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ACS NSQIP:
Preventing complications
Reducing costs
Improving surgical care
Wednesday, October 8, 2014
Presentation to:
New South Wales Agency for Clinical
Innovation
Sydney, Australia
ACS Mission Statement
ACS Mission: Dedicated to improving the care of
the surgical patient and to safeguarding
standards of care in an optimal and ethical
practice environment
NSQIP: Improving Surgical Care and
Outcomes
High Quality Surgical Care
Tools/
Guidelines/
Teamwork/
Set Standards/
Partnerships
Data Collection/
Analysis/
Risk-adjusted outcomes
Feedback;
QI Planning
Improving Care, Reduce Costs
Current Participants
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
What is ACS NSQIP?
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Hospital based quality improvement program
Risk and Case Mix-Adjusted 30 Day Clinical Outcomes
Data collected by trained abstractors
Allows benchmarking among participating sites
Data entry via web-based Workstation
Based solely in English
Based upon CPT Codes
Multi-specialty (GS, Vasc, Ortho, NS, Uro, Gyn…)
Improvement/Educational “Tools”: Best
Practices/Guidelines (e.g. SSI, UTI), case studies,
collaboratives, Calculator, partnerships (Joint Commission,
IHI, CMS, AHRQ, CUSP, ERAS, others)
Data Integrity
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Trained Surgical Clinical Reviewers (SCRs)
Annual SCR Certification Exam
Data Validation in Workstation
Inter Rater Reliability Audits
Webinars/Conference calls
Clinical & Technical Support
ACS NSQIP National Conference
Surgeon Champion/SCR/Administrator Toolkits
CPT Codes
• Procedure selection within
the NSQIP workstation
• -ICD-9 and CPT Code Look
Up in the Outcome
Database
• -Ingenix Procedural Cross
Coder book
• -Ingenix ICD-9-CM for
Hospitals – Volumes 1, 2, &
3
• -American Medical
Association CPT 2012
• http://www.codapedia.com
Clinical Data Better for Measuring Quality
Following Patients After Discharge
• Half or more of all complications occur after
discharge
• Quality programs based on admin data don’t
track post-discharge
• Complications after discharge can lead to
readmissions
Tracking quality can’t stop at the hospital’s door
30-Day Post-Op Follow Up Review
Outcome /follow-up information can be
obtained in a variety of ways:
• Review of the patient’s medical record.
• Screen for readmissions
• Separate clinic or the private surgeon’s office outpatient follow-up visits
• Additional methods would be either a phone call
placed directly to the patient or a follow-up letter
can be mailed for the patient to respond to in writing
Program Staffing
Surgeon Champion (SC)
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Program Mentor/Advocate
Surgical Clinical Reviewer (SCR)
•
Data Collector
*Remember that the nature of this relationship will
determine the success of your program
Surgeon Champion Qualifications
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Well Respected & Highly Regarded
Chief of Surgery or Chief Medical Officer
Program Mentor/Advocate
Must be trusted by peers and administration
Experience with Quality Improvement
Lead Quality Improvement Initiatives
Participate in Monthly SC Conference Calls
Surgical Clinical Reviewer Qualifications
Recommended …
• 1 Year experience in surgery,
medical records, clinical
research
• Nursing Background
• Computer and Internet
experience
• Quality improvement or
patient safety knowledge and
experience
SCR Training
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Registration available after invoice payment
Online, Web-Based Training
4 Weeks Total
Weekly webinars and Conference Calls
– 1 to 2 every week
• Recorded Sessions available due to time
difference
• Workstation Access – Week 2
• Data collection starts - Week 2
