MANAGEMENT BRIEF

Number 11 Overviews of Health Care Topics for VA Senior Managers September 1999

Quality Improvement in Surgical Care

“The National VA Surgical Quality Improvement Program is a remarkable collaboration

among policy makers, researchers, and clinicians.”

John R. Feussner, M.D.

Chief Research and Development Officer

“The National VA Surgical Quality Improvement Program is a model for how quality

improvement should be done. Our task is how to replicate this in other areas of VHA.”

John G. Demakis, MD

Director, Health Services Research and Development

What is the National VA Surgical Quality

Improvement Program?

The National VA Surgical Quality Improvement Program, or NSQIP, was implemented in 1994 to provide reliable, valid and comparative information about surgical

outcomes (morbidity and mortality rates) among the 123

VAMCs performing major surgery. This information enables

researchers, clinicians and managers to identify factors that

contribute to high-quality surgical care, as well as those factors that result in less than optimal care, and to identify best

practices that will improve care. Thus, this Program aims to

develop performance measures that will result in better practices that improve the quality of surgical care for veterans.

To accomplish this, the NSQIP was designed based on the

hypothesis that the quality of surgical care can be measured,

compared and enhanced in various institutions by the use of

proper, validated and peer-reviewed models for risk-adjusted

reporting of outcomes1. Serving as an internal review mechanism, the NSQIP builds upon the methodology, analysis and

reporting developed in the National VA Surgical Risk Study

(NVASRS). The statistically determined expected outcome

(E) is compared with the actual observed outcome (O) for all

patients in the study, using an observed to expected (O/E)

outcome ratio. The numerical values obtained allow risk-adjusted comparisons of outcomes in evaluating the quality of

care in each surgical program. Reports on these comparisons

are then provided to VA chiefs of surgery, medical center directors, and network directors, providing a tool with which

the quality of surgery for veterans can be monitored, compared and improved.

Why was the NSQIP developed as a

risk-adjusted model?

Patients’ health status after medical treatment is a reflection of the process of care they receive. In comparing postsurgical mortality and morbidity rates, the assumption is that

surgical services with low rates of complications and death

have better processes and structures than surgical services

with higher rates. However, clinicians recognize that some

surgical services may operate on patients who are sicker.

Therefore, the NSQIP developed methods of adjusting for

how sick patients are before major surgery and provides postoperative morbidity and mortality rates that are adjusted for

patient risk and severity of illness.

In 1997, NSQIP identified 11 surgical services with 30-day

postoperative mortality rates that were significantly lower

than the VA average and 13 surgical services with mortality

rates that were significantly higher than the VA average. If

risk adjustment had not been applied, 64% of these would

have been misclassified as high or low outliers1

 (The term

“outliers” indicates a rate that falls two standard deviations

from the mean of all services.).

Why is the NSQIP important to VA managers?

The National VA Surgical Quality Improvement Program

was designed to operationalize research results; in other

words, to translate research results into better standards

of care. The quality of surgical care at VA hospitals has

improved significantly since the inception of NSQIP, a collaborative effort of HSR&D and VA’s Office of Quality

Management and Patient Care Services. The NSQIP has been

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instrumental in identifying ways to improve surgical care and

has resulted in:

• better surgical and anesthesia techniques,

• improved supervision of residents in surgical

training, and

• improvements in technology and equipment that have

resulted in measurable improvements.

For example, since 1994, the 30-day mortality and morbidity rates for major surgery have fallen 9% and 30%, respectively. In addition, improvements in postoperative morbidity

and mortality rates after major surgery have occurred at the

same time that the median postoperative length of stay in

VAMCs has declined by 4 days between 1991 and 19972

.

NSQIP serves as a tremendous resource for VA managers

in enhancing the quality of surgical care. The high quality

information provided to managers on surgical care allows for

consistent monitoring and improvement. This type of study

also serves as a model for the facilitation of continuous quality improvement programs that will decrease the variability in

surgical care while increasing quality of care. Improving the

quality of surgical care is probably the most effective means

of reducing costs and increasing value3

.

What are some future plans for NSQIP ?

The success of NSQIP has led to two major initiatives.

One is a pilot study collecting pre- and postoperative functional outcomes of veterans undergoing major surgery in

urology and orthopedics in 14 VAMCs. Another initiative is

collaboration with three affiliated academic health centers to

implement the NSQIP at non-VA hospitals in order to provide

comparison data from non-VA hospitals performing major

surgery1. The NSQIP encourages surgical centers to examine

their practices and learn from each other; thereby fostering a

continuous sharing of information that results in improved

practices and better patient care.

Below are recent findings from the National VA Surgical

Quality Improvement Program and its predecessor, the National VA Surgical Risk Study.

Patient outcomes related to coordinating

work responsibilities

Growing evidence exists that patient outcomes are related

to how effectively health care organizations coordinate work

responsibilities among their staff. Surgical services are an excellent setting for studying the role of coordination in patient

care delivery. A typical surgical service is comprised of several interdependent units among which patients are transferred during the course of an inpatient stay for surgical care.

