AMERICAN COLLEGE OF SURGEONS
National Surgical Quality Improvement Program
Local, State, and
National Initiatives
Barbara J. Martin RN MBA CCRN
Sherree Levering RN
Oscar D. Guillamondegui MD MPH FACS
National Surgical Quality
Improvement Program
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Objective: Describe components of National Surgical Quality Improvement Program
(NSQIP)
In order to receive full contact-hour credit for the CNE activity, you must
– Be present no later than five (5) minutes after starting time
– Remain until the scheduled ending time
– Complete /submit Evaluation form before leaving at the conclusion
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Conflict of Interest: None
Commercial Support: None.
Non-Endorsement of Products: None
– Accredited status does not imply endorsement by Vanderbilt Medical Center, TNA or ANCC of any
products that might be displayed in conjunction with this program.
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Off-label Product Use: N/A
Accreditation Statement
– Vanderbilt University Medical Center, Department of Nursing Education and Professional
Development is an approved provider of continuing nursing education by the Tennessee Nurses
Association, an accredited approver by the American Nurses Credentialing Center’s Commission
on Accreditation.
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1.0 Contact Hour
National Surgical Quality
Improvement Program
• Initially developed by the VA to risk-adjust
outcomes in response to public concerns
• American College of Surgeons expanded the
program to the private sector in 2004
• Currently 408 hospitals enrolled
– Community / Private / Academic
– Half have fewer than 500 beds; program is
expanding options to include smaller facilities
ACS NSQIP
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Validated, clinically-based data collection
Collects and analyzes clinical outcomes data
Measures quality of systems of care
Quantifies 30-day risk-adjusted surgical
outcomes, including morbidities and mortality
• Blinded comparison with national performance
• Currently working with CMS to develop outcomes
measures for surgical procedures
We Give NSQIP . . .
• 40 cases every 8 days (minimum 1680 / year)
– Random sampling General and Vascular Surgery
– Targeted procedure selection: 100% capture
• Colectomy
• Proctectomy
• Ventral Hernia Repair
– Inpatient and outpatient procedures
• Selected by service and CPT code
• Age > 17
• Trauma / Transplant excluded during that admission
Data Collection
• Manual chart review and abstraction
• Strict definition of abstracted elements
• 150 variables
– Demographics, preoperative factors and labs
• Medical and surgical history
• Acute and chronic clinical risk factors
– Intraoperative events
– Postoperative occurrences, discharge data
• Infectious complications—surgical site, urinary, pneumonia
• Technical occurrences—graft failure, bleeding
• Other events—reintubation, renal failure, cardiac arrest
Preoperative Risk Factors
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BMI
Smoking
Diabetes
CHF Exacerbation
Ascites
COPD
Weight loss
Functional Status
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Surgery within 30 days
Open wounds
Sepsis / Septic shock
Impaired Sensorium
Acute Renal Failure
Dialysis
Preoperative Steroids
Blood transfusions
Postoperative Occurrences
• Infectious complications: Surgical Site
Infection, UTI, Sepsis
• Respiratory Occurrences: Pneumonia,
Unplanned Intubation, On vent > 48 hours
• Cardiac Occurrences: MI, cardiac arrest
• Renal Failure
• Stroke
• Peripheral nerve injury
Abstraction Requirements
• All patients are followed for 30 days after surgery
• Surveillance definitions are not the same as
clinical definitions
• The abstractor’s clinical judgment is valuable, but
not always assignable
• All elements of the definitions must be met for
preop risk and postop occurrence
– Do the findings meet the purpose of the definition?
– Do they meet the letter of the definition?
A Note about Clinical Abstraction
Elements may be consistently “findable”. . .
Or not . . .
SIRS, Sepsis, Septic Shock
• Systemic Inflammatory Response Syndrome:
presence of two or more of the following:
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Temp >38 C or < 36  C
HR > 90 bpm
RR >20 /min or PaCO2 <32 mmHg
WBC >12,000 , <4000, >10% bands
Anion gap acidosis
• Sepsis
– Two of the above AND purulence or positive culture
• Septic Shock
– All the above AND evidence of organ dysfunction
SIRS? Sepsis? Septic Shock?
• 72 year old male presents to the ED in distress
with severe chest / epigastric / flank pain
• VS T 36.4 BP 118/74 HR 110 RR 24
• PMH Coronary artery disease, insulin
dependent diabetes mellitus, chronic
pyelonephritis
• Loses consciousness BP 80/40 HR 116
• Taken to CT scan
Septic Shock?
Shock? Yes
Septic? NO
30 Day Follow Up
• Many patients are seen in clinic at 30+ days
• Minor operations (appendectomy, hernia
repair) may not be seen after two weeks.
• If no documentation in StarPanel, patients are
contacted via telephone. No less than three
attempts are made.
• Vanderbilt’s fully integrated medical record
improves follow-up rates on pateints with and
without postoperative occurrences.
NSQIP Gives Us . . .
