative. The surgeon champion has a responsibility to insure the NSQIP data is used for quality improvement at the institutional and state level. The potential for political or market-driven manipulation of data must be avoided. The specific responsibilities for the surgeon champion include: 1. Serve as liaison for NSQIP with medical and administrative staff. 2. Meet regularly with surgical clinical reviewer on a mutually determined schedule, monthly meetings recommended. 3. Review semi-annual O/E data reports with medical staff and appropriate quality personnel and assist in developing related QI initiatives. Review TSQC quarterly reports and monitor progress on TSQC QI plans. Hospital TSQC team (nurse reviewer, surgeon champion, quality staff) to provide a written progress report semi-annually to TSQC coordinator. 4. Present on hospital’s surgical quality improvement progress during TSQC quarterly meetings at a minimum annually. 6. Attend at least 50% of TSQC networking meetings. 7. Attend NSQIP national meeting at least every other year. Adopted May 2011
TENNESSEE SURGICAL QUALITY COLLABORATIVE Guiding Document
January 2012
This document sets forth the roles and relationships of the participants in the Tennessee Surgical Quality Collaborative. The Tennessee Surgical Quality Collaborative will be overseen and administered by the Tennessee Center for Patient Safety with guidance from the Clinical Leadership committee. The Tennessee Center for Patient Safety shall have fiduciary responsibility for all activities of the Collaborative. The purpose of the Tennessee Surgical Quality Collaborative is to improve surgical outcomes. The data base of the American College of Surgeons and the National Surgical Quality Improvement Project (NSQIP) model will be utilized. The data base collects preoperative, intraoperative and 30 day outcome variables on more than 117,000 major operative procedures. This robust clinical data collection is risk-adjusted to compensate for differences among patients which would otherwise affect healthcare outcomes. The Tennessee Center for Patient Safety solicits and supports Tennessee hospitals to participate in the ACS NSQIP program and the TSQC. Each participating hospital will have a surgeon leader and a surgical clinical reviewer to collect the data. Membership in the TSQC is open to all Tennessee hospitals who participate in the ACS NSQIP program. TSQC Clinical Leadership Committee The Clinical Leadership Committee is comprised of four surgeons appointed by the TN Chapter of the American College of Surgeons, one or more hospital administrators, one clinical reviewer and TN Center for Patient Safety staff. Committee Appointments and Terms Terms for committee appointments shall be for two years. Committee members may be re-appointed for consecutive terms. There is no maximum term limit. Nominations for membership on the TSQC leadership committee will be solicited every two years from the TSQC participating hospitals and the surgeon champions. Retired surgeon champions are also eligible for appointment. The Clinical Leadership Committee responsibilities include review of TN aggregate data, identification of quality improvement opportunities, serve as mentors for new hospital participants and surgeons, review national and regional best practices, and help plan and implement the collaborative participant’s regional meetings. Ad hoc committees and taskforces will be established as needed to further the collaborative’s goals. The leadership committee and TSQC participants will appoint members to committees and taskforces. The Tennessee Surgical Quality Collaborative will consist of the Tennessee Center for Patient Safety staff, the participating hospital administrators, quality directors, the surgeon leaders, and the clinical reviewers from all of the NSQIP hospitals. The
Tennessee Center for Patient Safety will provide coordination support for the collaborative including securing participation of hospitals, coordinating of training for hospitals and surgical reviewers with the ACS NSQIP, convening collaborative meetings and activities, data reports and analysis, identifying opportunities from the data for statewide surgical quality improvement and documenting the improvements in surgical outcomes for Tennessee patients. The best practices identified from the work of the collaborative will be shared at state conferences and meetings including TN ACS annual meetings and statewide meetings of the Center for Patient Safety. January 2012
Tennessee Surgical Quality Collaborative Overview
January 2012
Revised January 2012
Coordinating Center
(Tennessee Center for Patient Safety)
Clinical Leadership Committee (TN Chapter ACS Surgeon Champions and hospital Representatives)
ACS NSQIP (National Surgical
Quality Improvement
Program)
Tennessee Hospitals
Hospitals Collects required surgical data and sends to ACS
NSQIP o Surgical Clinical Reviewer (SCR) collects
data and submits via online program Receives reports from NSQIP and TSQC and
shares with Surgical Champion o Shares with internal operations
Works with Coordinating Center Participates in collaborative regional meetings
and NSQIP Annual Conference Implements Best Practices
ACS NSQIP Receives required data from Hospitals Develops and shares reports with Hospitals
o Semi Annual Reports (O/E ratios, Logistic Regression, etc.)
o Real Time Online Reports (monitor performance against National Avgs)
o Ad hoc reports for Hospitals Allows TSQC Coordinating center access to data and
reports per data agreements Continually disseminates ‘Best Practices” to Hospitals
Coordinating Center Identify and secure NSQIP participation from
Tennessee hospitals Receives funds from BCBS THF and distributes funds
to participating hospitals and surgeons Accesses data from hospitals and NSQIP per data use
agreements Coordinates NSQIP Training for Hospitals (Clinical
Reviewer) Creates Ad Hoc Reports as requested Coordinates collaborative meetings 3 times per year Shares data with Collaborative Monitors ongoing Quality Improvement (QI) efforts Shares best practices with all hospitals at statewide
meeting Identifies best practices and shares with hospitals
statewide Ensures NSQIP program compliance
o Data submission, Timeliness, etc
Clinical Leadership Committee Led by TN ACS Surgical Champions from Hospitals Reviews aggregate TN data Identifies QI opportunities Selects/presents topics for collaborative meetings Serve as mentors for new hospital participants and
surgeons Discuss national and regional best practices
Note: The Tennessee Surgical Quality Collaborative is the complete collaborative effort between NSQIP, Hospitals, TN Center for Patient Safety and TN Chapter of American College of Surgeons
Tennessee NSQIP Surgical Quality Collaborative Participation Agreement
This agreement (Agreement), effective _______________, 20__, is hereby made by and between the Tennessee Health Education and Research Foundation (THERF) on behalf of the Tennessee Surgical Quality Collaborative (“hereinafter “TSQC”) operated by the Tennessee Center for Patient Safety, a program of the Tennessee Hospital Association, a non-profit corporation with offices located at 500 Interstate Blvd., South, Nashville, Tennessee 37210 and ________________________________, (hereinafter “Hospital”), a Tennessee hospital participating in the National Surgical Quality Improvement Program (“NSQIP”) administered by the American College of Surgeons (“ACS”).
WHEREAS, Hospital is a participant in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP);
WHEREAS, THA developed the Tennessee Center for Patient Safety to improve the quality of health care for Tennesseans;
WHEREAS, the Tennessee Center for Patient Safety administers the Tennessee NSQIP Surgical Quality Collaborative in consultation with the TN Chapter of the American College of surgeons with the guidance of its Clinical Leadership Committee;
WHEREAS, the purpose of the Tennessee NSQIP Surgical Quality Collaborative is to improve surgical outcomes utilizing the data submitted to the ACS NSQIP as part of quality improvement activities;
WHEREAS, Hospital desires to participate in the Tennessee NSQIP Surgical Quality Collaborative,
NOW, THEREFORE, the parties agree as follows:
1. Definitions
a. “ACS” is the American College of Surgeons b. “Clinical Leadership Committee” shall consist of the following voting
members: four surgeon champions appointed by the TN Chapter of the American College of Surgeons, one or more hospital administrators, one surgical reviewer and one member from the staff of the Tennessee Center for Patient Safety. The Clinical Leadership Committee responsibilities will include review of the TN aggregate data, identification of quality improvement opportunities, serve as mentors for new hospital participants and surgeons, review national and regional best practices, and help plan and implement the TSQC hospital participants’ collaborative meetings.
c. “Data” includes the data variables as identified in the ACS NSQIP
i. “NSQIP” is the National Surgical Quality Improvement Project ii.“SCR” is the Surgical Clinical Reviewer hired by each hospital participant to capture and submit data. iii.“Tennessee Surgical Quality Collaborative” shall include the Tennessee Center for Patient Safety, the participating hospital administrators, the surgeon champions and the surgical clinical reviewers.
2. Program Participation
The Tennessee Surgical Quality Collaborative (TSQC) a project of the Tennessee Center for Patient Safety (“TCPS”) in consultation with the TN Chapter of the ACS and in cooperation with Hospitals participating in the ACS NSQIP has embarked upon an initiative to improve surgical quality delivered by general and vascular surgeons in the State of Tennessee by participating in the ACS NSQIP. Each Hospital participant will hire a surgical clinical reviewer (SCR) to capture outcomes data as defined by ACS NSQIP. The SCR will submit each Hospital participants’ data to the ACS NSQIP. The collaborative will use aggregated state reports and de-identifiable individual reports from participating hospitals to identify improvement opportunities, identify areas that have better than average results, evaluate and identify differences in practice between the hospitals in the state, and ascertain and disseminate best practices in Tennessee.
3. Obligations of Hospital
a. Hospital shall participate in the ACS NSQIP in accordance with ACS guidelines. b. Hospital shall designate a surgeon champion within the hospital. The surgeon champion shall:
i. Lead the implementation of clinical performance improvement efforts within their respective facilities
ii. Participate in TN NSQIP surgical quality collaborative meetings.
iii. Participate in ACS NSQIP monthly surgeon champion calls and
attend the annual NSQIP national conference
c. Hospital shall direct the SCR, hired by the hospital to collect and submit data to ACS NSQIP.
d. Hospital shall actively participate in the Tennessee Surgical Quality Collaborative of the Tennessee Patient Safety Center.
4. Obligations of Tennessee Center for Patient Safety
a. In exchange for the participation of the hospital with the Tennessee Surgical Quality Collaborative of the Tennessee Center for Patient Safety, the TCPS shall make the following payments as provided herein:
i. Each hospital shall receive an annual grant of sixty thousand
dollars ($60,000.00) to defray the costs of participation in NSQIP.
ii. The surgeon champion designated by each hospital shall receive from TCPS an annual stipend in the amount of five thousand dollars ($5,000.00) to perform the duties outlined in Sec. 3(b).
b. TCPS shall provide data analysis and reports to the TSQC and other
coordination functions including the coordination of training for hospitals and surgical reviewers, convening collaborative meetings and activities, and documenting the improvements in surgical outcomes for Tennessee patients.
