VA’s surgical QI program could be available to all

Using data to find best practices, problem areas

The innovative quality improvement program that greatly improved patient care in the Department of Veterans Affairs (VA) health care system could be available to all hospitals within a year, according to program leaders who say the system could revolutionize health care quality.

Known as the National Surgical Quality Improvement Program (NSQIP), the program is the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. Currently, the NSQIP incorporates 128 VA medical centers (VAMCs) and 14 beta sites in the private sector, but the VA is working on a plan that could make it possible for any health care provider in the United States to adopt the same system of data collection and quality improvement.

The chairman of the NSQIP tells Hospital Peer Review that the VA is working with the American College of Surgeons (ACS) to request congressional authority for making the VA’s program available nationwide by turning the NSQIP into a nonprofit agency under the oversight of the VA and the ACS.

Shukri Khuri, MD, chief of surgical service at the VA Boston Healthcare System and professor of surgery at Harvard Medical School, says he and the other NSQIP leaders are confident that Congress will grant permission to turn the NSQIP into a nonprofit agency. The effort is aided by a $6 million grant from the Agency for Healthcare Research and Quality.

"The nonprofit will be an umbrella for all the other medical centers in the country to participate," Khuri says. "This could all happen within a year if things go well. We fully expect to see NSQIP made available to everyone very soon."

NSQIP tracks surgical outcomes

If that plan comes to fruition, NSQIP could be a major resource for quality improvement. VA medical centers already have benefited in significant ways.

The system got its start in 1991, prompted by the need to assess comparatively the quality of surgical care in 133 VA hospitals. The VA conducted the National VA Surgical Risk Study (NVASRS) between 1991 and 1993 in 44 VA medical centers. The study developed and validated models for risk adjustment of 30-day morbidity and 30-day mortality after major surgery in eight noncardiac surgical specialties. Similar models were developed for cardiac surgery by the VA’s Continuous Improvement in Cardiac Surgery Program (CICSP).

Based on the results of the NVASRS and the CICSP, the VA established the NSQIP in 1994 in all the medical centers performing major surgery. An NSQIP nurse at each center oversees the pro-spective collection of data and their electronic transmission for analysis at one of two data coordinating centers, says Jonathan Perlin, MD, PhD, deputy undersecretary of health at the VA.

Feedback to the providers and managers is aimed at achieving continuous quality improvement. It consists of comparative, site-specific, and outcome-based annual reports; periodic assessment of performance; self-assessment tools; structured site visits; and dissemination of best practices.

A gold mine of QI data

The NSQIP also provides an infrastructure for the VA investigators to query the database and produce scientific presentations and publications. Since the inception of the NSQIP data collection process, the 30-day postoperative mortality after major surgery in the VA has decreased by 27%, and the 30-day morbidity has decreased by 45%.

"The program is based on our compulsiveness for collecting reliable data," Khuri says.

"What differentiates us from other programs is that we have been very consistent about the need to collect data in a reliable way," he explains. Most importantly, we assigned a clinical nurse in each of our VA centers to collect data in accordance with a very structured, standardized protocol."

Those data regarding surgical outcomes are transmitted to VA coordinating centers in Denver, where they are checked for reliability and then entered in the NSQIP database.

An executive committee reviews the information quarterly, and then each year generates the annual NSQIP report. This report is a gold mine of quality improvement data, Khuri says. Each VA medical center receives a copy of the report, showing the surgical outcomes data for each hospital in the system.

All of the data are blinded, except for the recipient hospital’s own data. That way, the chief of surgery and the quality improvement director can compare the hospital’s performance to the overall quality measures in the VA system.

Best and worst scores

A key measure of outcomes in the NSQIP is the "outcomes to expected" or "O/E" ratio for certain procedures and patients. That ratio is determined by comparing the actual outcome of a surgical procedure to what would be expected when considering various factors, including the patient’s severity.

If a hospital’s outcome data are considerably worse than the average, the hospital is deemed a "high outlier." A hospital with surgical outcome data that is considerably better than the system average is called a "low outlier." The whole NSQIP system is intended to help the high outliers learn from the low outliers.

"When the data show that a hospital is a high outlier, that obviously implies that there may be a problem with the quality of care in that institution," Khuri says. "On the other hand, if the hospital’s O/E ratio is low, that implies that there is superior performance and a higher quality of care. In both cases, we want to go in and look at why."

Site visits may result from NSQIP data, either to help a hospital determine why its surgical outcomes are unusually high or to see how an especially good program achieved such good results. The annual report in January includes lists of problems that were identified in the high outliers and best practices that were found in the low outliers.

All VA hospitals can benefit from the list of potential problems and best practices, even if their own hospitals’ quality ratings are average, Perlin says.

Substantial improvements achieved

"NSQIP has led to substantial improvements in the VA system," Perlin says. "Early on when we started this program, there were some real concerns about morbidity and mortality in the VA, but now the observed mortality is lower than what would normally be expected for the patient. The NSQIP data provide managers in the system a rational basis for comparison, a means for sharing best practices and improvement."

Khuri says the NSQIP analyses have led to dramatic improvements in some VA medical centers. In one case, a high outlier’s data prompted an in-depth investigation that revealed a rampant infection control problem in the surgery unit. Until the NSQIP data prompted the investigation, the infection was completely unnoticed. Once the problem was corrected, the hospital became a low outlier.

In addition to the annual reports, the NSQIP is amassing a large database on surgical outcomes. The database now has information on more than 1 million surgical cases from the past 10 years.

Data system expanding beyond VA

Initial efforts at expanding the NSQIP beyond the VA have been encouraging, Khuri and Perlin say. Three medical centers initially tried the system, with good results, and now the trial has been extended to a total of 14 hospitals across the country.

Initially, there was some concern over whether the VA’s success could be replicated in more typical hospitals that treat a wider array of patients, including children and procedures not often seen in the VA system.

Those concerns were dispelled in the early testing and the ongoing experience affirms that the system can be used by any hospital, Khuri points out.

Making the VA’s NSQIP available to all hospitals could revolutionize quality improvement in the surgical arena, Perlin says, and the next step is to expand the system beyond surgery. In the future, the NSQIP could include data on other forms of clinical care as well as issues such as patient satisfaction.

"One of the exciting things is that the NSQIP allows hospitals to measure quality systematically," Perlin says. "It’s the measurement that has led to better outcomes."

[For more information, contact:

  • Shukri Khuri, MD, Chief of Surgical Service, VA Boston Healthcare System, 940 Belmont St., Brockton, MA 02301. Phone: (508) 583-4500.
  • Jonathan Perlin, MD, PhD, Deputy Under- secretary of Health, Department of Veterans Affairs, Washington, DC 20011. Telephone: (800) 827-1000.]