ACS NSQIP:
Preventing complications
Reducing costs
Improving surgical care
May 17, 2014
Scott Ellner, DO, MPH, FACS
Saint Francis Hospital and Medical Center
Disclosures
No relevant disclosures related to this
presentation.
2
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 valuebased purchasing
• Hospital Compare
and other public
reporting
• Physician quality
reporting
• General surgery
registry rule
3
Which Direction will
Quality Improvement Go?
We’ve Found Common Ground
5
ACS NSQIP: What’s Different?
Developed by surgeons
Clinical, not administrative, data
Risk-adjusted and case-mix adjusted
National benchmarking
30-Day patient follow up
Audited
Trained data collector
6
Clinical Data Better for
Measuring Quality
7
Risk and Case-Mix Adjustment Matters
To judge care fairly and understand where
problems are occurring:
Health of the patient must be considered
Risk of the procedure must be considered
8
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.
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ACS NSQIP: Proven to Reduce
Complications, Save Lives
2009 Annals of Surgery
study:
 Prevent 250-500
complications
annually
Save 12-36 lives
annually
Leading to reduced
costs
10
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%
11
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
12
ACS NSQIP Meets Regulatory
Requirements
 CMS general surgery registry rule began this FY
 ACS 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 participation
 Part of SUSP program supported by AHRQ
13
ACS NSQIP Meets Regulatory
Requirements
 CMS general surgery registry rule began this FY
 ACS 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 participation
 Part 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: 1.64
Status: 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
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:
• Education
During Insertion:
• Trained personnel
• Hand hygiene
After Insertion:
• 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
UTI
Pre
Intervention
Post
Intervention
N=1,404*
N=2,469*
36
2.6%
38
p
1.5%
<.05
Pre-Intervention: September 2007 – December 2008
Post-Intervention: January 2009 – December 2010
*Number of patients undergoing
general surgery captured in the NSQIP database.
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C. Difficile Prevention
Derkonja DM JAMAintmed 2013
Silver Prices
Pickard P Lancet 2012
$160,000 savings/year
Barriers
1)
2)
3)
4)
Complacency
Resistance
Exposing failures
Challenging years of
embedded culture
5) Compliance
6) Training
7) Uneasy Leadership
Return on Investment
A Business Case for Reducing CatheterAssociated Urinary Tract Infections
A Study Using ACS National Surgical
Quality Improvement Program Data
Return on Investment
General &
Vascular
Surgery
UTI
Length of
Stay (days)
Excess
Costs/Patient*
N=74
Mean
Mean
Cases Identified
Inpatient
Comments
Patient
Occurrences
5 deaths
9 C. Diff (+)
41
28.5
$52,384
2 readmissions
4 ED visits
Outpatient
29
33
Zimlichman E JAMAint 2013
6
$758
* Variable
Costs
62% Reduction
Observed Rate:
1.23%
Expected Rate:
1.43%
O/E Ratio: 0.86
Status: As
Expected
2008
2014
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