You have NSQIP.Great!!!

Now what?

Robert R. Cima, MDAssociate Professor, Division of Colon

and Rectal SurgeryMayo Clinic, Rochester

No Disclosures

What is Quality?

http://www.ibiblio.org/wm/paint/auth/vinci/joconde/ http://www.merello.com/modern-art.htm

Health Care Quality Improvement

• The National Quality Strategy will pursue three broad aims. These aims will be used to guide and assess local, State, and national efforts to improve the quality of health care.

• Better Care: Improve the overall quality, by making health care more patient-centered, reliable, accessible, and safe.

• Healthy People/Healthy Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social and, environmental determinants of health in addition to delivering higher-quality care.

• Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government.

• Report to Congress: National Strategy for Quality Improvement in Health Care. March 2011. http://www.healthcare.gov/law/resources/reports/quality03212011a.html#es

Now What?

http://homeinthetrenches.com/wp-content/uploads/2011/02/trench-warfare-1.jpg?w=288

Quality Improvement (QI)

• A fundamental requirement of any QI project is there needs to be a metric that can be assessed

• Requirement• Clearly defined• Readily measured• Reliable measurement technique• Timely

Quality Improvement

• Health care outcomes are the result of an interaction between natural andhealth care delivery processes

• Common cause variation• Phenomena constantly active within the system • Variation predictable• Irregular variation within an historical experience

base• Lack of significance in individual high or low values

Quality Improvement

• Common cause variation

-0.1

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

Pro

porti

on

05/2

006

07/2

006

09/2

006

11/2

006

01/2

007

03/2

007

05/2

007

07/2

007

09/2

007

11/2

007

01/2

008

03/2

008

05/2

008

07/2

008

09/2

008

11/2

008

01/2

009

03/2

009

05/2

009

07/2

009

09/2

009

11/2

009

01/2

010

03/2

010

05/2

010

07/2

010

Month/Year

0.088

LCL=0.000

UCL

Quality Improvement

• In any complex system, successful QI requires reducing as much variation within the system as possible

Diversity is good for creativityUniformity leads to predictability, improved process control, and efficiency

The Role of NSQIP in QI

• Understand variation• Patients• Disease profile• Surgeons

• Outcomes data• Reliable• Timely• Actionable

•Systematic Sampling Process• 8-day cycle assures cases have equal chance of

being selected

• The first 40 cases meeting inclusion/exclusion criteria are selected

•Inclusion/Exclusion Criteria•Inclusion based on CPT codes• Exclusion criteria

• Under age 16• >3 inguinal herniorrhaphies, >3 lumpectomies, or > 3

laparoscopic cholecystectomies per cycle • Trauma and Transplant• ASA class 5

The Role of NSQIP in QI

•Preoperative data• Demographics - 9 variables• 40 clinical variables and 13 laboratory variables

•Intraoperative data• Surgical Profile - 9 variables • 18 clinical variables and 3 complications

•Postoperative data• 30-day outcomes (inpatient and outpatient)• 20 complications, 12 laboratory variables, and 9

discharge variables

The Role of NSQIP in QI

Data Analysis for Mayo Clinic Colorectal SSI Reduction Effort

130+ NSQIP Variables

40 NSQIP VariablesAgeGenderBMIWound ClassDiabetesTransfusionVarious LabsCPT4 CodesDisease

Significant VariablesAge (p = .0002)BMI (p = .0495)Wound Class (p = .0004)Diabetes (p = .046)Laparscopic (p = .0005)Open (p = .0005)Intra-op Blood (p = .0024)Duration (p = .0005)Sepsis (p = .026)Steroid use (p = .001)CPT-4 code (p = .024)

Factors that influenced MCR CRS SSI

• Diagnosis• Crohn's Disease • Diverticular

disease • Ulcerative Colitis

• Represented over half of all identified SSIs

• BMI• Operative time

NSQIP Data Reliable, Timely, Actionable

Quality Improvement as a Process

The DMAIC Method

Improvement cycle

D M A I C

Define Measure Analyze Improve ControlProject

selectedby sponsor

Projecteither closedor transitionedto operationalowner

Principles of MCR Colorectal SSI Reduction Effort

• Interventions across the episode of care• Multi-disciplinary• Engage staff, patient, and families• Standardize as many processes as

possible• Ensure high compliance with elements

• Quick audits• Build the elements into the system• Frequent feedback and communication

Define Phase• Goal: Reduce colorectal surgical site infections by 50% and improve OE

ratio from 4th decile to 2nd decile by Oct 31 2011. 2009 overall SSI rate was 10.5%.