5. Data Utilization and Non-Disclosure a. Hospitals participating in the TSQC will sign an amendment to the ACS NSQIP contract outlining the data access, use and agreements between the hospital, TSQC and ACS NSQIP. “The Hospital and the TSQC will have continuous access to the Hospital's own ACS NSQIP Data. The Hospital and the TSQC will also have continuous access to cumulative non-risk-adjusted ACS NSQIP Data of all contributors, in a manner that does not identify or permit identification of the contributors, and presented for the purpose of comparison to national averages and peer groups. Notwithstanding the ownership rights of contributing hospitals to the data submitted to the ACS NSQIP, ACS owns all right, title, and interest in the ACS NSQIP Database and the aggregated data contained therein. ACS hereby grants to the Hospital and the TSQC a limited, non-exclusive, revocable license to utilize these non-risk-adjusted ACS NSQIP Data for appropriate internal purposes only. The ACS NSQIP will provide reports to the Hospital from time to time, which will contain risk-adjusted ACS NSQIP Data. ACS hereby grants the Hospital and the TSQC a non-exclusive license to use the risk-adjusted data for appropriate internal and external purposes.”
a. Neither the TCPS, the TSQC nor any hospital or surgeon champion shall disclose all, or any portion of the data, data files or output received or processed pursuant to this Agreement, except that:
i. Data shall be accessible to all Hospital participants in an aggregate non- identifiable non-risk-adjusted form for the purpose of comparison to national averages and peer groups.
ii. Data and data files consisting solely of hospital specific information shall be accessible only to the hospital to which the information pertains. iii. TCPS staff and contractors as coordinators for the TSQC have access to hospital specific information for TSQC data analyses and reporting within the collaborative participants.
iii. TSQC and TCPS have permission to use and release aggregate or de-identified Tennessee performance data for the sole purpose of demonstrating the benefits of the collaborative. Aggregate reports for public release will be reviewed by the leadership committee prior to release.
b. All data, including data files and output, prepared under the provisions of this Agreement, as well as any personal identifiers referring to patients or physicians, shall be subject to adequate security and access protective procedures that provide effective physical and electronic safeguards.
6. Compliance with the Health Insurance Portability and Accountability Act
a. Both parties to this Agreement agree to and are committed to comply with
any and all requirements of the Standards for Privacy of Individually Identifiable Health Information (the “Privacy Standards”) under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).
b. TSQC, as a business associate of Hospital, provides services (“Services”)
for Hospital that involve the use and disclosure of individually identifiable health information which is transmitted or maintained in any form or medium (“Protected Health Information”)as delineated in the business associate agreement (Appendix A) attached hereto and incorporated by reference herein.
7. Term and Termination
a. The term of this Agreement shall begin January 2012 and extend through May 2016.
b. Either party hereto may terminate this Agreement upon written notice to
the other party if that party has failed to perform a material obligation hereunder and has not cured such failure within thirty (30) days after receipt of written notice of such failure.
8. Miscellaneous Provisions
a. Severability. In the event that any one or more of the provisions of this
agreement shall for any reason be held to be unenforceable in any respect under Tennessee law such unenforceability shall not affect any other provision, but this agreement shall then be construed as if such unenforceable provision or provisions had never been contained herein.
b. Modification. This agreement shall not be altered, modified, or amended
in any respect except in writing and signed by each party.
c. Non-waiver. The failure of one party to enforce at any time any of the duties or obligations of the other party hereunder shall not constitute a waiver of such other party’s duties or obligations under this Agreement.
d. Notices. Any notice to be made in connection with this Agreement shall
be in writing and shall be deemed effectively given when delivered in person or sent by registered or certified mail, regular mail or electronic mail by one party to the other party at the addresses set forth above or such other addresses as either party may specify by written notice to the other.
e. Successors and Assigns. All the terms and provisions of this Agreement
shall be binding upon and inure to the benefit of the parties hereto, and their successors and assigns and legal representatives, except that no party may assign this agreement nor any right granted hereunder, in whole or in part (except in connection with a reorganization, merger or sale of such party’s business or assets to a third party), without the other party’s prior written consent, which shall not be unreasonably withheld.
f. Force Majeure. Notwithstanding anything else in this Agreement, no
default, delay or failure to perform on the part of either party shall be considered a breach of this Agreement if such default, delay or failure to perform is shown to be due primarily to causes beyond the reasonable control of the party charged with such default, including, but not limited to, causes such as strikes, lockouts, or other labor disputes, riots, civil disturbances, actions or inactions of governmental authorities or suppliers, epidemics, war, embargoes, severe weather, fire, earthquakes, acts of God or the public enemy, nuclear disasters, or default of a common carrier.
g. Governing Law. The validity, performance, construction and interpretation
of this agreement shall be governed by Tennessee law.
h. Attorney’s Fees. The prevailing party in any legal action brought by one party against the other with respect to this agreement or the respective
rights or obligations of the parties set forth herein shall be entitled, in addition to any other rights and remedies it may have, to reimbursement for its expenses incurred hereby, including court costs and reasonable attorney’s fees.
i. Headings. The headings used in this Agreement are for convenience of
reference only and shall not be interpreted or construed to modify or alter any of the terms hereof.
j. Entire Agreement. This Agreement represents the entire agreement
between the parties and supersedes all prior arrangements and understandings with respect to all matters covered in this Agreement.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement as evidence by affixing there signatures below to be effective on the date of execution. Hospital Name: _____________________ Tennessee Health Education __________________________________ Research Foundation (THERF) By (printed name): __________________ By: Craig A. Becker Signature: _________________________ Signature: ____________________ Title: _____________________________ Title: President Date: _____________________________ Date: ________________________
Revised January 2012
Publications
Using the National Surgical Quality ImprovementProgram and the Tennessee Surgical QualityCollaborative to Improve Surgical OutcomesOscar D Guillamondegui, MD, MPH, FACS, Oliver L Gunter, MD, FACS, Leonard Hines, MD, FACS,Barbara J Martin, RN, MBA, William Gibson, MD, P. Chris Clarke, RN, BSN, William T. Cecil, MBA,Joseph B Cofer, MD, FACS
BACKGROUND: Led by the Tennessee Chapter of the American College of Surgeons, in May 2008 a 10-hospitalcollaborative was formed between the Tennessee Chapter of ACS, the Tennessee HospitalAssociation, and the BlueCross BlueShield of Tennessee Health Foundation. We hypothesizedthat by forming the Tennessee Surgical Quality Collaborative using the National SurgicalQuality Improvement Program (NSQIP) system to share surgical process and outcomes data,overall patient surgical outcomes would improve.
STUDY DESIGN: All NSQIP data from the 10-hospital collaborative for the time periods January to December2009 (period 1) and January to December 2010 (period 2) were collected. Data on 20 categoriesof postoperative complications and 30-day mortality were compared between periods. Com-plication comparisons and hospital costs associated with complications were calculated per10,000 procedures. Statistical analysis was performed by Z-test.
RESULTS: There were 14,205 total surgical cases in period 1 and 14,901 surgical cases in period 2. Betweenperiods (per 10,000 cases) there were significant improvements in superficial surgical siteinfections (�19%, p � 0.0005), on ventilator longer than 48 hours (�15%, p � 0.012),graft/prosthesis/flap failure (�60%, p � 0.0001), acute renal failure (�25%, p � 0.023), andwound disruption (�34%, p � 0.011). Although mortality (per 10,000) was higher in period 2(237.6 vs 232.3), no statistical difference was noted. Net costs avoided between these periodswere calculated as $2,197,543 per 10,000 general and vascular surgery cases.
CONCLUSIONS: Data organization and scrutiny are the initial steps of process improvement. Participation in ourregional surgical quality collaborative resulted in improved outcomes and reduced costs. Al-though the mechanisms for these changes are likely multifactorial, the collaborative establishescommunication, process improvement, and frank discussion among the members as best prac-tices are identified and shared and standardized processes are adopted. (J Am Coll Surg 2012;xx:
xxx. © 2012 by the American College of Surgeons)f
Disclosure Information: Nothing to disclose.Presented at the Southern Surgical Association 123rd Annual Meeting, HotSprings, VA, December 2011.
Received December 5, 2011; Accepted December 15, 2011.From the Department of Surgery, Vanderbilt University Medical Center(Guillamondegui, Gunter, Martin); the Tennessee Valley Healthcare System,Veteran’s Affairs (Guillamondegui); and the Tennessee Hospital Association(Clarke, Cecil), Nashville, TN; the Department of Surgery, University ofTennessee Graduate School of Medicine (Hines) and Premier Surgical Asso-ciates, Parkwest Medical Center (Gibson), Knoxville, TN; and the Depart-ment of Surgery, University of Tennessee College of Medicine-Chattanooga,Chattanooga, TN (Cofer).Correspondence address: Joseph B Cofer, MD, FACS, Department of Sur-
igery, Suite 401, 979 E Third St, Chattanooga, TN 37403. email: [email protected]
1© 2012 by the American College of SurgeonsPublished by Elsevier Inc.
Surgery has long been a rapidly evolving field that has beenaffected by multiple factors including information technol-ogy, improved understanding of anatomy and physiology,and maturation of health care systems. As the rapid changeshave slowed into a plateau phase, the focus is shifting fromdevelopment and application of novel procedures to thestandardization of outcomes. The current era of surgerydepends heavily on complex health care delivery systemsthat must remain plastic in order to optimize outcomes.Although constantly minimizing practice variability by us-ing practice management guidelines has been advocatedand is deeply ingrained into current health care deliverymodels,1 implementation of evidence-based medicine isrequently dependent on local culture and resources. There
s rarely a “one-size-fits-all” solution that solves some of theISSN 1072-7515/12/$36.00doi:10.1016/j.jamcollsurg.2011.12.012
chgmp
tmpadiitcci
At(fctdctoaart((cgncsudTcAnt
2 Guillamondegui et al NSQIP State Collaborative to Improve Outcomes J Am Coll Surg
complex systems problems faced in modern surgicalpractice.
