Multihospital collaborations for surgical quality improvement.

THE US HEALTH CARE SYSTEM IS PLAGUED BY A PARAdox. Creativity is prized and innovation is commonplace, but clinical quality, at least as judged in comparison with other industrialized countries, is seen as lackluster. One aspect of this problem is the large gap between the generation of evidence, which would be produced by a well-conducted clinical trial, and the reliable implementation of that evidence in the community hospital. One of the difficulties in translating and applying evidence to the bedside might relate to hospital organization. The problems start at the top. The hospital CEO has resources but often no clinical credentials, and works with the physician leader, who has clinical credentials but no resources. This often results in ambivalence about strategy and a corresponding lack of a clear and well-accepted plan. Strategic confusion also stems from the strong professional identification physicians have to the practice of medicine rather than to the hospital, hospital system, or hospital administrator. This limits the sense of “organizational citizenship” a physician might develop toward a hospital-led quality effort, perhaps partly due to the administrators-vsphysicians culture that exists at some institutions. Moreover, quality will not improve unless it can be measured. A powerful fuel for change is comparative evaluation of performance. This is tricky business unless there is confidence by clinicians in the validity of the measurement, and an organizational structure that permits nonjudgmental but comparative evaluation. Collaborative groups of hospitals have formed to circumvent some of these important obstacles by organizing outside of the individual hospital environment. One of the earliest was the Northern New England Cardiovascular Disease Study Group, which focused on outcomes following cardiovascular procedures in 3 New England states. Exchange of information and analysis of causes of mortality resulted in a reduction of 24% in mortality in 8 participating hospitals performing open heart surgery. Other multihospital collaborations have had similar success. In each case, the collaborative environment provided a new and previously nonexistent platform on which comparative performance could be assessed, existing practice patterns could be evaluated, and best practices could be identified and implemented. Despite its promise, securing financial support for such collaborations has been difficult. Two large collaborations have recently formed and address this problem in different ways. The Surgical Care Outcomes Assessment Program (SCOAP) involves 50 hospitals in the state of Washington and focuses on the prevalence of important process of care measures, in-hospital outcomes, and appropriateness of care. Financial support is provided by participating institutions, funding agencies such as the Life Sciences Discovery Fund, and various regional health plans. The experience of SCOAP underscores the point that if surgeons design and lead a quality effort, they will share information with colleagues from other institutions to improve outcomes. Some of the interesting quality metrics chosen by SCOAP surgeons are the rate of negative appendectomies, the rate of reoperation for elective colorectal operations, the rate of venous thromboembolism prophylaxis in colorectal operations, and the percentage of patients undergoing colorectal procedures for cancer in which at least 12 lymph nodes are resected. Results are provided in an anonymous fashion, such that the single participating hospital knows where it stands along a spectrum of results, but does not know the identity of the other member groups. This has resulted in measurable improvements in all of the process and outcome measures listed above. Using a different approach, the Michigan Surgical Quality Collaborative (MSQC) has developed a partnership with regional third-party payers (Blue Cross and Blue Shield of Michigan/Blue Care Network) to support its collaborative efforts. The MSQC consists of 34 Michigan hospitals, most of which are community-based and nonacademic. The MSQC is a higher cost system than SCOAP because it uses the American College of Surgeons-National Surgical Quality Improvement Program quality outcomes system, which is quite detailed and relies on a full-time nurse data collector at each site.