Improving Surgical Care and Saving Lives: Lessons from the American College of Surgeons

Transcription

1 Convened by the American Medical Association The Physician Consortium for Performance Improvement Improving Surgical Care and Saving Lives: Lessons from the American College of Surgeons September 17, 2015

2 Today s Moderator Stephen L. Davidow, MBA-HCM, CPHQ, APR Quality Improvement Program Manager Performance Improvement American Medical Association Chicago, IL 2 physicianconsortium.org

3 Reminders Please share your QI program or initiative case story Today s webinar is being recorded The slides and a link to the recording will be posted on the PCPI QI program website Please use the chat for the Q&A 3 physicianconsortium.org

4 Save the dates - Webinars October 15: Quality Improvement in the Ambulatory Setting: Lessons in Scale and Spread from a National and State Perspective, Mary Ellen Benzik, MD, Co- Associate Director, Michigan Primary Care Transformation Demonstration Project November 11: Turning Patient Centeredness from Ideal to Real: Lessons from Two Success Stories, Michael Millenson, Northwestern University December 15: Using Patient-Reported Outcomes to Promote Patient-Centered Care, Claire Snyder, Ph.D., Johns Hopkins University 4 physicianconsortium.org

5 Save the date PCPI Conference October 29: PCPI Conference - Scale and Spread Strategies for Quality Improvement from the Washington State Clinical Outcomes Assessment Program (COAP), a 35-hospital Washington State initiative focused on improving cardiac and the Keystone Project Michigan, which has gone national. 5 physicianconsortium.org

6 QI and Measures Workshops PCPI will be hosting two training sessions: Measure Development Boot Camp: Morning Introduction to Quality Improvement: Afternoon October 27, , 3-hour training sessions, CME credit. AMA Plaza, 330 N. Wabash Ave., Chicago 8:30-11:45 a.m., 1-4:30 p.m. 6 physicianconsortium.org

7 Today s Faculty Matthew M. (Matt) Hutter, MD, MPH Associate Professor of Surgery Harvard Medical School Director or the Codman Center for Clinical Effectiveness in Surgery Massachusetts General Hospital Boston, Mass. Leadership role with the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) and has been a Surgeon Champion since the Patient Safety in Surgery Study. 7 physicianconsortium.org

8 Improving Surgical Care and Saving Lives: Lessons from the American College of Surgeons Matthew M. Hutter, M.D., M.P.H. Director, Codman Center for Clinical Effectiveness in Surgery. Department of Surgery Massachusetts General Hospital Harvard Medical School PCPI Webinar September 17, 2015

9 Disclosures None. No financial disclosures. I am not employed by the American College of Surgeons.

10 Dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment

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12 Ernest Amory Codman The Founder of Surgical Outcomes Research MGH Surgeon. A founder of the American College of Surgeons. A founder of the Joint Commission which accredits hospitals The End Results System 1910.An idea before its time.

13 So, I am called eccentric for saying in public: that hospitals, if they wish to be sure of improvement, 1.Must find out what their results are. 2.Must analyze their results, to find their strong and weak points. 3.Must compare their results with those of other hospitals... 4.Must welcome publicity not only for their successes, but for their errors Such opinions will not be eccentric a few years hence. Dr. Ernest A. Codman, 1917

14 American College of Surgeons Quality Improvement Programs 500+ hospitals hospitals TQIP COMMITTEE ON TRAUMA SSR 400+ hospitals 700+ hospitals hospitals 5,000+ surgeons

15 Improving surgical care and outcomes High Quality Surgical Care Tools/ Guidelines/ Teamwork/ Set Standards Data Collection/ Analysis/ Risk-adjusted outcomes Feedback; QI Planning

16 ACS-NSQIP The National Surgical Quality Improvement Program The first nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care.

17 NSQIP National Surgical Quality Improvement Program Public Law December 1986 The VA should report its surgical outcomes in comparison to the national average. The VA should report its surgical outcomes with risk-adjustment, accounting for the severity of patient illness.

18 A burning platform makes people move their feet

19 The NSQIP History of the NSQIP Patient Safety in Surgery Study Alpha sites 1/99 to 12/00 Beta Sites Kentucky Michigan Emory MGH Brigham Shands U. Utah UCSF UVA Barnes Columbia Cornell U. Maryland St. Louis

20 Importance of Good Data What is good data? Garbage in, garbage out Prospective. Risk Adjusted. Standardized Definitions. Collected by audited, trained data collectors who are not involved in direct patient care. Benchmarked. Sound statistics, responsible conclusions.

21 Assessing Quality Outcomes Standardized Definitions Must be clinically meaningful and measurable. (can take years to agree upon and refine) You have to compare apples to apples. A UTI in a VA hospital in San Francisco is the same as a UTI in rural North Dakota is the same as a UTI in a Boston teaching hospital.