Arguably, one significant historical barrier to process im-provement was the lack of reliable data from which to drawconclusions and change processes. The development of so-phisticated systems to collect surgical data began with theNational Veterans Surgical Risk Study.2 Process improve-ments based on these data have been shown to considerablyreduce morbidity and mortality.3 This has since developedinto the American College of Surgeons National SurgicalQuality Improvement Program (ACS NSQIP), which is awell-validated tool that collects risk-adjusted data in-tended to drive quality initiatives.4 Although there islear benefit to the use of these data on a national level toelp establish benchmarks and comparisons, regional sur-ical quality groups have also shown significant improve-ents in surgical outcomes by sharing data and auditing
ractice patterns.5,6
In 2008, a regional surgical quality collaborative wasformed in the state of Tennessee using infrastructure simi-lar to that of the Michigan Surgical Quality Collaborative.7
Led by the Tennessee chapter of the American College ofSurgeons, funding from Blue Cross/Blue Shield of Ten-nessee was used to create a 10-hospital Tennessee SurgicalQuality Collaborative (TSQC). We hypothesized that byforming the TSQC using the ACS NSQIP system to sharesurgical processes and outcomes data, overall patient surgi-cal outcomes would improve.
METHODSThe TSQC used an interrupted time-series study to ex-amine trends in surgical outcomes among the 10-hospital group during 2 phases: January 2009 throughDecember 2009 (period 1) and January 2010 throughDecember 2010 (period 2). We used several outcomesmeasurements. The primary outcome was postoperativecomplications. Secondary outcomes included 30-daymortality and hospital costs associated with postopera-tive complications.
TSQC consists of 10 member hospitals: Erlanger Hos-
Abbreviations and Acronyms
ACS NSQIP � American College of Surgeons NationalSurgical Quality Improvement Program
DVT � deep venous thrombosisROI � return on investmentRR � relative riskSSI � surgical site infectionTSQC � Tennessee Surgical Quality Collaborative
pital (Chattanooga, TN), Vanderbilt University Hospital
(Nashville, TN), St Francis Hospital (Memphis, TN), Bap-tist Memorial Hospital (Memphis, TN), Cookeville Re-gional Medical Center (Cookeville, TN), Jackson MadisonCounty General Hospital (Jackson, TN), Johnson CityMedical Center (Johnson City, TN), Methodist UniversityHospital (Memphis, TN), Parkwest Medical Center(Knoxville, TN), and the University of Tennessee MedicalCenter (Knoxville, TN). These 10 institutions perform ap-proximately 25% of the entire general and vascular surgicalinterventions performed annually within the state.8 Usinghe infrastructure of the ACS NSQIP and data use agree-ents among the participating parties, the Tennessee Hos-
ital Association serves as the coordinator for the collabor-tive and has confidential access to the TSQC performanceata. Although the collaborative was chartered in 2007, an
nitial 18-month period was used to finalize grant funding,dentify and recruit the 10 participating hospitals, and es-ablish the appropriate personnel (RN abstractor, surgeonhampion, CEO) within each system. Appropriate dataollection among the entire collaborative began in earnestn January 2009.
Demographic and risk factor data including age, race,merican Society of Anesthesiologists (ASA) classifica-
ion, risk factors, body mass index, diabetes mellitusinsulin and noninsulin dependent), smoking status andunctional health status before surgery, COPD, previousardiac surgical history, hypertension requiring medica-ion, and dialysis status were derived from the NSQIPataset provided by each institution with the TSQC,ompared between period 1 and period 2, as well as tohe NSQIP population during period 2. The primaryutcome of postoperative complication was defined asny of the 21 postoperative occurrences by the NSQIP:cute renal failure, bleeding/transfusions, cardiac arrestequiring cardiopulmonary resuscitation, coma longerhan 24 hours, deep incisional skin and soft tissue infectionsurgical site infection [SSI]), deep venous thrombosisDVT)/thrombophlebitis, graft/prosthesis/flap failure, myo-ardial infarction, postoperative ventilatory supportreater than 48 hours, peripheral nerve injury, pneumo-ia, pulmonary embolism, progressive renal insuffi-iency, stroke/cerebrovascular accident, superficial inci-ional skin and soft tissue infection (SSI), sepsis,nplanned intubation, urinary tract infection, woundisruption, organ/deep space SSI, and septic shock.hirty-day mortality was considered as a secondary out-
ome. Hospital costs per event were applied using theCS NSQIP Return on Investment (ROI) calculator,ormalized to savings per 10,000 procedures, and usedhe differences between period 1 and period 2.9,10 Sen-
sitivity analysis of the event cost levels was assessed using
ripb
pnp02�5ti
D
CF
ity Im
3Vol. xx, No. x, Month 2012 Guillamondegui et al NSQIP State Collaborative to Improve Outcomes
Monte Carlo method of simulation. All completed caseswere included in the analysis. Collaborative-wide aggre-gate postoperative rate improvement significance wasidentified using the Z-test.
RESULTSOverall, the TSQC submitted caseloads in periods 1 and2 were 14, 205 and 14, 901, respectively, with a 4.9%rise in the latter dataset. The TSQC patient populationhad greater burden of preoperative risk factors than thenational comparison (Table 1). In terms of preoperativeisk, the TSQC group had a higher proportion of Amer-can Society of Anesthesiologists class 4 or 5 and moreatients with 3 or more preoperative risk factors. Comor-
Table 1. Comparison between the TSQC Surgical Populatio
Variable 1/1/09 – 12/
n 14,205Age, y 56Race, %
White 79.5Black or African American 18.6
ASA classification, %ASA 1 – no disturb 5.1ASA 2 – mild disturb 34.4ASA 3 – severe disturb 48.6ASA 4 – life threat 11.2ASA 5 – moribund 0.6ASA 6 – brain death 0.0
Emergency case, % 11.4Risk factors, %
Cases with 0 risk factors 20.1Cases with 1 risk factors 26.3Cases with 2 risk factors 19.2Cases with 3 risk factors 11.8Cases with 4 risk factors 7.5Cases with 5� risk factors 15.1
Body mass index, kg/m2 30.2iabetes mellitus, %Noninsulin 12.0Insulin 9.0
urrent smoker within 1 year, % 26.8unctional health status before surgery, %Total dependent 2.6History of severe COPD 6.9Previous cardiac surgery 8.9Hypertension requiring medication 56.4Currently requiring or on dialysis 3.4
ASA, American Society of Anesthesiologists; NSQIP, National Surgical Qual
idities such as diabetes, COPD, dialysis-dependent renal v
disease, previous cardiac surgery, hypertension, and depen-dent functional status were more common in the TSQCgroup as well.
Postoperative occurrences per time period (normalized per10,000 cases) are listed inTable 2. Significant improvement ineriod 2 postoperative occurrences was identified in acute re-al failure (75.3 vs 56.4, �25.1%, p � 0.0227), graft/rosthesis/flap failure (45.8 vs 18.1, �60.5%, p �.0001), ventilator greater than 48 hours (293.6 vs50.3, �14.7%, p � 0.0116), SSI (357.6 vs 289.9,18.9%, p � 0.0005), and wound disruption (90.8 vs
9.7, �34.3%, p � 0.011). An increase in complica-ions in period 2 (normalized per 10,000 cases) wasdentified in DVT/thrombophlebitis in period 2 (66.2
d the National NSQIP PopulationTSQC NSQIP
9 1/1/10 – 12/31/10 1/1/10 – 12/31/10
14,901 312,24056.5 56
72.6 77.217.6 9.3
5.2 9.434.5 45.049.1 38.410.9 6.70.3 0.30.0 0.0
11.2 11.5
20.6 30.026.7 29.418.8 17.611.5 9.48.1 5.3
14.3 8.230.6 29.9
12.1 9.38.2 5.7
25.8 19.7
2.4 1.58.0 4.97.9 5.4
57.1 46.43.5 1.6
provement Program; TSQC, Tennessee Surgical Quality Collaborative.
n an
31/0
s 89.3, 34.9%, p � 0.0126), pneumonia (224.6 vs
srcsrhrttitb
MO
UUWMT
4 Guillamondegui et al NSQIP State Collaborative to Improve Outcomes J Am Coll Surg
276.5, 23.1%, p � 0.0023), and urinary tract infections(164.7 vs 233.5, 41.8%, p � 0.00001) (Table 2).
For skin and soft tissue infections, there was a significantaggregate improvement in overall morbidity from period 1to period 2 although the decrease in individual morbiditytype reached significance for superficial incisional SSI only.This includes the decline in deep incisional SSI (93.6 vs76.5, relative risk [RR] 0.82, 95% CI 0.63 to 1.06 andsuperficial incisional SSI (357.6 vs 289.9, RR 0.81, 95%CI 0.71 to 0.92), while organ/space SSI increased (157.7 vs181.2, RR 1.15, 95% CI 0.96 to 1.38), for an overallreduction in cases from period 1 to period 2 of 603.3 to546.9 cases (normalized by 10,000 cases) and an RR reduc-tion of approximately 10% (RR 0.906, 95% CI 0.82 to0.99) (Table 3). There was no significant increase in mor-tality within the TSQC from period 1 to period 2 (RR
Table 2. Postoperative Occurrences by Time Period
Postoperativeoccurrences
Postoperativeoccurrences per
10,000 proceduresChange, %2009 2010
Acute renal failure* 75.3 56.4 �25.1Cardiac arrest requiring
CPR 55.6 51.7 �7.0Coma � 24 h 5.6 5.4 �3.6Deep incisional SSI 93.6 76.5 �18.3DVT/thrombophlebitis* 66.2 89.3 34.9Graft/prosthesis/flap
failure† 45.8 18.1 �60.5yocardial infarction 62.0 59.1 �4.7n ventilator � 48 h* 293.6 250.3 �14.7
Organ/space SSI 157.7 181.2 14.9Peripheral nerve injury 2.8 2.0 �28.6Pneumonia* 224.6 276.5 23.1Progressive renal
insufficiency 52.8 55.0 4.2Pulmonary embolism 34.5 39.6 14.8Sepsis 216.8 193.9 �10.6Septic shock 108.4 125.5 15.8Stroke/CVA 28.3 26.8 �5.3Superficial incisional SSI† 357.6 289.9 �18.9
nplanned intubation 181.6 166.4 �8.4rinary tract infection† 164.7 233.5 41.8ound disruption* 90.8 59.7 �34.3ortality 232.3 237.6 2.3
otal general andvascular surgery cases 14,205 14,901
*p � 0.05.†p � 0.001.CVA, cerebrovascular accident; DVT, deep venous thrombosis; SSI, surgicalsite infection.
