Over the past decade, the number of quality measurement programs has grown

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1 Performance improvement Surgeon sees standardization and data as keys to higher value healthcare Over the past decade, the number of quality measurement programs has grown exponentially as hospitals respond to public and government demands for greater accountability and improved patient care. During this time, quality programs have been focused largely on how to do quality, how to measure it, how to improve it, how to scale it, and how to sustain it, says Clifford Y. Ko, MD, MS, MSHS, FACS. But now with the payment system changing, he says, we are looking at more than quality we are looking also at costs and ultimately value. Dr Ko spoke during a panel session at the 2014 American College of Surgeons Clinical Congress. Surgeons increasingly are being measured on quality and costs, and they have to start to address this, says Dr Ko, director of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). He is also a colon/ rectal surgeon and professor of surgery at the University of California Los Angeles School of Medicine. Even if we don t know how we are doing, others do, he says. My hospital knows exactly how I am doing. Our payers know how we are doing. They are gathering data from many different sources and putting it together. Surgeons have to start looking at their data, Dr Ko says. Surgeons need to know their costs and their quality to know their value. A number of reimbursement programs are value based, and surgeons will have to meet the requirements of those programs. If their costs are above average, they need to look at what is causing those high costs and fix the problem. Is it because their patients are requiring more tests? Is it because surgeons are using expensive equipment and devices? Is it because their patients are being readmitted? One of the key things we know from hospitals that don t do well is that they don t look at their data and they don t drill down on their data, explains Dr Ko. The more we drill down on our data, the more we will see things we might not be happy seeing, but if we don t see the data we all think we are doing well, and that might not be true. Standardization The fix for a lot of cost and quality problems is standardization, notes Dr Ko. That s a word a lot of us hate to hear and use because we think it s recipe and it s cookbook, but it s the variability that we see across hospitals, across service lines, across surgeons, and across patients that leads to a lot of inefficiencies in quality, throughput, and cost. When hospitals do things well consistently and sustainably, it is through standardization, he notes. I think we have to get used to that. Dr Ko cited enhanced recovery protocols as an example of how standardization of evidence-based practices leads to better outcomes. Median length of stay for a patient who has had colon surgery is 6 to 7 days. Hospitals that use advanced recovery protocols, however, have a median length of stay of 3 to 4 days. By standardizing what the nurses, surgeons, anesthesiologists, and other providers do for a patient, hospitals can cut a patient s stay in half, he says. Patients also have fewer urinary tract infections and fewer readmissions. Copyright Access Intelligence. All rights reserved. 888/

2 Evidence-based practice Standardized, evidence-based practices are the cornerstone of highly reliable organizations and hospitals that do well, says Dr Ko. But evidence-based practice doesn t always mean clinicians have to use what s in the literature. Sometimes there is no evidence base or not enough evidence base. A huge piece of this is also clinical expertise, Dr Ko says. For example, Brent James, MD, the executive director of the Institute for Health Care Delivery, Salt Lake City, is an expert on standardization of clinical care. Dr James urges surgeons to get together as a group and standardize a practice or process themselves. He would rather have them all doing the same thing, and figuring out what works and doesn t work, and what s best for the patient, than to just use whatever they find in the literature, says Dr Ko. Clifford Y. Ko, MD, MS, MSHS, FACS Therefore, he says, when we talk about evidence-based practice, it s not just what s in the literature. It s what s in the literature plus the clinical expertise of the surgeon or group of surgeons doing something in a very reliable way. That is how we get to a highly reliable organization. Variability Though clinicians are told the higher the quality, the lower the costs, that is not always the case, says Dr Ko. There is variability. In a study, Dr Ko and colleagues evaluated the relationship between cost and quality for colectomy procedures to identify characteristics of high-value hospitals defined as high quality, low cost. They found that higher hospital quality was significantly correlated with lower cost. About half (52%) of hospitals classified as high quality had low costs, but 14% (1 in 7) of high-quality hospitals had high costs. More than 40% of low-quality hospitals were high cost. When we go to see these hospitals to find out why they have high costs, we find a lot of different reasons for the variability, says Dr Ko. This has led us to a truism with quality you see one, you see one. These hospitals must look at themselves and their own data and break it down to see the reasons for their high costs, he says. Readmissions Readmissions are a good place to start when analyzing costs, says Dr Ko. They tend to be expensive, and they usually provide a myriad of things to work on. NSQIP data show complication rates of 53% and 16% for readmitted patients and non-readmitted patients, respectively. We know that when surgeons work on addressing complications, without even trying, readmissions go down, he says. When complications go down, readmissions go down, costs go down, and the value equation goes up. NSQIP data also show that no hospital is great in everything, he says. There are always opportunities for improvement. Our main aim should be to improve our value, he says. We know that hospitals and individuals that are doing well are the ones that address quality, costs and, ultimately, value. Judith M. Mathias, MA, RN 2

3 References Ju M H, Ko C Y, Hall B L, et al. A comparison of 2 surgical site infection monitoring systems. JAMA Surg. Published online November 26, Ko C Y. Association between occurrence of a postoperative complication and readmission: Implications for quality improvement and cost savings. Presented at the 2014 American College of Surgeons Clinical Congress. Lawson E H, Zingmond D S, Stey A M, et al. Measuring risk-adjusted value using Medicare and ACS-NSQIP: Is high-quality, low-cost surgical care achievable everywhere? Ann Surg. 2014;260(4): Stey A M, Brook R H, Needleman J, et al. Hospital costs by cost center of inpatient hospitalization for Medicare patients undergoing major abdominal surgery. J Am Coll Surg. Published online November 7, Photo of Dr Ko courtesy of the American College of Surgeons. 3

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