• Risk-adjusted surgical morbidity and mortality
• Semiannual Observed /Expected Ratio reports
• Interim reports: ongoing monitoring,
comparison with internal and external peer
groups
• Internal data analysis: access to institutional
data for report development, integration with
other data sets
Semiannual Report
• Reports 12 months of data, with risk adjusted
outcomes
• 39 Risk Adjustment Models
– Mortality
– Overall Morbidity
– Cardiac Occurrences
– Respiratory Occurrences
– Surgical Site Infection
– Colon surgery LOS
• Observed / Expected Ratios for each model
Mortality and Morbidity O/E Ratios
• Observed / Expected Outcomes
– An O/E of 1 indicates the outcomes were the same as
expected
• Less than 1 indicates better than expected
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• Greater than 1 indicates worse than expected
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– High outliers have confidence intervals greater than 1
– Low outliers have confidence intervals less than 1
Sample Hospital O/E Report
High outlier
Low outlier
Risk Factors determine the
“Expected”
Case
Number
Mort
Probability
004377
0.2352%
004378
1.0114%
004379
53.8254%
004380
12.7381%
004381
0.0477%
004382
3.7919%
004383
0.0975%
Occurrences determine the
“Observed”
Occurrences by Inpatient vs Post D/C
100.0%
Pre-discharge
90.0%
Prior to discharge
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
196
10
19
41
45
77
92
SSI
PULMONARY
EMBOLISM
DVT REQUIRING
THERAPY
URINARY TRACT
INFECTION
UNPLANNED
INTUBATION
PNEUMONIA
ON VENTILATOR > 48
HOURS
Semiannual Report Statistics
July 2011
•January 1 – December 31, 2010
• 258 hospitals
• ~375,000 cases
•Vanderbilt: 1,560 cases
•1,393 General surgery cases
•168 Colon and rectal surgery (all services)
•167 Vascular surgery cases
Cases by Service
Vascular Hepatobiliary
4%
11%
Onc/Endo
26%
CRS
14%
EGS
22%
GI / Lap
23%
Procedure Distribution
160
140
120
100
80
60
40
20
0
Risk Adjustment Models
Mortality
Morbidity
SSI
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Functional Status
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CPT Risk
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CPT Risk
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ASA Class
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ASA Class
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BMI
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CPT Risk
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SIRS / Sepsis / Shock
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Inpatient Status
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Age
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Inpatient / Outpatient
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Wound Class
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SIRS / Sepsis / Shock
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Functional Status
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Current Smoker
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Disseminated Cancer
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Preop Albumin
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ASA Class
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SGOT > 40
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Surgical Specialty
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Bilirumin > 1
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Albumin
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COPD
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Steroid Use
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Emergency
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BMI
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Work RVU
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Creatinine > 1.2
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Creatinine
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Transfer Status
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Platelets < 150
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Vent dependence
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Surgical Specialty
Data
Analysis
Hepatobiliary
5%
CRS
13%
Onc/Endo
27%
Vascular
13%
EGS
17%
GI / Lap
25%
VUMC Initiatives
• VPEC
– Assessment and documentation of risk elements
including smoking history, functional status
• Bariatric Surgery
– Early foley discontinuation
– Incentive spirometry education and postop monitoring
• Vascular Surgery
– Pulmonary assessment pre / postop
• Emergency General Surgery
– Documentation of emergent status
Current VUMC Initiatives
• Colorectal surgery
– Clinical analysis of NHSN-identified infections with
NSQIP variables
– Evaluation of NHSN / NSQIP case selection variation
• Vascular Surgery analysis of postop respiratory
failure and pneumonia
• ICU Database multicenter project
• NSQIP PARS analysis: evaluating correlation
between clinical outcomes and provider
complaints
NSQIP, NHSN, and Administrative Data
• NHSN
– SSI surveillance based on ICD-9, otherwise very little difference
– HAI surveillance primarily inpatient
• Device associated infections initially monitored in the critical care setting
• Currently monitoring CLABSI in general care; CAUTI soon
• Administrative data (UHC)
– Based on provider documentation, coding data’s primary purpose initally
was reimbursement.
– Only the index hospitalization is captured.
• NSQIP
– Like NHSN, abstraction is from clinical documentation, based on strict
definitions
– Follows all patients for 30 days—inpatient, outpatient, discharged
– No device associated infection designation
NSQIP
Participants
400 + Hospitals
About half are academic
UHC
369 hospitals
114 academic / 255 affiliates
Risk Adjustment Clinical risk factors as
documented in medical
record
APR-DRG based on coding, other
administrative data
Outcomes
(Mortality)
30 days post-op
Inpatient hospitalization
Service
designation
Surgical service for included
procedure
Discharge / Major Service
Inclusion
By procedure
Inpatient / Outpatient
All hospital discharges by attending
service
Inpatient only
(Outpatient data is now being
submitted)
Comparison
data
Blinded risk-adjusted data
Comparison with peer hospitals
Tennessee Surgical Quality
Collaborative
Tennessee
Chapter of
American
College of
Surgeons
Tennessee
Hospitals
Blue Cross
Blue Shield
of
Tennessee
Tennessee
Center for
Patient Safety
(THA)
Tennessee Surgical Quality
Collaborative
• A consortium of surgeons and hospitals committed to
evaluate and improve surgical care by surgeons in the
state of Tennessee
• 10 member hospitals with active engagement of
surgeon champions, nurse reviewers, and
administrators.
