Karl Bilimoria MD MS Director, ISQIC. Faculty Scholar, American College of Surgeons

Karl Bilimoria MD MS Director, ISQIC Faculty Scholar, American College of Surgeons Director, Surgical Outcomes and Quality Improvement Center Vice Chair for Quality, Department of Surgery Feinberg School of Medicine, Northwestern University @kbilimoria

54 Illinois Hospitals

Mission To facilitate hospitals working together to improve the quality of surgical care in Illinois

ACS NSQIP in Illinois -2013 18 hospitals 75+ hospitals not participating Many had shown some interest Detailed assessments of needs and barriers

Interviews with Hospitals Unsure if worth the startup costs Unsure how to act on the data Surgeon Champions unsure of what to do Data and project overload Unsure how to undertake QI projects Little opportunity to learn from other hospitals

QI Resources Survey: Barriers to QI 70 60 57.3% 50 40 30 20 31.6% 30.5% 23.0% 10 0 Physician/ Surgeon Engagement and Leadership Transparency and Data Sharing Lack of Time Culture and Lack of Leadership

Hospital Involvement in Surgical QI Percent Involvement 100 90 80 70 60 50 40 30 20 44.7 68.1 83 78.7 87.2 70.2 25.5 10 0 President or CEO Senior Managers Manager Docs Nurses Pharmacists Other clinicians (PT, OT, RT) 2014-2015 ISQIC. Not for reuse or distribution without permission

Hospital Board Priorities Board oversight priorities Area Median Mode Financial Performance 1 55.3% ranked a 1 Operations (Staffing and facility management) 5 42.6% ranked a 6 Business Strategy 3 27.7% ranked a 2 Clinical Quality 3 [2.6, 3.4] 25.5% ranked a 2 and 25.5% ranked a 3 Patient Satisfaction 4 27.7% ranked a 5 Community Benefit 5 40.4% ranked a 6

Data FeedbackConcerns We struggle with being data-rich but information-poor

Implementation Issues getting all physicians and staff to fully support performance improvement initiatives and be open to change. implementation of improvements [as well as] communicating and putting plans into action.

Collaboration Requests new suggestions on developing process improvement plans and solutions. working with partners to share process improvement solutions 2014-2015 ISQIC. Not for reuse or distribution without permission

Financial Barriers developing financial models that support PI work. PI initiatives are being done with limited resources. Staff time commitment resources and time

ISQIC Baseline Assessment Assesses ISQIC Team s familiarity with QI/PI Average scores Experts 88% Overall 66% New hospitals 64% Old hospitals 69% Novices 45%

Surgical QI and Safety Culture Survey

Hospital Safety Climate 100 90 Percentages 80 70 60 50 40 In this clinical area, it is difficult to speak up if I perceive a problem with patient care. I am encouraged by my colleagues to report any patient safety concerns I may have. My suggestions about safety would be acted upon if I expressed them to management. All the personnel in my clinical area take responsibility for patient safety. Incident reporting is non-punitive. Information obtained through incident reports is used to make patient care safer.

Collaborative Effort Illinois and Metro Chicago Chapters 54 Illinois Hospitals

Advisory Committee ACS Chapter representatives ACS NSQIP staff Coordinating Center BCBS-IL representative New hospitals Surgeon Champions SCRs Administrators Current hospitals Surgeon Champions SCRs Administrators

ISQIC Large Hospital Characteristics 45 Large Hospitals 75% affiliated with hospital system 72% are teaching hospitals Ownership % Public 4% Not-for-profit 90% For Profit 4% Public Not-for-Profit 2% Hospital Beds % < 100 2% 100-300 36% 300-500 47% > 500 15% Average Bed Size 359 Surgical Cases % 1000-5000 10% 5000-10000 57% 10000-15000 18% 15000-20000 4% 20000-25000 6% 25000+ 6% Average/Year 10,233

ISQIC Small-RuralHospital Characteristics 9 Small-Rural Hospitals Ownership % Public 11% Not-for-profit 89% For profit 0 Public Not-for-profit 0 Hospital Beds % 0-25 22% 25-50 22% 50-100 44% 100+ 11% Average Bed Size 67 Inpatient Cases/year 563

NSQIP Not Associated with Improved Outcomes

ISQIC Strategies to Accelerate and Enhance Improvement 5 Domains: 1) Guided Implementation 2) Education 3) Comparative Reports 4) Networking 5) Financial Support 2014-2015 ISQIC. Not for reuse or distribution without permission