1.023, 95% CI 0.88 to 1.19).
When the financial model was applied to the outcomesdata there appeared to be an overall program savings fromperiod 1 to period 2 of $4,476,515. Based on the ACSNSQIP ROI calculator for each significantly changed post-operative occurrence, the benefits were derived per unitcost. In this model all data were normalized as net savingsper 10,000 procedures. For acute renal failure the unit costwas $28, 359, with a net savings of $535,985. Graft/prosthesis/flap failure unit cost was $14,851, with a netsavings of $411,373. Ventilator greater than 48 hours unitcost was $27,654, for a net savings of $1,197,418. The SSIunit cost was $27,631, with a net savings of $1, 870,619.Wound disruption unit cost was $14,827, with a net sav-ings of $461,120. The total normalized savings from pe-riod 1 to period 2 was $4,476,515 (Table 4).
Although a net improvement was identified, there were3 areas in which outcomes worsened in the later period.These included DVT, pneumonia, and urinary tract infec-tions, as described above. DVT unit cost was $10,804, witha net cost of $249,572. Pneumonia unit cost was $22,097,with a net cost of $1,146,834. Urinary tract infection unitcost was $12,828 and net cost was $882,566. Using theNSQIP ROI calculator, the total increased costs incurredby these complications was $2,278,972 from period 1 toperiod 2. When net costs over the comparison periods weresubtracted from net savings incurred by avoiding compli-cations, the overall savings were $2,197,543.
Sensitivity analysis11 showed that for each event cost,imulation from zero to the upper end of the distributionesulted in a positive y-intercept for net savings at an eventost of zero, ranging from just above zero to $326,000. Netavings increased with higher event costs for events with aeduced second period rate, and net savings declined withigher event costs for events with an increased second pe-iod rate. Event cost distribution specification was based onhe distribution of length of stay for cases with postopera-ive complications. Simulation of the NSQIP ROI model,ncluding both increased and reduced event rate complica-ions, resulted in 84.5% of the iterations of net savingseing greater than zero.
DISCUSSIONNSQIP has shown in previous work that participation in asystems-based approach to medical care will lead to significantreduction in postoperative occurrences.12,13 The TSQC hasidentified several areas of postoperative morbidity improve-ment over the 2-year period of involvement in the ACSNSQIP. These areas of improvement include acute renal fail-ure, graft failure, ventilator use, and SSI/wound disruption.The reason for such a dramatic change, however, is not readily
apparent. As was identified in the landmark VA-NSQIP study
tamai
afto
aettDmpybacs
tWltct
pthbT
5Vol. xx, No. x, Month 2012 Guillamondegui et al NSQIP State Collaborative to Improve Outcomes
in 1998,3 these changes may be attributed to process improve-ment secondary to increased scrutiny of surgical interventionwhen incorporated in a quality improvement program, or tothe Hawthorne effect, as was noted in the cardiac surgeryprograms of New York State during the 1990s with the adventof public reporting.9,14,15
TSQC identified areas of significant improvement incare ranging from an approximate 15% reduction in pa-tients ventilated more than 48 hours to a 60% reduction ingraft/prosthesis failure. Also included in this are significantimprovements in acute renal failure, skin/soft tissue infec-tion, and wound disruption. Although improved reduc-tions in areas such as skin/soft tissue infection, wound dis-ruption, and ventilator dependence may be attributable toidentification of a problem, and associated rapid change inpractice based on evidence-based medicine,16 it is unlikelyhat the reduction of renal and reconstructive graft failuresre attributable to such measures. These improvementsay be a byproduct of observation and novel realization ofproblem that was not thought to exist before involvement
n NSQIP.The obvious cost savings associated with the initiation of
quality improvement program collaborative and the ef-ect this may have on the consumers and vendors was ini-ially described by the Michigan Surgical Quality Collab-rative (MSQC), with the added observation that an
Table 4. Financial Model
Postoperative occurrence
Occurrences per 10,00procedures, n
2009 20
Acute renal failure 75.3 5Graft/prosthesis/flap failure 45.8 1On ventilator � 48 h 293.6 25Superficial incisional SSI 357.6 28Wound disruption 90.8 5Full year 2010 savingsFull year 2010 costsNet savings
Table 3. Surgical Site Infections
Postoperative occurrence
Postoperative10,000 p
2009
Deep incisional SSI 93.6Organ/space SSI 157.7Superficial incisional SSI* 357.6All SSIs* 603.3
*p � 0.05.SSI, surgical site infection.
SSI, surgical site infection.
pproximate 2% reduction in overall morbidity would beffective in supporting any quality collaborative.6 Althoughhere were some increases in morbidity identified withinhe TSQC after the second year of involvement, namelyVT, pneumonia, and urinary tract infections, the overallorbidity reduction led to a projected cost savings of ap-
roximately $2 million per 10,000 cases within the first 2ears of formation. Although projections of overall mor-idity improvement may slow in the ensuing several years,s was initially identified by the VA-NSQIP studies, thisost containment is substantial and implies the ability ofuch a collaborative to be self-supportive.
The sensitivity analysis shows that event cost levels andhe event rates determine the magnitude of savings.
hether net savings are positive for any program is moreikely to be dependent on the changes in event rates ratherhan event cost. In this study, event costs near zero did nothange the direction of net savings, which remained posi-ive although small.
The limitation of this study is that the reason for im-rovement is not readily obvious. It is our belief that par-icipation in a quality improvement program will initiallyave some manner of Hawthorne effect, as each institutionecomes aware of its flaws and attempts to remedy them.here must also be an added benefit of discussion at the
Unit costs, $Net savings per
10,000 procedures, $
28,359 535,98514,851 411,37327,654 1,197,41827,631 1,870,61914,827 461,120
4,476,5152,278,9722,197,543
rrences perures, n Relative risk (95% CI)
2010 2010 compared with 2009
76.5 0.82 (0.63–1.06)181.2 1.15 (0.96–1.38)289.9 0.81 (0.71–0.92)546.9 0.91 (0.82–0.99)
0
10
6.48.10.39.99.7
occuroced
6 Guillamondegui et al NSQIP State Collaborative to Improve Outcomes J Am Coll Surg
local level with a jury of one’s peers, which enables a frankdiscussion without repercussion.
CONCLUSIONSDeveloping a collaborative that allows the sharing of infor-mation without institutional retribution may have led tosome of the improvements and successes identified withinthe group. Future analysis and implementation of improve-ment strategies in a prospective fashion will help to deter-mine whether the potential cost savings are sustainable.
Author ContributionsStudy conception and design: Cofer, Guillamondegui,
Gunter, Gibson, Hines, Martin, Cecil, ClarkeAcquisition of data: Guillamondegui, Gunter, Cecil,
Clarke, Martin, CoferAnalysis and interpretation of data: Cecil, Clarke, Martin,
Cofer, Guillamondegui, Gunter, Hines, GibsonDrafting of manuscript: Guillamondegui, Gunter, CecilCritical revision: Cofer, Martin, Hines, Gibson, Cecil,
Guillamondegui, Gunter, Clarke
REFERENCES
1. Rhodes M. Practice management guidelines for trauma care:presidential address, Seventh Scientific Assembly of the EasternAssociation for the Surgery of Trauma. J Trauma 1994;37:635–644.
2. Khuri SF, Daley J, Henderson W, et al. The National VeteransAdministration Surgical Risk Study: risk adjustment for thecomparative assessment of the quality of surgical care. J Am CollSurg 1995;180:519–531.
3. Khuri SF, Daley J, Henderson W, et al. The Department ofVeterans Affairs’ NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the mea-surement and enhancement of the quality of surgical care. Na-tional VA Surgical Quality Improvement Program. Ann Surg
1998;228:491–507.4. Fink AS, Campbell DA Jr, Mentzer RM Jr, et al. The NationalSurgical Quality Improvement Program in non-Veterans Ad-ministration hospitals: initial demonstration of feasibility. AnnSurg 2002;236:344–353; discussion 353–354.
5. Malenka DJ, O’Connor GT. A regional collaborative effort forCQI in cardiovascular disease. Northern New England Cardio-vascular Study Group. The Joint Commission Journal on Qual-ity Improvement 1995;21:627–633.
6. Englesbe MJ, Dimick JB, Sonnenday CJ, et al. The Michigansurgical quality collaborative: will a statewide quality improve-ment initiative pay for itself? Ann Surg 2007;246:1100–1103.
7. Share DA, Campbell DA, Birkmeyer N, et al. How a regionalcollaborative of hospitals and physicians in Michigan cut costsand improved the quality of care. Health Affairs 2011;30:636–645.
8. Tennessee Hospital Association. Tennessee Hospital Associa-tion’s Health Information Network, 2010. Report generatedNovember 2011.
9. Vaughan-Sarrazin M, Bayman L, Rosenthal G, et al. The busi-ness case for the reduction of surgical complications in VA hos-pitals. Surgery 2011;149:474–483.
10. Shreve J, Van Den Bos J, Gray T, Halford M, et al; Society ofActuaries Health Section and Milliman. The Economic Measure-ment of Medical Errors. http://www.soa.org/files/pdf/research-econ-measurement.pdf. Published June 2010. Accessed January3, 2012.
11. Law AM, Kelton WD. Simulation modeling and analysis. 2nded. McGraw-Hill Series in Industrial Engineering and Manage-ment Science. 1991, New York: McGraw-Hill; xxii.