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Learn from high performers
Develop best-practice recommendations
Identify system variables influencing clinical performance
Non-competitive environment for shared learning
TSQC Mission and Vision
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.
TSQC Development
2007 Partnership
model proposed to
Blue Cross
2008 3 year grant
awarded to TSQC
2009 Hospitals
enrolled, training and
abstraction in progress
April 2011 AHA NPSF
Fellowship
January 2011 Draft
Action Plan for
Statewide Initiatives
July 2010 First O/E
September 2011 Grant
Renewal application
submitted
October 2011 Eleven
additional hospitals
submit applications
21 TSQC
Hospitals?
Grant Overview
• 3 year grant May 2008- May 2011
• Initial grant to support of 8 hospitals; BCBS
increased funding to support 10 hospitals /
surgeon champions
• THA’s TN Center for Patient Safety serves as
coordinating center for the collaborative
• Initial grant period extended to October 2011;
renewal application has been submitted
Pre-Op Risk Factors*
Comparative Data Analysis
Diabetes:
Insulin
Non-Insulin
Dialysis
Smoked in last yr
COPD
Functional Status
Dependent
Hypertension
*Not actual data
VUMC
TSQC
NSQIP
9.8%
14.5%
2.6%
25.3%
5.6%
9.3%
15.4%
2.8%
28.5%
8.0%
5.4%
7.6%
1.9%
20.6%
4.9%
4.4%
57.3%
3.5%
60.2%
1.9%
46.4%
30 Day Mortality and Post – Op Occurrences*
Comparing Tennessee Outcomes to National Performance
ONLY CONFIRMED 30-DAY FOLLOW-UP CASES
TSQC
NSQIP
10,635
211,930
Total Number of Cases
Outcome
Cases Alive at 30 Days
Cases Dead Within 30 Days
10,433
191
98.2%
1.8%
208,243
3,687
98.2%
1.8%
Superficial SSI
240
2.3%
5,206
2.5%
Deep SSI
52
0.50%
833
0.4%
Organ Space SSI
219
2.1%
5,414
2.6%
Wound Disruption
31
0.3%
1,458
0.7%
Pneumonia
198
1.9%
5,206
2.5%
Urinary Tract Infection
209
2.0%
7,289
3.5%
Severe Sepsis
94
0.9%
2,499
1.2%
Postop Occurrences
Mean # of Occurrences
*Not actual data
0.2 (+ 0.7)
0.2 (+ 0.7)
TSQC Members Comparison
12
10
SSI
Pneumonia
Mortality
8
6
4
2
0
Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital
A
B
C
D
E
F
G
H
I
J
*Not actual data
Key Successes: 2009 -2010
• Acute Renal Failure –
– Collaborative-wide improvement
– Seven of 10 sites showed improvement; one site significantly improved
• Graft/Prosthesis Flap Failure
– Collaborative-wide improvement
– Eight sites improved; one significantly.
• On Ventilator > 48 hours
– Collaborative-wide improvement
• Superficial Incisional SSI
– Collaborative-wide improvement
– Thirteen procedure groups improved while hernia repair showed significant improvement.
– Seven sites improved; one significantly
• Wound Disruption
– Collaborative-wide improvement.
– Eight sites improved; two significantly.
• Financial Model Shows Positive Results
TSQC Opportunities
• Surgical Site Infections As the First Focus
– Colorectal surgery bundle
– Evaluation and implementation in 10 hospitals
• Rationale:
– High Volume occurrence in TSQC data
– 9 of 10 SCNRs identified SSI as opportunity
– Aligns with hospital current focus on SSI via CMS SCIP
public reporting
– Business case – Length of Stay and Costs significant
TSQC Member Hospitals
NSQIP Hospitals
TSQC Member Hospitals
NSQIP Hospitals
Future NSQIP hospitals?
NSQIP and the Nation
• The Centers for Medicare and Medicaid
Services (CMS) is considering five measures
from ACS NSQIP for national implementation
• NSQIP – based programs
– Bariatric Surgery Center Network
– NSQIP-Pediatric
– Trauma Quality Improvement Program
• ACS Goal: 1000 member hospitals by 2012
NSQIP Innovations
• 2011 Additional Options
– Small and Rural: hospitals with < 1680 cases / year
– Essentials: smaller data set
– Procedure Targeted: 100% of specific cases
– Classic: allows additional variables for research
• Florida Surgical Care Initiative
• 2012 Updates
– Procedure targeted variables
Special thanks to
Sherree Levering
Oscar Guillamondegui
Naji Abumrad
Chris Clarke Senior VP Tennessee Hospital Association
Joe Cofer Erlanger Medical Center
TSQC Leadership Committee and Membership
TN Chapter American College of Surgeons
Blue Cross - Blue Shield of Tennessee
Tennessee Hospital Association / Tennessee Center for
Patient Safety