ACS NSQIP:Preventing complications Reducing costsImproving surgical care

May 17, 2014

Scott Ellner, DO, MPH, FACSSaint Francis Hospital and Medical Center

Disclosures

No relevant disclosures related to this presentation.

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Increasing Focus on Improving Quality While Reducing Costs

Decisions are being made now – and we have opportunities to get ahead of CMS actions:

• CMS readmissions penalties and value-based purchasing

• Hospital Compare and other public reporting

• Physician quality reporting

• General surgery registry rule

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Which Direction will Quality Improvement Go?

We’ve Found Common Ground

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ACS NSQIP: What’s Different?

Developed by surgeonsClinical, not administrative, dataRisk-adjusted and case-mix adjusted National benchmarking30-Day patient follow upAuditedTrained data collector

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Clinical Data Better for Measuring Quality

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Risk and Case-Mix Adjustment Matters

To judge care fairly and understand where problems are occurring: Health of the patient must be consideredRisk of the procedure must be considered

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Following Patients After Discharge

• Half or more of all complications occur after discharge1

• Quality programs based on admin data don’t track post-discharge

• Complications after discharge can lead to readmissions2

Tracking quality can’t stop at the hospital’s door

1 Ko CY. “ACS NSQIP Conference Overview.” Presentation to the 2009 ACS NSQIP National Conference. July 2009.2 Kassin MT et al. “Risk Factors for 30-Day Hospital Readmissions among General Surgery Patients.” J Am Coll Surg. 2012; 215: 322-30. 9

ACS NSQIP: Proven to Reduce Complications, Save Lives

2009 Annals of Surgery study: Prevent 250-500

complications annually

Save 12-36 lives annually

Leading to reduced costs

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Surgical Complications Drive Readmissions

2012 Journal of the American College of Surgeons study: • Surgical complications

key driver of 30-day readmissions

• SSIs – 22%• Gastrointestinal – 28%• Pulmonary – 8%

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ACS NSQIP: Better Care, Lower Costs

Not only will patients benefit, but hospitals see a significant return on their investment with ACS NSQIP.• Significant cost savings per year• Reduced readmissions and

reduced lengths of stay translate to better patient outcomes, better satisfaction and even more cost reduction

• Pays for itself by avoiding about a dozen surgical complications

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ACS NSQIP Meets Regulatory Requirements

CMS general surgery registry rule began this FYACS NSQIP measures reported on Hospital Compare

(voluntary) Five ACS NSQIP measures being considered for

national adoption by CMS ACS NSQIP’s SSI harmonized with CDC’s NHSN

program Joint Commission Quality Check for participationPart of SUSP program supported by AHRQ

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ACS NSQIP Meets Regulatory Requirements

CMS general surgery registry rule began this FYACS NSQIP measures reported on Hospital Compare

(voluntary) Five ACS NSQIP measures being considered for

national adoption by CMS ACS NSQIP’s SSI harmonized with CDC’s NHSN

program Joint Commission Quality Check for participationPart of SUSP program supported by AHRQ

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Why the Foley?

Everybody gets a catheter

Post-Operative Urinary Tract Infections

Observed Rate: 2.41%Expected Rate: 1.47%O/E Ratio: 1.64Status: Needs Improvement

2008

The CAUTI Gang

32-40% of all nosocomial infections

Adds an average of 1-3 additional hospital days

UTIs increase a patient's hospital costs by 47 % at teaching hospitals and 35 % at community hospitals

Roberts RR Clin Infect Dis , 2009

Next Steps

Build a guiding coalition

Drill down on data

Determine why patients developed the infection

Share key findings with key stakeholders

Surgeons

Quality

ICU/Ward Nurses

Infection Prevention

Admin

OR Staff

Share Data

Leadership

Model the Way

Challenge the Process

Share a Vision

Empowerment

CAUTI Sub-Committee

Goals – Time Sensitive

Drill down

Pilot Audit

Implementation

Sustainability

ACS Clinical Guidelines

Prior to Insertion:

During Insertion:

After Insertion:

• Education

• Trained personnel• Hand hygiene

• Secured catheter• Closed Drainage• Urimeter positioning

Nurse Driven Protocol

Automatic Order Set

Catheter Needed?

Remove by Post-op Day 2

Catheter Still In? Why?

Documentation Situational Leadership

Nurse Driven Protocol

Patients PreIntervention

N=1,404*

PostIntervention

N=2,469*

p

UTI 36 2.6% 38 1.5% <.05

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Pre-Intervention: September 2007 – December 2008

Post-Intervention: January 2009 – December 2010

*Number of patients undergoing general surgery captured in the NSQIP database.

C. Difficile Prevention

Derkonja DM JAMAintmed 2013

Silver Prices

$160,000 savings/yearPickard P Lancet 2012

Barriers

1) Complacency2) Resistance 3) Exposing failures4) Challenging years of

embedded culture5) Compliance6) Training7) Uneasy Leadership

A Business Case for Reducing Catheter-Associated Urinary Tract Infections

A Study Using ACS National Surgical Quality Improvement Program Data

Return on Investment

Return on Investment

General &VascularSurgery

UTI

N=74

Length of Stay (days)

Mean

Excess Costs/Patient*

Mean

CommentsPatient

Occurrences

Cases Identified

Inpatient 41 28.5 $52,384

5 deaths9 C. Diff (+)

Outpatient 33 6 $758

2 readmissions4 ED visits

29 * Variable CostsZimlichman E JAMAint 2013

62% Reduction

Observed Rate: 1.23%Expected Rate: 1.43%O/E Ratio: 0.86Status: As Expected 2014

2008

Surgical Checklist Verified with ACS NSQIP Data

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Take Home Points

• ACS NSQIP metrics are actionable• Share data and acknowledge need

for change• Implement a CAUTI prevention protocol• Recognize and address barriers• It’s all about leadership