12. Carey K, Stefos T, Shibei Z, et al. Excess costs attributable topostoperative complications. Medical care research and review:MCRR 2011;68:490–503.
13. Hall BL, Hamilton BH, Richards K, et al. Does surgical qualityimprove in the American College of Surgeons National SurgicalQuality Improvement Program: an evaluation of all participat-ing hospitals. Ann Surg 2009;250:363–376.
14. Franke R, Kaul J. The Hawthorne experiments: First statisticalinterpretation. Am Sociol Rev 1978;43:623–643.
15. Chassin MR. Achieving and sustaining improved quality: les-sons from New York State and cardiac surgery. Health Affairs2002;21:40–51.
16. McGlynn EA. Intended and unintended consequences: what
should we really worry about? Medical Care 2007;45:3–5.
News from the American College of Surgeons > News from JACS
News from the American College of Surgeons For Release: January 23, 2012
Contact: Sally Garneski 312-202-5409 E-Mail: [email protected]
Regional Surgical Quality Collaborative Significantly Improves Surgical Outcomes and Reduces Cost
Journal of the American College of Surgeons Study Reports Tennessee Collaborative Saves More Than $2 Million and Improves Quality of Care
CHICAGO (January 23, 2012) – A new study published online this week in the Journal of the American College of Surgeons finds hospitals participating in a regional collaborative of the American College of
Surgeon’s National Surgical Quality Improvement Program (ACS NSQIP®), achieved substantial improvements in surgical outcomes, such as reducing the rates of acute renal failure and surgical site infections. The collaborative also saved $2,197,543 per 10,000 general and vascular surgery cases when comparing results from 2010 with results from 2009. ACS NSQIP is the leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care in the private sector.
The Tennessee Surgical Quality Collaborative (TSQC) collected ACS NSQIP data from 10 participating hospitals to examine and identify trends in surgical outcomes and evaluate best practices among these hospitals. The study evaluated 20 categories of postoperative complications, 30-day mortality rates, and hospital costs associated with postoperative complications in a total of 14,205 surgical cases in 2009 and 14,901 surgical cases in 2010.
“We demonstrated that hospitals in a collaborative can greatly improve their quality by sharing data, comparing results, and evaluating best practices and process improvement approaches with their peers,” said Joseph B. Cofer MD, FACS, statewide surgeon champion for the collaborative, author of the study and professor of surgery and surgery residency program director, Department of Surgery, at the University of Tennessee College of Medicine-Chattanooga.
The Tennessee collaborative saw improvements in such procedures as acute renal failure (25.1% reduction, P = 0.023), graft/prosthesis/flap failure (60.5% reduction, P < 0.0001), ventilator greater than 48 hours (14.7% reduction, P = 0.012), superficial site infection (18.9% reduction P = 0.0005), and wound disruption (34.3% reduction, P = 0.011), according to the researchers. These improvements led to a net savings of nearly $2.2 million per 10,000 general and vascular procedures, according to the study. As ACS NSQIP collects only a sample of cases done, the implications for total costs avoided are much greater. It is estimated that 10,000 cases represents only about one fourth of the total general and vascular surgery cases done in the TSQC hospitals in 2009 and 2010. If the ACS NSQIP methodology were applied to all cases, the total costs avoided might be more than $8 million when comparing the results from 2010 with those from 2009.
Page 1 of 3News from the American College of Surgeons: News from JACS: R...
2/21/2012mhtml:file://C:\Documents and Settings\rcarroll\Local Settings\Temp...
According to the researchers, improvements in areas such as skin and soft tissue/wound disruption and ventilator management may be credited to the identification of a problem and rapid change in practice based upon evidence-based medicine1. Improvements in renal and graft failure may be attributed to overall attention being focused on a problem that was uncovered through involvement in ACS NSQIP.
“While previous studies have shown that participation in quality improvement programs such as ACS NSQIP have been shown to save lives, improve health and reduce costs, the Tennessee collaborative illustrates that participation in an ACS NSQIP collaborative can accelerate those benefits and take quality improvement to a whole new level,” said Oscar D. Guillamondegui, MD, MPH, FACS, lead author and associate professor of surgery at Vanderbilt University Medical Center, Nashville.
As the health care system seeks to find ways to reduce costs, many hospitals and health care professionals are organizing themselves into “collaboratives” to work together to share best practices. The TSQC was formed in 2008 and is led by the Tennessee Chapter of the American College of Surgeons (TnACS) and the Tennessee Hospital Association with funding from the BlueCross BlueShield of Tennessee Health Foundation. The TSQC consists of Erlanger Hospital, Chattanooga; Vanderbilt University Hospital, Nashville; St. Francis Hospital, Memphis; Baptist Memorial Hospital, Memphis; Cookeville Regional Medical Center, Cookeville; Jackson Madison County General Hospital, Jackson; Johnson City Medical Center, Johnson City; Methodist University Hospital, Memphis; Parkwest Medical Center, Knoxville; and the University of Tennessee Medical Center, Knoxville. The study will appear in print in the upcoming April issue of the Journal of the American College of Surgeons.
ACS NSQIP collects patient and surgical procedure information, as well as 30-day postoperative outcomes. The results are reported semiannually to the participating sites, along with comparisons of the results from other health care facilities across the United States. There are currently more than 20 ACS NSQIP collaboratives in existence or in development, including collaboratives within hospital systems and additional statewide collaborates in Florida and Oregon.
About the American College of Surgeons The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and to improve the care of the surgical patient. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 78,000 members and is the largest organization of surgeons in the world. For more information, visit http://www.facs.org/index.html.
# # #
1 McGlynn, E.A., Intended and unintended consequences: what should we really worry about?Medical care, 2007. 45
(1): p. 3-5.
News from the Journal of the American College of Surgeons (JACS)
News from the College
Page 2 of 3News from the American College of Surgeons: News from JACS: R...
2/21/2012mhtml:file://C:\Documents and Settings\rcarroll\Local Settings\Temp...
Evaluation
- 1 -
Tennessee Surgical Quality Collaborative Grant Evaluation
January 2012
Executive Summary Objectives & Accomplishments This report updates the June 2011 evaluation by including an additional six months of performance for January through June 2011. The Tennessee Surgical Quality Collaborative (TSQC) officially was launched in May 2008 as a partnership between the Tennessee Chapter of the American College of Surgeons (TN ACS) and Tennessee Hospital Association’s Tennessee Center for Patient Safety (THA TCPS), with the goal of improving surgical care using the American College of Surgeons’ national surgical quality improvement program (ACS NSQIP). The TSQC collaborative model is unique in the design and formal partnership between a state ACS chapter and state hospital association, and was the first such model in the country. Mission: To improve the care of the surgical patient by supporting an open discussion and transfer of information through a collaborative team effort. Vision: To identify best surgical practices, examine how the surgical team obtains best outcomes and teach other surgical teams how to improve outcomes. Grant Objectives The overall objectives of the TSQC grant included:
• Establishing a collaborative model and related operational documents • Implementing data collection and reporting mechanisms using the ACS
NSQIP risk-adjusted outcomes database • Convening TSQC partners for shared learning and collaboration • Identifying quality improvement opportunities from the aggregate data • Evaluating quality improvement strategies to develop best practices for
shared learning among participants
The collaborative has accomplished the major objectives of the grant, demonstrating that Tennessee hospitals and surgeons can work together collaboratively to improve surgical quality. The TSQC now has matured in the building of relationships and trust among hospital participants and in the analysis and understanding of the performance data and semi-annual national
- 2 -
comparison reports. The reduction in complications demonstrates the value of participation in the national ACS NSQIP program, as well as the benefits of a state collaborative to support local sharing and learning. Detailed data analysis of the aggregate performance of the collaborative hospitals have identified specific areas for improvement and informed the quality improvement development and plans. The collaborative is actively implementing a focused quality improvement project for reduction of surgical site infections. Hospital leaders are enthusiastic about the program and 11 new hospitals have expressed interest in joining in the future. Target Population Ten Tennessee hospitals participate in the collaborative (Appendix 1), with representation from all regions of the state. The sites include teaching and non-teaching facilities and one rural facility. The TSQC sites are focused on general and vascular surgery outcomes within the NSQIP database and collectively contribute approximately 26 percent of the total general and vascular surgery cases performed each year in Tennessee (THA 2010 HIN data). The ACS NSQIP is the first nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care. The program employs a prospective, peer-controlled, validated database to quantify 30-day risk-adjusted surgical outcomes, which allows valid comparison of outcomes among all hospitals in the program. ACS NSQIP classic collects data on 136 variables, including preoperative risk factors, intraoperative variables, and 30-day postoperative mortality and morbidity outcomes for patients undergoing major surgical procedures in both the inpatient and outpatient settings. Key Results
1. The TSQC showed significant improvement when comparing the period July 1, 2010-June 30, 2011 with the period July 1, 2009-June 30, 2010 for morbidity and mortality. The collaborative showed statistically significant improvement as a group on eight of 21 postoperative occurrences monitored within the ACS NSQIP.
2. Total postoperative occurrences declined by 5.2 percent and mortality
improved by 7.25 percent since the inception of monitoring in January 2009.
3. Using ACS NSQIP estimated costs for selected complications, the TSQC
improvements resulted in the avoidance of $5,688,476 in costs associated with postoperative complications in the 12-month period from the third quarter 2010 through the second quarter 2011 among the 10 participating sites.
- 3 -
4. If the key successes described below were exported to all other Tennessee hospitals, an additional estimated reduction of $8.99 million in excess costs could have been realized.
5. Peer approval of the TSQC approach to surgical improvement also is
shown in publication efforts where the ACS Bulletin and the Journal of the American College of Surgeons have accepted the TSQC model and results for publication.