• Certification Exam - 6 months and every October
Data Collection
Case Selection
Inpatient and
Outpatient excluding …
• Trauma
• Transplant
• Ophthalmology
• C-Sections
• Endoscopy
• Colonoscopy
Data Collection
Sampling Methodology
• A randomized sampling system called
the 8-day cycle
- Required to submit data on 42, 8-day cycles/year
- ~40 cases every 8-day cycle = 1,680 cases annually
Risk and Case-Mix Adjustment Matters
To judge care fairly and understand where
problems are occurring:
• Health of the patient must be considered
- Patient characteristics
- Pre-op Risk Factors
• Risk of the procedure must be considered
- All variations in surgical outcomes
- Surgical Complexity
Risk Adjustment
Odds Ratios
An Odds Ratio of 1 is like “par on a golf course” –
the score that is expected
It is a metric showing the risk-adjusted performance at a specific site compared
to
the average hospital
• An Odds ratio < 1 means that the site is performing better than
expected, while a ratio > 1 indicates an excess of adverse events
• The odds is defined as the #events / #non-events
i.e. 5/95=.053, is the odds for a hospital if there are 5 deaths among
100 patients
• Our Odds Ratio is the risk-adjusted odds for an event at a site divided
by the odds for an event at the average site
• Our Odds Ratios are also adjusted so they are useful even for hospitals
that provide very small samples
Audits
Data Needs to be Believed:
Validation with Audits
10%
2005
2006
2007
2008
3.15%
2.26%
1.99%
1.56%
0%
Inter-Rater Reliability (% Disagreement)
Audits
Annual random 5% selection of all ACS NSQIP participating hospitals
Hospital is given 4 to 6 weeks’ notice of a site visit
12 to 24 charts are selected and access to the OR Log Book
ACS representatives are sent to review charts
1 to 2 day process
Results are provided within a summary report
o Disagreement(s) of variables/operative log book
o Re-education requirements if needed
o Pass/Fail/Incomplete score
Available Data
Real-Time/On Line Reports
• Allows comparison to other ACS NSQIP
hospitals using online reports
Interim & Semiannual Benchmark Reports
• Provides risk-adjusted comparisons of all ACS
NSQIP hospitals regarding morbidity, mortality,
and complications
Participant Use File
• Contains all cases reported from 2004 to date
Reporting
Real Time Reports
• Workflow Reports
• Site-Level Reports
• Database Statistics
• Data Analysis
Reporting
30 Day Post-Op Summary
Reporting
Mortality Patient Report
Reporting
Post-Operative Occurrence Analysis
Reporting
Reporting
Online Collaborative Report: Hospital
Online Collaborative Report: Leadership &
Administration
Reporting
Semiannual Report
Risk adjusted for hospital-to-hospital patient mix differences.
Reporting
Over 195 Risk-Adjusted Models
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30-Day Mortality
30-Day Morbidity
30-Day Death and Serious Morbidity
Cardiac Occurrences
Pneumonia
Unplanned Intubation
Ventilator Dependence >48 hours
DVT/PE
Renal Failure
Urinary Tract Infection/UTI
Surgical Site Infection/Deep & Organ Space SSI
Colorectal LOS
Unplanned Return to the OR
Reporting
High Outliers
1st Decile
10th Decile
Exemplary
Needs Improvement
278,198
4,429
1.59
2
6
28
29
28
29
289
278,198 27,427
9.86
34
41
28
29
37
45
289
278,198
2,423
0.87
5
16
28
29
28
29
Pneumonia
Unplanned Intubation
289
289
277,791
277,890
3,792
3,535
1.37
1.27
13
8
35
21
28
28
29
29
28
28
40
29
Ventilator > 48 Hours
289
276,643
4,505
1.63
9
21
28
29
28
33
289
289
278,198
277,979
2,591
2,096
0.93
0.75
0
1
14
9
28
28
29
29
28
28
29
29
289
277,724
3,881
1.40
15
38
28
29
28
40
289
275,905 11,002
3.99
32
46
28
29
35
54
Observed Rate
Low Outliers
Low Outliers
Observed Rate
289
Morbidity 1
Total Cases
Mortality
Sites Included
Observed Events
SAR Model Summary Reports
