2013: The Year of Achievement through NSQIP
By Doug Cochrane
Last year was an exciting year for surgical services in British Columbia. With the support of the Health Services Purchasing Organization (HSPO) and the BC Patient Safety and Quality Council (BCPSQC, the Council), the health authorities implemented the National Surgical Quality Improvement Program (NSQIP) in 22 of their sites across the province. Each site has one or more surgeon champions, often an anaesthesiologist champion, and clinical data reviewers. Supporting this core team are improvement experts as well as teams and administrators working within the surgical services and operating suites.
During the past year, sites have been gathering data according to NSQIP protocol and have been engaged in data submission to the American College of Surgeons (ACS) for analysis. In July, 21 sites received risk-adjusted reports from the ACS showing their performance relative to peers. The results of these Semi-Annual Reports (SARs) confirmed some assumptions and stimulated investigation into other areas where performance is wanting.
The ACS is using odds ratios and box plots to show sites’ performance relative to their peers but, while although it is a more valid statistical approach to comparison, this reporting format may not be intuitive to many. To assist sites in the correct interpretation, the Council is offering individualized report review and commentary with NSQIP site teams. If you are interested, Peter Doris (surgeon lead), Jonathan Berkowitz (UBC statistician), and Kimberly McKinley (SCR liaison/data support) can lead education sessions on the SARs at your site or virtually.
Many health authorities have supported their facilities in sharing non-risk-adjusted data and improvement efforts with other BC sites. In BC, sites will be using non-risk-adjusted data for improvement. The BCPSQC and Surgical Quality Action Network (SQAN) are also working with statistical experts to assess the feasibility of providing more frequent risk-adjusted reports using simple statistical models. These data would be concurrent and will allow for both risk-adjusted and non-risk-adjusted data to inform improvement efforts. The semi-annual reports from the ACS would then verify assumptions and interpretations.
NSQIP is a data collection process; the data itself does not improve clinical care for patients without the efforts of improvements teams. Every site has one or more teams in place working under the guidance of the champions and supported by the BCPSQC on areas of care where they are performing less well than their peers.
Members of the improvement teams and clinical data reviewers gathered in Richmond in May 2012 to share ideas and to continue their learning. Examples of improved care were shared, including strategies to decrease the risks of urinary tract infection and even an example of learning made fun (UTI Skit). These learnings, while coming forth from one or a small number of sites, are generalizable to BC surgical care overall. They are great examples of ideas and changes in care that made surgery safer, and they are applicable to all.
We all are aware that the culture of the environment in which we work is critical to the quality of care that we deliver and the experience that patients’ perceive. SQAN, working with Pascal Metrics and the BC NSQIP sites, has dared to look into social interactions in the operating theatre. Based on a culture survey tool, the study shed a light on communications, respect and teamwork in the operating room environment. The communication channels are shown in this figure (percentages indicate providers reporting “high” or “very high” levels of communication and collaboration with other OR caregivers).
We all see ourselves doing our best and, while this is necessary, it is not sufficient to delivery quality surgical care. It is how we interact with others that is key to successful and safe care for patients. Only by asking and talking will we, as individuals and as teams, learn how best to use these powerful tools to support patient care.
In July, NSQIP sites from across North America met in Salt Lake City. We can be very proud of BC’s accomplishments and role in this meeting. Not only were we able to come together as champions and teams for BC but we also showcased the work we are doing. This work is leading amongst NSQIP teams continent-wide. You can all be very proud.
Last fall, the SQAN held a meeting to share progress in improvement efforts and further team development. We heard from Martin Makary, who spoke about health care’s elephant in the room: as much as 30% of the care that we provide isn’t necessary. Listen to Marty’s message in these videos (Talking with Dr. Marty Makary). We also heard about amazing work by local teams reducing pneumonia, UTIs, and SSIs; teams implementing the surgical safety checklist; units using teamwork tools like huddles; care pathways and so much more! All presentations are available online (Spotlighting Event).
2013 will be a significant year for the surgical community. Almost 2 years after implementing NSQIP we are firmly embedded and we will receive our second risk-adjusted report from the American College of Surgeons. This report will inform us where further investigation is necessary and hopefully reaffirm our current focus. This is the year for surgical leadership to guide our action teams as we engage our front line clinicians and implement best practice. This is the time to build on our successes and strive for outstanding improvements. Let’s make 2013 the year of achievement!