Overall Impact The TSQC has established the analytic infrastructure to support a data-driven surgical quality improvement strategy. Risk-adjusted clinical data and comparisons are driving improvements in surgical care in the collaborative and adding focus to strategy and resource allocation. Coupled with the relationships to the sponsoring organizations, surgeons, nurses and hospital quality leaders are enabled to pursue quality objectives and postoperative occurrence risk reduction. Lessons Learned 1. The TSQC preoperative patient risk level is higher than the national
NSQIP preoperative risk level: Preoperative Risk Measure TSQC
(Tennessee) NSQIP (National)
ASA class 4/5 11.6% of cases 6.8% of cases 5+ preoperative risk factors 13.2% 6.8% Diabetes mellitus 20.7% 15% Total dependence 2.4% 1.2% COPD 8.4% 4.9% CVA/stroke 6% 3.5%
2. Hospital leadership must be engaged: While physician leadership
through the role of the surgeon champion is essential, the surgeon champion and nurse surgical case reviewer cannot achieve a hospital-wide improvement alone. Hospital leadership also must be engaged to energize hospital resources for improvement.
3. Focus: Identification of improvement opportunities and successes add necessary focus and improved resource allocation. Results segmentation by procedure further enhances focus in the case of high-volume procedures, such as hernia and colectomy.
4. Action expectation: Identification of improvement opportunities are accompanied by the creation of an action plan and expected plan results reporting at quarterly TSQC meetings.
5. Reference values: NSQIP and local collaborative-based reference values for postoperative occurrence rates provide useful comparison measures
- 4 -
for individual site performance and add context to the level and trend of performance.
6. Data Sharing: Sharing the NSQIP data within the hospital’s organized committees and aligning the NSQIP quality improvement opportunities with the hospital’s quality improvement priorities is essential to make the necessary system and process changes for surgical improvement.
7. Building Relationships: Critical to the success of any collaborative is building relationships of trust among all parties to develop a culture of shared learning and continuous improvement. TSQC has been successful in building trust among the lead agencies, as well as among the individual surgeons and collaborative team members across the participating sites.
The collaborative demonstrates through this report that the June 2011 report of improvement progress is being consistently achieved over time. The TSQC continues to accomplish the major objectives of the grant by demonstrating that Tennessee hospitals and surgeons are committed to working together collaboratively to continuously improve surgical quality. As noted in the previous report, the reduction in complications demonstrates the value of participation in the national NSQIP program, as well as the benefits of a state collaborative to support local sharing and learning.
TIMELINE AND MEASURES OF SUCCESS TIMELINE ACTIVITIES MEASURES OF SUCCESS
January – May 2012 June- December 2012
Complete memorandums of understanding and data use agreements with new hospital partners
Secure commitment of surgeon champions from new hospital participants
Hospitals hire surgical clinical reviewers SCRs complete ACS NSQIP training and education Begin data submission to NSQIP for new hospital
participants and continued data submission for existing hospitals
Consult with NSQIP and other state collaboratives Participate in conference calls with NSQIP Match existing participant hospitals as mentors to new
hospital partners Provide education and mentoring for hospitals and
surgeon champions Host quarterly networking meeting of collaborative
partners Participate in national ACS NSQIP meetings and TN
ACS annual meeting Present TSQC update at TN ACS annual meeting Data Analysis
o Quarterly trends for QI monitors o Annual analysis of year to year aggregate
performance trends Review of blinded site-specific TN hospital data reports
Expansion of up to 11 additional hospitals (up to 21 total) Execute MOU and data use agreements among ACS
NSQIP, hospitals, and TSQC coordinating center Renewal of clinical leadership committee of TN ACS
surgeon champions Established criteria for participation and hospital selection
of program module i.e. classic, essentials, small/rural Host organization meeting of participating hospitals and
surgeons New surgical clinical reviewer training completed Monthly meetings/conference calls conducted among nurse
reviewers with mentoring by experienced nurse reviewers New surgical clinical reviewer training completed New surgeon champion orientation completed Participating hospitals meet NSQIP data validation
requirements Participation of hospitals in collaborative regional meetings Presentations and case studies on QI opportunities from at
least three hospitals per meeting Data analysis and identification of QI focus area(s) from TN
aggregate and blinded site-specific data Implementation of QI plan for TSQC participants based on
identified QI opportunities
TIMELINE AND MEASURES OF SUCCESS TIMELINE ACTIVITIES MEASURES OF SUCCESS
January –December 2013
to identify QI opportunities by clinical leadership committee
Quarterly CEO/Leadership summary performance reports
Host state/regional surgical care conference with national speakers and provide a forum for presenting best practices to improve surgical outcomes with all Tennessee hospitals
Continue collaborative partners networking meetings
four times a year Education for new members on NSQIP risk adjusted
reports (first report July 2013) and TSQC data analysis Data Analysis
o Quarterly trends for QI monitors o Annual analysis of year to year aggregate
performance Implementation of strategies and sharing of best practices
based on data analysis and QI plan Develop best practice interventions/toolkits from national
NSQIP resources and TSQC findings Evaluation of QI strategies – quantitative and qualitative
to develop best practices and lessons learned for sharing
Based on data analysis, the QI plan will include
identification of specific procedures and/or processes for improvement, planned interventions, study and evaluation of resultant outcomes
Annual update of QI plan for TSQC based on identified QI
opportunities Sharing and site visits among surgeon champions/mentors
and participating hospitals Presentations and case studies of lessons learned and best
practices among participants Presentations at regional and national meetings and in peer-
reviewed publications Documented improvements in outcomes (TN aggregate and
blinded site-specific data) based on implementation of QI plan
Identification and sharing of lessons learned and best practices at statewide meetings of the TN Center for Patient Safety and TN ACS annual meeting
TIMELINE AND MEASURES OF SUCCESS TIMELINE ACTIVITIES MEASURES OF SUCCESS
January-December 2014
Continue Collaborative Partners meeting four times a
year Education for new members on NSQIP risk adjusted
reports; development of site specific action plans for improvement
Data Analysis o Quarterly trends for QI monitors o Annual analysis of year to year aggregate
performance Implementation of strategies and sharing of best practices
based on data analysis and QI plan Evaluation of QI strategies – quantitative and qualitative
to develop best practices and lessons learned for sharing Project Evaluation
o Documented Improvements o QI Interventions and Outcomes o Participant surveys and feedback
Sustainability Plans o Financial Impact Analysis o Identification of future funding opportunities
Host a surgical care conference with national speakers and provide a forum for sharing TSQC results and best practices with hospitals across the state
Annual update of QI plan for TSQC based on identified QI
opportunities Sharing and site visits among surgeon champions/mentors
and participating hospitals Presentations and case studies of lessons learned and best
practices among participants Presentations at regional and national meetings and in peer-
reviewed publications Documented improvements in outcomes (TN aggregate and
blinded site-specific data) based on implementation of QI plan
Identification and sharing of lessons learned and best practices at statewide meetings of the TN Center for Patient Safety and TN ACS annual meeting
Completed Program Evaluation by March 1, 2015 Development of Sustainability Plans
QI
2012 Colorectal SSI Reduction Initiative The Tennessee Surgical Quality Collaborative (TSQC) is introducing a quality improvement initiative across our 10 hospitals for the goal of reducing colorectal SSI. Colorectal SSI is an important source of patient morbidity and increased cost, and in 2012 CMS will be publishing non-risk adjusted hospital infection rates. Based on study of peer-reviewed surgical literature, a “best-practice” bundle has been created for implementation and eventual data collection. This bundle is a manageable way of focusing attention on reducing SSI in colorectal surgery by consistently implementing 4 evidence- based practices.
I. Normothermia: Core temperature should be maintained >36 degrees Centigrade for the duration of operation and recovery room stay. II. Normoglycemia: Blood glucose levels are ideally maintained < 200 on the day of surgery and throughout the post-operative care phase. III. Appropriate antibiotic use: Pre-operative antibiotics should be chosen appropriately, given within one hour before incision, and re-dosed in operations longer than 3 hours when appropriate. IV. Supplemental Fi02: Fraction of inspired oxygen at 80% administered through the anesthesia ventilator and by non-rebreather at 15L/minute for 6 hours post-operatively has been shown to be beneficial in SSI reduction. TSQC participating hospitals are encouraged to implement these practices for the combined goal of improving patient outcomes and affecting cost savings across our state.
Colectomy Bundle Recommendation Evidence Summary
Resource Summary Findings Comments A bundle of interventions to
reduce colorectal surgical infections Bull A, et al
Implementation of • Normothermia • Normoglycemia • Oxygen delivery • Appropriate antibiotics
Colorectal surgical site infection 15% > 7% (not statistically significant
Small sample size Difficulty to implement and maintain; low compliance with individual components Infection rates fell over the subsequent 12 months.
Oxy
gena
tion
Perioperative supplemental oxygen therapy and surgical site infection: a meta-analysis of randomized controlled trials Qadan M et al
Meta-analysis 5 RCTs Control FiO2 .30 - .35; Study FiO2 .80 for 2-6 hours postoperatively 30 day follow up 3 studies colorectal; 2 studies multispecialty
Surgical site infection rates 12% control; 9% hyperoxic. Relative risk reduction Greater benefit in colorectal procedures
Variable use of abx, blood loss among studies No standard definition of infection Significant improvement in all but one study, where SSI rate increased.
Nor
mot
herm
ia Perioperative Normothermia
to reduce the incidence of surgical wound infection and shorten hospitalization Kurz et al
Double-blind RCT demonstrating triple the incidence of SSI and pronged hospitalization in patients undergoing colectomy with intraoperative hypothermia
Surgical site infection in 19% of patients with intraoperative hypothermia and 6% of patients with intraoperative normothemia.
Standard preoperative prep; cases risk-adjusted for smoking, BMI, wound class, length of surgery. Clinical diagnosis of SSI.
Glu
cose
Co
ntro
l
Scientific Principles and Clinical Implications of Perioperative Glucose regulation and control Akhtar, S et al
Review article evaluating glucose control in the preoperative, intraoperative, and postoperative periods
Though there are unresolved questions regarding appropriate control it is prudent to maintain glucose levels < 180 mg / dL
The authors site heterogeneity in many of the included studies as a limitation to the analysis; postoperative control appears to have the most significant effect on postoperative complications
Ant
imic
robi
al
prop
hyla
xis
Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project Bratzler DW et al
Consensus position statement from the Surgical Infection Prevention Guidelines Writers Group
Optimal prophylaxis ensures that adequate concentrations of an appropriate antimicrobial are present in the serum, tissue, and wound during the entire time that the incision is open and at risk for bacterial contamination.