Overall (General / Vascular)
Cardiac
3
DVT / PE
4
Renal Failure
UTI 11
10th Decile
Exemplary
Needs Improvement
5,368
1.35
7
6
28
29
28
29
398,906 34,993
8.77
43
54
28
29
45
56
289
398,906
2,968
0.74
9
24
28
29
28
33
Pneumonia
Unplanned Intubation
289
289
398,397
398,545
4,772
4,320
1.20
1.08
18
15
42
28
28
28
29
29
28
28
45
31
Ventilator > 48 Hours
289
397,033
5,362
1.35
17
31
28
29
28
35
289
289
398,906
398,656
3,728
2,540
0.93
0.64
2
1
23
11
28
28
29
29
28
28
30
30
289
398,137
5,847
1.47
28
48
28
29
34
50
289
396,257 12,961
3.27
31
59
28
29
32
60
Observed Events
398,906
289
Total Cases
289
Sites Included
1st Decile
6
High Outliers
SSI
5
Overall (Multispecialty - All Cases)
Mortality
Morbidity
Cardiac
1
3
DVT / PE
4
Renal Failure
UTI 11
SSI
6
5
Site Summary Report (SAR & ISAR)
Semi-Annual Report:
Site Specific Bar Plot
SAR Collaborative Report
SAR Collaborative Report
• Collaborative ranking by decile for the most recent SAR period
• Collaborative “Minimum” and “Maximum” OR based on Hospital ORs
Model Name
GEN Mortality
GEN Morbidity
GEN Cardiac
GEN Pneumonia
GEN Unplanned Intubation
GEN Ventilator > 48 Hours
GEN DVT/PE
GEN Renal Failure
GEN UTI
GEN SSI
GEN ROR
1
7
6
9
6
8
6
7
6
7
7
8
2
7
6
9
6
8
6
7
6
7
7
8
Decile
3-8
7
6
9
6
8
6
7
6
7
7
8
9
7
6
9
6
8
6
7
6
7
7
8
10
7
6
9
6
8
6
7
6
7
7
8
OR Range
Min
Max
0.79
1.38
0.85
1.26
0.87
1.55
0.55
1.46
0.90
1.34
0.84
1.38
0.87
1.44
0.77
1.39
0.72
1.64
0.81
1.50
0.91
1.66
Rank of Collaborative Hospitals
• Each collaborative hospital is represented by a yellow dot on the
corresponding line (which represents all NSQIP hospitals)
– All hospitals may not have cases fitting a specific model. Thus, fewer dots
would appear on the corresponding line.
• Rankings are based on Hospital ORs from the most recent SAR
– Lower ranks indicate lower ORs, while higher ranks indicate higher ORs
Collaborative GENERAL Dashboard
• Collaborative ORs and Deciles from the current and past SAR
• Percentage of “Exemplary”, “As Expected”, and “Needs Improvement”
hospitals from the most recent SAR
• Provided for 6 GENERAL NSQIP models:
– Mortality, Morbidity, Pneumonia, Unplanned Intubation, DVT/PE, SSI
Previous SAR values
Collaborative Current SAR Summary
• All of NSQIP
• Collaborative Level
– Full OR Range
– Interquartile OR Range
– Case Counts
– ORs and Deciles
– Hospital Percentages
Collaborative
NSQIP ORs
Total
Cases
Observed
Cases
OR
Decile
Percent
"Exemplary"
Percent "As
Expected"
Percent "Needs
Improvement"
Minimum
OR
25th
Percentile
75th
Percentile
Maximum
OR
13 GEN Mortality
9031
119
1.10
7
0
71
29
0.56
0.90
1.14
2.02
14 GEN Morbidity
9031
680
1.06
6
0
86
14
0.51
0.87
1.19
3.00
15 GEN Cardiac
9031
57
1.16
9
0
71
29
0.60
0.91
1.10
1.78
16 GEN Pneumonia
9001
90
1.01
6
14
86
0
0.32
0.76
1.34
5.09
17 GEN Unplanned Intubation
9022
98
1.16
8
0
100
0
0.55
0.87
1.17
2.02
18 GEN Ventilator > 48 Hours
8996
97
1.01
6
0
100
0
0.36
0.83
1.22
2.81
19 GEN DVT/PE
9031
74
1.10
7
0
86
14
0.49
0.87
1.16
2.46
20 GEN Renal Failure
9023
46
1.03
6
14
57
29
0.52
0.90
1.13
3.25
21 GEN UTI
9014
97
1.19
7
0
86
14
0.46
0.84
1.23
2.26
22 GEN SSI
8935
345
1.14
7
0
71
29
0.49
0.83
1.22
4.54
23 GEN ROR
9031
250
1.16
8
0
71
29
0.54
0.89
1.14
2.14
SAR Model Name
General
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
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%
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
ACS NSQIP: Reducing Costs
Surry Memorial Hospital in Vancouver, BC
• $2.7 million savings over two years by reducing breast
surgery SSI by 13.3% and general and vascular SSI by 5.7%
• Averted ~$380,000 in costs over 4 months via initiatives to
reduce UTI’s
Henry Ford in Detroit
• $2 million annual savings and 1.54 days reduced LOS
Baptist Hospital of Miami
• $4 million annual savings
