Surgical Clinical Outcomes

Assessment Program (SCOAP)

Surgical Clinical Outcomes

Assessment Program (SCOAP)

David Flum, MDSCOAP Medical DirectorSurgeon, University of Washington Medical Center

PresentersPresenters

Miriam Marcus-SmithQuality Improvement Program Director, Foundation for Health Care Quality

Nancy Fisher, MDMedical DirectorWashington State Health Care Authority

Leigh CooleyQuality Improvement Director, Skagit Valley Hospital

Claudia SandersVice President, Policy DevelopmentWSHA

Goals of Web CastGoals of Web Cast

To make sure hospitals are informed about SCOAP, currently under development at the Foundation for Health Care Quality

To make sure hospitals are preparing for the program

To provide an opportunity for hospitals to ask questions

Presentation OverviewPresentation Overview

Background and components

Rationale for SCOAP: surgical variability

SCOAP recommendations

SCOAP current status

Hospital concerns

Questions and discussion

Background and Components

Background and Components

COAPCOAP

Physician-led with all stakeholders included

CQIP status (Coordinated Quality Improvement Program)

Participation directed by HCA contracts with plans

Regular descriptive and risk-adjusted data reports

COAP (cont.)COAP (cont.)

Currently includes all coronary artery bypass grafts (CABG) and percutaneous heart procedures and programs

Will add valves in 2006

COAP (cont.)COAP (cont.)

Tracking of outlier status and coordinating QI activity has led to: Improvements in use of best

practices (arterial grafts) Reduction in rate of adverse

outcomes (prolonged time on ventilators)

SCOAP BackgroundSCOAP Background

HCA engaged Foundation for Health Care Quality (FHCQ) HCA support of COAP, interest

in SCOAP Decision to proceed with

SCOAP Future contract requirements Expansion to Medicare,

Medicaid, private insurance Methods

FHCQ partnership with UW Literature review, analyses,

stakeholder discussions

Rationale for SCOAP: Surgical Variability

Rationale for SCOAP: Surgical Variability

Variability in Surgical Practices

Variability in Surgical Practices

There is significant variability in general surgery Process Outcome Cost

Best Practices There are “best practices” “Best practices” can be

encouraged

Variability in Other Industries

Variability in Other Industries

Variability in Other Industries

Variability in Other Industries

Risk falls below threshold Variability is being addressed

AppendectomyAppendectomy

Most commonly performed emergency abdominal procedure ~5800/yr

15 percent misdiagnosed 1 in 4 women of reproductive

age

AppendectomyAppendectomy

0%

5%

10%

15%

20%

25%

30%

35%

Hospital

% N

A

Variability in Outcome% Negative Appendectomy (NA), by

Hospital

Gastric Bypass for Obesity

Gastric Bypass for Obesity

0

400

800

1200

1600

1996 1997 1998 1999 2000 2001 2002 2003

Year

Operations per Year in Washington

Variability in Adverse Outcome

Variability in Adverse Outcome

0

2

4

6

8

10

12

14

A B C D E F G H I J K L M NHospital ID

Ad

ve

rse

ou

tco

me

%

30-day mortality 90-day reoperation

Gastric bypass for obesityby hospital

Colorectal SurgeryColorectal Surgery

5000/year

Adverse outcomes result in significant morbidity, mortality, and cost

Increasing use of laparoscopic colon resection has not been well studied

Colorectal Surgery Outcomes

Colorectal Surgery Outcomes

0%

5%

10%

15%

20%

25%

30%

1 8 14 21 23 27 30 35 37 39 46 50

Hospital Code

90-day mortality 90-day reintervention

Is SCOAP Worth It?Is SCOAP Worth It?

Colorectal Surgery Outcomes

90 day percuatneous or operative reintervention after colorectal resection

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%

1 8 14 21 23 27 30 35 37 39 46 50

Hospital

Mea

n(S

D)

2-5 years old−no clinical detail“Apples and apples?”

Is SCOAP Worth It? (cont.)

Is SCOAP Worth It? (cont.)

Is SCOAP Worth It? (cont.)

Is SCOAP Worth It? (cont.)

Length of operation (hours)

Procedure priority: elective

Procedure method (Open vs. Laparoscopic)

ASA class IV Lowest intra-op

temperature Insulin administered

in OR Highest periop BG Part removed: Ostomy: Anastomosis Anastomosis tested

Pathology results confirm diagnosis

Perioperative interventions:• Heparin/LMWH

within 2 hrs • Intermittent

pneumatic compression

Beta blocker within 12 hrs

Antibiotics within 60 min.