ISQIC s 21 Strategies to Accelerate and Enhance Quality Improvement Guided Implementation Surgeon Mentor Process improvement coach Coordinating Center Education Formal QI/PI Training Leadership engagement plan Semiannual collaborative meetings Collaborative projects Structured local and statewide QI initiatives Networking Opportunities get advice and share experiences Funding Support local program Pilot grants Bonus for improvement

Guided Implementation 1. Surgeon Champion (SC) Leads NSQIP and ISQIC initiatives for the hospital 2. Surgical Clinical Reviewer(SCR) 3. Surgeon Mentor 4. Process Improvement (PI) Coach 5. Coordinating Center (CC) 6. Annual Statewide Collaborative Quality Improvement Project (CQIP) 7. Annual hospital-specific QI project Nurse who performs data abstraction and manages QI projects Surgeon Champion who has successfully lead ACS NSQIP elsewhere and serves as mentor for SC Highly trained in PI to coach hospital QI teams through QI/PI projects Provide leadership and support staff for all aspects of ISQIC implementation QI project that is identified by ISQIC Advisory Committee to address statewide need. Carried out with assistance from Mentor, Coach and Coordinating Center. QI project identified by individual hospital QI team to address a specific area of poor performance.

The ISQIC Team

Quality Improvement Projects 1 statewide project per year 1 local project per year Formal process improvement approch

2015 Statewide Project: Ideal VTE Prophylaxis Early ambulation Mechanical prophylaxis Chemoprophylaxis All doses Correct dose Correct frequency

Year 1 VTE CQIP Implement abstraction of a new, complex process measure IT changes Documentation improvement Identify and categorize local failures

Year 2 VTE CQIP Implement selected VTE Toolkit components Implementing the toolkit components will be challenging and time consuming

Education 8. Formal QI/PI curriculum Formal process improvement training through online modules and in-person training sessions 9. Project Management Training Training SCRs on effective project management skills 10. Hospital Board Engagement Program Training and guidance for engaging the hospital s board in ISQIC initiatives and surgical QI 11. Best Practice Guidelines Evidence-based best practices identified by expert panel 12. Surgical QI Case studies 13. Toolkit for SC/SCR and Administrators Examples of how other NSQIP previously examined and addressed high rates of common postoperative complications Step-by-step guide on how to be an effective SC/SCR and Administrator focused on QI

ISQIC Curriculum

ISQIC Curriculum: Online Modules YEAR 1 Introduction to NSQIP and ISQIC Define (What are we trying to accomplish?) Measure (How will we know that a change is an improvement) Analyze (What change can we make that will result in an improvement) Improve (Executing/testing the change) Control (How do we ensure sustained performance?) YEAR 2 How to use and interpret ACS NSQIP reports Key Features of Quality and Stakeholder Interests Organizational Knowledge and Leadership Skills Patient Safety Principles Teamwork and Communication Change Management

ISQIC Curriculum: In-Person Training Brief talks to synthesize modules Half day of practical exercises DMAIC RCA FMEA Work through a project with coaches

Hospital Board Presentations Favorable board response from all New and Experienced Hospitals Board comments Program aligned with strategic goals Liked idea of cost savings Excited about potential benefit Added to system dashboard

Site Retreat Targeted to surgical staff Process and quality improvement primer Brief talk SSI DMAIC exercise How to get involved Participate on projects Propose projects How to get additional training

Comparative Reports 14. Hospital-level risk-adjusted comparative data Reports that allow hospitals to compare data on process of care and postoperative outcomes benchmarked against hospitals in Illinois and the U.S. Hospital-level return on investment reports are provided as well. 15. Surgeon-level risk-adjusted comparative data Reports that allow surgeons to compare data on process of care and postoperative outcomes benchmarked against hospitals in Illinois and the U.S.

