By Matthew Hutter, MD
Dr. Matthew Hutter is director of the Codman Center for Clinical Effectiveness in Surgery, and a surgeon at Massachusetts General Hospital. This post is adapted from a talk he just gave at the American College of Surgeons’ Surgical Health Care Quality Forum in Boston.
Surgery to remove part of the colon is prone to nasty complications nearly one-third of the time. Even though the colon can be rinsed, it is never really “clean,” and so the procedure is prone to infection that can lead to open wounds. Other complications include abscess, bowel obstruction, pneumonia and worse. Sometimes, people die.
This high rate of complications is one reason why our quality consortium – five Partners Healthcare hospitals – chose partial colectomy as our first target for improving patient outcomes. Although our collective 29-percent complications rate was lower than the national average, we thought it could get still better.
It did. Over one year, we cut our complication rate by a dramatic 23 percent. How? Please read on for the lessons we learned about how to improve quality and save money at the same time — lessons we think may be broadly applied across surgery.
We chose partial colectomy for our quality experiment both because the complication rate is high and because it is a high-volume procedure that is performed at both academic and community hospitals. Our consortium includes Massachusetts General, Brigham and Women’s and Faulkner in Boston, Newton-Wellesley in Newton and North Shore Medical Center in Salem.
Given the high cost of treating complications – which add more than $11,000 to a procedure on average, according to conservative estimates – we negotiated a pay-for-performance contract with a commercial insurer that would pay our group an incentive if we were able to reduce the consortium’s average complication rate by 1 percent in a year. Even a seemingly minor reduction in complications has major implications for overall patient health and cost savings.
We had one more hurdle to cross before we got going: What quality improvement program would we use to assess our performance? The programs typically have several flaws.
Most get their data from medical bills, which are an abundant source of information but are not well suited to measuring performance. Also, many do not take into consideration the condition of the patient in assessing performance; this is a critical drawback, since you are more likely to get better results from operating on a healthy 25-year-old than a chronically ill 75-year-old. Finally, most quality programs do not track the patient after they leave the hospital, which is when most complications occur.
Fortunately, the hospitals in our consortium all participate in the American College of Surgeons National Surgical Quality Improvement Program. It uses clinical data, is risk-adjusted and tracks outcomes 30 days after the procedure. In our minds, it offers the best surgical outcomes data available.
Using its national database, it identifies hospital results as “exemplary,” “needs improvement” or “as expected” for many surgical procedures or measures. Typically, best practices from the “exemplary” hospitals are used to help the “needs improvement” hospitals get better, and a number of studies have shown that this approach works well. But we found little published information related to how hospitals like ours can use this data to improve an “as expected” procedure.
We got together to discuss present practices at each hospital, reviewed the scientific literature for best practices and brainstormed improvements, ultimately deciding to focus on reducing infections. We came up with a list of seven recommended process measures that we sent around to the participating hospitals. The list – dubbed “better colectomy ‘Lite’” – included practices such as administering preventive antibiotics an hour before the procedure, warming patients whose core temperature falls below 97.8 F., and opting for a less invasive (and less prone to infection) laparoscopic approach when possible.
In one year, our consortium was able to reduce the average complication rate from 29.1 percent to 22.4 percent, a reduction of 23 percent. That was great news for patients, but it also helped us meet our pay-for-performance incentive and reduce our costs.
You might ask: “If these quality measures are so effective, why weren’t they being taken already?” The answer is that although there is an incredible volume of research done, there is not enough clear-cut evidence telling us which processes should be used in specific situations.
Part of why we formed our consortium was to further distill and define what are “the best practices” that theoretically make sense and put them to work in real-life surgical settings to see if they actually improve care. As a collaborative, we learned a lot about how to reduce complications in partial colectomies.
But more than that, we also learned some elements critical to inculcating a quality culture, such as:
• All quality improvement is local. Each hospital had very different ways of approaching the same target, including how they used the best practices list. Each hospital’s plan depended on the available resources, the culture, and the leadership at each institution — so each plan had to be highly customized.
• Working together offers important advantages. We explored alternatives that might not have been apparent to any one of us on our own. We had a centralized resource for data collection and reporting, and our regular meetings kept our focus on quality improvement. None of us wanted to let our other team members down by not reaching our goal.
• Quality improvement is a continuous process. Our consortium and its members have since taken on other quality improvement projects, such as reducing urinary tract infections and complications for vascular, bariatric or emergency surgeries. We have seen improvements in all of these areas.
• To improve performance, you must first be able to measure it. The American College of Surgeons’ improvement program enabled us to negotiate a fair pay-for-performance contract and accurately measure outcomes when significant performance incentives – and patient health – were at stake.
Surgical complications harm patient health and raise hospital costs. Many are preventable and all could be reduced. So if you hear your hospital is undergoing “quality improvement,” don’t yawn or roll your eyes. It could save money — and your life.