This article is a primary source document for SCIP guidelines
Colectomy Bundle Recommendation Evidence Summary
Bull A, Wilson J, Worth LJ, Stuart RL, Gillespie E, Waxman B, Shearer W, Richards M. A bundle of care to reduce colorectal surgical infections: an Australian experience. J Hosp Infect. 2011 Aug;78(4):297-301. Epub 2011 Jun 12. PubMed PMID: 21664720.
Qadan M, Akça O, Mahid SS, Hornung CA, Polk HC Jr. Perioperative supplemental oxygen therapy and surgical site infection: a meta-analysis of randomized controlled trials. Arch Surg. 2009 Apr;144(4):359-66; discussion 366-7. Review. PubMed PMID: 19380650.
Kurz A, Sessler D, Lenhardt R Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. NEJM 334(19): 1209-1215. 10.1056/NEJM199605093341901.
Akhtar, S; Barash, PG; Inzucchi, SE Scientific Principles and Clinical Implications of Perioperative Glucose Regulation and Control. Anesthesia and Analgesia, 110(2): 478-497. 10.1213/ANE.0b013e3181c6be63.
Bratzler DW Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis. 38(12):1706-15. Epub 2004 May 26. PMID: 15227616.
Using TSQC data to preoperatively assess postoperative risk.
The chart at the left shows preoperative characteristics that, based on TSQC data, constitute a risk for a postoperative occurrence. The preoperative characteristics are listed in the first column and the postoperative events are shown vertically in the column headings. Elevated risk of a specific postoperative event is shown by a red square. Example: Pneumonia Elevated risk of pneumonia exists at:
1) Increasing age 2) The presence of COPD preoperatively 3) The case is an emergency surgery 4) Pre-surgical functional status is partial or total
dependence. 5) The presence of renal failure preoperatively 6) Current smoker 7) Transfer from an acute care or chronic care
facility to have surgery 8) Preoperative transfusion 9) Preoperative weight loss 10) Contaminated or dirty/infected wounds.
Prevalence of preoperative risk factors (3rd quarter 2009 through 2nd quarter 2011):
Case Type
Preoperative Characteristic Pneumonia All
Age(years) 63.4 55.9
COPD 23.1% 7.9%
Emergency 31.5% 11.3%
Partial/Total Dependence 61.8% 6.2%
Renal Failure 5.7% 0.7%
Smoker 33.2% 26.0%
Transfer from acute or chronic care facility 17.3% 4.2%
Transfusion 7.1% 1.4%
Weight loss 5.1% 2.0%
Contaminated or dirty/infected wounds 71.1% 50.1%
Cases 819 29298
Preoperative Risk Assessment Tools
Significant Preoperative Risk Factor ACUTE REN
AL FA
ILURE
CARDIAC ARREST REQ
UIRING CPR
COMA > 24 HOURS
DEEP IN
CISIONAL SSI
DVT Requiring Therapy
GRAFT/PROSTHESIS/FLAP FAILURE
MORTA
LITY
MYO
CARDIAL INFA
RCTION
ON VEN
TILATO
R > 48 HOURS
ORGAN/SPACE SSI
PERIPHERAL NERVE INJURY
PNEU
MONIA
PROGRESSIVE REN
AL INSU
FFICIENCY
PULM
ONARY EM
BOLISM
SEPSIS
SEPTIC SHOCK
STROKE/CVA
SUPERFICIAL INCISIONAL SSI
UNPLANNED
INTU
BATION
URINARY TRACT INFECTION
WOUND DISRUPTION
AGE
ALKALINE PHOSPHATASE > 125
ANGINA
ASA1
ASA2
ASA3
ASA4
ASA5
ASA6
ASCITES
BILIRUBIN > 1.0
BLEEDING
BMICLASS1 < 18.5
BMICLASS2 18.5 ‐ 24.99
BMICLASS3 25.0 ‐ 29.99
BMICLASS4 30.0 ‐ 34.99
BMICLASS5 35.0 ‐ 39.99
BMICLASS6 > 40
BUN > 40
CANCER
CHEMOTHERAPY
CHF
CNS
COMA
COPD
Creatinine > 1.2
CVA_NEURO
CVA_NO_NEURO
Diabetes Insulin
Diabetes Oral Med
DIALYSIS
DNR
DYSPNEA AT REST
DYSPNEA MODERATE EXERTION
EMERGENCY
ESOPHAGEAL VARICES
ETOH
FEMALE
GANGRENE
Hematocrit > 45
HEMIPLEGIA
HYPERTENSION REQUIRING MEDS
MALE
MI
OPEN_WOUND
PARA(PLEGIA/PARESIS)
PARTIALLY DEPENDENT
Platelets > 150
PNEUMONIA
PREGNANT
PREVIOUS CARDIAC SURGERY
PRIOR OPERATION WITHIN 30 DAYS
PT > 13.2
PTCA
PVD‐REVASC OR AMPUTATION
QUADRI(PLEGIA/PARESIS)
Race‐African American
Race‐Asian
Race‐White
RADIOTHERAPY
RENAL FAILURE
SENSORIUM
SEPSIS
SGOT > 40
SMOKER
Sodium < 135
Sodium > 145
STEROID
TIA
TOTALLY DEPENDENT
TRANSFER FROM ACUTE CARE FACILITY
TRANSFER FROM CHRONIC CARE
TRANSFER FROM OTHER
TRANSFER FROM VA ACUTE CARE
TRANSFER FROM VA CHRONIC CARE
TRANSFUSION
VENTILATOR
WBC > 11.0
WEIGHT LOSS
WOUNDCLASS CLEAN
WOUNDCLASS CLEAN/CONTAMINATED
WOUNDCLASS CONTAMINATED
WOUNDCLASS DIRTY/INFECTED
Significant Risk (OR Lower Bound > 1.0)
Postoperative Occurrences
Preoperative Risk of Postoperative Occurrence
The quantitative methodological capacity to identify significant risk for a specific postoperative occurrence by procedure is limited due to small numbers, but for some, typically higher volume procedures, some risks can be identified; those are shown in the table below:
Procedure ACUTE REN
AL FA
ILURE
CARDIAC ARREST REQ
UIRING CPR
COMA > 24 HOURS
DEEP IN
CISIONAL SSI
DVT Requiring Therapy
GRAFT/PROSTHESIS/FLAP FAILURE
MORTA
LITY
MYO
CARDIAL INFA
RCTION
ON VEN
TILATO
R > 48 HOURS
ORGAN/SPACE SSI
PERIPHERAL NERVE INJURY
PNEU
MONIA
PROGRESSIVE REN
AL INSU
FFICIENCY
PULM
ONARY EM
BOLISM
SEPSIS
SEPTIC SHOCK
STROKE/CVA
SUPERFICIAL INCISIONAL SSI
UNPLANNED
INTU
BATION
URINARY TRACT INFECTION
WOUND DISRUPTION
AAA
AI OPEN
Amputation
Appendectomy
Bariatric surgery
Breast
Carotid endarterectomy
Cholecystectomy
Colectomy
Debride / I&D
Endo AAA
Esophagectomy
Ex lap / enterectomy
Gastric
Hepatobiliary / pancreatic
Hernia
LE Bypass Open
other, gen
Other,vasc
Proctectomy
Rectal
Thoracic Aneurysm
Thyroidectomy
Tumor excision / lymphadenectomy
Vascular bypass / repair
Significant Risk (RR Lower Bound > 1.0)
Postoperative Occurrences
Procedure Risk for Specific Postoperative Occurrences
The procedure risk of any postoperative occurrence (rather than a specific postoperative occurrence) is shown in the chart titled “Risk Adjusted Postoperative Occurrence by Procedure Group”, above where all postoperative occurrences are summed for each procedure. The procedure group risk of a specific postoperative occurrence in groups with small numbers cannot be estimated well. For example in thoracic aneurysm there are only 67 cases in our data set, while there are 3,257 colectomies. This chart helps illustrate the overall risk of a postoperative occurrence even for small number procedures.
Example: The procedure risk of urinary tract infection (UTI) is elevated only for colectomy where the prevalence of UTI is 4.9% (126/2,551) compared to 2.1% for all cases (621/29,298).
Resources
How to Read the TSQC Leadership Report
How to Read the Leadership Report Page 1
Risk adjustment – A risk model is employed to estimate the expected number of postoperative occurrences based on the characteristics of the patients on which procedures are performed. Charts – All of the charts display relative risk either over time or across postoperative occurrences. The relative risk can fall into one of three categories; 1) as expected, 2) significantly above expected or 3) significantly below expected. Reading the relative risk – The relative risk is a comparison of risks for a specific measure, usually a postoperative occurrence the ratio is the observed occurrence of the postoperative occurrence compared to the expected value based on the risk adjustment model. 1) If the expected number of postoperative occurrence is less than the observed the relative risk will be greater than one; 2) if the expected number of postoperative occurrences is larger than the observed number the relative risk will be less than one. The sample chart below shows that the statistical significance of the relative risk and associated 95 percent confidence interval can be read in two ways: 1) If the relative risk and its confidence interval crosses the value of 1 the relative risk is neither greater nor less than the average, it is “as expected”. If the lower limit of the confidence interval is greater than 1 the relative risk is “significantly above expected” and if the upper limit of the confidence interval is below 1, the relative risk is “significantly below expected”. 2) If the relative risk is represented by a green square the relative risk is “as expected”; if a red square the relative risk is “significantly above expected”; if a blue square the relative risk is “significantly below expected”.
