NSQIP Comes Home

June 2015

Comparison Data from National Surgical Quality Improvement Program (NSQIP) Drives Quality Improvement 

Surgeons from nine surgical subspecialties at University of Colorado Health (UCHealth) and six surgical subspecialties at Children’s Hospital Colorado now have the ability to see how their rates of complication compare to national surgical outcomes data, through the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP).

Robert Meguid​, MD, MPH, FACS, oversees the NSQIP program at University of Colorado Hospital (UCHA), which began participating in NSQIP in 2013. (Pictured on right)

“Here at UCHA, we’re using NSQIP as a tool to identify what we do well and what we do poorly so that we can change our behavior patterns,” he said. “It’s becoming a useful tool to guiding our quality improvement efforts.” 

Did you know?

Although UCHA and CHCO only recently became involved with NSQIP in its current form, School of Medicine faculty members Fred Grover, MD, Karl Hammermeister, MD and William Henderson, PhD, MPH were among its founders within Veterans Affairs Medical Centers over twenty years ago. 

In 2007, the ACS began working with the American Pediatric Surgical Association to develop the NSQIP Pediatric program, which also has roots in Colorado, as Moritz Ziegler, MD, worked in collaboration with three other children’s hospitals across the country to begin collecting data. 

How NSQIP Works 

NSQIP participating hospitals receive risk-adjusted outcomes reports quarterly, providing a forum for identification of a hospital’s areas of excellence and weakness. It also helps hospitals compare their data with national data and provides access to other institutions’ best practices to decrease complication. 

UCHealth Forms a System-Wide Collaborative

Robert McIntyre​, Jr., MD, FACS, oversees the UCHealth Surgical Quality Collaborative, which includes UCHA, Poudre Valley Hospital, Memorial Hospital and Medical Center of the Rockies. It was formed as a way to raise the entire system as compared to national surgical quality data. 

“As you might expect, as a system, we have good performance in some measures, and we have opportunities for improvement,” said Dr. McIntyre. (Pictured on left)

Children’s Hospital Colorado in Unique Position for NSQIP Pediatric 

Although the program has the same goals as the adult NSQIP, there’s a big difference between the adult and pediatric programs—namely that an established pediatric program didn’t exist until recently. 

Jennifer Bruny​, MD, admits that when they started, they weren’t sure it was going to work. “It’s a challenge. Kids have different risk factors, and they have 10-fold fewer complications than adults—which is great for kids. But it’s not so great when you’re collecting complications data for statistical comparison,” she said. “We just weren’t sure that the project would result in a useful database.” 

How Data are Gathered 

Data are abstracted by certified surgical clinical reviewers (SCRs). At UCHA, Nora Hennecken, RN, JD, and Sandra Espinoza, RN review 2,500 clinical patient charts per year. At Children’s Colorado, SCR Debra Liebrecht, RN, CPHQ, assesses 35 cases every eight days.

The SCRs find there are some misconceptions surrounding data abstraction. “It’s important that faculty understand that we are trained RNs who take a certification test for NSQIP to become SCRs,” said Espinoza.

Hennecken agrees. “Everyone should understand that the variables are very precise, and we have very little leeway in making a decision to assign or not to assign per NSQIP protocol,” she said.

Outcomes Data Leads to Quality Improvement Projects

According to Dr. Meguid, UCHA is on par with what is expected nationally concerning overall mortality, unplanned intubation and prolonged ventilator support. And the hospital experiences better than expected outcomes concerning post-operative cardiac events and post-operative renal failure. But they have also identified areas that need attention. The comparison data has led to ongoing quality improvement projects surrounding urinary tract infections after surgery, reducing reoperations, unplanned readmissions and post-operative pneumonia. 

Across the UCHealth system, Dr. McIntyre believes the greatest opportunity for improvement is improving rates of surgical site infections (SSI). 

“When UCHealth looked at rates of readmission, unplanned return to the OR and sepsis, the primary driver was SSI,” he explains. “As a system, we have multiple issues to address. But we need to put our greatest effort into areas for which we’ll see the greatest return. In my mind, we can address all issues, but currently our main issue is SSI.”

At Children’s Colorado, Dr. Bruny said pediatric NSQIP data has helped them examine their assumptions. “It’s interesting to see what risk factors don’t necessarily matter,” she said. “The data is showing us that certain variables, such as nutrition or failure to thrive, don’t influence outcomes like we’ve always thought.” 

Pictured at left: Debra Liebrecht, RN and Jennifer Bruny, MD.

In addition, pediatric NSQIP data helped Children’s Colorado recognize that they use CT scans far more than nationwide averages. “When you see a graph and you’re on the wrong end, it’s a big incentive to improve,” said Dr. Bruny. “Now there’s a full clinical effectiveness team using this data to reduce the amount of unnecessary CT scans.” (See related article, this issue, "Bajaj Drives Value​")

Documentation Remains a Challenge

In both hospitals, manual abstraction is an issue. The fact that data is manually abstracted—even data that doesn’t require interpretation, such as demographics or lab values, is an issue that has recently been addressed. “We are just now getting started on automatic uploads,” said Hennecken.

There are also issues associated with training and educating the providers entering data into Epic.

 “We know there’s a documentation issue—and cases where our documentation has skewed the results. For example, when we drill down into the data, the unplanned OR return rate at UCHA would have been about a third less if the documentation had been better,” said Dr. McIntyre.

“Even though we would like to assume things, we can't. So if it is not documented in Epic by the doctors, it can’t be reported,” said Espinoza.

Dr. McIntyre cautions that fixing documentation doesn’t change the quality of care. “It just changes the scorecard,” he said. “So even if our documentation had been better about planned versus unplanned returns to the OR, the quality of care hasn’t changed. We’d be on par with the average score.”

Dr. McIntyre adds, “We don’t want to be average. We want to be a high performer.”

Providers Welcome NSQIP Data

Dr. Meguid says that after the initial shock of the information, UCHA physicians are rolling up their sleeves to analyze the data and translate it to better patient care. “Physicians have been very receptive to getting feedback on how we’re doing as an institution and using it to improve patient outcomes.”

What’s Next

Drs. Meguid and McIntyre are preparing to attend the annual NSQIP meeting in July to participate in collaborative sessions. “We’ll attend to get ideas from the existing collaboratives,” said Dr. McIntyre.

At Children’s Colorado, the increased reliability of data and the focus on disease-specific modules has been a good motivation for quality improvement. “We’re getting more organized around all the divisions so there’s greater access to the data so it can be used throughout the surgical departments,” said Dr. Bruny.

NSQIP-related projects will continue to be a major driver of QI on campus for many years to come. For more information, visit ACS NSQIP and ACS NSQIP Pediatric.