• Sustained efforts to reduce its rate of hospital-acquired
infections have led to a savings of about $4 million a year
since 2007
ACS NSQIP: Reducing Costs
Winthrop University Hospital, Mineola, NY
• Reduction in Pneumonia from 1.36% (July 2011) to 1.25% (July 2012)
= $1,436,305.00 (65 averted cases)
• Ventilator >48hours reduction from 1.9% (July 2011) to 1.04% (July 2012)
= $2,903,655.00 (105 averted cases)
Savings exceeding >$4,000,000.00
Beaumont Hospital in Royal Oak, MI
• $2.2 million savings reduced average LOS by 6.5 days by reducing SSI.
• Nearly 300 SSI’s prevented in 2009
Stanford in Stanford, CA
• SSI reduced from 1.03 to 0.58 at a savings of $28,000 per SSI.
Case Study: Improvement in CAUTI in Surgical Wards,
(Sheikh Khalifa Medical City, Abu Dhabi, UAE)
• High outlier status identified in
SAR, (Jan, 2011)
• Multidisciplinary Task Force
• Education/QI Initiative
• Expansion throughout entire
hospital
*Results:
> 3 CAUTI/yr since Aug. 2012
Sheikh Khalifa Medical City (SKMC), Managed by the Cleveland Clinic, Abu Dhabi, United
Arab Emirates; ACS NSQIP Best Practice Case Studies, Vol. 4, July 2013
ACS NSQIP System Participation
• Discounts for systems enrolling multiple hospitals
• Ability to work on QI together, as other hospitals
enroll
• Ability to collect custom variables to tailor to
system’s needs
• Possible to share resources across system
hospitals
• Greater impact on system’s bottom line
Collaborative Case Study: BC UTI Improvement Project
Notable Gains in UTI Rates across 10 Hospitals
• A collective drop in
UTI rates from 3%
before Apr. 2012 to
2.25% in 2013
• A combined
average of 39
events/month
before Apr. 2012 to
31.5/month after
Apr. 2013
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Case Study: Vancouver General Hospital
CLEAN Program
Cost Avoidance of ~$100, 000.00 over 5 months
• GOAL: Reduce
Cardiac SSI’s from 6%
to 2% by Jan. 2014
• SSI team
collaboration with
Infection Control
• Best Practices
identified &
implemented
• No SSI’s since July
2013
• ~$100,000 cost
avoidance
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Return on Investment
Non-Monetary Benefits …
• Valid benchmarking for surgical outcomes
• Provides proactive, value-oriented performance
measurement before it’s dictated by outside agents
• Improves local market position through publicly visible
improvement programs
• Optimizes cross-departmental partnerships and
collaboration through shared knowledge
• Helps build high performance surgical teams and employee
retention, (i.e. nurses)
• Offers CME’s for Surgeon Champions and CEU’s for SCR’s
NSQIP Provides Improvement Tools and
Education
• Robust Interactive Training for Abstractors (Surgical
Clinical Reviewers)
• Surgeon Champion/SCR/Administrative Toolkits
• Best Practice Guidelines
• Case Studies
• Collaborative learning (Regional or Specialty)
• ERAS: Enhanced Recovery After Surgery in NSQIP
• NSQIP Annual Conference
Best Practice Guidelines
• Complete yet concise resource for health care
providers and QI professionals
• Evidence-based
• Expert panel-rated
• Framework to:
• Prevent postsurgical complications
• Prioritize/direct QI efforts aimed at reducing
incidence/impact of postsurgical complications
Best Practice Case Studies
Surgeon Champion Toolkit
Recent Publications
•
American University of Beirut Medical Center, Beirut, Lebanon
Postoperative outcomes after laparoscopic splenectomy compared with open
splenectomy. Musallam KM, Khalife M, Sfeir PM, Faraj W, Safadi B, Abi Saad GS, Abiad F,
Hallal A, Alwan MB, Peyvandi F, Jamali FR.Ann Surg. 2013 Jun;257(6):1116-23. doi:
10.1097/SLA.0b013e318275496a. [PubMed - in process]
•
Vancouver General Hospital, Vancouver, British Columbia
Surgical-site infections within 60 days of coronary artery by-pass graft surgery.