22 First SAR 2006 Now 37 hospitals 407 hospitals 6 models 184 models 33,000 cases 596,000 cases O/E ratios Odds Ratios Logistic Regression Hierarchical with Shrinkage Caterpillar Plots Bar Plots NSQIP Conference attendees 1,011 attendees

23 Risk adjusted, benchmarked results: O/E Ratios Observed Expected

24 General

25 Model Reports

26 Real-time, risk-adjusted outcome reports

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28 Results- Change in O/E 118 Institutions Present Change 2006 to 2007 Complication Mortality Mean Change in O/E P-value (mean not zero) < < Volume weighted mean % Institutions Improved 82% 66%

29 Preventing Complications Reduces costs Dimick JB et al. J. Am. College of Surgeons 202(6): June Hall BL et al. Annals of Surgery 250(3): Sept = $ 2.75 to $5.5 million saved per hospital per year.

30 Targeting Hospitals with High Value (Good quality / Low Cost) Quality as measured by NSQIP Good Quality Cost (Payment) as measured by CMS High Cost As Expected Cost Low Cost 14% 33% 52%

31 Collaborative Reports: Collaboratives accelerate the rate of quality improvement.

32 Collaboratives: What is a collaborative? col lab o ra tive adjective or noun Main Entry: col lab o rate Pronunciation: \kə-ˈla-bə-ˌrāt\ Etymology: Late Latin collaboratus, past participle of collaborare to labor together, from Latin com- + laborare to labor 1 : to work jointly with others or together especially in an intellectual endeavor 2 : to cooperate with or willingly assist an enemy of one's country and especially an occupying force

33 Collaboratives: What is a collaborative? col lab o ra tive adjective or noun Main Entry: col lab o rate Pronunciation: \kə-ˈla-bə-ˌrāt\ Etymology: Late Latin collaboratus, past participle of collaborare to labor together, from Latin com- + laborare to labor 1 : to work jointly with others or together especially in an intellectual endeavor 2 : to cooperate with or willingly assist an enemy of one's country and especially an occupying force

34 Collaboratives: What is a collaborative? Any group of hospitals that choose to share their data.

35 What are the collaboratives of the ACS-NSQIP? National Payers State initiatives Hospital Systems Insurers

36 What are the collaboratives of the ACS-NSQIP? National Payers Dept of Defense (DoD) / TRICARE 10 DoD Hospitals Walter Reed, Wilford Hall, San Diego Madigan, Brooke, Tripler, Womack, Darnall, Eisenhower and Navel Medical Center Portsmouth. State initiatives Florida Surgical Care Initiative 100+ hospitals enrolled.. Oregon Rural initiative OHSU and 10 to 12 hospitals

37 What are the collaboratives Continued. of the ACS-NSQIP? Hospital Systems Kaiser Southern California (5-6 hospitals) Partners (Massachusetts) (5 hospitals) Insurers Michigan Surgical Quality Collaborative (MSQC) BCBS P4Participation 34 hospitals Massachusetts BCBS P4Performance hospitals Tennessee NSQIP Surgical Quality Consortium BCBS -- 8 hospitals Upper NY Surgical Quality Initiative (UNYSQI) Excellus BCBS -- 4 hospitals

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39 The MSQC vs. the NSQIP Collaboration and Quality Improvement % Morbidity MSQC QI efforts begin The NSQIP N = 115 The MSQC N =

40 Where the NSQIP stands today. Hospitals in the US 5, 723 (2012 data. American Hospital Association. www. AHA.org) NSQIP hospitals in the US 407 (NSQIP sites with O/E ratios 12/13)

41 History of Accreditation Accreditation of hospitals: ACS founded the Hospital Standards Committee Became JCAHO in Now The Joint Commission Accreditation of Trauma centers Committee on Trauma est Trauma Centers (202) Level I = 77 Level II 91 Level III 19 Accreditation of Cancer centers 1,425 nationwide National Cancer Database est. 1986

42 ACS Perspective: Accreditation

43 A burning platform makes people move their feet VA Scrutiny: Congressional Mandate NSQIP Cardiac Surgery: NY state Public Reporting STS Data Collection Bariatric Surgery: CMS noncoverage proposal accreditation programs MBSAQIP

44 Increased Number of Bariatric Surgery operations NEJM 2004; 350:1076

45 Published Mortality Rates 1/21/05 Gastric Bypass Surgery Gone Bad: 1 In 50 People Die Within A Month Of Surgery 30-day mortality: 1.9% J Am Coll Surg 2004; 199: % JAMA 2005; 294: % Arch Surg 2006; 141:

46 Accreditation Programs February 12, 2005: ACS Board of Regents decided to develop additional accreditation programs: To establish standards of care To provide reliable outcomes data To develop approvals/verification processes for hospitals and outpatient facilities To establish credentialing criteria for surgeons. First area of focus: Bariatric Surgery Launched May, 2005.

47 MCAC. November 4, Mortality rates were greater for those aged 65 years or older compared with younger patients (4.8% VS 1.7% at 90 days, and 11.1% vs 3.9% at 1 year, P<0.001). Non-coverage Proposal. November 23, For patients 65 years or older

48 Period for Discussion (30 days) National Coverage Determination February 15, Cover for age greater than 65. Cover Bypass and LapBand. Cover BMI 35 and over, with comorbidity. Cover if accredited by ASBS or ACS.