• Unit of Improvement: Colorectal Surgical Procedures –All patients undergoing colorectal surgery (emergency and elective) at Rochester Methodist Hospital. NSQIP CPT codes for colorectal surgery.–All types of Surgical Site Infections (Superficial Incisional, Deep Incisional, and Organ/Space).–Excludes: Trauma and Primary Transplant patients. Patients under 18 years of age

• Defect: Any Surgical Site Infections

• Data source: NSQIP Data Set

Measurement PhaseObserved Colorectal SSIs

-0.1

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

Pro

porti

on

05/2

006

07/2

006

09/2

006

11/2

006

01/2

007

03/2

007

05/2

007

07/2

007

09/2

007

11/2

007

01/2

008

03/2

008

05/2

008

07/2

008

09/2

008

11/2

008

01/2

009

03/2

009

05/2

009

07/2

009

09/2

009

11/2

009

01/2

010

03/2

010

05/2

010

07/2

010

Month/Year

0.088

LCL=0.000

UCL

Data Analysis & Collection Plan130+ NSQIP Variables

40 NSQIP VariablesAgeGenderBMIWound ClassDiabetesTransfusionVarious LabsCPT4 CodesDisease

SignificantVariablesAge (p = .0002)BMI (p = .0495)Wound Class (p = .0004)Diabetes (p = .046)Laparscopic (p = .0005)Open (p = .0005)Intra-op Blood (p = .0024)Duration (p = .0005)Sepsis (p = .026)Steroid use (p = .001)CPT-4 code (p = .024)

Key Factors (examples)Patient preparation (Pre/Intra& Post-op)Appropriate Abx re-dosingContinued SCIP ElementsClosing trayFresh glove changeDressing change @ 48hDismiss with HibiclensEnsure complete intra-op cleansing and coverageAdd’l cleansing for pts BMI>30

Reduce SSI by 50%

(10 5%)

Pre-operative Processes

Post-operative Processes

Post-hospitalization

Processes

Patient Cleansing

Antibiotic administration

Closing protocol @

time of fascia closure

Patient and Hand

hygiene

Chlorhexidine cloths @ AM admission

Hibiclens® shower night before and day of surgery

Ensure understanding by reading pamphlet “Preventing SSI”

Ensure SCIP compliance1. Right antibiotics2. Administer 60 min prior to incision3. Discontinued with in 24 hoursEnsure re-dose of cefazolin with in 3-4 hours after incision

Chloraprep applied – use appropriate amount to ensure complete coverage of incisional area

Use Closing tray for closure of fascia and skin

Glove change by staff before closure of fascia

Practice good hand hygiene

Patient shower with Hibiclens® following dressing removal

Hand Cleansing agent readily available

Signage encouraging hand hygiene

Purell ® hand wipes made available to patients

Ensure dressing removal with in 48 hours

Dismiss patient with 4 oz. bottle of Hibiclens®

Patient education on wound care and recognizing infection symptoms

Follow-up phone call from nurses

Critical to Quality Tree: SSI for Colorectal Surgery

Intra-operative Processes

The MCR Colorectal SSI Improvement Team

• Project Leader/Surgeon Champion: Robert Cima, MD• Black Belt: Gene Dankbar, Systems and Procedures• Kimberly Aronhalt, RN, Infection Control and Prevention • Diane Foss, RN, Kim Gaines, RN, Nursing, Pamela Grubbs, RN, • Pamela Maxson, RN, PhD, Jennifer Wolforth, RN, Nursing• Sharon Nehring, RN, Roxanne Hyke, RN, Diane Tyndale, RN,

NSQIP• Jenna Lovely, PharmD, Pharmacy Services• Sarah Pool, RN, Surgical Services, Lynn Quast, RN, Surgical

Services• Jim Rogers, Systems and Procedures• Rajesh Pendlimari, MBBS, Research Fellow, CRS• Karen Piotrowicz, RN, Mid-level Provider, CRS

Improvement Phase

• Need to know what is really happening

• Build change into the system

Improvement PhaseAnesthesia Antibiotic Reminder Screen

Improvement Phase:Process audits

• Cefazolin re-dose after 3-4hr if Op time > 3hr

• Antibiotic “watcher” effective after 1/1/11

• Re-dosing after 4 hr improved from 8/12 (66%) in 2/2010 to 17/17 (100%) in 2/2011

0

5

10

15

20

Sam

ple

Size

(n)

2010 2011

# cases > 180 min received Cefazolin

# re-dose missed after 3 hr

# re-dose missed after 4 hr

Sep-11May-11Jan-11Sep-10May-10Jan-10Sep-09May-09Jan-09

0.4

0.3

0.2

0.1

0.0

InfoMonth

Prop

orti

on

_P=0.0421

UCL=0.2092

LCL=0

2009 2010 2011

Tests performed with unequal sample sizes

Percentage Chart of Total Observed SSI by Phase

Improvement Phase

Control Phase

• Monitor monthly event rates• Observed/Expected data is nice but

rarely drive frontline QI

• Regular team meetings• Make sure processes haven’t been

changed• Other processes may have been

implemented with unintended consequences

Quality ImprovementLessons from the Frontline

• It is a process that• takes time• takes effort• takes a team

• The team is always bigger than you think• requires data

• Timely• Reliable

• is unique to the people, place, and system of care

Quality ImprovementLessons from the Frontline

• You need to observe every step of the process

• Make no assumptions that you actually know exactly what is going on in the process

• It rarely is• a single change that achieves success• the same solution from somewhere else• found in a randomized control trial

Thank You & Questions