VA program for surgical quality called a success

The Department of Veterans Affairs’ (VA) patient safety system can be mined for strategies that could work well in your own organization, but another successful program from the VA could be directly available to all hospitals within a year. The VA’s National Surgical Quality Improvement Program (NSQIP) is an outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care, and its leaders say it has been a tremendous success. The NSQIP incorporates 128 Veterans Affairs Medical Centers (VAMCs) and 14 beta sites in the private sector, but the VA is trying to set up a system in which NSQIP could include any health care provider in the United States.

The VA is working with the American College of Surgeons (ACS) to turn the NSQIP into a nonprofit agency under the oversight of the VA and ACS, says Shukri Khuri, MD, chief of surgical service at the VA Boston Healthcare System and professor of surgery at Harvard Medical School. The groups must first obtain Congressional authority to make the VA program available to others, but Khuri says he is confident that the plan will come to fruition. "This could all happen within a year if things go well. We fully expect to see NSQIP made available to everyone very soon," he says.

Research for the system began in 1991 as a way to comparatively measure the quality of surgical care in 133 VA hospitals. A two-year study developed and validated models for risk adjustment of 30-day morbidity and 30-day mortality after major surgery in eight noncardiac surgical specialties, and then similar models were developed for cardiac surgery by the VA’s Continuous Improvement in Cardiac Surgery Program (CICSP). The NSQIP was established in 1994 in all medical centers performing major surgery. An NSQIP nurse at each center oversees the prospective 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. 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 by 45%.

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.

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.

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. 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.