49 Architect of the National Bariatric Surgery Data Collection Program All bariatric programs must be accredited if they are to care for Medicare and Medicaid patients, and most other insurance companies hospitals across the US. Over 500,000+ cases of data collected. About 13,000 cases per month

50 Bariatric Surgery 100% of cases. Not a sample. Bariatric specific data points: Leaks, strictures, internal hernias etc. Clinical Effectiveness (not just death and destruction ) Weight. Weight related illnesses. Diabetes, HTN, High Cholesterol, GERD, Obstructive Sleep Apnea Long term follow-up. 30 days, 6 months, one-year..annually Accreditation program, and quality improvement program. 755 hospitals. >90%+ of all bariatric procedures in the USA.

51 Morbidity and Mortality Report

52 BMI Reduction over Time Report

53 Reduction in Comorbidities Over Time Report

54 ACCREDITATION is a Remarkable Sucess Accreditation has led to a dramatic improvement in the quality of care provided. 0.11%

55 Decrease in Mortality after Accreditation Requirement

56 ACS MBSAQIP and CMS PQRS QCDR and VBM

57 CMS PQRS QCDR and VBM CMS: Centers for Medicare and Medicaid Services PQRS: VBM: Physician Quality Reporting System Value Based (Payment) Modifier QCDR: Qualified Clinical Data Registry PhysicianCompare.gov PENALTIES: PQRS: VBM Total 2014: 0.5% bonus on Part B 2015: - 1.5% (penalty) -1.0% - 2.5% 2016: - 2.0% (penalty) -2.0% - 4.0%

58 CMS PQRS QCDR 9 Metrics (no more than 20) 3 of the 6 NQS Domains 1. Person and Caregiver-Centered Experience and Outcomes 2. Patient Safety 3. Communication and Care Coordination 4. Community/Population Health 5. Efficiency and Cost Reduction 6. Effective Clinical Care One must be an Outcome.

59 CMS PQRS QCDR MBSAQIP QCDR Measure Title 1. Risk Stratified Overall Complication Rate. 2. Risk Stratified 30 Day Readmission Rate. 3. Risk Stratified 30 Day Reoperation Rate.. 4. Risk Stratified 30 Day Anastomotic/Staple Line Leak Rate. 5. Risk Stratified Perioperative Bleeding Rate. 6. Risk Stratified Postoperative Surgical Site Infection Rate. 7. Risk Stratified Postoperative Nausea, Vomiting or Fluid, Electrolyte, Nutritional Depletion Rate. 8. Postoperative Extended Length Of Stay. (>7 days) Day Postoperative Follow-Up Rate. Effective Clinical Care Efficiency and Cost Reduction Patient Safety Communication and Care Coordination

60 American College of Surgeons History of Accreditation Programs?

61 Future Create more meaningful metrics for tomorrow. Clinical Effectiveness. Longer term outcomes (?). Process measures (?) Patient Centered. Patient Reported. Aggregated Outcome Metrics. Composite Measures.

62 A burning platform makes people move their feet

63 Patient Protection and Affordable Care Act Obamacare March 23, 2010 Signed into Law by President Obama

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65 Value = Quality Cost MACRA and MIPS Medicare Access and CHIPS Reauthorization Act 2015 and Merit-based Incentive Payment System

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67 American College of Surgeons Quality Improvement Programs 500+ hospitals hospitals TQIP COMMITTEE ON TRAUMA SSR 400+ hospitals 700+ hospitals hospitals 5,000+ surgeons

68 Overall Experience with the ACS Quality Programs Most Rewarding. Inspiring Quality. Most Challenging. Changing the Culture. Motivating Surgeons. Good data is essential, but not sufficient Identify your burning plaform(s). Collaboratives accelerate the rate of Quality Improvement. It Takes Time! Continuous Quality Improvement.

69 Already in 1900 I had become interested in what I have called the End Result Idea, which was merely the common-sense notion that every hospital should follow every patient it treats, long enough to determine whether or not the treatment has been successful, and then to inquire if not, why not? From the Preface to The Shoulder By Dr. Ernest A. Codman, 1934

70 Codman Center for Clinical Effectiveness in Surgery Matt Hutter, MD, MPH David Shahian, MD David Chang, PhD, MPH, MBA Alex Haynes, MD, MPH Serguei Melnitchouk, MD, MPH Haytham Kaafarani, MD, MPH Todd Lancaster, MD, MPH Andrew Loehrer, MD Naveen Sangji, MD, MPH Craig Jarrett, MD, MBA Elizabeth Lancaster, MBA Donna Antonelli Lynn Devaney, RN Shaun Sutcliffe, RN Kathy Swierzewski, RN Roberta Dee, RN Justin Vamenta (Lab Computer Science) Sarah Bird. Director