How to Read the TSQC Leadership Report
How to Read the Leadership Report Page 2
Reading the trend – in the sample trend chart below the trend of the relative risk over time has been plotted. The trend shows that the postoperative occurrence Z is increasing significantly. Significance is shown by the P value listed in the text box in the chart. The P value may be interpreted as follows: P > 0.1 the trend is not different than zero P < 0.1 and > 0.05 is a marginally significant trend P < 0.05 is a significant trend
An r-squared statistic can be interpreted as the proportion of the variation in y (relative risk) that is explained by the variation in x (in this case time). The sample chart shows a statistically significant worsening trend for the risk of postoperative occurrence X at site Z. Reading the table – The table displays the digital form of the relative risk by postoperative occurrence and a comparison of observed postoperative occurrences to expected postoperative occurrences estimated from the risk model. A cost measure is shown that compares the additional cost of health care for cases in which the observed numbers of postoperative occurrences are greater/lesser than the expected number of postoperative occurrences. Lower costs than expected are shown in blue while greater costs than expected are shown in red. The unit cost estimates are based on references cited in the report.
Tennessee Surgical Quality Collaborative Scorecard for 2010 Site: Example Total Site Cases: 1, 624 Total TSQC Cases: 14,901
TSQC Scorecard Page 1
Full Year 2010Postoperative Occurrences Observed Expected TSQC Observed/TSQC(%) Upper Bound Lower Bound Relative Risk Avoidable Cost* Unit Costs**
Cases 1624 14901 10.9%
ACUTE RENAL FAILURE 10 10 77 13.0% 2.7 0.4 1.0
COMA > 24 HOURS 0 0 7 0.0% 0.0 0.0 0.0
CARDIAC ARREST REQUIRING CPR 8 9 80 10.0% 2.6 0.3 0.9
DEEP INCISIONAL SSI 3 10 108 2.8% 1.2 0.1 0.3
DVT Requiring Therapy 28 22 110 25.5% 2.3 0.7 1.3GRAFT/PROSTHESIS/FLAP FAILURE 2 2 36 5.6% 13.8 0.1 1.0MYOCARDIAL INFARCTION 7 8 80 8.8% 2.8 0.3 0.9ON VENTILATOR > 48 HOURS 76 62 372 20.4% 1.7 0.9 1.2ORGAN/SPACE SSI 77 61 263 29.3% 1.8 0.9 1.3PULMONARY EMBOLISM 7 5 57 12.3% 5.6 0.4 1.4
PERIPHERAL NERVE INJURY 0 0 3 0.0% 0.0 0.0 0.0
PNEUMONIA 77 49 384 20.1% 2.3 1.1 1.6 610,463$ $22,097
PROGRESSIVE RENAL INSUFFICIENCY 12 10 80 15.0% 3.1 0.5 1.2
SEPTIC SHOCK 31 22 178 17.4% 2.6 0.8 1.4
SEPSIS 64 46 251 25.5% 2.1 0.9 1.4STROKE/CVA 4 3 44 9.1% 9.1 0.2 1.3
SUPERFICIAL INCISIONAL SSI 102 67 429 23.8% 2.1 1.1 1.5 975,273$ $27,631
UNPLANNED INTUBATION 37 30 242 15.3% 2.1 0.7 1.2
URINARY TRACT INFECTION 48 43 314 15.3% 1.7 0.7 1.1
WOUND DISRUPTION 3 8 97 3.1% 1.6 0.1 0.4
MORTALITY 36 34 352 10.2% 1.7 0.6 1.1
Total 632 499 3564 17.7% 1,585,736$ * Formula is for significant
observations only (observed
occurrences - expected
occurrences)*unit costs
** Unit Costs Source NSQIP and
Society of Actuaries
95 % Confidence Interval
Tennessee Surgical Quality Collaborative Scorecard for 2010 Site: Example Total Site Cases: 1, 624 Total TSQC Cases: 14,901
TSQC Scorecard Page 2
Tennessee Surgical Quality Collaborative Scorecard for 2010 Site: Example Total Site Cases: 1, 624 Total TSQC Cases: 14,901
TSQC Scorecard Page 3
Tennessee Surgical Quality Collaborative Scorecard for 2010 Site: Example Total Site Cases: 1, 624 Total TSQC Cases: 14,901
TSQC Scorecard Page 4
American College of SurgeonsInspiring Quality:Highest Standards, Better Outcomes
ACS NSQIP® Partners with Johns Hopkins and Dr. Peter Pronovost to Develop Surgical CUSP Program
Johns Hopkins University and the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) are partnering to develop, implement and evaluate a program to improve surgical patient outcomes and prevent complications based on the successful Comprehensive Unit-Based Safety Program (CUSP).
Funded by a contract from the Agency for Healthcare Research and Quality (AHRQ), this unique program brings learnings from CUSP to a new level by incorporating clinical, risk-adjusted, 30-day outcomes data from ACS NSQIP.
ACS NSQIP provides the best possible metrics for measuring outcomes and improvements in the program, which will focus on implementing evidence-based protocols to prevent complications, improving teamwork, and understanding process to implement and sustain organization changes. The goal is to develop an educational toolkit that can be used nationally to improve surgical care.
The program will focus on ImPlemeNTINg evidence-based protocols, ImProvINg teamwork and SUSTAININg organizational change.
CUSP was developed in 2001 at Johns Hopkins University to improve the culture of safety in intensive care units. CUSP focuses on educating and improving awareness of patient safety and quality of care, empowering staff to take charge to improve safety, building partnerships between units and hospital administration to improve organizational culture, and providing tools to investigate and learn from mistakes.
Many of the important learnings from the CUSP program will be used in developing Surgical CUSP. Initially, participating hospitals will use Surgical CUSP tools to improve colectomy outcomes and prevent surgical site infections (SSI). In the future, the team’s goal is to expand the program into other surgical procedures and address other complications/outcomes.
The program will be rolled out beginning in 2012 with a pilot program involving 100 ACS NSQIP hospitals – 10 hospitals in 10 states. ACS NSQIP Hospitals will work together to implement specific quality improvement initiatives, including a recognized teamwork program developed by the Department of Defense and AHRQ, and a modified version of the World Health Organization’s (WHO) surgical checklist. In the future, the program will be expanded nationally.
ACS NSQIP hospitals will have a distinct advantage in measuring outcomes and driving improvement based on clinical, risk-adjusted data.
The program’s principal investigators are Dr. Peter Pronovost, Johns Hopkins University, and Dr. Clifford Ko, American College of Surgeons.
Watch for more information in the coming months. For questions, contact:
Phased rollout of Surgical CUSP
INITIAl PHASe: 100 ACS NSQIP participating hospitals – 10 in 10 states
FUTUre PHASe: National expansion
Gina M. Pope, RN, CNORBusiness Development RepresentativeEmail: [email protected]: 312-202-5607
Tresha RussellBusiness Development RepresentativeEmail: [email protected]: 312-202-5441
Join Leading Hospitals in CMS National Surgical Quality Pilot
For the first time, hospitals across the country have the opportunity to report surgical outcomes to Hospital Compare, the Centers for Medicare and Medicaid Services website that provides quality information to health care consumers.
By joining the Pilot, hospitals will gain invaluable insight into CMS’ new direction in surgical measures and will be well positioned for the future of public reporting.
Hospitals can voluntarily, publicly report one or any combination of three surgical measures—elderly surgery outcomes, colectomy outcomes, and lower-extremity bypass outcomes—through the American
College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®).
ACS NSQIP hospitals can join the Hospital Compare Pilot by indicating their interest to ACS by May 1, 2012. Non-NSQIP hospitals should contact ACS to learn how to join the pilot by March 1, 2012. CMS will publicly release information on Oct. 19, 2012.
Benefits of Participation
Put your hospital ahead of the curve for the future of public reporting•Showcase your hospital’s leadership in the pursuit of surgical quality and accountability•
Improve your quality & financial performance. Per hospital, per year, ACS NSQIP hospitals1: •Prevent 250-500 complications ◦Save an average of 12-36 lives◦Save millions of dollars in preventable complications◦
For questions or to indicate interest, e-mail [email protected] or phone Gina Pope 312-202-5607 or Tresha Russell 312-202-5441.
1. Hall BL. Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program. Ann
Surg. 2009: 250.
Online January 19, 2012
This page and all contents are Copyright © 2012 by the American College of Surgeons, Chicago, IL 60611-3211
Page 1 of 1American College of Surgeons: CMS National Surgical Quality Pilot
2/21/2012mhtml:file://C:\Documents and Settings\rcarroll\Local Settings\Temp...
Joint Commission Center for Transforming Healthcare
Currently Recruiting Pilot Sites for Colorectal Surgical Site Infection Project The Center for Transforming Healthcare is currently recruiting organizations interested in participating as pilot sites for the Colorectal Surgical Site Infection (SSI) project. The SSI project was launched in August, 2010 in collaboration with the American College of Surgeons with the goal of reducing SSI in patients having colorectal surgical procedures. The project is now entering the pilot testing stage to validate the root causes and solutions that were determined by the participating hospitals. There are two phases of pilot testing. In Phase 1, pilot sites will be working with Center staff to complete an SSI project to validate the root causes and solutions developed by the original collaborating organizations. There are approximately four conference calls and three to four on‐site visits at the pilot organizations that last approximately one to two days. Project support, including data analysis, will be provided by a Center Black Belt. Pilot sites are required to provide resources for their staff to participate and pay for travel and lodging of one Black Belt during the on‐site visits. Recruitment goal for Phase 1 pilot testing is four to six organizations by April, 2012. In Phase 2, pilot sites will be conducting an SSI project at their organization while testing the Targeted Solutions Tool™. The tool is self‐guided, but Center Black Belts are available to provide distance support to organizations as they complete their projects. Pilot sites are required to provide resources for their staff to participate in the project, but additional financial resources are not required. Recruitment goal for Phase 2 pilot testing is ten organizations by August, 2012. There are many benefits to organizations that serve as pilot sites:
Assisting the Center in its aim to transform health care into a high‐reliability industry by
solving healthcare’s most critical safety and quality problems
Access the Center solutions prior to national release
Access to the tools developed and used by the participating hospitals
Additional information is available on the attached brochure, “The Surgical Site Infections Project”. If you are aware of any organization that is potentially interested in being a pilot site, please contact Siew Lee Grand‐Clement, sgrand‐[email protected] or Donise Musheno, [email protected].