Swenne CL, et al.; Society of Thoracic Surgeons. Adult Cardiac Surgery Database Executive
Summary. Available at:
http://www.sts.org/sites/default/files/documents/20112ndHarvestExecutiveSummary.pdf
. Accessed July 27, 2014.
• Sheikh Khalifa Medical City, Abu Dhabi, United American Emirates
Are results of bariatric surgery different in the Middle East? Early experience of an
international bariatric surgery program and an ACS NSQIP outcomes comparison.
Nimeri A, Mohamed A, El Hassan E, McKenna K, Turrin NP, Al Hadad M, Dehni N.
J Am Coll Surg. 2013 Apr 23. doi:pii: S1072-7515(13)00160-9.
10.1016/j.jamcollsurg.2013.01.063. [Epub ahead of print]
Surgical Risk Calculator
http://riskcalculator.facs.org/
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ACS NSQIP National Conference
ACS NSQIP Options
Four Adult ACS NSQIP options
1.
2.
3.
4.
ACS NSQIP Essentials
ACS NSQIP Small & Rural
ACS NSQIP Procedure Targeted
ACS NSQIP Measures
ACS NSQIP Pediatric
The Options
Regardless of Which Option, All Hospitals Will Receive:
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Interim and Semi Annual Reports
Real Time Online Reports (including new SPCs)
Benchmarking
ACS NSQIP Best Practices/Guidelines
ACS NSQIP Improvement Case Studies
Additional Items (e.g. Risk Calculator, Public Use
File)
The Options
For All Options, the Rigor and Validity
of ACS NSQIP is Unchanged
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Risk Adjustment
30 Day Follow Up
Clinical Data
Data Audits
SCR Training
SCR Certification
ACS NSQIP Essentials
• General/Vascular = 1,680 cases per year,
8-day sampling cycle
• Multispecialty = 20% total case volume by
specialty, 8-day sampling cycle
• Collection of core variables for QI purposes
– approximately 46 clinical variables
• 1 FTE
ACS NSQIP Small & Rural
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Small Hospital: < 1,680 cases per year
100% collection of cases across all
specialties
•
Collection of core variables for QI purposes
– approximately 46 clinical variables
•
1 FTE (or less depending upon case
volume)
ACS NSQIP Procedure Targeted
• Larger hospitals targeting high-risk/high volume
procedures
• Hospital selects procedures
• Selection may be CPT code-driven
• Minimum of 1,680 cases per year:
- 15 “Core” cases per 8-day cycle
- 25 “Procedure Targeted” cases per 8-day
cycle
• Minimum 1 FTE (or more depending on volume)
ACS NSQIP Procedure Targeted
Nine Subspecialties
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General Surgery
Vascular
Gynecologic
Urologic
Plastic & Reconstructive Surgery
Otolaryngology
Orthopedic Surgery
Neurosurgery
Thoracic Surgery
ACS NSQIP Procedure Targeted
30+ Procedures
Pancreatectomy▪ Colectomy ▪ Ventral Hernia Repair ▪ Bariatric ▪
Proctectomy ▪ Hepatectomy ▪ Thyroidectomy ▪ Esophagectomy ▪
Appendectomy ▪ Cartoid Endarterectomy ▪ Cartoid Artery Stenting ▪
Open AAA Repair ▪ EVAR ▪ Open Aortoiliac Bypass ▪ Endo Aortoiliac