The interdependency among these units implies a strong need

for coordination among surgical staff (i.e.,

surgeons, anesthesiologists and nurses).

A study sponsored by VA’s HSR&D utilized the NSQIP to

determine how surgical services can be managed most effectively. Study participants were the 44 largest VA surgical

services. There were two primary data collection activities:

1) a survey of surgical staff at each participating site, and

2) site visits to 20 of the 44 participating sites – 10 with the

highest and 10 with the lowest risk-adjusted morbidity and

mortality rates. The study team used the survey and site

visit data to assess the relationship between surgical outcomes and different patterns or approaches to coordinating

surgical staff.

Overall, study results indicated that the surgical services

that used a variety of both personal and standardized coordination practices had better outcomes. Regarding personal

approaches, the surgical services with the best outcomes

were more likely to emphasize interdisciplinary meetings

and discussions. With respect to standardization, the highperforming surgical services were typically farther along

than the other surgical services in the development and

implementation of clinical pathways and protocols. High

performers also emphasized training and education to standardize the skills of their staff.

Young GJ, Charns MP, Daley J, et al. Best practices

for managing surgical services: The role of coordination.

Health Care Management Review, 22: 72-81, 1997.

Young GJ, et al. Health Services Research, winter

issue, 1998.

Young GJ, Charns MP, Desai K, et al. Patterns of

coordination and clinical outcomes: A study of surgical

services. Health Services Research, 33(5): 1211-36, 1998.

Validating risk-adjustment surgical outcomes

The primary assumption in using risk-adjusted outcomes

as a measure of quality of care is that providers with the

best outcomes will be those with the most effective structures and processes for delivering care. A study was conducted to assess the validity of risk-adjusted surgical

morbidity and mortality rates as measures of quality outcomes. [These risk-adjusted surgical outcome measures

were initially developed as part of the NVASRS.] A structural survey of 44 VAMC surgical services and site visits to

20 surgical services with higher than expected and lower

than expected risk-adjusted 30-day mortality and morbidity

rates were conducted. The staff was blinded to outlier status. Main outcome measures included assessment of technology and equipment, technical competence of staff,

leadership, relationship with other services, monitoring of

quality of care, coordination of work, relationship with

affiliated institutions, and overall quality of care.

Surgical services with lower than expected risk-adjusted

surgical morbidity and mortality were those identified by

the site visit teams as having the best practices. Other factors associated with lower than expected risk-adjusted surgical morbidity and mortality included significantly better

technology and equipment in operating rooms and intensive care units. This study provides further evidence that
For more information or to send comments contact:

Gerry McGlynn, M.Ed., MDRC, Manager, Information

Dissemination Program, 150 S. Huntington Avenue, Boston,

MA 02130. Phone: FTS 700-839-4433 or 617-278-4433.

Fax: 617-278-4438. Visit the Research and Development

web page at http://www.va.gov/resdev/prt or the Intranet site

at vaww.va.gov/resdev, or utilize the MDRC Fax-on-Demand

system at 617-278-4492 to see additional MDRC publications and reports.

This is our eleventh MANAGEMENT BRIEF. Please give us your

suggestions and comments:

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The MANAGEMENT BRIEF is produced by the Management Decision

and Research Center, a program within the VA’s Office of Research &

Development, Health Services Research & Development Service. The

purpose of the MANAGEMENT BRIEF is to provide VA senior management

with a concise and timely overview of a specific health care topic that

includes topic definition, benefits, VA research activities, and resources

for further information.

significant differences in several aspects of process and structure of the delivery of surgical care are associated with differences in risk-adjusted surgical morbidity and mortality rates.

It is hoped that the “best practices” of surgical services with

better than expected outcomes will serve as a source of innovation and possible process redesign for other surgical services both in and outside the VA.

Daley J, Forbes MG, Young GJ, et al. Validating riskadjusted surgical outcomes: Site visit assessment of process

and structure. Journal of the American College of Surgeons,

185(4): 341-351, 1997.

References:

1. Daley J, Forbes MG, Young GJ, et al. Validating riskadjusted surgical outcomes: Site visit assessment of

process and structure. Journal of the American College

of Surgeons, 185(4); 341-351, 1997.

2. Khuri SF, Daley J, Henderson W, et al. The Department of

Veterans Affairs’ NSQIP The first national, validated. Outcomes-based, risk-adjusted, and peer-controlled program

for the measurement and enhancement of the quality of

surgical care. Annals of Surgery, 228(4); 491-507, 1998.

3. Jones RS, Meakins JL. The future is now. (Editorial).

Journal of the American College of Surgeons, 185(4);

408-409. 1997.

For more information about NSQIP, or to receive a list

of their publications, such as their biannual newsletter, call

Jeannette Spencer, R.N., National Clinical Coordinator,

National VA Surgical Quality Improvement Program

(Chairman’s Office); Brockton/West Roxbury VAMC;

phone: 617-323-7700, x6740.

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