Pain management within 24 hrs

NGT RBC transfusion

Mechanical ventilation post RR

Process Measures: Coloectomy & ProcectomyProcess Measures: Coloectomy & Procectomy

SCOAP Recommendations

SCOAP Recommendations

SCOAP GoalsSCOAP Goals

Create a system to evaluate and improve surgical quality Define practice patterns Risk adjusted outcomes Track and reduce variability

Initial Focus on Three ProceduresInitial Focus on

Three Procedures

Appendectomy

Colectomy/proctectomy

Bariatric

Procedure Selection Rationale

Procedure Selection Rationale

Performed widely

High cost, high volume and/or growing fast

High variability in process and outcomes

Complications in the inpatient setting

Program Features Similar to COAP

Program Features Similar to COAP

Physician leadership

Confidentiality

CQIP status and protection

Universal participation (eventual)

Existing infrastructure/ administration

Requirements to participate

Program Features Different from COAPProgram Features

Different from COAP

Funding sources Initial Ongoing

Coordinated QI activities

SCOAP Current StatusSCOAP Current Status

SCOAP Progress to Date

SCOAP Progress to Date

Secured funding from HCA to develop infrastructure

Data variables, forms, and definitions developed and tested

Report formats developed

Initial set of participating hospitals

Contracted with data management firm

SCOAP Management Committee

SCOAP Management Committee

Fred Bowers, MDKadlec Med. Center

Leigh Cooley, RN, MNSkagit Valley Hospital

Patch Dellinger, MDUniversity of Washington Med. Center

Denise Dominik, RN Sacred Heart Med. Center

Michael Florence, MDSwedish Med. Center

David Flum, MDUniversity of Washington Med. Center

Eric Froines, MDGroup Health Cooperative

Jerry Jurkovich, MDHarborview Med. Center

Ben Knecht, MDWenatchee Valley Med. Center

David Lauter, MDEvergreen Hospital Med. Center

Paul Lin, MDSacred Heart Med. Center

David Simonowitz, MDOverlake Hospital Med. Center

Richard Thirlby, MD Virginia Mason Med. Center

SCOAP Timeline and Next Steps

SCOAP Timeline and Next Steps

Hospitals begin to collect and submit data

Secure program funding support effective January 2006

Expand to additional hospitals this summer

Initial reports early 2006

Bring in rural and critical access hospitals

SCOAP Hospital Roles SCOAP Hospital Roles

Early (2005) participants help shape SCOAP

Sign contract for data submission with Foundation

Work with SCOAP staff for training re variables, definitions, etc.

Submit data Engage surgical and QI staff

and leadership

SCOAP CostsSCOAP Costs

No fee in 2005

Effective 2006, assume $15-$20 per case for budgeting

Staff time: 15-20 minutes per case for abstraction

Clinical FAQsClinical FAQs

What are the alternatives? SCIP/SIP NSQIP Centers of Excellence

Why are we focusing on process rather than outcome? Balanced appraisal needed Process is more actionable

than outcome data

Administrative FAQsAdministrative FAQs

Who will know a hospital’s results? Hospitals and surgeons

Hospital ConcernsHospital Concerns

Hospital Concerns with SCOAP

Hospital Concerns with SCOAP

Increased hospital reporting

Meetings regarding SCOAP

Costs/employee time

Extension of program to rurals

Hospital interest in not just reporting information, but desire for focus on quality improvement

Where We All AgreeWhere We All Agree

Surgical COAP is consistent with increasing trend toward quality reporting

It will affect any hospital that performs the procedures and wishes to contract with insurers of state employees and will extend as other payers come on board

Information is available to help with planning and budgeting

POLLPOLL

How will SCOAP affect your hospital?• SCOAP will be very beneficial to

improving surgical care.

• SCOAP will be somewhat beneficial.

• SCOAP is okay – an equal combination of benefit and burden.

• SCOAP will be a reporting burden with little benefit.

• SCOAP will be very burdensome with no benefit.

QuestionsQuestions

Contact InformationContact Information

Leigh Cooleylcooley@skagitvalleyhospital.org

Miriam Marcus-SmithMmarcus-smith@qualityhealth.org

Claudia Sandersclaudias@wsha.org

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