The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality

Why focus on surgical quality? ~30 million major operations each year in the US –Despite advances in surgical and anesthesia technique and improvements in perioperative care, variations in outcomes for patients having surgery are well known

Why focus on surgical quality Patients who experience a postoperative complication have dramatically increased hospital length of stay, hospital costs, and mortality –On average, the length of stay for patients who have a postoperative complication is 3 to 11 days longer –Odds of dying within 60 days increases 3.4- fold in patients with a complication* *Silber JH, et al. Changes in prognosis after the first postoperative complication. Med Care. 2005;43:

4 Odds of Death after First Postoperative Complication Within 60 days Silber JH, et al. Changes in prognosis after the first postoperative complication. Med Care. 2005;43:

Who Pays for Surgical Complications? Hospital Reimbursement $ Costs of care $ Profit $ Profit margin % (uncomplicated) (complicated) Dimick JB, et al. Who pays for poor surgical quality? Building a business case for quality improvement. J Am Coll Surg. 2006;202: Complications were always associated with an increase in costs to healthcare payors: complications were associated with an average increase in payment of $7645 (54%) per patient.

Surgical Care Improvement Project National Goal To reduce preventable surgical morbidity and mortality by 25% by 2010

SCIP Steering Committee American College of Surgeons American Hospital Association American Society of Anesthesiologists Association of peri-Operative Registered Nurses Agency for Healthcare Research and Quality Centers for Medicare & Medicaid Services Centers for Disease Control and Prevention Department of Veterans Affairs Institute for Healthcare Improvement Joint Commission on Accreditation of Healthcare Organizations

Surgical Care Improvement Project Performance measures - Process Surgical infection prevention Antibiotics »Administration within one hour before incision »Use of antimicrobial recommended in guideline »Discontinuation within 24 hours of surgery end Glucose control in cardiac surgery patients Proper hair removal Normothermia in colorectal surgery patients

Surgical Care Improvement Project Performance measure - Process Perioperative cardiac events Perioperative beta blockers in patients who are on beta blockers prior to admission

Surgical Care Improvement Project Performance measures - Process Prevention of venous thromboembolism Proportion who have recommended VTE prophylaxis ordered Proportion who receive appropriate form of VTE prophylaxis (based on ACCP Consensus Recommendations) within 24 hours before or after surgery

Public Accountability and SCIP

13 Reporting Hospitals (Voluntary) Surgical Care Improvement Project Proposed IPPS rule suggested that hospitals needed to start reporting SIP measures in January to avoid losing 2% of their Medicare annual payment update. Final rule did not require reporting until July 2006.

14 Surgical Care Improvement Project Hospital Voluntary Self-Reporting, Qtr. 2, 2007 Benchmark rates were calculated for all HQA reporting hospitals in the US based on discharges using the Achievable Benchmarks of Care TM methodology (

15 Benchmark rates were calculated for all HQA reporting hospitals in the US based on discharges using the Achievable Benchmarks of Care TM methodology ( Surgical Care Improvement Project Hospital Voluntary Self-Reporting, Qtr. 2, 2007

16 Trends in Surgical Antimicrobial Prophylaxis

17 Ongoing Gaps in Performance Tennessee, Qtr. 2, 2007 Low- and High- Performers represent the average performance of those hospitals caring for 10% of the Tennessee surgical population.

18 Ongoing Gaps in Performance Tennessee, Qtr. 2, 2007 Low- and High- Performers represent the average performance of those hospitals caring for 10% of the Tennessee surgical population.

19 Patient Outcomes Can Improve The overall surgical infection rate fell 27%, from 2.28% (215 infections among 9435 surgical cases) in the first 3 months to 1.65% (158 infections among 9584 cases) between the first and the last 3 reporting months. Dellinger EP, et al. Am J Surg.2005;190:9–15.

20 More Reports of Success Henry D, et al. J Healthc Qual. 2007;29:50-6. –The result of the study was antibiotic prophylactic delivery 60 minutes prior to incision in the abdominal hysterectomy population from a baseline of 10% to greater than 90% from 2003 to McCahill LE, et al. Arch Surg. 2007;142: –The clearly defined roles of a cross-disciplinary team and the process improvements discussed in this article can easily be implemented in other institutions. These elements were integral to our success in improving the timely delivery and discontinuation of prophylactic surgical antibiotics. Hedrick TL, et al. Surg Infect. 2007;8: –The implementation of a prevention protocol resulted in a substantial trend toward a reduction in the incidence of SSI. These data support the use of protocol implementation as a cost-effective method of reducing perioperative infectious morbidity associated with intra-abdominal surgery.

Summary We need to find ways to make evidence- based processes of care routine for patients undergoing surgery –We have to quit relying on memory to ensure high quality care Recognize that there is now a national commitment to improving outcomes for surgical patients