Repair ▪ Lower Extremity Open Bypass ▪ Lower Extremity Repair
Endovascular ▪ Hysterectomy ▪ Myomectomy ▪ Reconstructive
Procedures ▪ TURP ▪ Bladder Suspension ▪ Radial Prostatectomy ▪
Radical Nephrectomy ▪ Radical Cystectomy ▪ Muscle/Myocutaneous
Flap ▪ Reduction Mammoplasty ▪ Breast Reconstruction ▪
Abdominoplasty ▪ Thyroidectomy ▪ Total Hip Arthroplasty ▪ Total
Knee Arthroplasty ▪ Spine Surgery ▪ Hip Fracture ▪ Brain Tumor
Procedure ▪Spine Procedure ▪ Lung Resection
ACS NSQIP Measures
•
5 High Impact Outcome Measures:
- UTI
- Colorectal
- SSI
- Lower Extremity Bypass
- Elderly
• Minimal Data Collection = 840 cases annually
• Collection of ~25 clinical variables
• 1/2 FTE
ACS NSQIP Peds
• >100 Clinical Variables
- Demographics
- Surgical Profile
- Pre-Operative Data (risk factors)
- Intra-Operative Data
- Post-Operative Data (outcomes)
• Patients under 18 years of age
• Additional data points for neonates for a minimum of
28 days old
SCR Staffing Requirements
Program Option Pricing
Recognition
Institute of Medicine named ACS
NSQIP
“the best in the nation”
for measuring & reporting surgical
quality and outcomes.
Thank You:
Questions & Discussion
Gina M. Pope RN, CNOR
Business Development
Representative
gpope@facs.org
312-202-5607
Additional Program Details
Surgery: 100 Years of Quality Improvement
>80% hospitals
improve, including top
USN&WR
Minimum
Standard for
Hospitals
Joint
Commission
2004
2011
2012
1951
1913
1922
1950
1998
TQIP
COMMITTEE ON
TRAUMA
80% of incident
cancers; 1500+
hospitals
Trauma center
designations, ATLS,
400+ hospitals
SSR
Improved safety and
survival; 800+ hospitals
Individual surgeon registry: endorsed for
MOC (ABS, ABCRS), PQRS (CMS), OPPE
(JC); 5000+ surgeon users
Clinical Variables
Participation Options for All Hospitals
Risk Adjustment
Risk adjustment has a profound effect in determining the true performance of a medical center
01
01
04
04
08
Rank by
unadjusted
Mortality
A
B
08
12
12
16
16
20
20
24
24
28
28
32
32
36
B
40
44
Rank by
risk-adjusted
Mortality
36
A
40
44
Changes in Medical Center Rank After Risk Adjustment For 30-Day Mortality
Customer Support
• Outcome Sciences/Quintiles: vendor support
• ACS NSQIP: Clinical support; administrative
– Staff of 50+ in ACS NSQIP
Reporting
Pre-Operative Risk Factor Summary
System Case Study: Kaiser Permanente Zero
Pneumonia Project
• Based on ACS NSQIP data,
implemented post-op
pneumonia bundle in Kaiser
Northern California
• Cross-functional team
• Clinical, cultural and patient
education issues identified
• Achieved zero pneumonia and
now among top performers for
this measure in ACS NSQIP
• Expect to save 200 lives/yr
Fuchshuber, PR, et al. The Power of the National Surgical Quality Improvement Program—Achieving A Zero
Pneumonia Rate in General Surgery Patients. The Permanente Journal/ Winter 2012/ Volume 16 No. 1.
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