Colectomy Performance Percentile 100 90 80 70 60 50 40 30 20 10 0 93* OR 1.06 53 OR 1.06 33 OR 1.06 67 OR 1.06 12 OR 1.06 77^ OR 1.06 80 OR 1.06 45 OR 1.06 66 OR 1.06 25 OR 1.06 35 OR 1.06 98 OR 1.06 89 OR 1.06 30 OR 1.06 *Outcome is statistically significantly better than expected

Adherence to VTE Prophylaxis Measures TJ8 100 90 98 80 Performance Percentile 70 60 50 40 30 75 50 20 10 0 Ambulation SCDs Chemoprophylaxis

Slide 40 TJ8 Could possibly break out the Chemoprophylaxis out into more detail; percent correct dose; percent correct frequency... Thomas, Juliana, 5/1/2015

Need for More Process Measures First step in drilling down on outcomes Good entryway to QI and PI Allows for an early win Gain local support for NSQIP/ISQIC

Patient Safety Organization (PSO) Patient Safety and Quality Improvement act of 2005 Organizations that collect and analyze patient safety data PSOs provide federal protection Patient Safety Work Product Not admissible into evidence nor subject to discovery Allows providers to share data freely

PSO for ISQIC ISQIC is housed within a PSO CMS will require hospitals to join a PSO to contract with a Qualified Health Plan under the Affordable Care Act by 2017 ISQIC will be begin contracting with hospitals within next few months

Networking 16. Conference Meetings Three in-person conferences (2 ISQIC, 1 NSQIP) to facilitate sharing of experiences, work on common projects, and conduct process improvement training 17. Monthly webinars for SC/SCRs Webinars to collaborate, share ideas, and trouble shoot issues 18. SCR-SC Meetings Meetings scheduled to foster communication among hospital team, discuss cases, and implement QI/PI projects

Semi-Annual Collaborative Meetings

Financial Support 19. Stipend to hospital Support for data abstractor, Surgeon Champion, NSQIP annual fee, travel to conferences, information technology, coordinating center, mentor, coach, comparative reports, pilot grants, PI curriculum, all resources 20. Pilot Grants for QI Projects Hospitals may receive additional funding to implement related QI/PI projects 21. Bonus for improved outcomes Financial bonus to hospitals that significantly improve outcomes by Year 3

Two Local Projects Are Perfect for Pilot Grants Work with coaches and mentors Feel free to contact us to discuss prior to submission Many grants available

Formal Evaluation of ISQIC Interventions Evaluation Approach ISQIC Domain Site Visits Artifact Analysis Surveys Guided Implementation X X X Education X X X Comparative Reports X X X Collaborative Projects X X X Networking X X X

Site Visits Semi-structured interviews Front-line staff: Surgeons Nurses Residents/Fellows QI personnel and higher-level administrators: Surgical Clinical Reviewer (SCR) Surgeon Champion (SC) Chief Medical Officer/Chief Quality Officer Director of Quality

Artifact Analysis Implements, notes, or materials used during the ISQIC adaptation and implementation, e.g.: Hospital ISQIC application Quality committee meeting minutes Mentor and coach call documentation forms and evaluations of their ISQIC hospital

Surveys Surgical Safety Attitudes Questionnaire (SAQ) Leadership Engagement Survey Quality Improvement Resources and Support Survey Quality Improvement Knowledge Application tool (QIKAT) Semiannual progress reports w/items assessing all 21 ISQIC components

Do these interventions result in better improvement? Overall Risk-Adjusted Morbidity Rate 13% 12% 11% 10% 9% 8% 7% Early NSQIP Hospitals (n=20) ISQIC Enrolled (n=26) 6% Year 1 Year 2 Year 3 Year of ACS NSQIP Participation

Shifting Our Focus Year 1: Education/ Infrastructure Year 2: Projects / Engagement Year 3: IMPROVEMENT

Future of ISQIC Just getting started Evaluating all of efforts and iteratively improving Planning for future Need to demonstrate engagement Need to show improvement

ISQIC Is Off to a Great Start!

ISQIC Offers Tremendous Opportunity True Learning Health System Statewide quality improvement Cost reduction Novel research platform

ISQIC Team Staff Paula Farrell, RN Juliana Thomas, MPH Remi Love Lindsey Kreutzer, MPH Allison Dahlke, MPH Emily Pavey, MS Aurelio Damiani Tom Kmiecik, PhD Jim Bruckner IT Team Faculty Tony Yang, MD Julie Johnson, PhD Kevin O Leary, MD MS Amy Halverson, MD Mark Williams, MD Kathy Barsness, MD Jeanette Chung, PhD Cindy Barnard, MBA Jane Holl, MD MPH Jonah Stulberg, MD PhD David Odell, MD MS Mike McGee, MD Process Improvement Steve Reinhart, MBA Mark Schumacher, MS 9 PI coaches External 27 Mentors Advisory Committee Fellows Mike Wandling, MD Christina Minami, MD Julia Berger, MD Elizabeth Berian, MD