National benchmarking program helping to streamline surgical processes at UTMB
By Michele Rainford
Since May 2005, UTMB has participated in a national benchmarking program to help streamline and improve processes in the Department of Surgery. The National Surgical Quality Improvement Program (NSQIP), administered by the American College of Surgeons (ACS), was instituted in General and Vascular Surgery.
NSQIP allows surgeons and hospitals to effectively measure, report, analyze and respond to surgical care data to improve the standard of care for all surgical patients.
The goal of NSQIP is synonymous with the goal of the American College of Surgeons (ACS), which was founded in 1913 with the aim of improving the care of surgical patients. Approximately 65,000 surgeons across the country belong to the ACS.
Dr. Courtney M. Townsend, the John Woods Harris Distinguished Chair in Surgery, was instrumental to UTMB’s early involvement in the program. Under his guidance UTMB embraced NSQIP as an effort that could potentially streamline its surgical care reporting efforts and lead to enhanced surgical care.
NSQIP is a relatively new standardization program. The Veteran’s Administration hospitals began specific monitoring of surgical care outcomes in 1991, which led to the development of their ongoing NSQIP program in 1994.
“The VA has attributed dramatic improvements in surgical care in its facilities to NSQIP,” said Dr. Dennis Gore, professor of surgery and surgeon champion for NSQIP at UTMB. “It’s been such a documented effective tool for the VA that it is hoped its success will be mimicked at UTMB. It’s a potential tool to direct improvements and a yardstick for comparisons with other institutions.”
As with implementing any new program, growing pains are expected. Many lessons were learned in the first year of implementation at UTMB that have already led to improved procedures. Further improvements are expected as the program matures.
Private hospitals first became interested in NSQIP in 1999 and a pilot study was initiated in three non-federal hospitals in the general and vascular surgery areas. Results after a year showed the feasibility of adopting the VA’s NSQIP program to private hospitals.
In 2001 the accomplishments of NSQIP in improving mortality and morbidity rates made it attractive to the ACS. The ACS pursued and received a grant that expanded the pilot to 14 additional medical centers. Later, data from four affiliated community hospitals were included in the pilot study.
NSQIP had proven itself a viable surgical-care tool to improve outcomes in medical centers, and after the pilot study ACS wrote a business plan and sought to offer the program to interested private hospitals. The ACS opened the program to new private hospitals in 2004.
It is hoped that continued participation in the program will bring far-reaching benefits for UTMB including improvements in patient care and the reduction of surgical mortality and morbidity, which, in turn, improves UTMB’s standing. Possessing good results in this program helps to make UTMB the hospital of choice for Galveston and surrounding communities. Patients and their families can feel assured that loved ones will receive the best possible surgical care at UTMB.
Participation in NSQIP is voluntary, but there are certain requirements to participating. Member care centers must have a surgeon champion and a surgical clinical nurse reviewer (SCNR).
As surgeon champion, Gore is charged with ensuring that the ACS NSQIP requirements are met, which is expected to lead to the program’s success. With such a monumental effort, success is measured in incremental steps and steady improvement. Already the effects of the program can be seen.
Michelle Gonzalez and Joan Killebrew are quality management specialists in Quality and Healthcare Safety at UTMB. They serve as SCNRs and work closely with Gore to collect and submit reliable data to NSQIP.
Gonzalez and Killebrew also coordinate with other members of the hospital community including staff in the Department of Surgery, Nursing, Health Information Management and Information Services, whose input is vital to the success of the program. They communicate regularly with the families of patients to gather post-surgery and post-release information on patients.
Currently, only General Surgery and Vascular Surgery follow the NSQIP guidelines, but in early 2008 the multi-specialty surgical areas of Urology, Neurosurgery, Orthopedics, Otolaryngology, Plastic, Thoracic, Gynecology and Cardio-Thoracic will all be included in NSQIP.
Any private-sector hospital may participate in ACS NSQIP as long as the facility meets the minimum participation requirements, completes a hospital agreement and pays the annual membership fee.
The Veteran’s Administration continues its parallel system, VA NSQIP, for its surgical facilities and will compare the results from its hospitals with ACS NSQIP non-VA hospitals data.
ACS NSQIP collects extensive data including pre-surgery risk factors, surgical issues and 30-day post-surgery mortality and mortality information for patients undergoing major surgical procedures. All data and case studies submitted to NSQIP closely adhere to the requirements of the Health Insurance Portability and Accountability Act (HIPAA).
ACS NSQIP follows four rigorous basic steps in collecting the necessary surgical data from hospitals and then processes them to help improve patient outcomes. Step one is capturing the data; step two analyzes the data; step three reviews the data; and step four follows an action plan to improve results.
The program produces comprehensive semi-annual reports that compare a site’s risk-adjusted surgical outcomes to other participating centers (blind comparison) on an overall basis as well as by sub-specialty. The program also provides national bench-marking tools, conducts an annual onsite audit, provides ongoing support, provides online site-specific reports, data automation software programs to support the nurse, continuing education credits for nurses that complete online training and four hours of ad hoc/specialized data analysis and reporting per month.
According to the NSQIP web site, UTMB is one of 182 ACS NSQIP members. For information on NSQIP, visit the web site at www.acsnsqip.org